Clinical leadership in teams in the ED Sissel Eikeland Husebø, Post doctor, University of Stavanger and Stavanger University Hospital

SimPro 2015 24.-25.8.2015, Jyväskylä, Finland

The ED at Stavanger University Hospital Øystein Evjen Olsen, Chief Medical Officer  Triages approximately 30 000 patients per year  120 ICNs and RNs  40 physicians 

Triage unit, 14 beds

Background 

Evaluation report from The regional office of the Norwegian Board of Health Supervision in 2008



Conclusion follow-up report (2013): Inadequate presence of qualified medical personnel Response: A Steering Committee involving the top leadership of the hospital and working groups



Rationale for the Clinical Leadership in Teams course 

No presence of experienced medical doctors and nurses (Doan et al. 2011)



The role of the nurse-in-charge has been reformulated



Senior doctors are not physically present (Bjørnsen & Uleberg, 2012) Healthcare education models do



not focus on the importance of CL (Guedes dos Santos et al. 2013)

Reformulating the concept of CL 

Health policy developments within the Norwegian health care system ◦ A separate specialty in Emergency Medicine

◦ Development of separate municipal emergency care facilities ◦ New guidelines for the service levels, availability and distribution of emergency services countrywide

◦ The Norwegian Board of Health Supervision (2008, 2013) give hospitals in general, and SUH in particular, no other options but to improve CL skill

Clinical leadership 

Lacking a standard definition and poorly understood (Mannix et al. 2013)



Driving service improvement and management of teams (Cook & Holt 2008)



Leadership skills for team building, confidence in and respect for others (McNamara et al. 2011)



Facilitating evidence-based practice and improved patient outcomes (Millward & Bryan 2005)



A prerequisite for quality of care and patient safety (Dickinson & Ham 2008)

Defining Clinical Leadership – Four core bedside values    

Trust Quality Responsiveness Efficiency



Trust (Giddens 1994)



Quality

(Institute of Medicine Committee on Health, 1990)

Responsiveness (WHO 2000)

Efficiency(Øvretveit 2005)

Definition of Clinical leadership: 

“to take responsibility for clinical decision-making, within the scope of your role in a clinical team at any given time, with a patient-centred perspective addressing four key values; 1) trust 2) quality 3) responsiveness 4) efficiency” (Olsen et al. 2015)

Collaborative process – who was involved?

Øystein Evjen Olsen

Sigrunn Anna Qvindesland

Helge Lorentzen

Development of the course 1)

Align team training objectives and safety aims with organizational goals

2)

Provide organizational support for the team training initiative

3)

Get frontline care leaders on board

4)

Prepare the environment and trainees for team training

5)

Determine required resources and time commitment and ensure their availability

6)

Facilitate application of trained teamwork skills on the job

7)

Measure the effectiveness of the team training program (Salas et al. 2009)

Overview of course design: operationalizing the course linking CL values to tools

Course curriculum and designOperationalizing the definition of clinical leadership

Definition of clinical leadership

Trust Quality

Responsiveness

Efficiency

Basics

Behaviour

Team

Safety

o ‘The what’ and limitations of the course o preparing in advance o level of application o understanding your role o ethics and integrity o shared objectives o contributing to shared learning

o team leader as supervisor o mentoring o attitudes toward own learning o constructive feedback o facilitation o frames, actions and results o understanding oneself o gaps - identity, mind and mend o deliberate practice o reflective practice

o situational awareness o situational leadership o decision-making o self-knowledge o assertiveness o address undesirable behaviour

o culture o risk and consequences o in the blunt/sharp end o Swiss cheese model (Reason) o sequences of events o boundary model (Rasmussen)

Tools o o o o o

Team Resource Management (TRM) Crew Resource Management (CRM) Situation, Background, Assessment, Recommendation (SBAR) Shared Mental Models Closed Loop Communication

Steps

1 and 2

3

Theory

Workshop

Main topics and objectives

o Introduction

Methods

Localization

Resources needed

4

Simulation

Implementation

o Skill development o Decisionmaking o Introduction to simulation o Understanding the CLT framework

o Apply theory in practice, establish own competence o Fluency and further development o From beginner to advanced competency levels o Establish teamwork

o Debriefing of actual experience o Transfer of knowledge to clinical practice o Sustainability and growth

o Self-study o Course booklet with assignments

o Case studies in groups (1-day)

o Simulation at SAFER (1-day)

o One hour introduction by course faculty within the hospital Selfstudy allocated to read booklet and answer questions o 1 faculty. o No need for additional instructors

o External session (SAFER) (1day)

o External session (SAFER) (1day)

o Group counselling and debriefing (4 meetings, 1.5 h) o One individual coaching session o Self-study, conducted at the ED

o 2 faculty o 1 additional facilitator per 5 participants (1-day)

o 2 faculty. o 1 additional facilitator per 5 participants (1-day)

o 1 faculty o 1 additional facilitator per 5 participants (5 meetings,1.5h)

o Acquisition of knowledge o Foundation theory

Workshop day 1 How does the ED look like? Who is communicating with who?

Scenarios

     

S1. Limited trauma with chest pain S2. Lack of resources/overcrowding in units S3: Prolonged length of stay S4: Unclarified patient S5: Bullying at work S6: Medication error with consequences

Trust Quality

Responsiveness Efficacy

S1. Limited trauma with chest pain Objectives



Identification of prioritized interventions Leadership



Teamwork



Short description 

A female, 68 years old, with no known medical history, fell on bike downhill is transported to the ED in ambulance

S2. Lack of resources/overcrowding in the units Objectives  situational awareness  apply leadership techniques Short description A male, 45 years old, afebrile with a lot of coughing and atrial flutter. He needs cardiac monitoring, but no relevant units have bed space

S3: Prolonged length of stay in the ED Objectives  identification of responsible professional for the patient  ensuring progress  prioritizing actions and distribution of resources Short description  An 85 year old demented female, accompanied by her daughter, is admitted five o’clock in the afternoon with suspected femoral neck fracture. Eight o’clock the next morning she is still in the ED waiting for a clinical decision to be made

S4: Unclarified patient Objectives  collaborate with relevant specialities to make a decision regarding the patient

Short description  A female, aged 52 is brought to the ED by her husband with suspected chest pain and syncope. During examination an ankle fracture is detected

S5: Bullying at work Objectives  defusing and professional guidance on the shift  maintaining progress and flow Short description  A doctor realizes a colleague has been bullied by her senior doctor. She is distracted and distraught reducing her ability to function during the shift.

S6: Medication error with consequences Objectives  defusing and professional guidance on busy shift  handling breaches in procedures with potentially serious consequences during a shift Short description  A nurse and doctor were involved in a medication error with serious consequences due to a misunderstanding

Research protocol Clinical Leadership in Teams course in the ED

Aim To evaluate the impact of a CLT course on quality, efficiency, responsiveness of health care services and interprofessional trust

Study design Trailing research Multiple quantitative and qualitative methods  Pre-test and post-test  Formative evaluation  

 (Song et al. 2010)

Characteristics of trailing research (Segaard, 2007)

Researcher

Timeframe

Not intervening Not responsible Dialogue partner Scientific knowledge Learning and evaluation Often formal contract based Division of roles (researcher/participants/stakeholders) Contemporary

View on data and knowledge

Humanistic, created through participants’ reflections

Focus and objective Respondent- researcher relationships

Research procedures

DISCUSSION AND CONCLUSION The definition of CL is reformulated  not based on empirical evidence 



Close link to hospital, Norwegian, European and global health policy



Rooted in the actual clinical setting of the participants



Improvement in patient-centered care and workforce satisfaction

Thank you for your attention!

[email protected]



[email protected]