Getting the leadership habit –Getting the leadership habit training 21st century physicians
@FMLM_UK @AoMRC @RCPLondon @HealthFdn
‘Leadership…. making it happen…..’
‘leadership and learning areleadership and learning are indispensible to each other’p
John F Kennedy, 1963
"It is not enough to do your best;It is not enough to do your best; you must know what to do, and ythen do your best”
W. Edwards Deming
Miller’s triangle of clinical competence
DoesDoesg p
DoesDoes
Shows
Knows how
KnowsKnows16
Adapt Miller’s triangle of clinical competence
Justify,mitigateimprove the
Justify,mitigateimprove the
gapsgaps
Do what you should do
Know what you actually do
Know what you should doy
Vaux, 2016 16
On our own we didn’t do anything….f d itt dso we formed a committee ….and
still didn’t do anything…..
Why wouldn’t you want to improve?
How do doctors fit in?How do doctors fit in?
Training 21ST CENTURY PHYSICIANSTraining 21 CENTURY PHYSICIANS
“In order to practise medicine in theIn order to practise medicine in the 21st century, a core understanding f lit i t iof quality improvement is as
important as our understanding of p g fanatomy, physiology and biochemistry”biochemistry
Stephen Powis, 2015
Bridging the quality gapBridging the quality gap
EDUCATION CLINICAL
Service versus trainingService versus training
Postgraduate Medical J, 1987
Reframe….Reframe….
Service as hands on patient care
and training
Connecting Education To Care Outcomes In G d t M di l Ed ti
Lessons Learned
Graduate Medical Education
Lessons Learned
Changing in this order is difficult
Changing in this order is better
Changing this way is bestorder is difficult:
1. Education 2 Care
order is better:1. System 2 Care
is best:1. System 1 Care2. Care
3. System2. Care3. Education
1. Care1. Education
Eric J. Warm, 2016. University of Cincinnati College of Medicine
What is Quality Improvement?
@NHS_HealthEdEng
Quality is:Patient care that focuses on safety effectivenessQI d tiPatient care that focuses on safety, effectiveness and patient experience
[NHS Constitution]
QI education
• Knowledge in improvement science systems andQuality improvement is:Using understanding of our complex healthcare
• Knowledge in improvement science, systems and measurement
• Skills in managing complexity, leading change, Using understanding of our complex healthcare environment,
applying a systematic approach
learning and reflection, and ensuring sustainability• Training in human factors that impacts those capabilities
designing, testing, and implementing changes using real‐time measurement for improvement,
to make a difference to patients by improving safety
capabilities
to make a difference to patients by improving safety, effectiveness & experience of care.
Managing complexity
Systems thinking Infl encingcomplexity
Leading h
thinking Influencing
change
Learning &
learningcreativity reflection
kno ledge
creativity
knowledge
HumanHumanfactors
Resiliencesustainability
learningResilience
SystemsInfluencing
Systems thinking
creativity
What type of leader are you?What type of leader are you?
Personal LeadershipPersonal Leadership
View own personal development as part of theView own personal development as part of the ongoing process of leading quality improvement
Before you are a leader success is all about growing yourself When you become a leadergrowing yourself. When you become a leader, success is all about growing others.
Jack Welch
How to fascinate
The RBFT QualityThe RBFT Quality Academy
T h i l L d hiTechnical Leadership
• Understand and have some experience of the full range of improvement methodologies
• Able to critically assess strengths and weaknesses of each methodology
• Able to decide and make the case for adoption and adaptation ofAble to decide and make the case for adoption and adaptation of particular improvement methodologies, dependent upon situation and context.
A l d i th t k th th d h thA leader is one that knows the way, goes the way and shows the way. John Maxwell
“All improvement requires change, but not all change leads to improvement”not all change leads to improvement
“In God we trust.
All others bring data.”
W. E. Deming
The Three Faces of Performance Measurement
Aspect Improvement Accountability Research
Aim Improvement of care Comparison, choice, New knowledgeAimreassurance, spur for
change
Methods:• Test Observability
Test observable No test, evaluate current performance
Test blinded or controlled
Test Observability• Bias Accept consistent bias Measure and adjust to
reduce biasDesign to eliminate bias
• Sample Size “Just enough” data, small sequential samples
Obtain 100% of available, relevant data
“Just in case” datasequential samples relevant data
• Flexibility ofHypothesis
Hypothesis flexible, changes as learning takes
place
No hypothesis Fixed hypothesis
• Testing Strategy Sequential tests No tests One large test• Testing Strategy Sequential tests No tests One large test
• Determining if achange is animprovement
Run charts or Shewhart control charts
No change focus Hypothesis, statistical tests (t-test, F-test, chi
square), p-values
© 2009 R C Lloyd and IHI
improvement p-values
• Confidentiality ofthe data
Data used only by those involved with improvement
Data available for public consumption and review
Research subjects’ identities protected
32
Contextual LeadershipContextual Leadership
• Understand healthcare environment, systems and processes
• Shape and influence locally
(• Take account of and work with existing contexts (both local and national) in leading quality improvement
The key to successful leadership today is influence, not authority.
Kenneth Blanchard
Registry
Health FoundationRA/BRS
BAPN
KQuIPKRUKBAPN
PatientsBKPA/NKF
NHSEngland
Relational LeadershipRelational Leadership
• Skilfully engage with others at all hierarchicalSkilfully engage with others at all hierarchical levels
• Lead or influence change at an individual, i i d id l lteam, organisation and system‐wide level.
‘A leader takes people where they want to go. A great leader takes people where they don’t necessarily want to go, g p p y y g ,but ought to be’ Rosalynn Carter
*
*ROI = return on investment
Getting the leadership habit…Getting the leadership habit…
A habitA habit….
i d b h i f ll d il iAn acquired behaviour pattern followed until it is almost involuntary
A prevailing character or qualityp g q y
Getting the leadership habit…Getting the leadership habit…
• Working together to implement change• Working together to implement change• Development of engagement and relationship skills
• Help run a department and organise a team• Manage uncertaintyg y• Embed sustainability into projects• Foster cultural and behavioural change• ‘L’ or ‘l’ leaders
Gamble & Vaux , 2014
WigglingWiggling• A client could not see how they could perform as a leader in their
role but felt they were under pressure to do sorole, but felt they were under pressure to do so
• The art of ‘wiggling’ is about incremental improvement, about spotting opportunities however small and being able to enable a fixspotting opportunities however small and being able to enable a fix
• Focus upon a small task or approach that is within your control and therefore it comes with the freedom for you to experimenty p
• It is also about tasks that you can take responsibility for.
Neil Tomalin, 2016
Anna & Alex CT1
“It i i thi H b t h th“It is a curious thing, Harry, but perhaps those who are best suited to power are those who h ht it Th h lik hhave never sought it. Those who, like you, have leadership thrust upon them, and take up the mantle beca se the m st and find to their o nmantle because they must, and find to their own surprise that they wear it well”
Albus Dumbledore
“Leadership…. It is to be done….”Leadership…. It is to be done…. Jane Dacre
"The aggregation of marginal gains."
‘You hear about projects and they
sound really huge but this has opened mythis has opened my eyes to how you can do little things and do little things andmake small changes that make a big
diff ’difference’
GOAL PRIMARY SECONDARY DRIVERS
Indication
GOAL PRIMARYDRIVERS
SECONDARY DRIVERS
Reduce urinary
Urinary catheter Education
urinary catheter related Diagnosis of
Diagnostic criteria
Evidence base
UTI in AMU by
50% within
UTIAntibiotic policy
50% within 6 months
Management of urinary catheter
Forgotten catheter
C thCare pathway
Indication
GOAL PRIMARYDRIVERS
SECONDARY DRIVERS
Catheter care bundle 20 care
Urinary catheter Education
bundle 2 care
Diagnostic AppReduce urinary catheter
Diagnostic criteria
Evidence base
Diagnostic App
related UTI in AMU by 50% within 6 months
Diagnosis UTI
Antibiotic policy
months
Management of urinary catheter
Forgotten catheterEPR Alert
yCare pathway
Getting the leadership habit….
‐ Change not liked to start withChange not liked to start with‐ Stakeholder involvementI fl i‐ Influencing
‐ Working beyond usual circleg y‐ Working as a teamBuilding self resilience‐ Building self‐resilience
‐ Understanding systems‐ Sustainability
30 degrees prevents the wheeze
HAP on 8 wardsBed heads raised to 30
1012141618
nts
with
HA
P
degrees at week 9 (17Dec) Oral hygiene measures Victoria Ward week 25 (8Apr) Oral hygiene
measures across 8 wards week 29
Trust w ide roll out w eek 43 (12 Aug)
2468
10
umbe
r of p
atie
n
01 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Week
N
Total on 8 wards Mean
Getting the leadership habit….g p
Improve Patient Experiencep p
“I was so distressed not onlyI was so distressed not only by being so ill in hospital but having to take 6 weeks off work afterwards to get
better”
“I thought I was going to die. I never imaginedI could get more unwell after coming into
hospital”
Two patients limp into two different medical clinics with the same complaint. Both have trouble walking and appear to require a hip replacement The firstBoth have trouble walking and appear to require a hip replacement. The first patient is examined within the hour, is x‐rayed the same day and has a time booked for surgery the following week.
The second sees his family doctor after waiting a week for an appointment, then waits eighteen weeks to see a specialist, then gets an X‐ray, which isn't reviewed for another month and finally has his surgery scheduled for a year from then. y g y y
Why the different treatment for the two patients?
h f ld h d i S i Ci iThe first is a Golden Retriever. The second is a Senior Citizen.
‘The defect rate’
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635‐2645 (June 26, 2003)
– 439 indicators of clinical quality of care– 30 acute and chronic conditions, plus prevention– Medical records for 6712 patients– Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%)
Conclusion: The “Defect Rate” in the technical quality of American health care is
45%
Takes an average of 17 years for research findings to be adopted into clinical practice
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65‐70
Translational Research
Quality Improvement is a T3 enterprise
Westfall, J. M., J. Mold, et al. (2007). "Practice‐Based Research‐‐"Blue Highways" on the NIH Roadmap.“ JAMA 297(4): 403‐406.
Khoury, M. J., M. Gwinn, et al. (2007). "The continuum of translation research in genomic medicine: how can we accelerate the appropriate integration of human genome discoveries into health care and disease prevention?" Genet Med 9(10): 665‐74
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trialssystematic review of randomised controlled trials
Gordon C S Smith, Jill P Pell. BMJ 2003;327;1459‐1461
Aim: To determine whether parachutes are effective in preventing major trauma related topreventing major trauma related to gravitational challenge.
Design: Systematic review of randomised controlled trials
Results: Our search strategy did not find any randomised controlled trialsfind any randomised controlled trials of the parachute.
Conclusions
As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by usingsubjected to rigorous evaluation by using randomised controlled trials
Ad t f id b d di i hAdvocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data
We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled crossover trial of the parachutecontrolled, crossover trial of the parachute
Reducing the risk of aspiration pneumonia amongst tube‐fed (NG or PEG) patients through correct bed positioning
Caroline Watson and Oliver CoenQuality Improvement Project
Stroke Unit, 2014
QIP: PDSA Cycle 2
QIP:PDSA Cycle 5
Sticker on
Nurse signs to confirm patient Sticker on
drug chart at >30 degrees
100
60
70
80
90
100
10
20
30
40
50 Bed position >30 degrees
Rates of pneumonia
0
10
Baseline PDSA Cycle 1
PDSA Cycle 2
PDSA Cycle 3
PDSA Cycle 4
PDSa cycle 5
Getting the leadership habit….g p
QIP: PDSA Cycle 3
Non‐intervention We left the Stroke Unit for 8 weeks to see if, without our presence
on the ward, the improvement in bed‐positioning would be maintainedmaintained.
We then audited again…
sepsissepsis
Never Events Premier League 2013
Top Five
Provider Organisation Never Event
1. Barts Health NHS Trust 8
2. Leeds Teaching Hospitals NHS Trust 8
3. King's College Hospital NHS Foundation Trust 6
4. Royal Berkshire NHS Foundation Trust 6
5 Newcastle Upon Tyne Hospitals NHS Foundation Trust 5
Ref :NHS England never events reported as occurring between 1/04/2013 & 31/03/2014
Never Events Premier League 2014Never Events Premier League 2014
Top FiveProvider Organisation Never Event
1. Leeds Teaching Hospitals NHS Trust 9
2. Royal Berkshire NHS Foundation Trust 8
3. Barts Health NHS Trust 8
4. King's College Hospital NHS Foundation Trust 7
5 Newcastle Upon Tyne Hospitals NHS Foundation Trust 5
Ref :NHS England never events reported as occurring between 1/04/2013 & 30/06/2014
Events 2013‐2014
Never Event Vision & Aims:Never Event Vision & Aims:1. Zero tolerance to never events2. To improve attitudes limiting
safety behaviour and practice3 C lt f ti f d3. Culture of reporting of adverse
events 4. Reduce waste (cost of4. Reduce waste (cost of
complications, cost to patients, cost to staff)
Peri Operative DriversPeri Operative Drivers
Domain 1 Safety Culture
Challenges and Lessons learntChallenges and Lessons learnt
1 i 18 th1 in 18 months
HSMRHSMR
• HSMRHSMR
Our approach
• December 2014• T+F Group – 4 nations• Recommendations that would• Recommendations that would
provide a robust structured framework for embedding improvement methodology asimprovement methodology as a core competence in all ddoctors
Education, learning & d l tdevelopment
‘No country has produced so many excellent analyses of the present defects of medical education as has Britain, and no country has done less to implement them’
George Pickering 1956
Curriculum
Knowledge Skills Values & Behaviours
Can compare and contrast quality assurance and quality improvement, and describe the
relationship of audit and qualityCurriculumUndergraduate
relationship of audit and quality improvement to clinical governance
Understands the principles of, and differences between, quality improvement, audit and research. Can describe PDSA
cycles, human factors and reporting error
Has actively contributed to a quality improvement project (this does not necessarily need to be in a clinical setting)
Recognises the importance of monitoring and
maintaining health and safety in the clinical settingSLEs
cycles, human factors and reporting error
FoundationHas taken part in systems of quality assurance and quality improvement, in the clinical environment, and actively contributes to a clinical quality improvement project
Recognises the need for continuous improvement in the quality of care, and for audit to promote standard
setting and quality Assessment? assurance
Core / Basic
Describes tools available for planning quality improvement interventions
Explains process mapping, stakeholder
Designs, implements, completes and evaluates a simple quality improvement project using improvement methodology as part of a multi‐disciplinary team
Supports improvement projects to address issues around Demonstrates the values d ti l t
Assessment?
Core / Basic Training
p p pp g,analysis, goal and aim setting, implementing
change and sustaining improvement
Understands and describes statistical methods of assessing variation
pp p p jthe quality of care undertaken by other trainees and
within the multi‐disciplinary team
Demonstrates how critical reflection on the planning, implementation, measurement and response to data in a QI project have influenced planning for future projects
and actively supports quality improvement in the
clinical environmentExamsp j p g p j
Higher Training
Compares and contrasts improvement tools and methodologies
Compares and contrasts the principles of
Proactively identifies opportunities for quality improvement and leads multi‐disciplinary QI project
teams with minimal supervision
Supervises a QI project involving junior trainees and other members of the multi disciplinary team using
Demonstrates advocacy for clinical quality
Appraisal Revalidationg g
measurement for improvement, judgement and research. Describes types of measures,
and methods of assessing variation
other members of the multi‐disciplinary team using improvement methodology involving junior trainees
Leads and facilitates team‐based reflective evaluation of a project
improvement
Education, learning & d l t
• Quality improvement as an integral part of all
development
Quality improvement as an integral part of all clinical encounters
• The workplace is the site and source of the j i f l i i imajority of learning opportunities
• Inter‐professional working and learning
Resources
Mapping examples of quality improvement in practice
Strategic & isupporting
infrastructure
M lti l l l
PhysicalPhysical
Multiple levels‐ National bodies‐ Colleges
PeopleP li
‐ Colleges‐ LETB/deanery‐ Trusts/Health Policy/
Boards‐ Medical schools
Training & education
Leadership & culture
Buildingcapability Communications
The key recommendations
• A progressive curriculum in quality• A progressive curriculum in quality improvement activity should underpin all training stagestraining stages
• Quality improvement should be integral to all clinical and non‐clinical job descriptions and appraisal
The key recommendations
• Patient involvement should be advocated andPatient involvement should be advocated and included at every level
• All trainees, and their trainers and multi‐f i l i h hi h h kprofessional teams with which they work,
should have access to quality improvement i itraining
The key recommendations
• Quality improvement activity supported at allQuality improvement activity supported at all levels
• Executives and non‐executives should role‐d l b i li imodel best practice quality improvement
approaches and create an open culture with h f l i hi dthe focus on learning, ownership and accountability
The key recommendations
A it f lit i t ti it• A repository of quality improvement activity should be established to empower learning d h iand sharing
• A stakeholder group should be established under the auspices of a national body such as the Academy of Medical Royal Colleges
What next?What next?
Quality Improvement – training for better outcomes
Report h
Into action…… March 2016
Frameworkm+
Frameworkogram+
3 4Goal is to move to Quadrant 4
ing Pro
education 3 4 Q
Different paths
Train
PS/Q
I
1 2to get there depending on where you start
Clinical Environment+
‐where you start
Intensity of PS/QI activity +‐Brian Wong, 2016. ICRE
‘This is impossible’ said AliceThis is impossible said Alice
‘Only if you believe it is’ said The Mad Hatter
Getting the leadership habit….Getting the leadership habit….
• Know yourselfKnow yourself• Learn by doing• Mind set & behaviours• Mind set & behaviours• Role modellingF ll hi• Followship
• Enabling environment• Getting the improvement habit…. Get the leadership habit
“We should start with the patient. It is important that quality improvement starts with what is important and not with what is easy to address”
Patricia Peattie, Chair Academy Patient Lay Group
@MyLifeScribble
[email protected] @VauxEmma
DiscussionDiscussion
• Leadership as a habit for all or an elite sport?Leadership as a habit for all or an elite sport?• Learning by doing or time out?
h d i li i l di id• How to cross the education‐clinical divide• Service versus training debate• QI as a way to get the habit• 2x2 table2x2 table