OVERVIEW Section 1: Context for Leadership and Management Section 2: National Mental Health Policy Framework Section 3: Economics

and Funding of Mental Health Services Section 4: Organisational Theory and Change Management Sectin5: Clinical Governance and Quality Improvement Part 1 Section 6: Clinical Governance and Quality Improvement Part 2 Section 7: Strategic Planning Section 8: Basic Concepts in Administration Section 9: Working with Consumers: The Challenges Section 10: Managing Career Transitions 3 essential learning components required by clinicians adopting management roles: 1. Strong and supportive mentor relationship with a respected senior colleague 2. Graded exposure to progressively more complex and challenging tasks or roles, and 3. Acquisition of appropriate knowledge and skills LEARNING OBJECTIVES: Attitudes

Appreciate the pros and cons of increasing clinician involvement in leadership and management roles; Shjow a commitment to enhancing skills in leadership and mental health in the service of improving patient care Aspire to embody the qualities of excellence required of a clinical manager

Knowledge

Describe the context and implementation of the national Mental Health Strategy and the major remaining challenges; Understand the current challenges in the context of state-run public sector mental health systems Understand some core concepts in health economics and their influence on the variety of funding models applicable to the Australian mental health service system Demonstrate knowledge of the language of clinical governance, risk management and quality improvement Understand own organisations budget process and the key levers to exert influence on it.

Skills

Apply major theories of organizational systems to their own service context Apply principles of quality improvement to a specific clinical practice/service system Identify necessary improvements in clinical practice or service systems in their own workplace and apply learned skills in quality improvement methodology to address the issues identified Obtain organizational data from their own work place, and know how to apply it within different planning frameworks Demonstrate improved communication with system administrators to ensure stronger alignment between clinical and management objectives Apply knowledge about models benefits and challenges of consumer participation to their own clinical practice to achieve greater and more consistent engagement with individuals and groups of consumers Identify potential career transition stressors, and feel empowered to manage them pro-actively

SECTION 1: THE CONTEXT FOR TRAINING Learning Objectives Understand why leadership and management training is important to clinicians Be able to articulate the issues relevant for clinicians working in a system Understand the pros and cons of clinician engagement with the management process Why do psychiatrists need leadership and management skills? Because of: the increasing complexity of mental health care the impact of structuring of health financing systems integrated hospital and community based care increased demand for quality improvement Review Point 1 Consider the following statement within the context of a mental health service in which you have worked. If physicians focus only on patient outcomes, whilst leaving others to worry about cost, they will lose control over how medicine is practiced. (Nolan 1998) Make notes here:

DEFINITIONS: Leadership: actions which focus resources to create desirable opportunities, inspiring others to follow. Management: increasing efficiency and effectiveness of organisational resource use

Leadership
Transformational Leadership Transformational leadership builds organizational culture and motivates followers to become leaders in achieving shared vision. Without capable management this is not possible they are different but complementary.

Management
Capable Management Capable management provides the context for exercising leadership within an organization. It comprises the following activities: - setting expectations - monitoring activity - rewarding performance

Leadership and Management Interaction

Works within 4 key questions: 1. What are we trying to accomplish? 2. How will we know when we have achieved this? 3. What are the plausible alternatives to the status quo? 4. How can new ideas be tested in the real world setting and modified?

THE COMPONENT TASKS OF CAPABLE MANAGEMENT Managing Down Ensuring staff who are accountable to a manager understand and perform their roles and functions Managing Across Comprises the networks, relationships with stakeholders, extending spheres of influence Managing Up Involves: - priority setting (influencing the agenda) - resource allocation - obtaining political support (consumer, community) - creating space for innovation (eg. challenging case management ideology: piloting new approaches). Review Point 2 Consider the service you currently work in. Identify any opportunities you have for managing up, down, and across. Make notes here:

Review Point 3 Note your observations of examples of mental health services where efficacious treatments do not translate into effective services. Why does this occur? What s the managers role in ensuring that it does translate into effectiveness? Make notes here:

SECTION 2: NATIONAL MENTAL HEALTH POLICY Learning Objectives

Demonstrate improved understanding of mental health policy issues Be able to articulate:o National mental health issues o Generic policy drivers and how to influence them o The main challenges facing mental health in their State

Part 1: The context of an Australian Mental Health Policy The determinants of health include: Education, housing, nutrition Treatment interventions o Prevention, promotion o Primary care/welfare sector o Specialist care o Tertiary specialist care (usually bed based) Consider how these are relevant in mental health. Choices about health spending are often historical / political. Health spending as %of GDP: USA 12% England 7%, Australia 8% o High spending on tertiary sector o Mental health spending ~7% of health spending in public sector mental health o Moving in direction of more balance between hospital and community Major issues include: 1. The dichotomy of funding responsibility for health services between State and Commonwealth departments 2. Commonwealth funding of individual care versus State hospital funding 3. State-run psychiatric institutions have a history of poor quality and scandal-driven enquiries. Review Point 1 Given the context for the development of an Australina mental health policy, what do you understand as factors drivingpolicy development? Make notes here:

Part 2: Policy Drivers 1. International concerns Globalisation has an impact on individual and community belief systems: the way in which individuals and communities understand the meaning of life changes and there is rapid sharing of information. Burden of Disease WHO/World Bank: Depression will be leading (or number 2_ cause of disability by 2020. This will have a major impact on productivity. 2. Population health perspectives o Individuals who present for treatment represent only a fraction of those who would benefit from it o Prevention of illness and promotion of mental health represent potentially more cost-effective ways of delivering mental health services o This includes identifiactiono frisk grups and applying targeted interventions to them o Integration of health service interventions across providers o Identification of non-health determinants and addressing those 3. Belief systems Ideology o Deinstitutionalisation and community based care Debates continue about safety of asylums versus the unpredictable responses of the broader health and human service system. The negative consequences of institutions are often overlooked in these debates. o Consumerism Better informed, strong advocates, are able to challenge the medical hedgemony and insist on being partners in treatment Strong push from families and carers tobe involved in treatment and policy decisions. 4. What works? o Evidence based care Is a strong reform driver in the health system Mental health is lagging behind, debating value of the evidence and insisting on clinical autonomy There are ongoing debates about clinical practice guidelines, clinical pathways and how they should be introduced. (incentives/penalties and national policy / local implementation) o Value for money raises questions like: Which treatments work for least cost?

 How do we measure this? Who should provide treatment? When do psychiatrist add value over other providers? o 5. Advances in thinking. Include a need to address community concerns about: Safety, stigma, discrimination of mental health patients Managing expectations that mental health services have solutions to all social and particularly behavioural problems Improving mentalhealth literacy to achieve: Early detection and intervention Reduction of stigman and discrimination Improvements in self-help intervention Technological advances: cost benefits of New medications New diagnostic interventions New treatment options using tele-medicine, computer driven interventions Review Point 2 Consider what drives mental health policy in the current national context. From the list below, priorities these policy drivers from 1 (most influential) 10 (least influential). Community concerns Globalization Value for money Consumerism Population health perspectives Community based care Evidence based care Deinstitutionalization Burden of disease Technological advances

Part 3: Concepts of Mental Health 1. The historical view Not always perceived as a real health issue Debates: o Social control vs isolation of institutions o Neurotic spectrum disorders (?real illnesses) o Emphasis on behavioural management of psychosis o Community confusion with intellectual disability vs mental illness o Deinstitutionalisation fuelling community concerns about homelessness and safety o Historically had no Commonwealth funding o Separate mental health policy/planning units within state health bureaucracies 2. A population health issue Global burden of disease issue emerges. Prior to this, mental health was often seen as a conscience issue; a good thing to do but of little value to society If 18% of the population have suffered mental illness during their lifetimes, this has a big impact on the community. This will have a severe impact on productivity and hence the economy. Treatment is effective, therefore investment is wise. There is a need to capitalize on this direction, with potential benefits for all mental illness groups. Part 4: Mental Health Strategy, Policy and Reform 1. National Mental Health Strategy 1991 Mental Health Statement of Righst and Responsibilities (consistent with UN 98B) 1992 National Mental Health Policy 1993 1998 National Mental Health Plan Medicare Agreement National Mental Health Report

2. Principles of Implementation of a National Mental Health Policy 1. Communicate the vision by key drivers of the policy. 2. Identify pressure groups and stakeholders and mobilize this using levers 3. Advocate to achieve the political will

4. Formulate and disseminate in practical terms 5. Communicate in an ongoing way 6. Build in incentives for implementation (where, when and by whom) 7. Articulate accountabilities (to whom, for what) 8. Ensure systematic monitoring of the implementation processes 9. Develop ongoing evaluation and adjustment 10. Identify strategies which maintain the momentum. Review Point 3 Match these terms with their meanings: Political will Stakeholders Drivers Levers

The issues or people or contexts which activate a system or organization to move in a direction. The combined motivation of groups of stakeholders to ensure that a vertain outcome occurs. Incentives which are used to push or pull the organization in the direction that is required. The individuals or groups hwo have a defined interest in the system or organization 3. Priority areas for national mental health reform Consumer rights Uniform rights based mental health legislation Standards Mainstreaming Comprehensive service mix Integration with other sectors Carers and the NGO sector Promotion and prevention Primary care Workforce development Research and evaluation Monitoring and accountability Part 5: Progress to Date 1. Rights and standards Consumer rights

Mental health legislation has been reviewed and anti-discrimination laws established Consumer Advisory Groups have been established, which increase consumer participation at a service level The National Mental Health Standards were released in 1996, with patchy compliance Rights based legislation but still significant cross border issues and other issues unresolved 2. Mainstreaming and service mix General hospital beds are % up, stand alone institutional beds are 5 down Mental health as core business of all health services not fully achieved eg ED Commonwealth funds still separate, limiting flexibility Many health services still have historically based funding and there are a variety of management arrangements across state jurisdictions 3. Integration with other sectors Carers and the NGO sector Reportedly, the neglect of carers views is worsening Mental Health Council Australia established 1998 (industry-consumer-care partnership) Many health and welfare services have moved from neglect of mental health Anti-discrimination legislation has not reduced implicit discrimination (eg. employment options) Links with other services have not translated from policy into widespread local action (eg. housing, police) Funding to the NGO sector % up but still at % of total spending Peak mental health bodies now exist at national and state levels, but there has been less progress at local levels 4. Prevention and Primary care Promotion and prevention National campaign has made few inroads in the broader community Unresolved debate about appropriate level of investment in primary prevention, and by whom (mental health specialist vs health promotion specialists) Promotion-Prevention-Earlyu Intervention Framework produced 2000 Child and Adolescent Mental Health Services Framework produced 2000 Patchy uptake at secondary and tertiary level. Primary Care Targets set for GP engagement in mental health Mental Health in Primary Care Frameowkr produced 1998 National Depression Initiative beyond blueestablished 2000 5. Workforce development

 6.

Few psychiatrists in public sector Inequalities in access between metro/urban and country Decline in nurses entering mental health Allied health numbers are stable Access to mental health specialist skills is poor overall Little access to data on availability and uptake of ongoing education of current workforce Loss of some specialist mental health expertise through genericisation of public sector workforce and concerns about the adequacy of skill levels in community based staff Public sector mental health staff have a pessimistic view of health outcomes Stigma towards mental health clients is apparent amongst primary care practitioners Accountability and Research Minimal achievement inthis area National Mental Health Information Strategy published 1993 National Mental Health information development funding 1999 2003 National Outcomes Measurement since 2002 National Mental Health report annually

Part 6 Overview and Lessons from Hindsight 1. National Mental Health Plan (1992 1997) Led to mainstreaming without adequate culture change in health services and an emphasis on serious mental ilness to the neglect of other issues Multiple workforce pressures resulted in some professional rejecting work in mental health and the remainder becoming more generic and homogeneous There is a focus on institutional level service system change, not community attitudes and a lack of attention to outcomes Second National Mental Health Plan (1998 2003) Getting the blance right between prevention, promotion, early intervention and specialist services (who should do what?) New paradign of mental health in primary care issues of training, skills, attitudes and incentives Safety and quality inmental health remains an issue Progressing the partnerships (reality vs rhetoric) remains an issue Review Point 4 1. Do you think there will be a Third National Mental Health Plan? Consider the advantages and disadvantages. 2. 2. Consider how a Third National Mental Health Plan might address the following issues: Burden of disease

2.

Early intervention and cost-effectivenss with low-prevalence disorders Stigma and discrimination in the wider community Children and adolescents: effective screening, detection, brief interventions

Part 7: Issues for Mental Health Policy at State Level Specialist mental health services (State funded) need to achieve a focus on early intervention, evidence-based, recovery model, consumer/carer perspective, sultural sensitivity and to broadern focus from low prevalence illnesses. Primary care (Commonwealth funded) historically low levels of detection and evidence based care Large specialist private sector issues (Commonwealth funding) focus on individual care, high degree of autonomy, low concern about waiting lists Each part of the system has different levers or incentives eg fee for service vs salary; individual treatment vs community demand; co-payment vs enforced treatment; high-prevalence conditions vs low. Achieving integration across public/private/primary care is needed in order to implement a population health approach This requires managing community attitudes and expectations, addressing workforce development and training issues Increased research and development needs to occur on what works for whom.

Conclusion NMHP has outlined a vision and direction for reform, tackled implementation of service system reform at State level, and commenced modifying some of the financial drivers The actual difference it has made to the consumer experience as an individual varies between States and regions for a variety of reasons Implementation of National Policy is dependent up0on consensus political will, and leadership and management skills at every level. There are major ongoing challenges for psychiatrist in this process.

Section 3: Economics and Funding Learning Objectives Gain an understanding of the core theories of health economics as they apply to the mental health service system Gain an understadnign of funding theory and policy in Australian MH services Develop a capacity to engage in discussion and debate about funding models, cost effectiveness and provider verses outcome priorities Part 1: What is economics? 1. Definition of economics: the practical and theoretical science of the production and distribution of wealth (Oxford English Dictionary) Economics is concerned with the determinants of 6 concepts: 1. Price (inflation) 2. Interest Rates 3. Employment rate 4. Balance of payments 5. National income 6. Value of national currency 2. Major economic policy questions include: What level of government interference with economic variables wuch as inflation should be. What interventions should be considered If governments do interfere, should it be at macro or micro economic level? Economists do not agree about these questions or their answers. 3. Macro and Micro Economics Macro Economics: interference with only a small number of aggregate economic variables such as money supply, exchange rate and Government expenditure. Leaves as much as possible to the market place (i.e. global buring and selling). Micro Economics: controls the supply and price of a large number of individual goods and services such as wages, interest rates, regional subsidies, tariffs. The argument is that markets fail to achieve a desirable outcome for the population, and detailed government intervention is required.

4.

The Market Central concept in economics Market = Network of interactions among those who potentially have commercial relationships with other buyers and sellers of similar commodities. Market for money (exchange rates between countries0 - labour (employment and wage rates) - goods and services In psychiatric services (if the market concept is applied) constellation of consumers and providers who may have commercial relationships with each other i.e. one groups provides (sells) services and the other receiveds (buys) services. Review Point 1 Consider your response to applying The Market concept to mental health services. Make notes on your thoughts. Is it an appropriate model for mental health services? Make notes here.

The Market (cont) A market requires: That the purchaser has sufficient income to purchase the service and a preference (taste) for that particular service and that provider based on full knowledge of what is offered compared to other choices they may have, That the provider is willing to sell their services at the price the consumer is prepared to pay. Health does not work like a market because the price is manipulated by subsidies (public sector free service/insurance); health services are not usually a free choice, and the consumer does not have complete information about what choices there are in providers (price, quality, style, etc)

Definition of health economics The practical and theoretical science of understanding availability and distribution of resources in the health care sector. It is predicated on the basic assumption that there is always a scarcity of resources so that choices must be made as to how they are distributed for the good that is hoped to be achieved. 3. The 3 major elements of health economics theory are: (1) Descriptions of phenomena eg. How many people in Australia access specialist MH service providers? (2) Explanations eg. Access to specialist MH providers is a product of the health status of groups in different parts of Australia, and the affordability (price, accessibility, distance, etc) of the providers (3) Evaluation eg. Judgements about what differences in access rates between different population groups are acceptable and if not at that level, what should be done about it. Part 3:Core economic concepts relevant to mental health Output: The output of the health care sector is either health care or health. Health can be achieved by: Receiving health caer Engaging in health care Providing better nutrition, housing, education, sanitation, etc Distributing resources to improve health therefore involves choices about what will achieve best value Distributing resources to health care services also involves choices. Such choices require knowledge about health economics. Cost: Can be money cost, opportunity cost, external cost, or social cost Money cost $ Opportunity cost (value of the activity that is foregone such as a days wages, in order to purchase the service) External cost (third party contributions to make up the difference between what the provider charges and what the consumer spends, usually insurance subsidy) Social cost: sum of all costs paid by all individuals (direct patient costs, relatives transport and opportunity costs, insurance costs, and services foregone such as schools in order to fund a health service)

Demand: Demand is the behaviour of attaining or attempting to obtain a service In a market model, there is a direct correlation between demand and price eg. a psychiatrist charging a lower fee will have a greater number of patients attempting to access her service. In choosing between similar prices, the consumer makes decisions based on convenience, availability and quality The market model does not apply well in mental health because Patient fee is subsidised by national insurance (Medicare) Referral comes via a third party (the GP) Patient knows nothing about the style and quality of the psychiatrist There may be an underlying need for a service which drives demand beyond consideration of price Need: The value judgement about what level of health status is desired May be an individual value (need for treatment of depression so as to restore ability to function at previous level) May be a collective need (target level of health to be achieved by a community) Usually linked to level of resources such as per capita bed rates thus implying that supplying this level of resources wilol riase the health status to target level

Review Point 1 Need is seen as one key driver of demand for health services. List some other key drivers of demand for health services. Makes notes here:

Perfect Information Consumers in a true market place have what is called perfect information They are able to assess the difference in value between various options for meeting their need (eg. for anxiety management - between alcohol, recreation, massage, psychological care and medication etc) In health care, there is rarely a situation of perfect information. Choice is made based on prejudice, prior experience, what other people tell them. What the doctor advises carries a lot of weight. The demand for a service is determined by what the provider has available. This is referred to as provider induced demand. Substitution: A commodity or service whose use can replace that of the original commodity. Consumers of mental health services have very little information about what could substitute for good quality mental health care. Improving mental health literacy may start to address this imbalance. Taste: The concept of the consumer choosing a particular service based on a set of valuations about it. This may involve things like gender of the therapist, age preference, location, or other aspects of availability (parking, transport, child care opening hours, etc). Review Point 3 Do you think the number of inpatient beds is an example of provider-induced demand? Make notes here.

Part 4: Population Need and Demand 1. Population need is based on: prevalence of specific illnesses risks associated with an illness notions of treatability individual values about mental health and illness socio-economic consequences of illness third party involvement (legislation to enforce treatment) 2 Population demand for mental health services will depend upon: estimates of need availability of substitutes accessibility of services (price, location, cultural sensitivity etc) taste perceived acceptability of usng a service versus pretnding there is no problem provider inducements (GPs valuing specialist mental health services above alternatives) perceived value what benefits are achieved at what cost? Eg. reduced community risk vs reduced individual autonomy preferred models of mental health care (beds vs community based etc) Part 5: Tools for Making Resource Allocation Decisions in Mental Health Care 1. Efficiency This is defined as the situation where there is either maximization of the outputs from a given level of resources OR minimization of the resources required to achieve specified standards or effects Technical efficiency refers to the situation where efficiencies are achieved by the systematization of a given process of care. It occurs when fewer resources achieve what was done with greater resources in he past, usually is the result of application of new technologies to old processes. In common circumstances it is said to occur when administrative overheads are reduced (eg. through computerization) and there is net gain (or at least no net loss) of clinical care. Allocative efficiency occurs when resources are diverted to an alternative form of care to achieve the same or better results. An example is the diversion of resources used in crisis management to early intervention program.

2.

Effectiveness This is defined as the ability for the program to deliver desired outcomes in terms of improved health status in a real life setting.

3. Efficacy This is the delivery of desired outcomes of health status but in controlled research settings. It is commonly used to describe the benefits of a new pharmaceutical product, in a controlled trial where there is homogeneity of patient groups, and of environmental factors. 4. Equity This refers to the fair distribution of resources, consistent with an individuals or societys judgments of how equal/unequal needs, wants or eligibilities should be met. It does not imply equal allocation of resources but rather a fair and acceptable unequal distribution. Comparative analyses Cost effectiveness evaluation compares the relative costs of two or more different programs in achieving similar health outcomes (eg differences in costs for the same level of stabilization of symptoms of acute psychosis between inpatient or outpatient based programs). Cost benefit evaluation translates all the variable into dollar equivalents and compares all the costs of a treatment program with all the benefits (eg. comparison of all costs of running day programs with all benefits in terms of relapse prevention). Cost utility evaluation compares costs associated with different interventions with similar global measure of outcomes such as QUALYs (eg. improved quality of life may be achieved with either improved supported accommodation options or by improved access to leisure options from an out dated boarding house style accommodation option). QUALYs and DALYs QUALY (Quality Adjusted Life Year): is an index of outcome which combines individual preferences/values about what constitutes quality of life with estimates of duration of years of life. DALY (Disability Adjusted Life Year): is a concept used to estimate the burden of illness: an index of the years of life lived with a disability, and has been used to compare the impact on quality of life of different illnesses. Eg. a person with blindness living 5 years can be compared with person with the disability associated with chronic schizophrenia who lives 20 years. The health resources required to achieve these two outcomes can be compared. QUALYs and DALYs are two common utility measures of health outcomes, which measure individual preferences for health status on a weighted index scale from 0 (death) to 1 (perfect health) and allow comparisons of relative health gain and change in number of years of life from different interventions. For example, different treatments may improve years of life; antipsychotics may reduce risk of suicide but may decrease quality of life through intolerable side-effects.

5.

Conclusion The science of understanding and applying economic theory to health systems increases our understanding of how best to manage population, community and individual demand. Concepts such as price, cost, substitutability, provider-induced demand, and equity all pose challenges to the psychiatrist who is predominantly trained in clinical practice. Meeting population need within available rsources rquires a different paradigm than merely arguing from a clinical erspective of individual need.

Section 4: Organisational Theory Learning Objectives Gain understanding of the major theories of organizations applicable to mh service systems Be able to apply some theories of change management to their own services/workplaces Gain skills and knowlesge in the processes of bringing about organisatinal change Gain an understanding of why organizational change is such an important issue for current MH services. Part 1: Theories of Organizations Definition of an organization: A collective system comprising human and other resources which gather together for a common purpose or goal within an environmental context which shapes it and is shaped to some extent by it. 1. Classical Organisation Theory Mechanical (machine) model which debated and analysed concepts such as: Hierarchy of control Span of control Amount of centralized decision making Degree of specialization Includes Webers Theory of Bureaucracy 2. Neo-Classical Theory Shifted from machine analogies towards relationships and individuals behaviours and how they impacted on the function of the organization Seminal works include: the Hawthorne Effect research (Roethlisberger et al 1939) McGregors theory of empowering workers to perform (1960) 3. Contemporary Theory New theories were required because of fundamental shifts in information processing and communications technology which have caused alterations in the roles and skills of workers, their need to cope with rapid and increasing change and improved consumer knowledge and demands.

4. New Theories based on Systems Theory: (1) Re-engineering (Hammer and Champy1993) This involves radical re-design of processes to achieve organizational objectives. Eg. in the health arena the move from professional line management (where doctors, nurses, allied health, clerical and support workers each with their own hierarchy and work practice) to functional management teams where doctors and allied health staff work together around a particular patient groups to achieve a whole of treatment impact. (2) The Learning Organisation (Senge 1990) This is defined as an organization that is continually expanding its capacity to create its own future. Includes 5 disciplines: Personal mastery Mental models Team learning Shared vision Systems thinking (3) Circular organization (Lartin-Drake 1996) Characterised by having a special focus on the external environment and includes clients/patients in the planning process Has a system of advisory boards integrated with the formal hierarchy of authority Uses data-based decision-making and continual feedback Promotes decentralized problem-solving (4) Chaos Theory and Complexity Science (Goldberger 1996) Introduces the concept of Complex Adaptive Systems which: Operate in a zone between order and chaos Display multiple levels of organization and communication Are non linear and unpredictable Have highly dispersed control This model is applicable in situations where there is low degree of both certainty and agreement (i.e. highly applicable to mental health service systems) Review Point 1 Read Essential Reading 1: Docherty et al :Organisational Theory

Part 2: Organisational Development and Change 1. Definitions Organisational development Is the application of behavioural science to the understanding and managing of organizational change and comprises planned effort across the whole organization (managed fro the top, but engaging from the bottom) which is designed to increase effectiveness and health of the whole, through interventions in processes based on organizational theory. Organisational change Is a subset of development and refers to a difference in the form, shape, or state of the entity over time. 2. Theory of Driving Organisational Change 1. Vision Change must be driven by a vision of what is to be achieved and where the organization is going 2. Culture Change can only occur when the organizational is receptive to the change (needs culture change models in place). 3. Process Attention must be paid to, and investments made in the process of achieving change by engaging stakeholders and negotiating about their concerns. 3. The Organisational Vision This is a statement of where the organization wants to go and is expressed in broad sweeping motherhood statements It requires buy in from stakeholders, and therefore cannot be generated by the management or the board alone It is accompanied by objective statements of intent which commit to defined outcomes using known resources within a given timeframe Review Point 2 Describe the organizational vision statement of your own service. Who developed it? How well does it fit with the National Mental Health strategy? How well does it translate into a meaningful description of where your organization wants to go?

Come up with a better vision statement and be prepared to discuss this at the weekly tutorial. Part 3: Implementing Organisational Culture Change 1. Preparing for organizational culture change Identify perceptions, attitudes, and behaviours of key stakeholders. Consider how you would do this. Acknowledge their concerns. Consider how far you should agree with them. Create a climate of uncertainty and challenge e.g. by suggesting an external review of one aspect of a mental health service Adopt a culture of learning. This involves encouraging an attitude of taking risks and learning from mistakes. 2. Implementing the process of change involves: Identifying opinion leaders Planning a process of communication and feedback to and from all levels of the organization Establishing small change teams to plan each stage or discrete step Ensuring opinion leaders are engaged with these teams Ensuring there is data to guide new decisions Investing appropriate resources in the team decision making to allow them to manage this process Investing in targeted staff development for the new system /continually evaluating the changes against the vision and ensuring this is both fed back to staff and also guides minor adjustments along the way.

Change Drivers in the Health System Capital resources Available to Develop new options New innovations are available Mission challenged by national directions

Quality is needing significant improvement

Cost-cutting is forcing new efficiencies

Review Point 3 Evaluate your own organization alone the 5 dimensions shown in Figure 1. Mark your organization from 1 (low impact near centre) to 5 (high impact near periphery) in terms of how important an impact will these drivers have on your organization. Connect up your dots. A larger space will indicate that there are major pressures for the organization to change. Conceptualising Strengths in an Organization Common purpose is apparent within all elements Openness of information is agreed and implemented Financial shape is strong

Distribution of power is maximized

Abundance of relationships with external stakeholders

(not centralized)

Review Point 4 Evaluate your organisations strengths along the 5 oint dimensions shown in Figure 2 Mark each dimension from 1 (low readiness, near centre) to 5 (high readiness, near periphery). Connect up your dots. A larger space will indicate greater strengths. Determining Organizational Readiness for Change Relative advantage will adoption of the change make the organisation more relevant? Flexible to new things? Triability can change be trialled and modified easily?

Simplicity is the change perceived in commonsense terms within your organization? Review Point 5

Observability can the change be brought about in a transparent way in your organization?

1. Evaluate your organisations readiness to make the changes being ushed by the forces described in Figure 3. Least readiness is marked 1 (near centre) on each dimension and most readiness is marked 5 9near periphery) on each dimension. 2. Compare the size and shape of the 3 diagrammatic representations of your organization. What does this tell you? Will your organization survive resistance to change? 3. What could be done to make change a more positive process?

Part 4: Balancing Technical and Profound Change It is a bad idea to try to drag a service through all kinds of change at the same time. It is far better to stairstep technical changes with profound changes, allowing each type to reinforce the other, and building the services competence in the skills of change. 1. Concepts of Change Technical Change Involves doing something differently (eg. more efficient Clozapine clinics) Profound (Fundamental) Change Involves the organization being something different (eg. an entirely new approach to compliance management based on patient ownership of the process).

Conclusion Organisational theory has become vastly more sophisticated in recent years and is more able to take into account the complex and ever-changing social and political environment. Understanding and applying change within health service systems needs complex theories. There are 3 major considerations required for organizational change. 1. Developing and articulating the vision 2. Preparing for the culture change required 3. Investing in an appropriate change management process