Publications

2004 Annual Conference Reports

Health Minister's Address

ACHIEVING CLINICAL LEADERSHIP 
4 NOVEMBER 2004

On my way back from last week’s Commonwealth Fund meeting in Washington and a visit to the Institute for Healthcare Improvement in Boston, I was pondering the old adage that “travel broadens the mind”.

Like many sayings, it is probably inaccurate as often as it’s accurate.

In terms of exposure to other health systems, however, I have no doubt that travel and experience of how other countries run their health systems does, in fact, broaden the mind in innumerable ways.

Before I begin discussing today’s topic of clinical leadership, and relating it back to learning from overseas, I want to thank your president Jeff Brown, your vice-president David Jones, and your executive director Ian Powell for inviting me here today and to last night’s function too. I wish I could have stayed longer last night, but it is difficult to get leave in Wellington when Parliament is sitting.

I would also like to acknowledge Dr David Pickersgill, of the British Medical Association, and Dr Robert Weinmann, President of the Union of American Physicians and Dentists, and to welcome them to New Zealand.

It is disappointing that Professor Phil Bagshaw, chair of the Council of Medical Colleges, was unable to take part in this discussion today, but I have been very interested in listening to Ken Clark, Chief Medical Advisor at MidCentral DHB, on the subject of clinical leadership anyway.

To return to the topic of the day, therefore, one area where travel and learning from overseas examples certainly does broaden the mind is the opportunity to talk to health professionals and managers in other countries about governance issues and clinical leadership.

I think it is useful to pose the question first --- why is clinical leadership apparently becoming a more pressing requirement?

To me, the answer to the question is simple enough, although the answers to how we go about embedding clinical leadership within our hospitals is far more complex.

New Zealand, like other social democracies, is facing growing pressures on resources coupled with increasing demand. In health terms, that means more patients, more complexity, a growing burden of chronic disease and greater expectations of quality in delivery.

We are taking initiatives here to cope with the growing pressures, such as moving to population preventative medicine, multidisciplinary teams (not job substitution), the HPCA and scopes of practice, and widening prescribing rights, to mention some areas.

The fact remains, however, that when it comes to our acute care hospitals, despite an apparent decrease in the supply of skills and resources and a definite increase in demand for them, the organisation of care today has not changed significantly in the last two decades.

One or two DHBs are trying new approaches, but if we are to manage this increased demand effectively, we must address the issue of the way we organize care, and to do so requires both clinical and managerial leadership.

The recent visit to the United States reinforced for me the extent of the problems faced by their health system, and at the same also reinforced the energy with which their best and most innovative thinkers are seeking solutions to those problems.

At times we have vigorous debate in New Zealand about our health system, but such debate pales into insignificance alongside criticisms in the US that the medical system is chaotic, fragmented and, despite being extremely expensive, does not offer anywhere like the cover we almost take for granted here.

The pressure for change is also extreme, and it comes from all quarters, especially those paying for the system. They are mainly employer organisations complaining that they are shelving out big bucks for not much return.

The good news is that as a result of this pressure a number of groups have arisen to address the real issues of poor quality services and medical error, and one of these is, of course, the Institute of Healthcare Improvement or IHI, whose chief executive Dr Don Berwick is an inspiring figure already well-known in New Zealand.

The IHI seeks to improve healthcare by supporting change, and one of the major ways it does so is through collaborative learning --- using a model for achieving breakthrough improvements that has been developed as the Breakthrough Series.

Teams from different hospitals work together to solve common problems. The IHI’s role is to bring the teams together, and to provide expertise and tools. Teams in such collaboratives have achieved dramatic results, including reducing waiting times by 50 per cent, reducing worker absenteeism by 25 per cent, reducing ICU costs by 25 per cent, and reducing hospitalisations for patients with congestive heart failure by 50 per cent.

It should be obvious to everyone, and I am sure it is to senior doctors, that simply addressing costs is not the answer to getting more effective health care. Of course, costs are important, but so is the quality of the way we spend our money. With a quality approach we can achieve better throughput and decreased costs, improved efficiency and effectiveness. Clearly, it is essential to involve senior staff closely in collaborative work on improving quality.

The IHI has numerous examples of its innovative work on its website, but it is worth briefly mentioning one practical example of the success of its work in terms of patient flow, addressing the primary-secondary interface, emergency departments and wards. The example concerns its collaborative work with the Devon and Exeter Trust in the United Kingdom, a trust not dissimilar from some of our District Health Boards.

Devon and Exeter had the same issues as us --- rising acute admissions, full emergency departments, long waits, long lengths of stay and high infection rates.

In this example dedicated multi-disciplinary teams from right across the sector (primary care, community hospital, teaching hospital) have succeeded in decreasing presentation to emergency departments, and decreased acute admissions by identifying and successfully managing more patients in community hospitals or at home.

The predictor tool developed by that Trust has been successful in planning workload and staff, smoothing patient flow peaks and ultimately has resulted in achieving significantly more elective volumes. Similar work on predictor tools is starting in New Zealand, with DHBs like Canterbury, particularly, and Counties-Manukau leading the way.

Clearly, such valuable exercises cannot succeed unless leadership from senior doctors in particular is available to assist chief executives and senior managers drive projects to their desired conclusions.

What we have to find is a formula that facilitates such clinical leadership rather than perpetuates old ways of doing things.

A facilitative approach takes time, focus and considerable effort. Doctors have to understand that chief executives and other senior managers are unlikely to be willing to invest time and resource to such an approach unless they are convinced clinical leaders are equally committed. You have to work together.

There are a number of elements that are fundamental to developing such a facilitative approach to leadership.

Firstly, the need to measure and track agreed objectives, such as standardized mortality rates and infection rates, to communicate these aims effectively and to achieve clinical and management buy-in, and to have oversight at the highest levels of governance.

Secondly, align system measures and quality activities to strategic aims. Just doing well is not enough. Good deeds need to have a strategic focus. Quality, financial and strategic plans need to fit together, and need to be regularly monitored and revised.

Channel leadership. Get the CEO involved at a hands-on level. It is crucial to get visibility and drive from the CEO, who must be seen to walk the talk and to be engaged.

Get the right team. Ensure the team understands the new approach, wants to do it, and has the skills to do so.

And get the chief financial officer aboard too.

Engage physicians and other clinical staff in a common agenda. Leaders need to be equipped to lead with social skills and even courage. All this takes training and time. Programmes must remain evidence based and data driven. Avoid paralysis by one loud voice!

Openly confront the autonomy issue. “Do you mean to say that you value your autonomy over the outcomes for your patients?”

Before answering any questions you might have, I would like to summarise the situation as I see it regarding clinical leadership in New Zealand.

I believe clinical leadership is the leadership of change. Leadership is about becoming the focus for change and taking responsibility for change, working with and acknowledging the efforts of others in that change.

The role of the clinical leader is to guide their colleagues through change. Clinical leaders should seize the opportunity to work with government and communities to adopt an agenda to improve societal health.

Senior doctors have a vital role to play both as clinicians and as decision makers. Effective clinical governance requires the support of District Health Boards. Collaboration and co-operation are the key elements of successful relationships. Open engagement and early consultation with senior doctors will go a long way to achieving better results in this area.

In my most recent Letter of Expectation to DHBs, I highlighted the importance of shared decision making. I said that ‘decisions will be best informed when clinicians are involved at all levels of the decision-making process.’ One way to achieve this is to ensure that clinicians are appointed to those teams, committees and boards responsible for the DHB’s policy development and operational functions. If this occurs clinicians will be involved in areas such as priority determinations, resource allocation and service redesign and configuration.

Our government has placed a particular focus and importance on healthcare. This has given us the opportunity to improve the care of patients markedly, but it cannot be realised unless health professionals lead change. No amount of structural reform, policy development or management change will achieve the patient-focussed outcomes we all want.

It means that clinical input into all aspects of DHB decision-making is vital if we are to maximise the gains from our investment in health. Medical specialists need to be high up in those consultation processes. And you must take some responsibility for making that happen. You must be proactive within your organisations, and ensure that your views are represented. And you must also be receptive to the views and ideas of your colleagues.

We are relying on your input not only within your own DHBs but also for you to become involved in College affairs and in wider regional service configurations beyond your own DHB boundaries.

Improving quality is central to the vision we all share for our health system, and we must enable a culture of quality improvement to get those outcomes. If we do not support and foster that culture then the cooperation that allows real quality improvement cannot occur.

Real quality improvement will only be achieved if it occurs at all levels of the health sector. For such an approach to make a difference to patients, it is essential it is a bottom-up initiative. We need to measure what we do, trial new interventions and measure results. Quality improvement must become part of what we do everyday, a core function of all our jobs. This requires vision, leadership and some resource. It will not happen unless people like you spearhead the approach.

Hon. Annette King
Minister of Health