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

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

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

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

4. 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

5. 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

6. 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

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

8. Clinical LeadershipWhat is it? • “Instrument for improvement” • Interface between administration and clinicians • (“Trouble shooting”)

9. Clinical LeadershipHow? • Engagement • Empowerment • Participation

10. 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

11. “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

12. My Experiences with Clinical Leadership • 70 independent surgeons • No hierarchical “sense” • Little sense of belonging, pride. • Uncoordinated activity • Disorganization, frustration communicated to junior staff

13. 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

14. 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

15. “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)

16. “KPI’s”- “efficiency” • Waiting List targets • Day of Surgery Admission Rates • Same day surgery rates • Theatre Cancellations • Hospital initiated postponements • Length of Stay

17. Theatre Cancellation Rates Initially unacceptable • Comparative Unit rates made “public” • Analysis tool created • Results reanalysed by Units • Reasons for cancellations determined

18. Theatre Cancellation Rates Theatre cancellations reduced by 80% in 3 months • Awareness • Competition • Practical changes • Preadmission ?assessment process • Theatre roster changes

19. 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

20. Process Evolution Director of Surgery KPI Data Individually analysed Heads of Unit

21. Process Evolution KPI Data Analysis created by “sponsor” Heads of Unit KPI Sponsor Surgical Management Committee

22. Surgical Audit • Whereas KPI’s assure us we are not doing badly, surgical audit can indicate whether we are doing well.

23. Surgical Audit The ingredients • Patient data • Disease data • Co-morbidity data • Intervention data • Outcome data

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

25. Vascular Surgical Audit • Box Hill • Commenced 1990 • Fully computerised 1996 • MVSA • Commenced 1999 • 20,000 episodes of inpatient care

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

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

28. Lower limb Bypass Occlusion 1999-2001 for hospitals

29. Lower limb Bypass Occlusion 1999-2001 for hospitals

30. Lower limb Bypass Occlusion 1999-2001 for hospitals

31. Lower limb Bypass Occlusion 1999-2001 for hospitals

32. Lower limb Bypass Occlusion 1999-2001 for hospitals

33. Lower limb Bypass Occlusion 1999-2001 for hospitals

34. MVSA Audit • How was it funded?

35. 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