How your leadership can create safe, compassionate and effective healthcare

Today is World Book Day. To celebrate this, I'm reproducing here the introductory chapter of my book "CAREFUL leadership" (available from Amazon.co.uk, here)

Introduction

The body is big. And wet. The unconscious form of a half-drowned man is wheeled into the Emergency Room by the ambulance crew. Whether by accident or design – drunk, depressed or both – he’s spent the night in the bilge of a rowing boat. He’s blue. And half-dead.

Four of us heave his cold and heavy form onto the resuscitation trolley and begin our work. He is still breathing, but only just; a sound barely audible as waves on a shore. A feeble pulse, life’s will to live, trickles in his neck. No blood pressure to speak of. He is cold as a tomb.

We set up a drip, warmed and pumped by a machine. We stab him in the groin to take blood. He doesn’t flinch. Nor do his pupils react to the bright lights we shine at him. We record his heart with an ECG. We order some X-rays and request a scan of his brain. We insert a catheter. We cover him with warming blankets. The flurry over, we stand back to wait.

The patient is critically ill, and will probably die. He needs to be put on a ventilator to protect his lungs. For that, he needs the treatment and support available from the Intensive Care Unit (or ICU as it is more casually known). We call the intensive care team and ask for their help. We’re told they’re busy with several other, critically ill, patients. He can remain safely with us. If his condition worsens, he’s in the right place and we can ring them back. We will have to wait before they can come and help.

I’ve been an Emergency Department doctor in this hospital for no more than a month. I’m still relatively junior and inexperienced so I am left to watch over him with some more experienced nursing colleagues. The patient is stable, but our concern grows as the time passes. He is barely alive, and is liable to deteriorate at any moment. We know that the warming blankets can cause a shift of chemicals within his bloodstream and precipitate a cardiac arrest. We stand by his side, watching the monitors.

Just then, a middle-aged man with glasses perched a long way down his nose comes up to my side and smiles. “Hello,” he says. “I’m David. From ICU.”

I feel a surge of relief. I thank him for coming so quickly and explain the situation as cogently as I can.

He nods, then says, “What’s his name?”

I look blank for a moment, then tell him the name we found in the patient’s wallet. This is all the information we have.

The ICU doctor nods, taking it all in, and then approaches the patient, leans down to his head and addresses him softly by name, reassuring him that he is now in hospital and that we are doing everything that we can for him. As the doctor begins his own examination of the patient, which he performs with meticulous fluidity, I hear him explaining to the unconscious man exactly what he is doing.

As I watch, I realise that this is the first time that anyone has addressed the patient directly during the time he has been in our department. Everyone, including me, has assumed that this patient is comatose, unable to sense what is going on.

The ICU doctor turns back to me, also addressing me by name, and we discuss the patient’s condition and prognosis. We study the results of the patient’s blood analysis, which shows that the patient is in poor condition. “He’ll need some bicarbonate,” says the doctor, looking inquisitively over his glasses at me.

“I’m not familiar with prescribing bicarb,” I confess. I sense he realised this. So, for a few minutes, he explains and teaches me how to calculate and prescribe the right dose and the likely effect on the patient’s blood results. We then discuss antibiotics and the fact that the patient needs to be on a ventilator before going for a brain scan.

After a few minutes, he returns to the patient and talks to him, again using his name. “We’re going to give you some medicines which should make you feel better. We’re going to help you breathe by putting a tube in your windpipe. To do that, we need to put you to sleep.”

A few minutes later, with the help of another member of staff, the patient is anaesthetised and put on a ventilator. Not long after that, he is wheeled out of our department, accompanied by the ICU doctor and the resus nurse, first to the CT scanner and from there to the intensive care unit. I finish my paperwork and move on to the next patient. The entire episode was over in less than 30 minutes.

Later that day I was sitting in the coffee room during my break, discussing the patient with a colleague.

“Good to have Prof by your side,” she said.

“Prof?”

“Yes, I heard ICU was really busy. I assume that’s why Prof came to

help out.”

“I didn’t know he was a professor. He seemed a really nice guy.”

“The word ‘nice’ doesn’t really do him justice – he’s much more than

nice. I tell you, if I was really sick, I’d want to be airlifted to his ICU, no question. He’s one of my heroes. When I was in ICU, he taught me everything I know about critical care medicine and about how to run a unit.” She paused and added: “And a lot about how to be a good doctor.

“What I really admire is the fact that he treats everyone with real kindness: staff, patients, relatives – all the time. He’s never too busy. And yet, despite that, he’s also one of the world-renowned experts in Intensive Care Medicine. He’s regularly over in the USA teaching and liaising over research programmes. He has, quite literally, written the book on the subject. It’s required reading in my view.

“But the most important thing is that we get really good results. Patients do much better on the unit than you would expect, given the type of patients we treat. According to the data, it’s safer and better than in any of the neighbouring units that treat the same population.

“I reckon that if it weren’t for him, this hospital would probably have lost its ICU long ago. He’s published hundreds of papers. And his staff love him. In fact, as a tribute, they’ve named one of the rooms in this hospital after him.”

“A tribute?”

She returned to her sandwich and then looked up. “Yes. He’s retiring this year. It’ll be a real loss.”

For a few moments I reflected on my brief experience of this man, a world-renowned expert on his subject who had come down in person to help out because his colleagues were busy. I remembered the sense of relief that I felt, and how he had made me feel better about the situation. I remembered how he had addressed me by name and how he had listened carefully to everything I had to say. He had even taken some time to teach me something – without making me feel stupid.

What I remembered, above all, was how he had immediately started talking to our patient by name, explaining and reassuring, even though he was unconscious. That, I realised, had had a calming effect on me. For the entire time we were working together, I felt this doctor had been totally present for me and, more importantly, for my patient.

YOU

If you are a leader or manager who works in healthcare – and that includes most doctors and nurses, as well as those with “manager” in their job title – this book is written for you.

In the UK, where I work, healthcare accounts for over ten per cent of our domestic spending and more than a million people work in the health services – roughly one in every 30 taxpayers. The same proportions are true in most developed countries, and in the USA the numbers may be doubled.

Of this vast number of healthcare workers, the majority are leaders. This includes the more obviously senior managers – the CEO and the board, for instance – as well as everyone who has manager in their job title: ward managers, general managers, practice managers and so forth. Less obviously, perhaps, it also includes almost all junior doctors since, after only a year in the job, they are themselves helping to lead and manage the doctors who have just left medical school. It includes every qualified nurse who manages clinical support workers or students as part of their job. It also includes every shift manager, team leader or supervisor – and this includes tutors – in any non-clinical or allied health profession.

My definition – admittedly quite wide – is that if you are required to take accountability for someone else’s work, you’re a leader. And by my estimate, that’s about 60 to 70 per cent of healthcare workers. That makes half a million healthcare leaders in the UK alone and maybe 30 to 40 million worldwide.

If you are one of these many healthcare leaders, please take a moment to congratulate yourself. You’re doing a difficult job and you are likely doing it well, perhaps without much specific training in leadership. All leadership roles are difficult, in most part because there is no handbook that can teach you all you need to know. But healthcare leadership has particular challenges since we are trying to deliver a high quality of service to patients under circumstances that are both unpredictable and challenging.

Healthcare leadership can be particularly challenging because it often deals with highly charged emotional situations. You may think that emotion is restricted to the patient-facing professions, but if you are, for example, a biochemistry shift leader running a lab overnight, you will not be immune to the fact that healthcare is emotionally charged. If an essential analyser goes down, you can be sure that you will be reminded rapidly that “lives depend on getting it fixed”. Dealing with the sick and dying, at however many steps removed, is a difficult business.

Leading healthcare services is also difficult because we are also of necessity consumers of these services. When one of our family falls sick we often come face to face with a service that is inadequate, uncaring, or merely inefficient. It can be disheartening to discover that we contribute to a service which regularly fails its patients.

Finally, healthcare leaders daily face the uncomfortable truth that there isn’t enough to go around. The demand for healthcare appears unlimited, while resources are relatively scarce. A form of Moore’s law seems to stalk everything we do: every few years we need twice the number of people, beds or appointments. Where healthcare ends, social care begins, and the dividing line between the two is rarely clear. As a result, you – as a healthcare leader – are always going to be asked to do more with less; to do more than is possible. How you deal with that, how you work with patients and staff to cope with these difficult boundaries and limitations, can be as difficult to manage as the care that you deliver.

Despite these challenges, I would wager that you strive hard at your work because you want to make a positive difference to patients. You try whenever possible to provide a safe, high-quality service. You know that the way you manage and lead within your own department, clinic or hospital has a direct bearing on the nature and the quality of the services that are delivered to your patients, and so you try to improve that service.

This book is about that. About your leadership. It’s a manual, of sorts. Not one that will tell you exactly how to do your job, but one that may give you some ideas and pointers on how to deliver a better service to your patients and, crucially, to your staff. Leadership is primarily about helping people – your people, the staff you work with – do a good job. If they do a good job, you will have succeeded. So this book provides a structure that you can apply to the problems that you face in your day-to-day job and in so doing create an environment in which your staff can flourish and provide better care, whether directly or indirectly, to your patients.

ME

From my story about Prof, which took place a few years ago, it will be apparent that I’m a doctor. For half my working week I still work as a physician in an emergency department – A&E as we call it in the UK – dealing occasionally with very sick patients like the one I have just described. More usually, I spend my time listening to and advising patients and colleagues in situations where people are less unwell, but may nonetheless be anxious, exhausted or confused. I love this work. I love doing what I can to reassure and help the people who come to our department. The work may be occasionally stressful, but I am thankful to find it deeply rewarding.

But I wasn’t always a medic. I spent several years away from medicine, working as a consultant and project manager helping multinational companies in the manufacturing, energy and utilities sectors to deliver large change projects. So, for the other half of my week, I now use this experience to work with healthcare leaders and managers from within the public and independent healthcare sectors. Through this work I try to help improve the way they, and their organisations, care for patients.

In an attempt to have the greatest effect, I have made the thrust of my work about helping these leaders find better ways to lead and care for their staff. My belief, backed up by studies within and beyond healthcare, is that staff who are well cared for do a better job. The clear implication for us is that the better we look after our staff, the better they will look after our patients.

What I have found, over 15 years of working in this field, is that leaders often become stuck. Leaders see the same old problem in the same old way, sometimes to the extent that the problem simply becomes part of the furniture, part of “the way things work around here”.

Many healthcare leaders spend years working competently in the same role. Many come to accept that change comes from above, and that change will make things worse, and that “this is as good as it gets”. Sadly, I find many of my clients and colleagues are depressed by their leadership responsibilities.

My sincerest hope is that this book can help to change that.

THE CAREFUL LEADER

I tell the story about Prof – who is, I should stress, not an amalgam of other individuals or some fictional character, but is a real, recently retired ICU consultant lauded by those who worked with him – because it was clear that even at the end of his career he was not stuck. He was fully engaged with his work, with his patients and with his staff.

The story summarises a leadership style that we find too rarely demonstrated by leaders in healthcare – especially, I am sad to say, by the medical profession. I recognise that this description of leadership is one particular presentation. I recognise that there are many other, equally valid styles and theories of leadership.2 Some models are very theoretical. Others, usually advocated by hyper-successful individuals, often suggest the need for toughness, strength and emotional distance. In my view, this can be counterproductive.

Healthcare is a nuanced and complicated arena, populated by highly motivated, intelligent and self-directed individuals, in which situations requiring uncompromising individualism rarely arise. The image of the be- gloved surgeon regarding an X-ray and declaring “We’re going in” is as far from the truth – and of what is desired or necessary – as can be imagined.

Healthcare leadership needs, in my view, to be the opposite of such unhelpful caricatures. We deal, in the daily round, with frightening and unpleasant situations in which both practitioner and patient may be uncertain and anxious. We need leaders who openly recognise, and work compassionately in, those situations.

As I’ve already suggested, it is the emotional complexity of the arena, for both patients and staff, which marks healthcare leadership out as particularly challenging. We must take this into account, even if we don’t need constantly to verbalise it.

Research tells us that an enormous change takes place in the majority of healthcare practitioners, and especially among doctors and nurses, in the period between starting their training and the first few years of practice.3 Most start out enthusiastic, altruistic and open. Within a few short years, many have become overtly cynical, seemingly uninterested, and often depressed. Junior practitioners take on the emotional characteristics and language of their older peer group and senior colleagues, many of which are negative and oppressive.

The fact is that you, as a healthcare leader, constantly influence your colleagues, especially your younger and more junior colleagues, more than you may care to acknowledge: each gesture, each throwaway remark, each choice of epithet, each attitude you strike, can have a far-reaching impact.

Such a simple act as identifying a patient by their condition can provide a retreat from emotionally challenging situations and perhaps, as it becomes habit, a stance in which the patient becomes objectified and eventually treated with disdain. Such forms of influence and their impact rest with you. Each time you speak, you encourage others to follow your example.

For this reason, in my leadership ideal I emphasise a combination of overt kindness mixed with something more focused and uncompromising. I characterise this as being both compassionate and rigorous. The word careful might be substituted for both characteristics: the empathetic quality that should characterise a caring profession and the attention to clinical and managerial detail that should characterise professional practice are two sides of the same coin.

We must not fail to recognise the humanity and fragility of the human frame and the human mind – our own, as well as that of our patients. If we don’t recognise in both our staff and our patients the adage “there but for the grace of God go I” then we fail to recognise the very reason we do our job: to salve and treat the human frame and human mind as they inevitably fail.

And we must remain positive and supportive in the face of those failures. One day they will likely be our own. We must empathise with both our patients and our staff. As fellow human beings, that honesty is what they most need from us. If we are to be human, we must show compassion to ourselves as well as to those around us.

Yet we cannot simply emote. We must also provide a service that is both safe and effective. We need to do the right things by patients and we need to learn from our mistakes. For that – to provide an objectively balanced service that monitors itself and improves – we must be rigorous and, as much as possible our decisions must be driven by numbers.

Finding the balance between these twin aspects of rigour and kindness can be difficult and occasionally paradoxical. To give it substance, I call it CAREFUL leadership.

The word careful acts primarily as a strong reminder of the reason we take up healthcare in the first place, namely to care for others. It is easy, in the frenetic pace of delivering healthcare to lose this most basic fact of our vocation. But it also here acts as an acronym, the letters of which refer to seven leadership qualities discussed in detail at the end of this introduction. The qualities are: Committed, Active, Responsive, Energetic, Focused, Uniform and Leading. These qualities can also be considered as skills. They can be developed with mindful application and practice. I have written this book in the hope that you may develop these qualities in yourself.