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