Ten years ago you would have found Bernie (Bernadette) Harrison at Intermountain Health Care in Salt Lake City, working with esteemed medical academic Dr. Brent James or in Boston under the tutelage of Dr. Donald Berwick at the Institute for Health Care Improvement. This was the result of her Fulbright scholarship to review curriculum and improvement methodologies in quality and safety. On her return, her profile continued to grow as she became Director for the NSW Blood Transfusion Improvement Collaborative and Acting Director of Quality and Education Programs for the Northern Center for Health Care Improvement.
Today, Harrison is Director of Clinical Leadership Development and Education at the NSW Clinical Excellence Commission, where she spearheaded the Quality Systems Assessment Program, looking at safety systems integration in NSW Public Hospitals. She is also the Program Director for the Blood Watch Program at the CEC and the inaugural Chair of the National E-Learning Transfusion Advisory Committee. On top of that she is also a clinical lecturer in the Faculty of Medicine at the University of Sydney and Adjunct Senior Lecturer at the Sydney Nursing School at the university. In addition to all this she is studying for a PhD at the University of New South Wales (UNSW) and maintains a Fellowship of the Australian Institute of Health Innovation at UNSW. To top it all off she's even a member of the Australian Women's Chamber of Commerce and Industry!!
Despite her intense working schedule Bernie Harrison graciously took time to be interviewed for this quarter's edition of PACEsetterS.
Q: What was the background to the formation of the CEC in NSW in 2004, and furthermore what is the reasoning behind the specific focus on Clinical Leadership?
The Clinical Excellence Commission (CEC) was established in 2004 and forms a major component of the Patient Safety and Clinical Quality Program in NSW. The CEC is a board-governed statutory health corporation with the CEO, Professor Cliff Hughes, reporting directly to the NSW Minister for Health. Its mission is to build confidence in healthcare in NSW by making it demonstrably better and safer for patients and a more rewarding workplace. The CEC vision is to be the publicly respected voice providing the people of NSW with assurance of improvement in the safety and quality of healthcare. A key role of the CEC, among other things, is building capacity and capability for quality and safety improvement in public health services across the state. This is driven through training and education initiatives such as Clinical Practice Improvement and Clinical Leadership programs. Both these programs are managed through my directorate at the CEC. Strategies for sustainable patient safety and system improvement are dependent on strong clinical leadership capabilities. By this we mean leaders with a vision of a better future for health services and the patients they serve and who can effectively guide others through a change process.
Q: Can you provide us with an understanding of the factors that make clinical leadership such an important topic, specifically when it comes to the safety and well-being of patients?
When I joined the CEC in 2005 and was asked by Professor Hughes to take over the Clinical Leadership programs (Foundation and Executive), the focus was on leadership development for quality and safety. Up until this time I had been running training programs in Clinical Practice Improvement (CPI) since 2001. CPI is a methodology for redesigning and improving service delivery, and although I had realized that leadership style was important in tackling change and redesign, I don't think I had personally realized that leadership was a competency that individuals could be trained in. It certainly had not been a focal point of my career at that point, which had been largely focused on delivery of clinical care, research into patient safety, and evidence-based care. I had not undertaken any formal leadership development and like many of us was learning "on the job." We were aware that internationally other groups were addressing issues of quality and safety and its relationship to leadership. Of particular note was Professor Lord Ara Darzi's The NHS Next Stage Review Report, High-quality Care for All, which stated that "leadership has been a neglected component of the reforms until relatively recently" and that "delivering change is not just the result of incentives, competition, and policies, but also requires high quality leadership at all levels of every organization and across local systems, particularly by clinicians" (The NHS Confederation Future of Leadership March 2009). Lord Darzi's publication was timely for the CEC as his review had put a spotlight on poor or lack of leadership as a key reason for why safety improvements had been slow to embed in health services in the United Kingdom. This added further impetus for us to continue to promote the importance of leadership for quality and safety along with tools for risk identification and improvement.
Q: Can you give some examples of the ways in which clinicians can influence health policy in NSW?
This is a very good question and I will answer it by describing what is involved in becoming a CEC leader and how participating in one of the two programs on offer assists with improving all leadership capabilities including influence.
The CEC Clinical Leadership Program (CLP) comprises two separate but related formats, delivered on an annual basis. The Executive CLP is directed toward senior clinicians who have responsibility for leading programs and teams at an LHD or sector/network/department level. The program is delivered centrally in Sydney via modular workshops with experts from the fields of negotiation, conflict, emotional intelligence, generations and genders, risk management, health improvement, and change management. Participants are required to complete a high-level clinical improvement project as part of the program. Enrollment is facilitated with LHD executive sponsors, with a maximum of 40 participants per intake across the state.
The Foundation CLP covers the fundamental aspects of leading improvement initiatives within the NSW health system. The program is based on uniform state-wide content which is designed to be delivered and adapted locally by LHD based facilitators, who link in to a CEC-coordinated program for resource and program support. Experiential and multidisciplinary in nature, it is directed towards clinical staff leading teams who are committed to improving patient safety and quality. Participants are supported to design and implement a local, team-based improvement project as part of the program.
Both formats have an integrated framework that incorporates knowledge of self, others, systems, and clinical practice improvement methodologies. Key distinctions between the two are the mode of delivery and the scope of improvement project. Both are designed to recognize and nurture talent, and interaction between participants from each format is encouraged. Both programs are based on the Miller framework, which is shown above. Effective leaders need to be competent in four key domains including: profound strategy, purposeful behavior, profound knowledge, and purposeful direction.
The focus of the leadership program is to create leaders who are self-aware as to the impact of their leadership style on others; who make sound judgements as to appropriate leadership style for the context they find themselves in; who show high degrees of emotional intelligence and negotiation, influencing, and conflict resolution skills. These core leadership competencies have generally not been taught in undergraduate education and clinicians can occupy senior roles in health systems with little professional development in leadership. The consequences can be disastrous not just for themselves but also for their staff, where the manifestations of poor leadership include high staff turnover, absenteeism, and at the extreme, complaints of bullying and harassment.
To further accelerate development in leadership competencies, clinicians are required to undertake an improvement project that relates to a real patient safety and quality issue within their work environment. They are taught a structured improvement methodology: Clinical Practice Improvement (CPI), which is a program adapted from Intermountain Health Care: the Advanced Training Program in Clinical Practice Improvement, led by Dr. Brent James in the United States. The structured approach to improvement when combined with leadership training and development has been a powerful combination in increasing the effectiveness of improvement efforts. To date, over 1,000 clinicians have completed the CLP program, with all undertaking an improvement project to improve the quality of care for patients. CLP participants are increasingly taking on formal and informal leadership positions within their health facilities and the State more broadly.
Q: What are the structures in place that allow the Clinical Excellence Commission to source and utilize valid and up-to-date evidence to support its range of programs?
CEC uses the same sources as other areas of the health system. We conduct systematic reviews of the literature for up-to-date evidence. Where evidence is lacking we may work with specialist groups to promote consensus approaches to care. In the area of blood transfusion we have lobbied the National Blood Authority, NH&MRC, to request further guideline development in massive transfusion and chronic transfusion settings. We review "gray" literature sources, such as improvement websites, and we use our local and international networks to identify trends and contemporary approaches, particularly around leadership and improvement competencies.
Q: On the CEC website it is stated that Clinical Leadership refers to "the process of leading a set of activities that improve the delivery of safe clinical care," as well as "the set of attributes required to lead a team, unit, stream, or cluster." Can you provide examples of some of these "attributes," and if you're able, please explain what processes (formal or otherwise) potential clinical leaders go through to develop these?
Some of the attributes that CEC envisions for effective Clinical leaders include the capacity to: demonstrate a high level of clinical mastery; build the capability of the clinical team; advocate for patient safety and integrate system improvement into clinical care; have insights into their own leadership style and its impact on others; work effectively with a range of clinicians and managers; use consensus development and vision to set, align, and achieve goals and resolve conflict and balance demands within the larger environment.
That is a pretty daunting list for most of us; however, using the leadership framework described above we have created a structure to acquiring leadership competencies and further opportunities to putting this into practice.
It is important to stress that our basic tenet for the CLP is "self." The more self-aware we are as leaders the better our leadership will become. For example, all participants undertake a 360-degree review, using a recognized online assessment tool focusing on leadership competencies. As confronting as this process can be by having your direct reports, peers, and boss give feedback on your performance, it is an incredibly powerful tool for gaining awareness of leadership style and its impact on others. Feedback and coaching is provided in relation to personal development plans to assist participants in enhancing their effectiveness. The other important area of the program is the emphasis on leadership flexibility and not overusing a preferred leadership style. We use case based examples and reflective discussion to explore the impact of styles for different leadership contexts; for example, the leader who prefers directive leadership and uses this dominant style when the situation calls for collaboration and consensus, resulting in less than optimum outcomes for themselves, team members, and potentially the initiative they were meant to lead.
Finally good leaders are great listeners!! Good listeners practice listening and we encourage our participants to start with their families as well as colleagues. The most common feedback from staff about bosses is that they talk too much and don't listen enough!!
Q: During your scholarship in the United States, you were awarded a certificate in Clinical Practice Improvement from Intermountain Health Care in America. How did this later impact on your career in Australia?
The receiving of a Fulbright professional award and the subsequent study at IHC and IHI has had a huge impact on my career. I was able to work with like-minded health professionals in designing training programs in healthcare improvement in NSW and around the world. I have been able to apply improvement methods to healthcare problems particularly in the blood sector to reduce risk and improve safety for patients. My scholarship was important in my appointment to a senior role in the NSW Clinical Excellence Commission, which has allowed me to contribute to a whole-of-system quality and safety agenda. It has also allowed me to meet some great leaders in clinical quality and safety who exemplify visionary and collaborative leadership styles, in particular Dr. Brent James and Dr. Don Berwick, who have become both friends and mentors.
Q: Working in an area like patient safety, even if not at the actual point-of-care, must bring with it a significant degree of personal satisfaction. Do you ever stop to think about the tangible impact that your work and that of the CEC has on the lives of patients?
I am enormously proud of the work that has been achieved at the CEC and more broadly, the NSW health system. It is a pleasure and privilege to work with the frontline clinicians and support them in improving care for patients. Effective leadership, when combined with practical approaches to improve processes in care, shows limitless potential in improving outcomes for patients, as well as reducing cost and improving the patient and carer experience. Leadership for improvement in clinical quality and safety is an aim worthy of all of us; the patients and families we serve are and will be the ultimate beneficiaries.