clinical leadership. engaging clinicians- a practical insight (and a personal perspective!)
TRANSCRIPT
Clinical Leadership.Engaging clinicians-a practical insight
(and a personal perspective!)
Clinical LeadershipWhy?
1.1. Changing CultureChanging Culture
2.2. Improved outcomesImproved outcomes- “Efficacy” (beneficial patient interventions)- “Efficacy” (beneficial patient interventions)- ““Efficiency” (institution benefit)Efficiency” (institution benefit)
3.3. Demonstrating that this is occurringDemonstrating that this is occurring
4. Providing an environment for recruitment
“employer of choice”
5.“Ambassadorial” enhancing reputation of Institution
6. “Horizon Scanning” - internal and external
Changing a Culture-Reasons for Difficulties
Clinicians are fiercely protective of their independence
Paranoid (sometimes justifiably) Clinicians exist in a changing world for which they
are untrained, ill-equipped Perceived conflict with “the best for the patient” and
the “best for the institution” Patient demands and expectations increasingly
unrealistic Clinicians tend to remain at an institution for the
duration of their working lives
Senior Management Misconceptions
Medical Staff Groups are cohesive bodies Clinicians like democracy Clinicians are working for the money The badly performing clinician does not
wish to improve Clinicians primary responsibility is to the
institution
Why do Clinicians choose to work in a Public Hospital?
Tradition Sense of belonging / pride Opportunity for peer environment Senior supervision / assistance Community Service Relationship with junior staff Teaching opportunities Prestige Keeping “up to date”/ Research Opportunities
Financial
Opportunities
Specialist Clinicians are highly motivated
Intelligent
Competitive (reputation is important)
Clinical LeadershipWhat is it?
“Instrument for improvement”
Interface between administration and clinicians
(“Trouble shooting”)
Clinical LeadershipHow?
Engagement
Empowerment
Participation
Clinical Leadership – engagement of clinicians
How? Establish a forum for communication Identify the issue / problem
-Why is it a problem? Wait Canvass solution Wait Propose implementation of solution Monitor solution
“Rules of Engagement” (of Clinicians)
Establish clear “chain of Command” Avoid “democracy” Utilise peer pressure Clearly enunciate expectations Avoid the abstract, nebulous Establish transparent procedures for dealing with
difficult issues Ensure efforts are appreciated and considered Publicise results – emphasize successes
i.e., involvement has been worthwhile
My Experiences with Clinical Leadership
70 independent surgeons No hierarchical “sense” Little sense of belonging, pride. Uncoordinated activity Disorganization, frustration communicated to
junior staff
Approach
Formation of Clinical Units (4-6 surgeons) Empowerment of Heads of Unit Establish lines of communication,
responsibility Regular meetings with Heads of Unit Regular Unit Meetings Allocation of tasks Provision of support, encouragement
Heads of Unit Meetings
Initially weekly, now fortnightly Early morning Create name “Surgical Management Committee” Create Agenda, take minutes, produce action plan Utilise peer pressures Regular invited speakers Provide information, act on advice Avoid voting, achieve consensus
“KPI’s”- “efficacy”
Unplanned return to operating theatre Unplanned admission to ICU Mortality Unplanned readmission Average length of stay Surgical Audit (Unit specific ACHS Indicators)
“KPI’s”- “efficiency””
Waiting List targetsWaiting List targets Day of Surgery Admission RatesDay of Surgery Admission Rates Same day surgery ratesSame day surgery rates Theatre CancellationsTheatre Cancellations Hospital initiated postponementsHospital initiated postponements Length of StayLength of Stay
Theatre Cancellation Rates
Initially unacceptable
Comparative Unit rates made “public” Analysis tool created Results reanalysed by Units Reasons for cancellations determined
Theatre Cancellation Rates
Theatre cancellations reduced by 80% in 3 Theatre cancellations reduced by 80% in 3 monthsmonths
Awareness Awareness CompetitionCompetition Practical changesPractical changes
Preadmission ?assessment processPreadmission ?assessment process Theatre roster changesTheatre roster changes
How was this achieved?
Identifying and defining a problem creating awareness
Means of Communication Utilising competitive instincts, peer environment Analysing the problem Implementing Change Reanalysing Publicising success
Process Evolution
KPI Data Director of Surgery
Heads of UnitIndividuallyanalysed
Process Evolution
KPI Data Analysis created by “sponsor”
Heads of UnitKPI Sponsor
Surgical Management Committee
Surgical Audit
Whereas KPI’s assure us we are not doing badly, surgical audit can indicate whether we are doing well.
Surgical Audit
The ingredients Patient data Disease data Co-morbidity data Intervention data Outcome data
Surgical Audit
Simple (entering and analysing data)Simple (entering and analysing data) Accurate, compliantAccurate, compliant Enable risk stratificationEnable risk stratification Allow outcome analysisAllow outcome analysis Comparable to an accepted standardComparable to an accepted standard
Vascular Surgical Audit
Box Hill Commenced 1990 Fully computerised 1996
MVSA Commenced 1999 20,000 episodes of inpatient care
Surgical Audit
Individual surgeons can compare their performance for individual procedures to a collective experience
Mean and standard deviations provided
Surgical Audit
Risk StratificationRisk Stratification Statistical Logistic regressionStatistical Logistic regression
Expected complication rate (morbidity and Expected complication rate (morbidity and mortality)mortality) For individual patientsFor individual patients For annual experienceFor annual experience
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
11
22
3 BHH3 BHH
44
55
66
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
Number of Bypasses
11 163163
22 232232
3 BHH3 BHH 261261
44 103103
55 268268
66 196196
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
Number of Bypasses
Actual Occlusions
11 163163 12 (7.4%)12 (7.4%)
22 232232 25 25 (10.8%)(10.8%)
3 BHH3 BHH 261261 15 15 (5.7%)(5.7%)
44 103103 13 13 (12.6%)(12.6%)
55 268268 25 (9.3%)25 (9.3%)
66 196196 20 20 (10.2%)(10.2%)
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
Number of Bypasses
Actual Occlusions
Expected Occlusions
11 163163 12 (7.4%)12 (7.4%)
22 232232 25 25 (10.8%)(10.8%)
3 BHH3 BHH 261261 15 15 (5.7%)(5.7%)
44 103103 13 13 (12.6%)(12.6%)
55 268268 25 (9.3%)25 (9.3%)
66 196196 20 20 (10.2%)(10.2%)
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
Number of Bypasses
Actual Occlusions
Expected Occlusions
11 163163 6.9% 6.9% (11)(11)
22 232232 8.2% 8.2% (19)(19)
3 BHH3 BHH 261261 6.6% 6.6% (17)(17)
44 103103 11.6% 11.6% (12)(12)
55 268268 7.6% 7.6% (20)(20)
66 196196 5.6% 5.6% (11)(11)
Lower limb Bypass Occlusion 1999-2001 for hospitals
HOSPITAL
Number of Bypasses
Actual Occlusions
Expected Occlusions
11 163163 12 (7.4%)12 (7.4%) 6.9% 6.9% (11)(11)
22 232232 25 25 (10.8%)(10.8%)
8.2% 8.2% (19)(19)
3 BHH3 BHH 261261 15 15 (5.7%)(5.7%)
6.6% 6.6% (17)(17)
44 103103 13 13 (12.6%)(12.6%)
11.6% 11.6% (12)(12)
55 268268 25 (9.3%)25 (9.3%) 7.6% 7.6% (20)(20)
66 196196 20 20 (10.2%)(10.2%)
5.6% 5.6% (11)(11)
MVSA Audit
How was it funded?
Clinical Leadership –by whom
Characteristics of a Clinical LeaderCharacteristics of a Clinical Leader
Perceived as a good, successful clinician Perceived as a good, successful clinician i.e. respectedi.e. respected
Highly motivated to bring about improvementHighly motivated to bring about improvement Seen as honest and straightforwardSeen as honest and straightforward Able to see both sidesAble to see both sides Able to be firmAble to be firm Supported by Senior ManagementSupported by Senior Management