By Harrison Thorn 2nd Year, Health Management Intern, Victoria It is uncommon for management interns to spend extensive time with health service executives and Boards, and when it does occur, it is usually in the context of a small rural hospital. What is even more uncommon is for interns to spend time with the executives or Boards of major metro health services. During my current rotation, I have had the extreme good fortune of working as the Executive Officer to the Board at Alfred Health. My commencement date coincided with the current Executive Officer going on maternity leave, and for reasons unbeknown to me, the Alfred saw fit to place a second-year intern with little secretarial experience and an aloofness to details into the role. The Alfred as an institution requires little introduction. It is one of the oldest and largest health services in Australia, renowned for its trauma and heart and lung services among others. Its CEO of thirteen years, Andrew Way, is a Professor and Order of Australia recipient, whose intelligence and depth of knowledge its matched only by his mastery of the Queens English and irritation for recurrent Boardroom IT issues. All of this is to say that it has been an honour and privilege to been among such a competent and well-respected group of people, let alone work for them and learn from them. This place, and those leading it, are among the giants of the healthcare sector in this State and around the Country. The sense of imposter syndrome has grown on me with each day I have been in the role. Claiming to walk among giants like these would infer some level of equivalence. It has definitely felt more like crawling, trying not to cause anyone to trip over. Nevertheless, the role has included regular meetings with Prof Way to discuss Board agenda’s, papers and schedules, collating and disseminating Board and Board Sub Committee papers, attending and writing minutes for Board and Sub Committee meetings, as well as a variety of other ad hoc tasks. Having time to reflect on the first three months of this placement there have been a few learnings that have particularly stood out: The Devil is in the Details As someone for whom focusing on details does not come naturally, this opportunity has given me great experience and practice at mastering the details. From ensuring information in papers is correct, that dates, headings and actions are accurate, just when you think you have considered them all, there is bound to be more. ‘Speak clearly if you speak at all; carve every word before you let it fall’. We all know the importance of communication, but this placement continues to cement many of the practical aspects of this for me. What messages to communicate, who to communicate them to, when to communicate them, the way you write or phrase something. Working with senior management has required that they are linked in on every detail, including asking for permission even when taking initiative. Whilst this has not previously come naturally, I definitely feel myself growing in how to communicate within hierarchies of authority. It’s a long way to the top – if you want to rock and roll. Good organisations ensure that executive management is not disengaged from its workforce, that it actively is involved in engaging and delivering for its staff. Alfred Health does this very well. However, when being a fly on the wall at Board and Executive meetings, its hard not to notice how ultimately, key discussions and decisions are made by those relative few with the delegated authority to do so. This may seem obvious, but as someone who looks at problems through a big picture lens and can lose perspective, seeing the complexities of decision making in action has helped me to refocus my efforts to contributing to what I can control. ‘The value of an idea lies in the using of it’. Most executive suites are made up of traditional business roles, including CEO, CFO, COO, Strategy & Planning, and People & Culture. To my knowledge, few are shaped by medical research. Prof Way recently has recently commenced a new executive position called the Chief Experience Officer (CXO), which is not a kitschy name for traditional People & Culture functions. This office was setup with the express KPI of determining whether, in line with current academic research, improving staff experience can in turn improve patient experience and outcomes. I found this to be an inspiring and ingenious approach to an executive office, and was impressed that Prof Way is using contemporary evidence to mould his executive structure and strategy. I have also been lucky to spend an hour with the Alfred Health Board Chair, Michael Gorton AM. Michael has enjoyed a successful legal career with a particular focus on the health sector. I spoke with him about a variety of topics, and he provided some insights into his career pathway and the industry. On the type of work legal teams contribute to the health system: ‘a lot of health law is contract law, …and administrative law – decision making, systems and processes. The legal experience gives you the audit and risk areas to make a contribution’. On a definition of corporate governance: ‘its systems and processes, the systems and processes of the organisation that manage and oversee all of its activities…the four elements of corporate governance are (1) liability – who is liable for what in an organisation, and how is the organisation liable. It’s about (2) accountability – which is delegation, you delegate basically all of the management powers to the CEO and an executive team, and in delegating down, good corporate governance is about the systems that bring the reporting and accountability back up…then (3) risk management – isn’t just the usual legal risk, its financial risk, environmental risk, political risk depending on the nature of the organisation… and finally (4) compliance – how do you know your organisation is complying with all the rules that apply. On the definition of clinical governance: ‘it is the principles of corporate governance applied to the clinical arena, except that it is broader than just the work of one committee. The Board delegates powers to a range of committees who do the heavy lifting on a range of subject areas’. On key learnings from COVID: ‘I can’t imagine a time where we have had to be so flexible and give up things, for the right reasons, but elements of governance – two years ago things I would have said were critical parts of governance we deferred for a period of time’. On the state of the Victorian health system and where it is headed: ‘the system of governance in Victoria has probably reached its use by date. If you look at NSW and QLD they effectively have one system, I suspect we need to move closer to that. What COVID has shown is that having separate hospitals and separate boards and separate legal entities has in part been a barrier to cooperation and collaboration rather than an enabler. We need to collaborate more’. On what makes a good relationship with a CEO: ‘trust, information and sharing. You get information because there is trust in the relationship’. On the skills Boards are trying to upskill on: ‘IT, which is not just about systems but cyber risk and how do you improve patient safety using IT. Culture, stronger understanding of people and culture’. On foundational topics for interns entering the industry: ‘ask questions about the subject matter of the organisation and ask then for a reflection about systems and processes, the way into the organisation is not about just asking questions about how does a board go about doing this, ask how does the organisation address this issue and then bring it back to systems and processes, I think you’ll get a more revealing response’. On legal aspects interns should be aware of: ‘understanding risk management is the most boring thing you can probably ever do, but it is the way in to a lot of the systems and processes that we have, its actually all about risk – about making sure we don’t do bad things – but a good question to ask is, what systems and processes do you have in place to make sure you do more of the good things, which is a much harder question to answer – how do we prove that most of our patients leave us in a better position than when they came or what percentage of our patients leave us in a worse position than when they came’. I hope these reflections and insights provide a glimpse inside the executive suite at the Alfred, and some learnings about governance that can prompt further investigation and learning. Views are those of individual authors and not those of ACHSM or management intern’s employers.