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Authenticity in Leadership – An Enabler for Patient Safety

Highly effective, high-impact leaders are those who make a difference by setting institutional tone, establishing institutional culture and moving performance into zones of continuous quality improvement and enhanced patient safety.  The attributes of effective leaders have been described thoroughly in the comprehensive report by Swensen, et.al.1 According to Swensen, an effective leader strives to “be a regular, authentic presence at the front line and a visible champion of improvement.” What he means, I believe, is that effective leaders instill a sense of purpose, establish the culture and set the parameters and expectations for improvement efforts.  They do this by measuring the pulse of an institution, by valuing and intimately understanding the challenges staff face in their efforts to do their jobs and to accomplish not only the institution’s goals, but also their own professional goals. Highly effective leaders earn and receive respect by sincerely extending cordiality and respect.

Authenticity includes multiple dimensions: legitimacy, genuineness and realism. Leaders who convey an authentic presence are those in whom we believe, we hold in high esteem and we follow. What distinguishes these leaders is that others are drawn to them, not because they may be charismatic, some are and others are not, but because they reach out to let people know that their needs and perspectives matter. They convey through their actions, not merely their words, that what is important to front-line staff is ipso facto important to them. Authentic leaders work hard to deliver on their promises and to exceed expectations whenever possible.

Higher-reliability healthcare organizations are those where leaders particularly value the contributions of front-line staff, those employees who enable, support and/or provide clinical services at the bedsides, in the operating rooms and clinics. Safe, highly reliable healthcare is thus facilitated by the authentic presence of effective leaders valuing the contributions of the “front-liners”. These leaders earn respect by extending respect – a distinct professional ethic within a moral construct of mutual obligation.

Case Study:

One of the most effective leaders I worked with was a nursing executive, a woman who had an exemplary professional bearing, one that conveyed trustworthiness and mutual veneration. When she walked into a room, her presence was comforting and reassuring, stability within a storm.

One hectic, challenging day after three auto accident victims had died in her hospital’s emergency department, she sat quietly with the staff and listened to their voices, their concerns, their dismays and frustrations over logistical issues they felt had interfered with their ability to save lives. She conveyed empathy and compassion that was palpable – and she took notes. After a period of silence, she thanked all for their efforts. Then she got up, walked around the room and softly touched each member of staff and whispered into each one’s ears a personal message and a specific thank you. She promised that things would improve and she delivered on her promises.

If this were the only example of her authenticity, one might pass it off as an anecdote attributable to the emotion of the moment. But as I came to know her, I realized her behavior was a clear example of who she was all the time. She had a way of carrying herself that projected responsibility, accountability, diligence, and also compassion and an interest in the individuals on her team. It wasn’t so much that she projected personal power or that she was immaculate in her appearance, although she certainly did and was, but rather that she conveyed sincerity and commitment toward the vision and goals of the organization, and most importantly, toward the staff and their efforts to achieve the institution’s goals and their own goals. Regardless of how busy her day might have been, when she was there, she was fully present.  She had a calming and reassuring presence. She was authentic and staff knew she was always there to support them, even when things went wrong.

Authenticity, as a crucial element of leadership, may be an inherent personality characteristic for some individuals, like my colleague, the nurse executive. Even if it is not, authenticity is a characteristic that can and should be taught in leadership development courses and simulation training may be an effective educational tool. Leaders who convey an authentic presence, who listen and take comments and suggestions for action and then deliver on them, will themselves be listened to and what they say will matter very much to many. They are the change agents for a culture of quality improvement and enhancements in patient safety!

References:

1. Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org

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We’re following the leader wherever he may go…”

“Following the leader, the leader, the leader, We’re following the leader wherever he may go…” (for better or for worse)

You will no doubt remember the song the Lost Boys were singing as they followed Peter Pan around Neverland. Peter was a charismatic leader, although I am not sure whether he was a good or bad leader; he was certainly entertaining and the Lost Boys had great fun.

In my career I have had the privilege of working with and for many excellent leaders and also, unfortunately, have had the calamity of working with and for several very poor leaders. I have learned a lot from these experiences and in some instances, have learned even more from observing the characteristics and behaviours of deficient leaders. Observing poor outcomes and harm done to patients, often the consequence in part of poor leadership, has enhanced my own skills considerably.

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Failures in Communication – “…things we don’t know we don’t know”

In this final commentary on communication challenges, I would like to address some egregious instances where communication of important facts simply never occurred, resulting in the potential for, or actual, catastrophic consequences.

A while back I assumed oversight of a hospital infection control program and committee. The committee met monthly to summarize hospital surveillance data regarding healthcare associated infections, antibiotic resistance patterns and the impact of community-based infection trends on hospital services. Since I was largely unfamiliar with the dynamics of this committee and the individual personalities of the participants, I decided to sit back and see how the meeting flowed without providing specific comment regarding reporting and analysis processes until I had observed the long-established workings of this group.

Every month the antibiotic resistance patterns of bacteria were discussed, with specific focus on MRSA (methicillin-resistant Staph aureus). At this point in time, MRSA was an organism most commonly associated with orthopedic care services and was most prominent in chronic care and rehabilitation nursing facilities, not acute care hospitals. You can imagine my surprise and alarm when the data revealed that 25% of Staph aureus culture isolates from this acute care hospital were MRSA, and that this pattern had been reported monthly for nine consecutive months. As a senior clinician, I had never been informed of this although I commonly treated patients with Staph aureus skin infections and cellulitis, and even a recent case of orbital cellulitis requiring operative intervention.

After the meeting, I held a private session in my office with the infection control officer, the head of the microbiology laboratory and the hospital’s chief public health officer. To my profound amazement and disappointment, none of them seemed to recognize the urgency of doing anything with the information at hand. Some of the processes of the committee were working well, reports received and summarized and filed, but the meaning of the reports escaped the comprehension of the committee members. I paused and then shared some carefully considered, yet very strong words with my staff. This kind of complacency was unacceptable and would not be tolerated in the future. Committee processes would change immediately!

While this group was still in my office, I called the local community public health authorities and laboratory directors of two other hospitals in our area to alert them of our MRSA issues, and not surprisingly learned that MRSA rates in these settings were less than 1.5 %, completely at variance with my hospital’s experience and more aligned with the patterns reported nationally.

I instructed the director of the microbiology laboratory to immediately investigate our testing procedures and to send any current or future presumed isolates of MRSA to an outside reference lab for confirmatory testing. Most important, I sent a personal email to hospital executives, all wards, clinics, remote settings and all members of the medical/surgical/dental professional staff alerting them of the findings of the infection control committee, with a recommendation for use of alternative antibiotics until such a time as the situation might be clarified. I then had the staff hand deliver the same message to the managers of every ward and clinic.

Within one week, the reference lab refuted the testing results of my hospital’s lab, which upon investigation had been found to be using outdated testing reagents. The hospital’s 20 most recent MRSA isolates were all, in fact, methicillin sensitive.

Fortunately, no one was harmed by this incident, but the key issue here was that the committee was functioning in isolation from the meaning of its work. There was a lack of committee leadership and committee “followership”. Complacency ruled instead of critical thinking! The committee lost sight of its key stakeholders, i.e., the patients we care for and the front-line clinicians who provide that care.

Similar instances of failures to communicate crucial information to appropriate authorities have recently received public notoriety, including an outbreak of highly virulent Carbapenem resistant Klebsiella pneumonia at a distinguished research hospital1 and a failure to report known instances of inadequate cleansing and sterilization of endoscopes resulting in infections due to Carbapenem-resistant Enterobacteriaceae2.

Processes controlled by individuals working in settings removed from the direct patient care environment contributed to serious harm and were complicated by the complacency of staff involved. Clinicians and communities were kept in the dark, patients were endangered and some harmed. We should have done, and can do, better. The use of automated triggers and bulletins are necessary and appropriate interventions, and individuals also must be held accountable.

We cannot know what we have not been told!

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.”

Donald Rumsfeld
Secretary of Defense, United States of America, 2001-2006

References:

  1. Snitkin ES, et, al. Tracking a Hospital Outbreak of Carbapenem-Resistant Klebsiella pneumonia with Whole-Genome Sequencing. Sci Transl Med. 2012 Aug 22;4(148).
  2. Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013. MMWR Weekly January 3, 2014; 62(51):1051-1051 (accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6251a4.htm?s_cid=mm6251a4_w).

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Patient Safety at the End of Life – The Importance of “That” Conversation #2

Last month I began the story of end of life discussions and the importance of setting the stage for these conversations before they become urgent matters at hand. I presented the story of an elderly friend, desperately ill with ischemic bowel disease in an intensive care setting and slowly, but progressively approaching her moment of death.

The story continues

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