WPBA: Leadership activity and MSF

This is a well-known idea used in the best organisations. Looking at an organisation with a fresh pair of eyes often reveals insightful opportunities or answers to problems that may have been troubling the organisation (in this case the GP practice) for some time.  This exercise involves the trainee spending time in the practice specifically looking at how the practice works, both on a structural and cultural level.  
   
If the trainee cannot think of anything that could be changed or improved, a member of the practice could describe an innovation challenge that they have and ask the trainee to use his/her fresh pair of eyes to help them identify a way forward.   

The process 

Very shortly after induction the trainee is informed that they will have an opportunity after approximately two months to present back to the team on a) what they have seen, and b) a couple of recommendations for change.  

Over this period, the task is to use their 'fresh pair of eyes' to see the organization from an objective viewpoint. As those embedded in it often do not buy virtue of being blinkered. The trainee is encouraged to consider several awareness-raising questions that will help them which include:  

• What's going well?  
• What isn't going so well?  
• Why are we doing this / why are we doing it this way?  
• I've seen this done better elsewhere - would it work here?  
• If there is something that’s done brilliantly here, how do I feed that back and let others know about it?  

 Once the trainee has collated these thoughts, they prioritise a couple of things that they think would benefit from changing in the practice and write these down. At a prearranged meeting with the practice, they present their thoughts and make a pitch for what needs to be changed and why. If desired and if time allows, the trainee could then go on to work with the relevant people to effect any changes.   

Intended outcomes  

Learning to use observational skills, thinking skills and the skills of persuasion. Making use of an evidence-base.  
 
More rapidly enabling them to become functional members of the team, rather than observational members. Feeling valued at a time when they are new to the practice and may consider themselves too junior to discuss new ideas for the practice.  
 
Seeing an organisation in a way that he or she probably has not looked at before and being helped to reflect on their possible future role in leading and running a practice.   
Done well, this sends the trainee a powerful positive signal and also encourages the team to look upon its junior members differently.  

All GPs will attend a variety of practice team meetings throughout their working life, and many will be put in the position of chairing at least one. A good chair enables a meeting to run smoothly and efficiently, making sure that all the business is discussed, everyone’s views are heard, clear decisions are reached, and the meeting runs to time.  
 
It is recommended that the trainee should do a questionnaire on their leadership style ahead of chairing the meeting and reflect on this as well within their write-up (see links below for an example of leadership questionnaire. 

The process  

Trainees are encouraged to sit in on a variety of practice meetings routinely.  During these meetings they are instructed to observe chairing in action.  
 
They should then have an opportunity to talk about chairing skills, either in debrief after a meeting, or as a tutorial when they are related back to skills in a leadership model. As part of this exercise, they may wish to look up the skills needed to chair a meeting and reflect on what they have seen.  
 
The trainee then participates in a role-play exercise in which a scripted issue is discussed by several people, including a chair, with a group-based debrief to follow.   
 
The next stage is for the supervisor to identify one or two issues in a future agenda where the practice feel it is appropriate for the trainee to take the chair. Highly controversial high-stakes issues should be avoided.  
 
The trainee will take the chair for a real-life meeting in the practice, either for the whole or part of the meeting.  
 
After this, and preferably immediately, debriefing should occur with the trainee receiving formative feedback, and being given an opportunity to reflect on the process and ask questions.  

Intended outcomes  

• Developing chairing skills – clarifying issues, areas of agreement, and the decision that needs to be made  
• Managing time-agreeing a timescale and running to time  
• Improving understanding of the roles of members within the practice team.  
• Understanding group dynamics and encouraging contribution from all, encouraging the quieter members, not allowing focus to settle on louder colleagues and achieving a balance of views.  
• Understanding how the organisation functions in terms of management as well as clinical.  
• Working with people in a difficult situation, managing conflict and disagreement  
• Reviewing written minutes and ensuring that the meeting notes are representative of the discussion; ensuring that decisions made are representative of the discussion  
• Facilitating the development of an action point or plan  

 It may be helpful to feedback following a structure relating to the intended role of the Chairperson e.g.  

• The chair ensures an agenda is set in a timely fashion and that all members have the appropriate documents prior to the session.  
• The chair outlines the purpose of the meeting and remind members why they are there.   
• The chair controls the meeting, and all remarks are addressed through the chair.  
• Members do not interrupt each other.  
• Members aim to reach a consensus.  
• The chair ensures that the meeting flows smoothly by involving all members present and by not permitting one or two people to dominate the meeting.    
• The chair uses summarising appropriately to indicate progress (or lack of), refocus discussion that has wandered off the point, conclude one point and lead into the next, highlight important points, and clarify any misunderstandings.  

Investing in the wellbeing of the practice team is essential to ensure that all can contribute to the delivery of excellent patient care now and in the future. There are a number of ways that the working environment can be modified in order to boost wellbeing, for example by integrating a team coffee break into the working day or by taking part in a regular activity as a team e.g. Parkrun.  

The process  

The trainee through discussion with various team members generates an idea for enhancing the wellbeing of the practice team. The trainee then ensures buy in from the key stakeholders before presenting their idea to the wider practice team. The trainee then works to embed this change within the practice. Trainees may wish to use Kotter’s 8-step Change Model to help them in the process  

Intended Outcomes  

• Learning to work with others and to tap into the wisdom of members of the practice team   
• Presenting ideas to others.  
• Considering how to make changes and how to negotiate those changes with others  
• Improving the wellbeing of the practice and thinking ahead to how they will contribute to the wellbeing of colleagues in their future roles  

Clinical protocols are used in GP practices as tools for offering structured care, whether by GPs, nurses, or other healthcare professionals. They represent the framework for the management of a specific disorder or clinical situation and define areas of responsibility. The purpose is to reduce variation, maintain the quality of patient care and they are documentary evidence of the gold standard of care to be provided. Protocols should be dynamic resources which are used regularly in clinical practice.  In addition, there may be areas of care which merit a protocol that would be useful for the practice.    
 
GPs are likely to be involved in developing, reviewing, and implementing protocols in many areas of their clinical work.  

The process  

The trainee decides either to review an existing protocol used in the practice or create a new protocol.  
 
For the review of an existing protocol, the trainee may consider the following:   

1. How is the protocol used? How is it used in practice, how is it accessed?  
2. Is the protocol fit for purpose?  
3. Is the protocol in line with local/regional/national guidance?  
4. How can practice team members provide feedback on the protocol?  
5. When was the protocol last reviewed, is it up to date? How does the surgery ensure that the protocol is updated in accordance with best practice clinical guidance and recommendations?  

For the creation of a new protocol, the trainee looks at the clinical activity of the practice to determine whether a new protocol might be helpful. It may be particularly beneficial to look at areas of care that have shifted from the GP to mainly nurse-led care, or new areas of clinical medicine for which a protocol does not yet exist.  
The trainee selects a topic that is important for delivery of care in the practice. This may be driven by national standards (for example NICE guidance) or through the identification of local service improvement priorities in areas not covered by national guidelines.  
 
If the protocol is about disease management, the trainee then considers the following two steps:  

1. How to define the circumstances where patients are referred on from nurse-run clinics to either a GP or directly to secondary care  
2. How to describe the practice’s criteria for stepped increases in therapy.  

 The trainee should also consider:   

• consulting other relevant members of the practice team for their opinions  
• how any protocol can be made accessible to all relevant team members in the practice  
• how the protocol might be reviewed and revised on a regular basis.  

 Once the trainee has completed the activity (a review of an existing protocol, or a suggested plan for new protocol) he/she will discuss this with relevant members of the practice team to ensure adoption of the new/updated protocol  
 
The ES and any other relevant members of the team will then give formative feedback to the trainee.  

Intended outcomes  

• Learning to look critically at a clinical process within the surgery, often one that has been taken on by a non-GP member of the team.  
• Using an evidence-based approach to review a clinical protocol or create a new protocol.  
• Reviewing local guidelines and practices e.g. With respect to prescribing or referring.  
• Engaging and working with other members of the team; valuing others.  
• Considering patient safety and mechanisms put in place to enhance this.

All NHS Practices must produce a practice leaflet. Regulations set out the core information that each leaflet must contain (NHS Brand Guidelines, General practitioner, 2016).   
 
Practice leaflets are an ideal way in which practices can inform the local population about the services on offer and how patients can access them. Production and revision of a practice leaflet is often a joint task shared between practice manager and GP.  It is therefore an appropriate exercise for trainees to look critically at the practice leaflet and consider ways of improving it.  

The process

The trainee looks at the practice leaflet to determine whether it meet NHS guidelines, including:  

• full names of each person performing services under the contract  
• services available  
• whether the practice premises have suitable access for disabled patients  
• rights and responsibilities of the patient, including the rights to express preferences  
• criteria for home visits, etc.   

The trainee may also consider whether any additional, non-mandatory information has been included or should be included, for example:   

• how to arrange advance appointments or telephone consultations  
• foreign languages spoken by healthcare professionals  
• details of healthcare professionals’ availability and areas of interest and expertise etc.  

It would be relevant to include the challenges of communicating with hard-to-reach patient groups and consider whether the practice leaflet fulfils this aim.  
 
Comparison with practice leaflets from other surgeries may also be helpful.  
 
Once the trainee has reviewed the current practice leaflet, a meeting is arranged with the practice to present their findings and suggestions as to what needs to be changed and why.   
 
If desired and if time allows, the trainee could then go on to work with the relevant people to effect any changes. It may also be appropriate to consider evaluation of the revised practice leaflet to find out whether it meets the intended audiences’ needs and expectations, for example by carrying out a patient survey.   

Intended outcomes  

• Learning to use observational skills and thinking skills.  
• Communicating with other members of the team, discovering their roles and interests.  
• Understanding the services provided by the practice.  
• Considering the rights of patients for information, as well as other rights and responsibilities relating to their interaction with the practice.  
• Looking at the practice from an equal opportunities perspective with respect to access and effective communication.  
• Thinking through how to make changes, and to evaluate those changes

Most practices have a practice website to inform and sometimes interact with patients. Many practices also have an intranet, and others have a folder of “favourites” on each desktop screen, containing useful information, templates, referral forms etc. This activity involves looking at an aspect of the website or how it is used within the practice to consider its purpose, how well it works, and whether it could be improved. The responsibility for updating a practice website is often a joint task shared between practice manager and GP. It is therefore an appropriate exercise for trainees to look critically at the practice website or intranet and consider ways of improving it.   

The process  

After the trainee has had time to understand the purpose of the practice website or intranet, they are encouraged to look at it critically and have conversations with a variety of stakeholders. Questions to be considered might include:  

• What content is on there and what is missing? What is out of date?  
• Why are we doing is this way / why aren’t we doing it another way?  
• What isn't working so well?  
• Is the information accessible to those who want/need to use it?  
• Is it interactive, and if not should it be?  
• Does it appear interesting and engaging to the user? Is it user-friendly?  

Once the trainee has had a chance to consider these issues, they prioritise a couple of areas that they think would benefit from changing and note these, along with any suggestions for improvement. At a prearranged meeting with the practice, they present their ideas and suggestions as to what needs to be changed and why.   

Intended outcomes  

• Learning to use observational skills and thinking skills in the context of IT and GP surgery websites.  
• Gaining a better understanding of web-based communication within the practice, and between the practice and its patients.  
• Understanding how computer-based resources are organized and utilized by the practice.  
• Looking at the practice from an equal opportunities perspective with respect to access and effective communication.  
• Thinking through how to make changes, and to negotiate those changes with others.