Health Leadership and Management - Essay Example

June 2006 Health leadership and management Introduction Health care is a high risk environment issue. Several elements drawn from the health environs impinge upon the final design of a health care system. A lot many concepts, drawn from the science of management, have to be understood theoretically and applied to health care systems in order to ensure meeting of the final objective of such systems viz.complete patient care and discharge. Any health care system is characterized by the presence of elements which are highly technical & hazardous. These elements generally relate to having adequate and comprehensive procedures and equipment, coping with incomplete and rapidly changing medical knowledge, addressing workforce shortages and ensuring teamwork. The management concepts of leadership and identification and establishment of a risk management process are to be applied for the ultimate design of a health care process. Such processes are more required at the Intensive Care Unit (ICU)/facilities of any hospital as ICU is one of the most critical services of any hospital and the quality of patients response is important in determining the success of the entire hospital itself. In the following paragraphs we examine the application of the leadership concepts and risk management processes to the ICU facilities so as to lead to identification and reporting of incidents that are potentially harmful to patients. ICU-Importance and critical Requirements in Management processes Nearly half all ICU patients suffer from potentially life-threatening adverse event, including infection.Nosocomial infections in ICU are 3-5 times higher than non ICU; 50% of all nosocomial epidemics occur among the 10% of ICU patients; more than 30% of US hospital costs are allocated for ICU care alone. Several evidence based practices have been identified in case of ICUs which help prevent infections. Low evidence based practices are cleaning insertion site, use of heparin,tunneling,routine catheter change, routine Ab prophylaxis, hand washing compliance and use of Sucralfate; medium level evidence based practices are peri-operative normothermia, continuous oscillation,suprapubic catheters, barrier Precautions and Ab restrictions; high evidence based practices include supplemental perioperative oxygen, semi-recumbent position ,selective decontam- GI tract and silver alloy-coated catheters, to quote a few. While these best practices are indicative of the desirable course of actions in ICU situations ;they perhaps indicate more to the risk perceptions and associated risk bearing events within the ICU environment.. Thus best practices are to be documented and diligently implemented and perhaps linked to performance evaluation. However there are noticeable gaps in prescription of these best practices and their actual practices which leads to occurrence of adverse events in ICU care. A careful identification and documentation of deviations which have resulted in adverse incidents is the much needed innovation for ICU management. However it must be remembered as Kaplan says," An appreciation of the power, productive and seductive, of stories of best practice, may provide some "heedfulness" to work in the strategy field(Kaplan,2003). In some evidence seeking research studies, nurses with higher patient load were linked to higher 30-day risk-adjusted mortality. Similarly studies observed a 7% increase risk of dying within 30 days for each additional patient added to nurse load. One study on adverse drug events showed that 78 percent of adverse drug events were due to system failures (Leape et al, 1995).Any design of an ICU health care system would require establishment of a system which would adherence to such practices by ICU staff at all levels with adequate motivation. Some authors have emphasized the need for organizational change in health care, calling it "the key to quality improvement". In discussing how such change can be managed, Davies and Nutley assert that cultural change needs to be wrought alongside structural reorganization and systems reform to bring about "a culture in which excellence can flourish".( Davies and Nutley,2000). Such a system would have the following important inputs: Flat hierarchy Standardization Automation Simplification Teamwork and communication Reduction of reliance on memory In the present day ICU care systems the above important inputs can be achieved through the following structures: (a)ICU Multidisciplinary Team: Successful ICU care requires efforts from a wide range of ICU caregivers and support staff forming a Multidisciplinary Team(Brilli et al,2001).Only Multidisciplinary Teams are able to ensure adequate address of the several complexities of todays ICU and envelop the many disciplines that necessarily pool in their cares to result in an output which is efficient, effective and safe care. (b) Effective and Relevant Team Leadership: A view holds that leaders are people oriented and their main task is to inspire people. Their primary functional output is a change (Veal, 2004) and their capabilities are assessed in terms of controlling the process of this change. They empower people to experience the vision on their own(Barry, Top) Every hospital with an ICU should have a physician-led multidisciplinary team that monitors and leads the evaluation of the performance of the ICU. The multidisciplinary team should be led by an intensivist or other appropriately qualified physician as defined by the regulatory/prescriptive bodies. For hospitals where these physicians are not readily available, the team should be led by a certified, hospital-based physician. In some situations, having a hospitalist may not meet the actual need of a hospital-based physician but may be simply considered an interim measure toward meeting the actual need. (c) Appropriate Team Constitution: Although the composition of multidisciplinary teams will vary based on patient characteristics and local needs, a team could include the following set of staff: An APACHE coordinator. APACHE, Acute Physiology and Chronic Health Evaluation System, is used to evaluate patient severity using statistical methods. Dietician Critical care nurse.Such staff must be share perfect relationship of trust with patients. Peter and Morgan opine that,"trust has long been acknowledged as central to nurse–patient relationships. It, however, has not been fully explored nor-matively. That is, trust must be examined from a perspective that encompasses not only reliability and competence, but also good will within nursing relationships(Peter and Morgan,2001). ICU nurse manager- the ranks of nursing managers have been thinned as part of redesign efforts, and nursing managers have been asked to manage multiple units and staff outside of nursing, resulting in less direct management support and clinical leadership for staff nurses (Sovie and Jawad, 2001).Thus assignment of nursing managers within ICU should be carefully considered to take care of above two aspects. Intensivist or other appropriately qualified physician as defined by the regulatory bodies. For hospitals where these physicians are not available, the team should be led by a certified, hospital-based physician. 30% reduction in mortality in ICUs managed by Board-certified “intensivists” i.e. those certified in subspecialty of critical care medicine, emergency medicine with critical care fellow ship ,certified in Medicine, anesthesiology, pediatrics, or surgery with ICU training or experience. Palliative care representative Occupational therapist Pastoral care representative Pharmacist Patient or family representative Physical therapist Social worker Psychologist Respiratory therapist Other attending physicians including surgeons where applicable. (d) Actual Implementation of Multidisciplinary Teams: The intensivist or the medical director of the ICU when an intensivist is not readily available should lead an ICU effort to include the nurse manager, required administrative executive staff and leadership personnel from each of the disciplines to put on board a plan for establishing and deploying a multidisciplinary team. The plan should address the constituency of the ICU’s multidisciplinary team; establish team roles and responsibilities, and a strategy for obtaining administrative approval for instituting multidisciplinary team-based care in the ICU. (e) Designing a work plan to implement ICU care system and inculcation of a patient safety culture: The plan must commence with identification of all members of the team. The plan should go on to identify the roles and responsibilities of team members. Illustratively the team responsibilities can include-establishing ICU operational procedures(best practices code should form the basis); participating in individual patient management decisions during multidisciplinary patient rounds; evaluating and setting practice standards for the ICUs; establishing a culture of patient safety within the ICU; planning and implementing patient safety improvement activities; measuring/monitoring the effects of safety improvement activities and taking correctives to fill the gaps. Specifically, the aspects that need monitoring include assessing team effectiveness as it relates to the safety, efficiency and effectiveness of ICU care; disease and surgery-specific patient outcomes; and related organizational outcomes. A minimum of one member of the multidisciplinary team should be assigned the task of monitoring the safety reporting literature and to scout for safety improvement opportunities which can be ingrained into existing ICU practices as appropriate. As the very last decision and a vital one at that, the plan should form an explicit a strategy for procuring administrative leadership approval for the multidisciplinary team and the linked responsibilities of its members in ICU. Once the plan is up from the drawing board, ICU leadership needs to obtain approval for the plan from the Hospital management and implement it in a scheduled manner. Goleman posits that the foundation of emotional competency is Self-Awareness, the knowledge of ones own abilities and limitations as well as a solid understanding of factors and situations that evoke emotion in ones self and others. Equipped with this awareness, an individual can better manage his own emotions and behaviors and better understand and relate to other individuals and systems (Goleman, 1998). A study conducted at Johnson& Johnson indicated that the leadership must have strong emotional competence in that there was strong inter-rater agreement among Supervisors, Peers, and Subordinates that the competencies of Self-Confidence, Achievement Orientation, Initiative, Leadership, Influence and Change Catalyst differentiate superior performers (Cavallo & Brienza,2003). The role of the leader in this new business environment is to influence staff to buy into a future vision for the business where constant change and upgrading are the norm(Gannon,2004).By doing this the leadership would have achieved its leadership responsibilities which can be condensed into the under mentioned four processes of Management and Leadership. They are: 1) Creating an Agenda 2) Developing a Team 3) Execution of the Agenda 4) Evaluation of the Outcome (Veal, 2004) The above system can be compared to a management by objective system about which Peter Drucker stated, “Management by Objectives tells a manager what he ought to do. The proper organization of his job enables him to do it. But it is the spirit of the organization that determines whether he will do it. It is the spirit that motivates, that calls upon a man’s reserves of dedication and effort, that decides whether he will give his best or do just enough to get by” (Drucker, 1954). Management by objectives defined by George Odiorne is “…a management process whereby the supervisor and the subordinate, operating under a clear definition of the common goals and priorities of the organization established by top management, jointly identify the individuals major areas of responsibility in terms of the results expected of him or her, and these measures as guides for operating the unit and assessing the contributions of each of its members” (Odiorne et al, 1980). As part of day to day activities in the ICU the components of Safety Culture in ICU requires focused and constant attention and directed efforts to create an environment that is trusting and open; compassionate and caring; has a skilled, coordinated and collaborative team; has excellent communication among the team ;has strong leadership that assures continuous improvement. Specific structures and processes that could be addressed include- team-building activities that improve communication, collaboration, and cohesiveness among ICU care providers; routine use of multi-disciplinary approaches to patient care management(as above) including multidisciplinary rounds, patient care conferences, and care planning; implementation of specific quality of care/patient safety improvement activities (e.g., improve pain management, reduce rates of failed extubations, improve rates of catheter-related infections; and use of state-of-the-art technologies such as telemedicine, electronic documentation and care management support systems. The above systems and processes would go along way in reduction of incidents that are adverse to patients. However it is important that whatever adverse events do take place are identified and reported for analysis of their causes and effects for future remedials. The ultimate goal of every intervention is to improve the health and quality of life of patients or to maintain high standards of quality at lower costs.(Bokhoven, Kok and Weijden,2003). The intended improvement of health, quality of life, and quality of care should therefore be described in quantifiable terms, and standards of good quality of care should have been set. (Woolf 1992, Grimshaw ,Eccles &Russel 1995). Identification and Reporting of Incidents in ICU A good amount of literature on adverse events within healthcare (across the UK, USA and elsewhere) has conclusively demonstrated that health care is a complex and at times high risk activity where occurrence of adverse events is inevitable; indeed, many studies, some as early as the 1960s, showed that patients were frequently injured by the same medical care that was intended to help them (Schimmel, 1964). Literature has recorded that the occurrence of adverse events and medical errors is quite an alarmingly and recurring phenomena in hospitals. In two large studies of hospital admissions, one in New York using 1984 data and another in Colorado and Utah using 1992 data, the proportions of admissions in which there were adverse events (defined as injuries caused by medical management) were 2.9 and 3.7 percent, respectively (Leape et al, 1991; Gawande et al, 1999). The Australian Review of Professional Indemnity Arrangements for Health Care Professionals (Commonwealth Department of Human Services and Health, 1995) also found error to be a serious cause of morbidity and mortality. One observer noted that many medical errors can be attributed to the simple fact that the knowledge base to effectively and safely deliver health care exceeds the storage capacity of the human brain (Millenson, 1997). Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers(Morris,2000). Adverse events can be broadly caused by three kinds of medical errors viz. overuse (the service is unlikely to have net benefit), under use (a potentially beneficial service is withheld), and misuse (a service is inappropriately used) (Chassin, 1998). Identification and recording information on adverse events, and analyzing them appropriately is a direct input in reduction of overall risk to patients, as is creating the right safety culture (as above) within health organizations. It must be supplemented with the recognition that it is infirm systems which create the conditions for, and the inevitability of, error leading to adverse events. All personnel deployed in the providing ICU healthcare should be expected to identify and learn from what are termed ‘significant events’, which might expose or harm or put at risk the safety of patients, staff and others. While the need for robust management systems (as observed above) may vary across the operational scale of the care providing organization, the requirements to identify and learn from patient safety incidents always remain in the backdrop as a necessary requirement. All organizations interested in promoting a proper system of identification and reporting of adverse events should make opportune use of the implementation of clinical governance particularly to fortify their existing procedures for adverse health care events, emphasizing specifically the responsibilities of staff, at all levels, for identifying and reporting events. The organization, on its part, must lay down a culture which does not brazenly bludgeon blames on mere assumptions and fallacies; on the contrary any situation requiring accountability affixation must carefully consider adherence to laid down identification and reporting instructions. In fact brazen affixation has proven counterproductive—it has driven the patient safety problem underground, leading to an implicit "conspiracy of silence" where problems and close calls are not discussed due to fear of reprisal (Koop, 1999). Yet when there is a mistake made in health care with disastrous consequences, the failure of interdisciplinary communication is often to blame. The recently published Kennedy Inquiry into the death of babies undergoing heart surgery at the Bristol Royal Infirmary reminds us all too tragically of the importance of teamwork and the costs of its limited performance and effectiveness(Rafferty,2001). Staff needs to be exposed to the general risk management awareness training as an essential input in this process; local annual clinical governance reports must make an explicit statement about the organizations adverse event reporting policy in ICU, and where possible should make an evidential display of material changes implemented owing to honest reporting and the appreciative and judicious approach taken towards such personnel who have the courage and commitment to report own errors. A data base management system focusing on medical errors and adverse events can be designed for use of ICU personnel. The essential features of this system should include. Definitions of adverse events and near misses/errors must be established for the purposes of logging and reporting them within the adopted data management system (which must itself move towards global computing standards); explicit and detailed guidance for organizations, staff and patients need to be prepared and circulated before pilot ICU sites are activated. A minimum data set with well defined variables must be formalized both for adverse events and near misses. This would enable development of a standardized format for reporting (to begin with paper based and gradually moving entirely to electronic version).Thereafter ICU multidisciplinary team must develop in house expertise in order to ensure comprehensive analysis of causal factors of adverse events-it may be instructive to link this analysis with citation from best practices. The depth of the analysis probing causal factors can be defined to vary according to gravity of adverse events or near misses. It must be ensured that all the complementary information emanating from all major existing adverse event reporting systems (e.g. medical devices, reactions to medicines, complaints from the ICU patients/families, serious accidents reported in the ICU) is also incorporated into the ICU data base so to ensure comprehensive retrieval and analysis. In fact, alongside, safety culture ICU leadership needs to promote an in-house culture of identifying and reporting all adverse events and errors into the data base system by logging in a timely manner. In fact entire concept of clinical governance needs to be extended and applied very specifically to the ICU part of the operations as such application is likely to result in a forthright attitude of ICU staff. The leadership of ICU multidisciplinary team should have the responsibility of smooth design, implementation and running of this very vital data base management system. Such leadership can identify second layer “designated lead” to ensure its proper and extensive use in all adverse situations. Low volume ICU trusts (10 procedures or less per annum) should view their caseload and undertake a risk assessment to decide if the service should continue to provide, for example, an intrathecal chemotherapy service and plan appropriately .Similarly high volume ICU trusts (500 procedures or more per annum) should undertake a risk assessment to include an assessment of capacity to check that the daily workload does not exceed locally agreed safe levels - to ensure the safety of the service being rendered. For example, a patient in an intensive care unit is the recipient of an average of 178 different activities performed per day that rely on the interaction of monitoring, treatment, and support systems (Leape, 1994). Taking the example of intrathecal chemotherapy further; a register can be commenced to serve maintenance of lists of designated personnel who have been trained and authorized to prescribe, dispense, issue, check or administer intrathecal chemotherapy .Staff shifting on employment mobility from one hospital to another would be able to take with them these certification in their training logbook or other training record for future use. New hospitals ICU must devise proper induction programs for the new incoming staff. This induction may be supplemented by appropriate training in the local realities and procedures at the new organization. This training must be appropriate to their roles in the prescribing, dispensing, checking, issuing or administering of intrathecal chemotherapy .Annual reviews of competence are required for all professional staff (including consultants) that remain on the register including written confirmation that they have read all categories of regulatory prescriptions and best practices codes. "At Johns Hopkins Medical Institutions, a Baltimore-based integrated delivery, research and education system, two deaths brought home the problem of medical errors in 2001 and led the organization to rethink the way it cares for patients.......it took an initiative to dissect and reshape its culture. Information technology figured prominently in improving the quality of its care processes. One of the first steps was creating a customizable, online patient safety program that includes a mechanism for clinicians to document medical errors, identify those responsible for addressing a problem, and report progress toward resolution of the problem"(Briggs,2005) One can have data base management system similar to the one quoted above supplanted with local realities and true spirit of perpetuating a total safety culture. Decision support tools are not new; it is the new attributes of explicit computerized decision support tools that deserve identification(Morris,2002).This decision support data system would remove the age old problem in ICU situations described succinctly by Edwards and Elwyn when they say that ,"In reality, data are rarely available to professionals when needed, so the relevant information is often not being used to maximum effect. Even when the information is available, professionals are unclear about how best to discuss the harms and benefits of treatment most effectively with users. There are certainly great risks of misleading users which depend on how the information is presented (Edwards and Elwyn,2001).Such a database management system for an ICU can come in smooth implementation only when the leadership and health care system aligns on the suggested lines.The use of an effective change framework is vital and it has been shown that strategies employed in effective innovation are not simply linear, but are complex, requiring effective leadership as an essential ingredient of achieving sustained change (Balfour & Clarke, 2001). Work Cited Kaplan, S. 2003. The seduction of best practice: Commentary on “Taking Strategy Seriously". Journal of Management Inquiry. 12(4), 410-413. Leape LL, Bates DW, Cullen DJ, et al. 1995.Systems analysis of adverse drug events. JAMA; 274(1):35-43. Davies ,Huw T O & Nutley,Sandra M.2000. Organizational culture and quality of health care. Quality in Health Care.9: 111-119. Brilli RJ, Spevetz A, Branson RD, et al.2001. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med. 29(10):2007-2019. Veal ,Ruffin.2004. Project Management and Leadership:Equal Partners for Project Success. www.asapm.org. Goleman, D. 1998. What Makes A Leader? Harvard Business Review. November-December. Cavallo, K. & Brienza, D. 2003. Emotional competence and leadership excellence at Johnson & Johnson: The emotional intelligence and leadership study, The Consortium for Research on Emotional Intelligence in Organizations.Downloaded June 30,2006 from http://www.eiconsortium.org/research/jj_ei_study.htm Gannon,Shaun. 2004. Helping Small and Medium sized organizations to profits from new ideas. Innovation Notes.6 September 2004(2). Drucker, Peter F. 1954.The Practice of Management. Harper & Row. New York. Odiorne, George, Weihrich ,Heinz, and Mendleson,Jack. 1980. Executive Skills: A Management by Objectives Approach. Wm. C. Brown Company Publishers. Dubuque, Iowa. Bokhoven M A van, Kok G and Weijden T van der.2003. Designing a quality improvement intervention: a systematic approach. Downloaded from on 30 June 2006 qhc.bmjjournals.com. Woolf SH.1992. Practice guidelines, a new reality in medicine. II. Methods of developing guidelines. Arch Intern Med.152:946–52. Grimshaw JM, Eccles M, Russel I.1995. Developing clinically valid practice guidelines. J Eval Clin Pract;1:37–48. Barry, Timothy R. Top 10 Qualities of A Project Manager. Project Management Article. www.esi-europe.com. Peter E and Morgan KP.2001. Explorations of a trust approach for nursing ethics. Nursing Inquiry. 8: 3–10 Sovie M. Jawad A. 2001. Hospital restructuring and its impact on outcomes. Journal of Nursing Administration. 31(12):588-600. Schimmel EM. 1964.The hazards of hospitalization. Ann Intern Med;60:100-10. Leape LL, Brennan TA, Laird N, et al. 1991. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med;324:377-84. Gawande AA, Thomas EJ, Zinner MJ, et al. 1999. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery;126(1):66-75. Commonwealth Department of Human Services and Health. November 1995.Review of professional indemnity arrangements for health care professionals. In: Compensation and Professional Indemnity in Health Care: A Final Report. Australian Government Publishing Service, Canberra. Millenson ML. 1997. Demanding Medical Excellence. Chicago: The University of Chicago Press. Morris,Alan.H.2000. Developing and Implementing Computerized Protocols for Standardization of Clinical Decisions. Annals of Internal Medicine.7 March 2000. Volume 132 Issue 5 . Pages 373-383. Chassin M. 1998.Is health care ready for six sigma quality? Milbank Quarterly; 76(4): 565-1. Koop CE. 1999. An ounce of error prevention. The Washington Post. Thursday, December 23,; Page A21. Rafferty, A M .2001. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Quality in Health Care 2001;10: ii32-ii37. Leape LL. Error in medicine. 1994.JAMA;272:1851-57. Morris,Alan.H.2002. Decision support and safety of clinical environments. Qual Saf Health Care.11:69-75. Edwards.A and Elwyn.G.2001.Understanding risk and lessons for clinical risk communication about treatment preferences. Quality in Health Care.10: i9-i13. Balfour M., &Clarke C. 2001.Searching for sustainable change . Journal of Clinical Nursing. 10, (1), 44-50. Read More