Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Leadership Support
- F C Gray Southon (27 May 2005)
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Leadership and teamwork skills are as important as airway management skills in critical care and can be taught using simulation
- Marino S Festa (31 May 2005)
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Clinical leadership in the provision of hospital care
- Norman A Matheson (1 June 2005)
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The right kind of clinical leadership
- Jan Walmsley (2 June 2005)
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Re: The right kind of clinical leadership
- Peter KK Au-Yeung (3 June 2005)
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Clinical leadership
- Graham Neale, Sisse Olsen, Research fellow. (16 June 2005)
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Training in management, not leadership
- David E Allen (19 July 2005)
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F C Gray Southon, Honorary Resaerch Fellow University of Auckland, New Zealand
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People have been crying out for better leadership for decades, but it does not seem to come. It is about time that we look beyond skills to the support that professional leadership needs, looking beyond institution to broad specialist networks. Such networks, when given responsibilities, have shown to enhance leadership considerably. Competing interests: Interest in a better health system. |
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Marino S Festa, Consultant in Paediatric Intensive Care Guy's Hospital, St Thomas Street, London SE1 9RT
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Dear Sir I agree wholeheartedly with the conclusion of Olsen and Neale's editorial, that improving leadership and teamwork skills among today's doctors is both important and necessary. Opportunities in everyday hospital medicine to acquire, practice and receive feedback on these skills however, remain scarce. Unlike other industries such as aviation, which allow for experienced team members to observe teams in their work environment, so allowing structured feedback on leadership and team behaviours, medicine has not yet placed adequate importance and resources into training clinical teams in similarly important non-technical skills. The focus of undergraduate teaching and postgraduate advanced life support courses remains the acquisition of technical skills and delivery of healthcare in the one doctor, one patient setting. Competent practitioners must learn to interact and eventually lead teams of healthcare workers, yet little or no formal teaching is aimed at developing individual doctors' leadership skills or to allowing individuals to gain insight into the impact of their behaviour and actions on the team. One way of allowing opportunities to develop, practice and gain insight into non-technical skills is by use of simulation training. Careful consideration of course aims and attention to maximising equipment, environmental and psychological fidelity does allow simulation to build the right environment for teams of doctors, nurses and other healthcare workers to be trained in leadership and teamwork skills(1). Opportunities for feedback and acquisition of leadership and teamwork skills, be it in a real or simulated clinical environment, should become an established part of postgraduate training. The current focus on technical skills acquisition alone is too narrow and should be seen as a failure of medical training. 1. N Gosling, M Moore, C Williams, M Festa. Can simulation recreate a realistic and appropriately stressful environment to observe team behaviours in the setting of paediatric critical illness? Arch Dis Child 2005;90(SII):A82 Competing interests: None declared |
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Norman A Matheson, retired consultant surgeon Head of Wood, Milltimber, Aberdeen AB13 0HX
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Editor- Olsen and Neale plead for clinical leadership of hospital care in the NHS.1 They lament that acquiring leadership skills is rarely part of clinical training and believe that improvement is important and necessary. I doubt that any clinician would disagree that clinical leadership is sorely needed, but there is little point in the acquisition of such skills as long as the career structure in NHS hospital medicine is not designed to regognise and foster it. University departments provide a hierarchical structure under which leadership at departmental level is at least possible. But in NHS hospital practice consultants, of whom there are some with inborn leadership skills and the motivation to express these, have little opportunity of influencing clinical practice on a wider scale that their own personal remit. The barrier to effective clinical leadership is the continued adherence of the profession to the outdated belief in the sacrosanct autonomy of each and every consultant. Do we really believe, even now, that all consultants are from the day of appointment equal in competence, deserving of complete clinical independence and would neither benefit from nor should be expected to accept guidance and advice? To introduce leadership requires revision of the hospital career structure so that motivated and able individuals have an opportunity of fulfilling a leadership role. Mechanisms of such a career challenge for consultants were dealt with in an earlier paper.2 Norman A Matheson retired consultant surgeon Head of Wood, Milltimber, Aberdeen, AB13 0HX normanmatheson@yahoo.co.uk 1 Olsen, Neale G. Clinical leadership in the provision of hospital care. BMJ 2005;330;1219-20 2 Matheson NA. A career challenge for consultants. J Roy Soc Med. 1999;92;55-7 Competing interests: None declared |
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Jan Walmsley, Assistant Director The Health Foundation
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Dear Sir Sissie Olsen and Graham Neale are right to point to the importance of clinical leadership in reducing adverse events in hospital care. What’s required, however, is not the leadership beloved of politicians, where bullish confidence and decisiveness, often in the face of considerable opposition, is the order of the day. Rather, what’s needed is an atmosphere of trust within the clinical team so that the most junior members of staff, or even the patient’s relative, have the confidence to raise concerns about the quality of patient care. This approach is being pioneered by The Health Foundation in partnership with the Institute of Healthcare Improvement in its Safer Patients’ Initiative. Launched in 2004, the £4 million initiative involves four acute trusts from across the UK which will become models of excellence in patient safety. The conventional leadership, trust board and clinical directors, has a vital role to play in encouraging safe practice through demonstrating its importance, collecting data, showing a willingness to listen to issues which concern clinical teams and acting on them. But the key is education and training of staff to adopt proven safer practice and to adapt it to the situation in which they find themselves. To achieve this, leadership needs to be shared throughout the system so that those nearest to the problem can identify its causes, offer solutions and take action, all the time feeling confident that they are being listened to and backed by senior staff. Whilst it is early days for the Safer Patients’ Initiative, The Health Foundation is committed to providing evidence that investing in leadership leads to significant improvements in the quality of patient care. Evaluation findings from our portfolio of work will be made available as work progresses. Jan Walmsley, Assistant Director, The Health Foundation, 90 Long Acre, London, WC2E 9RA. Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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Jan Walmsley's plea for a sort of devolved leadership recalls the Japanese embrace of Deming's Total Quality Management (TQM) - the Toyota approach. In healthcare, this translates to Continuous Quality Improvement (CQI). This is actually easier said than done as it involves a total change of heart. At its most ideal, conventional notions of hierarchy must disappear, as a good idea, even if it comes from the lowest rank, say a ward orderly, would be implemented on its merits, whereas the cherished principles of the Department Head, if shown outmoded and non-contributory to the patient care processes and agreed target outcomes, would be consigned to the historical dustbin it deserved. Alas, this calls for nothing short of a revolution in organizational culture within the NHS ( or at least the NHS I left nearly 13 years ago.) Competing interests: None declared |
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Graham Neale, Visiting professor Clinical Safety Research Unit, Department of Surgery, Imperial College, St Marys Hospital London W2, Sisse Olsen, Research fellow.
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Editor- We were pleased to receive positive support in the rapid responses to the editorial on the importance of clinical leadership in the provision of hospital care. We agree with Dr Au-Yeung that ‘Continuous Quality Improvement’ requires major changes in the organizational culture of the NHS. As a result of GMC-led changes in the training of medical students, ‘professional development’ has become an important component of the early part of the medical course. But we have observed how rapidly attitudes change as students adapt to hospital life, a phenomenon also observed in the USA (1,2). Thus changes from the top are also needed if clinicians are to be educated to strive for safer practices. In a research exercise in a DGH we trained specialist registrars, SHOs, senior nurses and ward pharmacists from 3 general medical and 3 general surgical wards to assess the overall care of 288 consecutive patients discharged from hospital care. Details of problems were recorded using a modified structured case record review process (3). Defects in practice were found in about 25% case records. Most of these defects occurred during ongoing ward care and at the time of discharge of patients. The evidence suggested that inadequate supervision of the work of ward staff and poor handover of care between hospital clinicians and to community carers were important factors (publication planned). We believe that training staff to undertake this sort of audit on a regular basis (perhaps annually) could alter attitudes and behaviour. It would need the GMC to build this kind of appraisal into the training programmes for specialist registrars; the Health Care Commission to examine the performance of Trusts in this respect and for the Royal Colleges to throw their weight behind improving clinical care at ground level. 1. Woloschuk W, Harasym PH, Temple W. Attitude change during medical school: a cohort study. Medical Education 2004; 38: 322-34. 2. Haidet P Dains JE Paterniti DA et al. Medical student attitudes towards the doctor-patient relationship. Medical education 2002; 36: 568 -74. 3. Woloshynowych M, Neale G, Vincent C. Case record review for adverse events: a new approach. Qual Saf Health Care 2003; 12: 411-15. Competing interests: None declared |
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David E Allen, management course development specialist Evidence for Population Health Unit, University of Manchester
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Leadership seems to be a major topic at the moment. Poor leadership was mentioned several times on Radio 4 by Sir Ian Kennedy this morning in connection with the Healthcare Commission report on maternity care. The editorial: Sisse Olsen and Graham Neale Clinical leadership in the provision of hospital care, BMJ 2005; 330: 1219-1220, says, "few, if any, UK medical schools include leadership training." That may be true, but it is not true of the undergraduate course in Manchester. Management training as part of the MPHe course is offered to undergraduates. However it is a mistake to demand that future doctors (or anyone else) need leadership training. Leadership, although an important management skill and indeed may be the most important skill, can not be studied in isolation. It is like asking what is the most important ingredient of a cake; flour, butter, eggs, etc. Without them all you will not get a cake. No manager can be a successful leader without understanding management of change, management of control (with its subcategory of quality management) and above all team development. Training in leadership in isolation is a waste of time. Competing interests: I organise management courses for doctors |
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