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VIEWPOINT
In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today Parashar Pravin Ramanuj,1 Howard Ryland,2 Edward W Mitchell,3 Nassim Parvizi,4 Krishna Chinthapalli5
1
South London and Maudsley NHS Foundation Trust, Adamson Centre, St Thomas’ Hospital, London, UK 2 Department of Forensic Psychiatry, Oxleas NHS Foundation Trust, Memorial Hospital, London, UK 3 NHS England, London, UK 4 Department of Clinical Radiology, Oxford University Hospitals NHS Trust, Oxford, UK 5 Department of Neurology, Royal Surrey County Hospital, Guildford, UK Correspondence to Dr Parashar Pravin Ramanuj, Lambeth Integrated Psychological Therapies Team, South London and Maudsley NHS Foundation Trust, Adamson Centre, South Block, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK; [email protected] Received 24 September 2013 Revised 11 March 2014 Accepted 27 March 2014 Published Online First 15 April 2014
To cite: Ramanuj PP, Ryland H, Mitchell EW, et al. BMJ Qual Saf 2014;23: 624–628.
624
ABSTRACT There have been repeated calls from all quarters of healthcare for more clinicians to be leaders. The risks of not accepting this responsibility have been demonstrated by harrowing reports into failed care in England. Ambiguity persists over what clinical leadership encompasses, how it can be developed and how to inspire clinicians to practise it. A supportive organisational culture, dedicated resources and national support are needed to foster leadership skills among trainee clinicians. Here we discuss a possible blueprint based on the recent reviews of English NHS Trusts with high mortality rates for future initiatives in empowering medical and nursing trainees to learn from leaders and practise leadership skills.
INTRODUCTION Repeated inquiries and policies in England, such as the recent Francis Inquiries into the Mid Staffordshire NHS Foundation Trust, have called for improved clinical leadership at all levels of the healthcare system,1–3 echoing concerns worldwide about clinicians’ preparedness to lead.4 The importance of progressive management practices such as employee engagement, team working and job enrichment was shown to be independently associated with significant reductions in hospital mortality over a decade ago.5 These findings were paralleled in 2011 by the NHS Institute for Innovation and Improvement, which found that top performing healthcare organisations consistently reported greater clinical engagement than poor performers.6 The Institute at the time stressed that engagement should be about “a process of strengthened contribution from all, rather than a potentially isolated few”.6 However,
these aspirations have not translated into widespread change, partly because it is not yet clear how they can be consistently realised.7 In this report, we describe a new process that offers a promising blueprint for engaging trainee clinicians in leadership roles by highlighting the value of their active involvement in peer-led quality assurance mechanisms. This article focuses primarily on the role of medical and nursing trainees as the junior clinicians directly involved in the process we describe, although similar barriers to leadership apply to all trainee healthcare professionals. A SPOTLIGHT ON LEADERSHIP IN TRAINING A growing literature recognises the potential for trainee clinicians to contribute to service improvement. For example, junior doctors are thought to carry out 80% of ward-based activity and make decisions that directly impact patient care and resource allocation early in the patient journey.8 In addition, trainee clinicians regularly engage in leadership activities. These include managing relationships with other healthcare professionals, conflict resolution and overseeing the training and development of others.9 10 Senior medical trainees are often expected to lead clinical teams.10 Yet several surveys in the USA and across Europe have found that junior doctors rate their ability to inspire others, aid improvement or challenge the norm to be moderate at best.11 12 Research suggests that almost all trainee doctors have ideas for improvement, but
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
Downloaded from http://qualitysafety.bmj.com/ on March 13, 2015 - Published by group.bmj.com
Viewpoint only 10% are able to implement these initiatives.13 Frontline staff frequently report feeling undervalued by their organisations and being disempowered by their supervisors when attempting to improve patient care.10 13 14 Junior team members are often prevented from expressing their ideas for improvement or identifying errors by a belief that their knowledge is inferior, by the hierarchical nature of medical teams or because they do not know how to initiate these discussions.15 Several facilitators and barriers to quality improvement and leadership development have been recognised (table 1).14 16 17 Here we explore how the new inspection process in England gives nursing and medical trainees access to a unique leadership development opportunity that provides a model for facilitating leadership development and overcoming some of these barriers. THE KEOGH REVIEW PROCESS Following the damning verdict of the two Francis reports, Professor Sir Bruce Keogh (Medical Director, NHS England) was asked by the Prime Minister and Secretary of State for Health to investigate the quality of care provided by 14 NHS Trusts (healthcare provider organisations) in England with persistently high mortality rates.18 Strongly influenced by recommendations made in the Francis Report that peer-led inspection be the ‘central means of monitoring’,2 a radical new review process was devised (box 1). This began with the synthesis of information from a wide range of sources about the quality of care provided by each Trust. Next, unplanned and planned site visits were undertaken to carry out observations, conduct Table 1 Facilitators and barriers to clinical leadership (adapted from Bagnall14) and quality improvement (adapted from Runnacles et al16) for medical trainees
Facilitators
Clinical leadership development
Quality improvement training
▸ Commitment to leadership development by seniors ▸ Mentorship and coaching ▸ Visionary role models ▸ Time out from clinical practice ▸ Cross-specialty working ▸ Integration with quality improvement ▸ Lack of interest and insight ▸ Diminished value placed on leadership ▸ Constraints of frequent rotations ▸ Lack of time
▸ ▸ ▸ ▸ ▸
Senior executive support Mentorship Engaging managers Accessible expert advice Flexibility around clinical commitments ▸ Achievable projects integral to clinical work
▸ Organisational culture unreceptive to change ▸ Poor engagement of clinical teams ▸ Lack of mentoring ▸ Lack of time due to clinical commitments The factors important for clinical leadership are derived from a semistructured interview conducted with trainee doctors that had completed high-profile leadership development programmes in the UK and abroad. The factors important for quality improvement training are from the experiences of senior staff in a world-leading English hospital. Note the clear consistencies between the factors. Barriers
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
Box 1 Structure of the Keogh review process. Induction A. Training provided for all members of the review team on understanding the purpose of the review, understanding the various hospital performance indicators and facilitation of interviews and focus groups. Stage 1–Information gathering and analysis A. Information gathering of relevant Trust performance indicators by support teams including demographics, staff surveys, patient surveys, audit data, critical incidents and mortality ratios. B. Pre-site panel briefing teleconference call for all team members to talk about the data packs and agree on the key lines of enquiry (KLOEs) for the review. Stage 2–Rapid responsive review A. Announced visit by whole review team over 2–3 days. B. Patient/public engagement session advertised locally beforehand and run independently of the Trust as an open forum for concerns. C. Unannounced visit by part of the review team usually out-of-hours to investigate one or more KLOEs or specific concerns raised in other parts of the visit. Stage 3–Risk summit and action plan A. Risk summit conference ( public and then behind closed doors) between all Trust stakeholders including primary care, national professional bodies and patient groups to discuss the findings. B. Individual action plan and report drafted primarily by the chair of the review team but using examples, feedback and comments sourced from the whole team. C. Overall report by Prof Sir Bruce Keogh acting as a synthesis of the individual reports and action plans. D. Feedback session to NHS England to identify what worked well and areas for improvement in future visits. focus groups, and interview staff, patients and local community representatives. The reviews concluded with a meeting called a ‘Risk Summit’ in which a plan of action to expedite improvements was agreed with each Trust. This new methodology hoped to prioritise clinical effectiveness, patient experience and safety, and avoid unnecessary blame. The extensive previsit planning and use of focus groups was to allow an approach that was sensitive to local contexts and enable recommendations to be tailored to each Trust. Review data were made freely available online at all stages to aid transparency. Significantly, medical and nursing trainees were for the first time intimately involved in a highprofile review process. Those who participated received training on health policy and care quality, and were closely supported by senior panel members.19 In his summative report of the reviews, Sir Bruce outlined eight ambitions for improvement.18 One of these is devoted to the value of trainee doctors in 625
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Viewpoint driving change. Sir Bruce wrote that “junior doctors are likely to be the best champions for patients and their energy must be tapped not sapped”.18 His ambition was that the NHS would view them as “not just… clinical leaders of tomorrow, but clinical leaders of today”. SETTING THE VISION: MAKING USE OF THE PROCESS The Keogh review process could be viewed as a 3-day workshop for trainee clinicians, comprising didactic, small-group and experiential training in aspects of healthcare management. This combination has been shown to most effectively enable trainee clinicians to bring about improvements in patient safety and quality of care.20 Much of the process, including its strong collaboration with medical and nursing trainees, has been adopted by the Care Quality Commission (CQC), the independent regulator of healthcare services in England. As with the Keogh review process, trainee doctors have been prominently involved in designing and implementing the new system for the CQC and are currently involved in improving it, for example, by developing more comprehensive training on healthcare regulation and care quality specifically designed for junior panel members (Personal Communication, Dr Bethan Graf, CQC, January 2014). Arguably, the process now represents a pathway for frontline staff to identify and disseminate good practice between healthcare providers. The endorsement of trainee clinicians by senior healthcare leaders in England confers a high degree of authority to both the process and the participants. Similar to other leadership development schemes, the process could significantly improve the development of personal skills and attributes,13 as well as the effectiveness of leadership skills at organisational, community and specialty levels.21 In turn, trainee doctors and nurses could act as strong advocates for the role of frontline staff in quality improvement, both to other panel members and in the organisations inspected. The majority of junior clinicians are not expected to take part in healthcare inspections. However, the benefits of participation could be shared with those who are unable or do not wish to take part in the process if participants act as catalysts for wider service improvement. A powerful mechanism by which this could be achieved is if both senior and junior participants help others to change and create a climate in which ideas can be shared and implemented. This parallels the classical notion of leadership in which a vision is articulated, support is garnered for the vision and others are then empowered to develop a vision of their own.22 Such an endeavour would require a focus on collaboration, empowerment and achieving feasible change that aligns with organisational goals— what Dixon-Woods et al17 have called a ‘quieter’ leadership.
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Collaboration
As healthcare delivery has become more complex, the team rather than individual clinical proficiency is seen as the prime determinant of clinical outcome.23 Quality improvement and leadership development should thus occur at the level of the team. While the frequent rotation of trainee doctors may be a means of disseminating good practice, it can also limit the time that junior doctors need to enact effective quality improvement.14 24 Nurses and other clinical professionals offer greater continuity within a service, emphasising the need for close collaboration between healthcare professionals. Despite this, trainee doctors’ attitudes to multiprofessional training remain lukewarm at best;25 26 and the majority of formal management and leadership programmes are rarely multidisciplinary.10 16 27 28 While each healthcare community has unique development needs that warrant individual consideration, frontline professionals often face similar challenges in delivering good patient care,10 and a wholly uniprofessional training experience risks further fragmenting service delivery objectives.29 A benefit of the new monitoring process is that it allows nurses and trainee doctors to develop leadership together, in a manner similar to their clinical partnership on wards and in communities. Further, the process provides a forum in which mutual understanding and respect between clinicians and nonclinical managers can be fostered early in careers so that the temptation to ascribe problems to a single professional group can be challenged.30 In a recent survey, almost 40% of medical trainees said that they had never worked with a manager; yet those who had felt more valued by their organisations.13 The new process, with its emphasis on monitoring and regulation, could highlight the fallacy of partisan thinking and emphasise the need to address problems in a collaborative manner. Similar ‘buddying’ initiatives have been shown to produce beneficial effects within clinician–manager relationships.31
Encouragement and empowerment
A supportive organisational culture has been recognised as the most important facilitator for quality improvement and adoption of leadership roles; particularly for healthcare professionals who may find it difficult to translate a desire to help into effective action.17 Attempts to secure improvements in an environment lacking a culture of encouragement or senior buy-in can result in the dissipation of enthusiasm and make leadership development more difficult to initiate and sustain.13 14 16 As an externally mandated forum, the new process could help circumvent some of these problems by allowing junior clinicians access to an environment that is sensitive to their leadership and training needs. This is particularly
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
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Viewpoint important for those trainee clinicians who may feel stifled by their working environments. A more complex problem than encouragement is the one of empowerment. A hostile organisational culture can prevent the identification of failings.14 15 In its most recent training survey, the General Medical Council (GMC) found that more than a tenth of the 54 000 trainee doctors questioned admitted to not raising concerns about patient safety.32 Research suggests that the most important factor to prevent speaking out is the receptiveness of seniors.15 Fear of punishment and the withholding of promotion or employment opportunities are other factors.15 Worryingly, a third of the doctors in the GMC survey had experienced or witnessed bullying.32 These are real and complex problems that are unlikely to be solved by a single mechanism. At a fundamental level, they require the frank endorsement by senior professionals of the value of frontline staff and the recognition of the importance of speaking up by trainee clinicians. The new review process may address some of these concerns through the use of focus groups and by flattening the hierarchy between panel members. Peer-led focus groups could be powerful enablers for junior staff to raise concerns without fear of recrimination. Collaborating with senior clinicians on an equal level as panel members and being given leave to question Trust Boards promotes a culture shift. In time this could result in frontline staff speaking out without the need for an explicit invitation. NEXT STEPS The new review process offers unique opportunities for trainee clinicians to develop leadership skills. We have identified some of the potential benefits to participants and the wider healthcare system; however, their sustainability rests on several key factors. Of vital importance is the continued need to place trainee clinicians at the heart of the process and treat them as professionals in their own right with valuable insight into the delivery of care. As the process is rolled out across the national landscape, risks such as variation in the quality of training given for the inspection process, clinicians scrutinising aspects of a Trust in which they have little knowledge (eg, finances) and junior panel members being sidelined by those of greater seniority will need to be addressed. Similarly questions on how the mechanism should be developed will need to be tackled in time: for example, how does one quantify the outcomes achieved by participation in the process? At what stage of their career should trainee clinicians be encouraged to join review panels? And if demand outstrips need, should the process become competitive? As it currently stands, the opportunity the process allows clinicians is unique. Although this has advantages over other leadership development opportunities, the scheme remains relatively untested. Evaluation of Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
potential beneficial outcomes such as service improvements that participants contribute to or leadership positions that they take after participation, could both shape the process as it develops, as well as highlight the benefits of centrally involving junior clinicians in the process.31 Long-term evaluation of the scheme’s impact on participants could be aided by establishing peer-support networks. These could help share and enhance learning after taking part in an inspection process as well as identify challenges that the participants faced and ongoing concerns. Similarly, we would welcome the introduction of post-participation mentorship schemes to provide sustained benefit for those involved.7 Mentorship as a means of cultivating and nurturing leadership has been repeatedly recognised, and one of the strengths of the scheme is the access it provides trainee clinicians to exemplary professionals on whom to model one’s own leadership style. CONCLUSIONS The process described in this report is not designed to replace or replicate comprehensive leadership development programmes; yet it may play a significant role in helping to redress poor care, not just by identifying and remedying failings through the review process but by fostering a new generation of leaders who see quality improvement as one of their primary roles. Whether such benefits can be sustained relies upon clinical leadership and management training on a wider scale and a joined-up approach that views service improvement as a multidisciplinary endeavour. Acknowledgements We would like to thank Professor Sir Bruce Keogh (Medical Director, NHS England), Mr Peter Lees (Medical Director, FMLM) and Dr Ashley McKimm (Head of BMJ Quality) for their advice in the preparation of this manuscript. Collaborators National Medical Director’s Fellows 2012–2013: Na’eem Ahmed, Marisa Casanova Dias, Bethan Graf, Mujtaba Husain, Mahesh Kudari, Esther Kwong, Veline L’Esperance, Lola Loewenthal, Saheel Mukhtar, Georgina Russell, Nina Wilson. Contributors This article is based on the reflections of PPR who has an academic interest in healthcare policy and leadership within the health sector. He has had overall oversight of the manuscript from conception to completion. All authors have contributed significantly to revised versions of the manuscript and expanded on topics and themes discussed in the article. Competing interests All authors were funded to complete a secondment on the National Medical Director’s Fellowship (2012–2013) under the overall supervision of Professor Sir Bruce Keogh. KC, NP and EWM were involved in the Keogh Mortality Rapid Response Reviews. EWM is currently employed by NHS England and has contributed to policy papers in his role here. The views expressed in this publication are those of the authors and not necessarily those of NHS England. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 The Mid Staffordshire NHS Foundation Trust Inquiry, 2010. Independent Inquiry into care provided by Mid Staffordshire
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NHS Foundation Trust January 2005—March 2009. [Online]. http://www.midstaffsinquiry.com/ (accessed Sept 2013). Francis R. The Mid Staffordshire NHS Foundation Trust public inquiry. http://www.midstaffspublicinquiry.com/report (accessed Aug 2013). Kennedy I. The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995: learning from Bristol. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov. uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4005620 (accessed Aug 2013). Stoller JK. Recommendations and remaining questions for health care leadership training programs. Acad Med 2013;88:12–15. West MA, Borrill C, Dawson J, et al. The link between the management of employees and patient mortality in acute hospitals. Int J Human Res Manag 2002;13:1299–310. Atkinson S, Spurgeon P, Clark J, et al. Engaging doctors: what can we learn from trusts with high levels of medical engagement? London: Academy of Medical Royal Colleges and NHS Institute for Innovation and Improvement, 2011. Baker GR. The challenges of making care safer: leadership and system transformation. Healthc Q 2012;15:8–11. Tooke PSJ. Aspiring to excellence: independent inquiry into Modernising medical careers. London: MMC Inquiry, 2008. Roueche A, Hewitt J. ‘Wading through treacle’: quality improvement from the frontline. BMJ Qual Saf 2012;21:179–83. Blumenthal DM, Bernard K, Bohnen J, et al. Addressing the leadership gap in medicine: residents’ need for systematic leadership development training. Acad Med 2012;27:513–22. Awad SS, Hayley B, Fagan SP, et al. The impact of a novel leadership training curriculum. Am J Surg 2004;188:481–4. Berkenbosch L, Schoenmaker SG, Ahern S, et al. Medical residents’ perception of their competencies and training need in health care management: an international comparison. BMC Med Ed 2013;13:25. Gilbert A, Hockey P, Vaithianathan R, et al. Perceptions of trainee doctors in the NHS about their training: results of a regional questionnaire. BMJ Qual Saf 2012;21:234–8. Bagnall P. Facilitators and barriers to leadership and quality improvement: the King’s Fund Junior Doctor Project. King’s Fund, 2012. Kobayashi H, Pian-Smith M, Sato M, et al. A cross-cultural survey of residents’ perceived barriers in questioning/ challenging authority. Qual Saf Health Care 2006;15:277–83. Runnacles J, Moult B, Lachman P. Developing future clinical leaders for quality improvement: experience from a London teaching hospital. BMJ Qual Saf 2013;22:956–63. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation’s programme evaluations and relevant literature. BMJ Qual Saf 2012;21:876–84.
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18 Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. London: NHS Choices. http://www.nhs.uk/NHSEngland/ bruce-keogh-review/Documents/outcomes/ keogh-review-final-report.pdf (accessed Jul 2013). 19 Parvizi N. On being a trainee doctor on the Keogh Review. BMJ Blogs 2013. http://blogs.bmj.com/bmj/2013/07/29/ nassim-parvizi-on-being-a-trainee-doctor-on-the-keogh-review/ (accessed Jul 2013). 20 Wong BM, Hollenberg E, Etchells E, et al. Integrating patient safety and quality improvement with postgraduate medical education. Members of the FMEC PG consortium, 2011. http://aomrc.org.uk/projects/enhancing-engagement-in-medicalleadership.html (accessed Nov 2013). 21 Woltring C, Constantine W, Schwarte L. Does leadership training make a difference? The CDC/UC Public Health Leadership Institute: 1991–1999. J Public Health Manag Pract 2003;9:103–22. 22 Goleman D. What makes a leader? Harv Bus Rev 1998;76:93–102. 23 Bohmer R. The instrumental value of medical leadership: engaging doctors in improving services. London: The King’s Fund, 2012. 24 Bethune R, Roueché A, Hilman T. Is quality of care improving? Improvement efforts need to be targeted at trainee doctors. BMJ 2011;342:d1323. 25 Gallen D, Lynch M, Buckle G. Addressing leadership and management competencies in Foundation Year 2. Clin Managem 2007;15:87–93. 26 Health Foundation. Quality improvement training for healthcare professionals. London: Health Foundation, 2012. http://www.health.org.uk/publications/quality-improvementtraining-for-healthcare-professionals/ (accessed Nov 2013). 27 Glenn R, Morrow E, Maben J, et al. The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: the Productive Ward in England. J Clin Nurs 2011;20:1196–207. 28 Ackerly DC, Sangvai DG, Udayakumar K, et al. Training the next generation of physician-executives: an innovative residency pathway in management and leadership. Acad Med 2011;86:575–9. 29 Nicol ED. Improving clinical leadership and management in the NHS. J Healthc Leadersh 2012;4:59–69. 30 Davies HTO, Hodges C-L, Rundall TG. Views of doctors and managers on the doctor-manager relationship in the NHS. BMJ 2003;326:626. 31 Kadir S, Nazir T, Ahmed-Little Y. Meet the management: a local initiative. Br J Healthcare Managem 2010;16:533–5. 32 General Medical Council. National Training Survey Report. http://www.gmc-uk.org/National_training_survey_key_findings_ report_2013.pdf_52299037.pdf (accessed Dec 2013).
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
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In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today Parashar Pravin Ramanuj, Howard Ryland, Edward W Mitchell, Nassim Parvizi and Krishna Chinthapalli BMJ Qual Saf 2014 23: 624-628 originally published online April 15, 2014
doi: 10.1136/bmjqs-2013-002534 Updated information and services can be found at: http://qualitysafety.bmj.com/content/23/8/624
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VIEWPOINT
In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today Parashar Pravin Ramanuj,1 Howard Ryland,2 Edward W Mitchell,3 Nassim Parvizi,4 Krishna Chinthapalli5
1
South London and Maudsley NHS Foundation Trust, Adamson Centre, St Thomas’ Hospital, London, UK 2 Department of Forensic Psychiatry, Oxleas NHS Foundation Trust, Memorial Hospital, London, UK 3 NHS England, London, UK 4 Department of Clinical Radiology, Oxford University Hospitals NHS Trust, Oxford, UK 5 Department of Neurology, Royal Surrey County Hospital, Guildford, UK Correspondence to Dr Parashar Pravin Ramanuj, Lambeth Integrated Psychological Therapies Team, South London and Maudsley NHS Foundation Trust, Adamson Centre, South Block, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK; [email protected] Received 24 September 2013 Revised 11 March 2014 Accepted 27 March 2014 Published Online First 15 April 2014
To cite: Ramanuj PP, Ryland H, Mitchell EW, et al. BMJ Qual Saf 2014;23: 624–628.
624
ABSTRACT There have been repeated calls from all quarters of healthcare for more clinicians to be leaders. The risks of not accepting this responsibility have been demonstrated by harrowing reports into failed care in England. Ambiguity persists over what clinical leadership encompasses, how it can be developed and how to inspire clinicians to practise it. A supportive organisational culture, dedicated resources and national support are needed to foster leadership skills among trainee clinicians. Here we discuss a possible blueprint based on the recent reviews of English NHS Trusts with high mortality rates for future initiatives in empowering medical and nursing trainees to learn from leaders and practise leadership skills.
INTRODUCTION Repeated inquiries and policies in England, such as the recent Francis Inquiries into the Mid Staffordshire NHS Foundation Trust, have called for improved clinical leadership at all levels of the healthcare system,1–3 echoing concerns worldwide about clinicians’ preparedness to lead.4 The importance of progressive management practices such as employee engagement, team working and job enrichment was shown to be independently associated with significant reductions in hospital mortality over a decade ago.5 These findings were paralleled in 2011 by the NHS Institute for Innovation and Improvement, which found that top performing healthcare organisations consistently reported greater clinical engagement than poor performers.6 The Institute at the time stressed that engagement should be about “a process of strengthened contribution from all, rather than a potentially isolated few”.6 However,
these aspirations have not translated into widespread change, partly because it is not yet clear how they can be consistently realised.7 In this report, we describe a new process that offers a promising blueprint for engaging trainee clinicians in leadership roles by highlighting the value of their active involvement in peer-led quality assurance mechanisms. This article focuses primarily on the role of medical and nursing trainees as the junior clinicians directly involved in the process we describe, although similar barriers to leadership apply to all trainee healthcare professionals. A SPOTLIGHT ON LEADERSHIP IN TRAINING A growing literature recognises the potential for trainee clinicians to contribute to service improvement. For example, junior doctors are thought to carry out 80% of ward-based activity and make decisions that directly impact patient care and resource allocation early in the patient journey.8 In addition, trainee clinicians regularly engage in leadership activities. These include managing relationships with other healthcare professionals, conflict resolution and overseeing the training and development of others.9 10 Senior medical trainees are often expected to lead clinical teams.10 Yet several surveys in the USA and across Europe have found that junior doctors rate their ability to inspire others, aid improvement or challenge the norm to be moderate at best.11 12 Research suggests that almost all trainee doctors have ideas for improvement, but
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
Downloaded from http://qualitysafety.bmj.com/ on March 13, 2015 - Published by group.bmj.com
Viewpoint only 10% are able to implement these initiatives.13 Frontline staff frequently report feeling undervalued by their organisations and being disempowered by their supervisors when attempting to improve patient care.10 13 14 Junior team members are often prevented from expressing their ideas for improvement or identifying errors by a belief that their knowledge is inferior, by the hierarchical nature of medical teams or because they do not know how to initiate these discussions.15 Several facilitators and barriers to quality improvement and leadership development have been recognised (table 1).14 16 17 Here we explore how the new inspection process in England gives nursing and medical trainees access to a unique leadership development opportunity that provides a model for facilitating leadership development and overcoming some of these barriers. THE KEOGH REVIEW PROCESS Following the damning verdict of the two Francis reports, Professor Sir Bruce Keogh (Medical Director, NHS England) was asked by the Prime Minister and Secretary of State for Health to investigate the quality of care provided by 14 NHS Trusts (healthcare provider organisations) in England with persistently high mortality rates.18 Strongly influenced by recommendations made in the Francis Report that peer-led inspection be the ‘central means of monitoring’,2 a radical new review process was devised (box 1). This began with the synthesis of information from a wide range of sources about the quality of care provided by each Trust. Next, unplanned and planned site visits were undertaken to carry out observations, conduct Table 1 Facilitators and barriers to clinical leadership (adapted from Bagnall14) and quality improvement (adapted from Runnacles et al16) for medical trainees
Facilitators
Clinical leadership development
Quality improvement training
▸ Commitment to leadership development by seniors ▸ Mentorship and coaching ▸ Visionary role models ▸ Time out from clinical practice ▸ Cross-specialty working ▸ Integration with quality improvement ▸ Lack of interest and insight ▸ Diminished value placed on leadership ▸ Constraints of frequent rotations ▸ Lack of time
▸ ▸ ▸ ▸ ▸
Senior executive support Mentorship Engaging managers Accessible expert advice Flexibility around clinical commitments ▸ Achievable projects integral to clinical work
▸ Organisational culture unreceptive to change ▸ Poor engagement of clinical teams ▸ Lack of mentoring ▸ Lack of time due to clinical commitments The factors important for clinical leadership are derived from a semistructured interview conducted with trainee doctors that had completed high-profile leadership development programmes in the UK and abroad. The factors important for quality improvement training are from the experiences of senior staff in a world-leading English hospital. Note the clear consistencies between the factors. Barriers
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
Box 1 Structure of the Keogh review process. Induction A. Training provided for all members of the review team on understanding the purpose of the review, understanding the various hospital performance indicators and facilitation of interviews and focus groups. Stage 1–Information gathering and analysis A. Information gathering of relevant Trust performance indicators by support teams including demographics, staff surveys, patient surveys, audit data, critical incidents and mortality ratios. B. Pre-site panel briefing teleconference call for all team members to talk about the data packs and agree on the key lines of enquiry (KLOEs) for the review. Stage 2–Rapid responsive review A. Announced visit by whole review team over 2–3 days. B. Patient/public engagement session advertised locally beforehand and run independently of the Trust as an open forum for concerns. C. Unannounced visit by part of the review team usually out-of-hours to investigate one or more KLOEs or specific concerns raised in other parts of the visit. Stage 3–Risk summit and action plan A. Risk summit conference ( public and then behind closed doors) between all Trust stakeholders including primary care, national professional bodies and patient groups to discuss the findings. B. Individual action plan and report drafted primarily by the chair of the review team but using examples, feedback and comments sourced from the whole team. C. Overall report by Prof Sir Bruce Keogh acting as a synthesis of the individual reports and action plans. D. Feedback session to NHS England to identify what worked well and areas for improvement in future visits. focus groups, and interview staff, patients and local community representatives. The reviews concluded with a meeting called a ‘Risk Summit’ in which a plan of action to expedite improvements was agreed with each Trust. This new methodology hoped to prioritise clinical effectiveness, patient experience and safety, and avoid unnecessary blame. The extensive previsit planning and use of focus groups was to allow an approach that was sensitive to local contexts and enable recommendations to be tailored to each Trust. Review data were made freely available online at all stages to aid transparency. Significantly, medical and nursing trainees were for the first time intimately involved in a highprofile review process. Those who participated received training on health policy and care quality, and were closely supported by senior panel members.19 In his summative report of the reviews, Sir Bruce outlined eight ambitions for improvement.18 One of these is devoted to the value of trainee doctors in 625
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Viewpoint driving change. Sir Bruce wrote that “junior doctors are likely to be the best champions for patients and their energy must be tapped not sapped”.18 His ambition was that the NHS would view them as “not just… clinical leaders of tomorrow, but clinical leaders of today”. SETTING THE VISION: MAKING USE OF THE PROCESS The Keogh review process could be viewed as a 3-day workshop for trainee clinicians, comprising didactic, small-group and experiential training in aspects of healthcare management. This combination has been shown to most effectively enable trainee clinicians to bring about improvements in patient safety and quality of care.20 Much of the process, including its strong collaboration with medical and nursing trainees, has been adopted by the Care Quality Commission (CQC), the independent regulator of healthcare services in England. As with the Keogh review process, trainee doctors have been prominently involved in designing and implementing the new system for the CQC and are currently involved in improving it, for example, by developing more comprehensive training on healthcare regulation and care quality specifically designed for junior panel members (Personal Communication, Dr Bethan Graf, CQC, January 2014). Arguably, the process now represents a pathway for frontline staff to identify and disseminate good practice between healthcare providers. The endorsement of trainee clinicians by senior healthcare leaders in England confers a high degree of authority to both the process and the participants. Similar to other leadership development schemes, the process could significantly improve the development of personal skills and attributes,13 as well as the effectiveness of leadership skills at organisational, community and specialty levels.21 In turn, trainee doctors and nurses could act as strong advocates for the role of frontline staff in quality improvement, both to other panel members and in the organisations inspected. The majority of junior clinicians are not expected to take part in healthcare inspections. However, the benefits of participation could be shared with those who are unable or do not wish to take part in the process if participants act as catalysts for wider service improvement. A powerful mechanism by which this could be achieved is if both senior and junior participants help others to change and create a climate in which ideas can be shared and implemented. This parallels the classical notion of leadership in which a vision is articulated, support is garnered for the vision and others are then empowered to develop a vision of their own.22 Such an endeavour would require a focus on collaboration, empowerment and achieving feasible change that aligns with organisational goals— what Dixon-Woods et al17 have called a ‘quieter’ leadership.
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Collaboration
As healthcare delivery has become more complex, the team rather than individual clinical proficiency is seen as the prime determinant of clinical outcome.23 Quality improvement and leadership development should thus occur at the level of the team. While the frequent rotation of trainee doctors may be a means of disseminating good practice, it can also limit the time that junior doctors need to enact effective quality improvement.14 24 Nurses and other clinical professionals offer greater continuity within a service, emphasising the need for close collaboration between healthcare professionals. Despite this, trainee doctors’ attitudes to multiprofessional training remain lukewarm at best;25 26 and the majority of formal management and leadership programmes are rarely multidisciplinary.10 16 27 28 While each healthcare community has unique development needs that warrant individual consideration, frontline professionals often face similar challenges in delivering good patient care,10 and a wholly uniprofessional training experience risks further fragmenting service delivery objectives.29 A benefit of the new monitoring process is that it allows nurses and trainee doctors to develop leadership together, in a manner similar to their clinical partnership on wards and in communities. Further, the process provides a forum in which mutual understanding and respect between clinicians and nonclinical managers can be fostered early in careers so that the temptation to ascribe problems to a single professional group can be challenged.30 In a recent survey, almost 40% of medical trainees said that they had never worked with a manager; yet those who had felt more valued by their organisations.13 The new process, with its emphasis on monitoring and regulation, could highlight the fallacy of partisan thinking and emphasise the need to address problems in a collaborative manner. Similar ‘buddying’ initiatives have been shown to produce beneficial effects within clinician–manager relationships.31
Encouragement and empowerment
A supportive organisational culture has been recognised as the most important facilitator for quality improvement and adoption of leadership roles; particularly for healthcare professionals who may find it difficult to translate a desire to help into effective action.17 Attempts to secure improvements in an environment lacking a culture of encouragement or senior buy-in can result in the dissipation of enthusiasm and make leadership development more difficult to initiate and sustain.13 14 16 As an externally mandated forum, the new process could help circumvent some of these problems by allowing junior clinicians access to an environment that is sensitive to their leadership and training needs. This is particularly
Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
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Viewpoint important for those trainee clinicians who may feel stifled by their working environments. A more complex problem than encouragement is the one of empowerment. A hostile organisational culture can prevent the identification of failings.14 15 In its most recent training survey, the General Medical Council (GMC) found that more than a tenth of the 54 000 trainee doctors questioned admitted to not raising concerns about patient safety.32 Research suggests that the most important factor to prevent speaking out is the receptiveness of seniors.15 Fear of punishment and the withholding of promotion or employment opportunities are other factors.15 Worryingly, a third of the doctors in the GMC survey had experienced or witnessed bullying.32 These are real and complex problems that are unlikely to be solved by a single mechanism. At a fundamental level, they require the frank endorsement by senior professionals of the value of frontline staff and the recognition of the importance of speaking up by trainee clinicians. The new review process may address some of these concerns through the use of focus groups and by flattening the hierarchy between panel members. Peer-led focus groups could be powerful enablers for junior staff to raise concerns without fear of recrimination. Collaborating with senior clinicians on an equal level as panel members and being given leave to question Trust Boards promotes a culture shift. In time this could result in frontline staff speaking out without the need for an explicit invitation. NEXT STEPS The new review process offers unique opportunities for trainee clinicians to develop leadership skills. We have identified some of the potential benefits to participants and the wider healthcare system; however, their sustainability rests on several key factors. Of vital importance is the continued need to place trainee clinicians at the heart of the process and treat them as professionals in their own right with valuable insight into the delivery of care. As the process is rolled out across the national landscape, risks such as variation in the quality of training given for the inspection process, clinicians scrutinising aspects of a Trust in which they have little knowledge (eg, finances) and junior panel members being sidelined by those of greater seniority will need to be addressed. Similarly questions on how the mechanism should be developed will need to be tackled in time: for example, how does one quantify the outcomes achieved by participation in the process? At what stage of their career should trainee clinicians be encouraged to join review panels? And if demand outstrips need, should the process become competitive? As it currently stands, the opportunity the process allows clinicians is unique. Although this has advantages over other leadership development opportunities, the scheme remains relatively untested. Evaluation of Ramanuj PP, et al. BMJ Qual Saf 2014;23:624–628. doi:10.1136/bmjqs-2013-002534
potential beneficial outcomes such as service improvements that participants contribute to or leadership positions that they take after participation, could both shape the process as it develops, as well as highlight the benefits of centrally involving junior clinicians in the process.31 Long-term evaluation of the scheme’s impact on participants could be aided by establishing peer-support networks. These could help share and enhance learning after taking part in an inspection process as well as identify challenges that the participants faced and ongoing concerns. Similarly, we would welcome the introduction of post-participation mentorship schemes to provide sustained benefit for those involved.7 Mentorship as a means of cultivating and nurturing leadership has been repeatedly recognised, and one of the strengths of the scheme is the access it provides trainee clinicians to exemplary professionals on whom to model one’s own leadership style. CONCLUSIONS The process described in this report is not designed to replace or replicate comprehensive leadership development programmes; yet it may play a significant role in helping to redress poor care, not just by identifying and remedying failings through the review process but by fostering a new generation of leaders who see quality improvement as one of their primary roles. Whether such benefits can be sustained relies upon clinical leadership and management training on a wider scale and a joined-up approach that views service improvement as a multidisciplinary endeavour. Acknowledgements We would like to thank Professor Sir Bruce Keogh (Medical Director, NHS England), Mr Peter Lees (Medical Director, FMLM) and Dr Ashley McKimm (Head of BMJ Quality) for their advice in the preparation of this manuscript. Collaborators National Medical Director’s Fellows 2012–2013: Na’eem Ahmed, Marisa Casanova Dias, Bethan Graf, Mujtaba Husain, Mahesh Kudari, Esther Kwong, Veline L’Esperance, Lola Loewenthal, Saheel Mukhtar, Georgina Russell, Nina Wilson. Contributors This article is based on the reflections of PPR who has an academic interest in healthcare policy and leadership within the health sector. He has had overall oversight of the manuscript from conception to completion. All authors have contributed significantly to revised versions of the manuscript and expanded on topics and themes discussed in the article. Competing interests All authors were funded to complete a secondment on the National Medical Director’s Fellowship (2012–2013) under the overall supervision of Professor Sir Bruce Keogh. KC, NP and EWM were involved in the Keogh Mortality Rapid Response Reviews. EWM is currently employed by NHS England and has contributed to policy papers in his role here. The views expressed in this publication are those of the authors and not necessarily those of NHS England. Provenance and peer review Not commissioned; externally peer reviewed.
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In the spotlight: healthcare inspections as an opportunity for trainee clinicians to be the leaders of today Parashar Pravin Ramanuj, Howard Ryland, Edward W Mitchell, Nassim Parvizi and Krishna Chinthapalli BMJ Qual Saf 2014 23: 624-628 originally published online April 15, 2014
doi: 10.1136/bmjqs-2013-002534 Updated information and services can be found at: http://qualitysafety.bmj.com/content/23/8/624
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