Getting the leadership habit –Getting the leadership habit training 21st century physicians

@VauxEmmaEmma.vaux@royalberkshire.nhs.uky

@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

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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

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atie

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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

Emma.vaux@royalberkshire.nhs.uk @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