Clinical Leadership' Engaging clinicians a practical insight and a personal perspective

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Clinical Leadership.Engaging clinicians-a
practical insight(and a personal perspective!)
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Clinical LeadershipWhy?

• 1. Changing Culture
• 2. Improved outcomes
• - Efficacy (beneficial patient interventions)
• Efficiency (institution benefit)
• 3. Demonstrating that this is occurring

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• 4. Providing an environment for recruitment
• employer of choice
• 5. Ambassadorial
• enhancing reputation of Institution
• 6. Horizon Scanning
• - internal and external

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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

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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

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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

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Opportunities

• Specialist Clinicians are highly motivated
• Intelligent
• Competitive (reputation is important)

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Clinical LeadershipWhat is it?

• Instrument for improvement
• Interface between administration and clinicians
• (Trouble shooting)

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Clinical LeadershipHow?

• Engagement
• Empowerment
• Participation

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Clinical Leadership engagement of
cliniciansHow?

• Establish a forum for communication
• Identify the issue / problem
• -Why is it a problem?
• Wait
• Canvass solution
• Wait
• Propose implementation of solution
• Monitor solution

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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

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My Experiences with Clinical Leadership

• 70 independent surgeons
• No hierarchical sense
• Little sense of belonging, pride.
• Uncoordinated activity
• Disorganization, frustration communicated to
  junior staff

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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

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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

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KPIs- efficacy

• Unplanned return to operating theatre
• Unplanned admission to ICU
• Mortality
• Unplanned readmission
• Average length of stay
• Surgical Audit
• (Unit specific ACHS Indicators)

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KPIs- efficiency

• Waiting List targets
• Day of Surgery Admission Rates
• Same day surgery rates
• Theatre Cancellations
• Hospital initiated postponements
• Length of Stay

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Theatre Cancellation Rates

• Initially unacceptable
• Comparative Unit rates made public
• Analysis tool created
• Results reanalysed by Units
• Reasons for cancellations determined

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Theatre Cancellation Rates

• Theatre cancellations reduced by 80 in 3 months
• Awareness
• Competition
• Practical changes
• Preadmission ?assessment process
• Theatre roster changes

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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

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Process Evolution
Director of Surgery
KPI Data
Individually analysed
Heads of Unit
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Process Evolution
KPI Data
Analysis created by sponsor
Heads of Unit
KPI Sponsor
Surgical Management Committee
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Surgical Audit

• Whereas KPIs assure us we are not doing badly,
  surgical audit can indicate whether we are doing
  well.

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Surgical Audit

• The ingredients
• Patient data
• Disease data
• Co-morbidity data
• Intervention data
• Outcome data

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Surgical Audit

• Simple (entering and analysing data)
• Accurate, compliant
• Enable risk stratification
• Allow outcome analysis
• Comparable to an accepted standard

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Vascular Surgical Audit

• Box Hill
• Commenced 1990
• Fully computerised 1996
• MVSA
• Commenced 1999
• 20,000 episodes of inpatient care

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Surgical Audit

• Individual surgeons can compare their performance
  for individual procedures to a collective
  experience
• Mean and standard deviations provided

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Surgical Audit

• Risk Stratification
• Statistical Logistic regression
• Expected complication rate (morbidity and
  mortality)
• For individual patients
• For annual experience

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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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Lower limb Bypass Occlusion 1999-2001 for
hospitals
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MVSA Audit

• How was it funded?

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Clinical Leadership by whom

• Characteristics of a Clinical Leader
• Perceived as a good, successful clinician
  i.e. respected
• Highly motivated to bring about improvement
• Seen as honest and straightforward
• Able to see both sides
• Able to be firm
• Supported by Senior Management