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138 A ustralian and New Zealand Journal of Public Health 2016 vol . 40 no. 2 © 2015 Public Health Association of Australia I n response to an identified need, the Clinical Leadership in Quality and Safety Course (the intervention), was developed to educate current and potential clinical leaders in the knowledge, skills and competencies required to successfully lead the healthcare quality and safety agenda, incorporating both an organisational and system-wide perspective. Participants included 60 medical, nursing and allied health professionals working in metropolitan, rural and regional acute, community health, long-term care and primary care settings in one state in Australia. This paper provides an evaluation of this initiative in equipping clinical leaders to enhance quality and safety within the healthcare organisations and broader system in which they worked. Clinical leadership While there are many definitions of clinical leadership, most suggest it is about clinicians working with others to continually enhance the provision of high-quality, safe healthcare services. For example, Ham describes clinical leadership as “attempting to harness the energies of clinicians and reformers in the quest for improvements in performance that benefit patients”. 1 (p.1980) Clinical leadership requires clinicians to augment their clinical knowledge and skills with leadership skills that are rarely learned as part of their pre- registration educational preparation. 2 While the literature suggests that all clinicians should demonstrate these leadership skills, 3,4 in reality a few outstanding clinicians are usually selected to receive additional on- the-job or formal leadership development.

However, there is little robust evidence on best-practice development of clinical leaders. 5 Development of clinical leaders Meta-analysis has shown that general leadership development is effective in enhancing leadership knowledge, skills and attitudes in many industries, 6 with multifaceted interventions found to be more effective than single interventions. 7 Leadership development is not a ‘curriculum’ but a comprehensive network of processes designed to support the continuing development of leaders outside the classroom. 8 In healthcare, the published studies on clinical leadership development have shown mixed results with a concern that there are few robust evaluation studies. 5 While there are suggestions that non-technical skills, such as: communication, people skills and emotional intelligence; strategic planning and situational analysis; teamwork and working with other professions; and evidence-based practice and informatics were the most useful components of clinical leadership development programs, the evidence is weak. For example, while a systematic review suggested a positive relationship between teamwork training and these non-technical skills, 9 there was no evidence of a further relationship with quality of care.

With similarly weak evidence, there were suggestions that the best methods of clinical leadership development included organisational accountability, 10 visible senior management participation, 11 Equipping clinical leaders for system and service improvements in quality and safety: an Australian experience Sandra G. Leggat, 1 Anne Smyth, 2 Cathy Balding, 1 Iain McAlpine 3 1. School of Psychology and Public Health, La Trobe University, Victoria 2. Organisational Consulting, Victoria 3. Learning and Teaching Centre, Macquarie University, New South Wales Correspondence to: Professor Sandra G. Leggat, School of Psychology and Public Health, La Trobe University, Bundoora, VIC 3086; e-mail: [email protected] Submitted: January 2015; Revision requested: March 2015; Accepted: June 2015 The authors have stated they have no conflict of interest.

Aust NZ J Public Health. 2016; 40:138-43; doi: 10.1111/1753-6405.12462 Abstract Objective: To develop clinical leadership among health professionals working in public sector organisations to improve their skills in ensuring high quality and safe health services.

Methods: A longitudinal pre-post-intervention mixed methods study that included 60 health professionals working in one state in Australia.

Results: The program was successful in the development of clinical leaders.

Conclusions: An interdisciplinary, inter-sectoral leadership development program involving health professionals from metropolitan, regional and rural areas can be successful in developing knowledge, skills and competencies among these health professionals in health service quality and safety.

Implications: Health professionals can participate in a development program to enhance their clinical leadership skills. While this was a post-qualification course, targeting experienced health professionals, the learnings could be applied to pre-qualification education of health professionals.

Key words: clinical leadership, quality of care, leadership development SERVICE DELIVERY 2016 vol . 40 no. 2 A ustralian and New Zealand Journal of Public Health 139 © 2015 Public Health Association of Australia organisational projects with mentoring support, 12 simulations and approaches combining content delivery with application.

11 The educational literature supported interventions based on interprofessional practice and collaborative behaviour, using sound educational and psychological theories. 13,14 In this context, a knowledge-building approach to curriculum development is appropriate, where participants take an active role in generating and advancing the knowledge, incorporating collaborative problem-solving and knowledge advancement in learning communities. 15 Action learning theory and practice, drawing on adult learning and reflective practice principles also supports the value of engaging participants, learners and their managers in shaping and applying what is learned in the workplace by situating that learning in context and in real time. 16,17 Finally, there is increasing evidence that clinical leadership does not just rest with individuals, but that there are organisational requirements for effective clinical leadership. 18 In particular, studies have identified essential system and organisational support that values and sustains the work of clinician leaders distributed throughout the organisation.

3 The review of the literature led to our research question: Can practising health professionals develop leadership skills that have a positive impact on the quality and safety of health service and care delivery in their organisation? Methods The intervention The intervention was designed with a focus on enquiry-based learning (EBL), as recent research suggests that deeper learning that is more applicable to practice takes place when learners are presented with a scenario enquiry and are encouraged to understand the context and reflect on the wider implications. 19,20 Given that the participants were senior clinicians, EBL seemed appropriate given that “EBL differs from problem-based learning (PBL) in that it is less directive and empowers students to take ownership of the course”.

21 (p. 85) Participants already had high levels of expertise and this knowledge was capitalised on, with additional knowledge organised around structural, interpersonal and leadership issues and problems that encouraged the participant to engage with the other participants.

The curriculum comprised a quality and safety simulation and a workplace project, which were supported by online materials, face-to-face workshops and regular communication with learning set colleagues and the program faculty. The simulation was undertaken using three enquiries using hypothetical scenarios within team learning sets. The enquiries were based on realistic scenarios in a hypothetical web-based community. Employing a public health approach, the focus was on the health of the community, and not just focused on services within an organisation. The enquiries were supported by a structured series of online learning modules including printed resources, such as journal articles, book chapters, quality and safety tools and frameworks, and a variety of media, such as online videos, webinars, and other resources. The resources were organised to provide a ‘just in time’ resource to assist the participants in their learning sets in researching and solving the three enquiries. Notably the participants were provided with both robust and questionable resources and were required to evaluate the evidence they used, often leading them to search for more reliable sources.

The workplace project required the participants to identify, plan, implement and evaluate a quality or safety initiative in their workplace. The project evolved and was progressively implemented in parallel with the simulation, online learning space and face-to-face workshops. The final workshop required the participants to present their projects in a scenario revolving around a ‘minute’ with the State Minister of Health.

All except one of the participants were employed by a public health service and volunteered for the Program. To be accepted to the Program in the two years of operation (2011/12 and 2013), written support was required from their organisation. The program was targeted to clinicians, and of the 62 total participants, 15 (24%) clinicians reported a management role. All health professions were represented with seven (11%) medical, 22 (35%) allied health and 33 (54%) nursing participants. Evaluation Formative and summative evaluation was conducted over the two program cohorts in 2012 and 2013, comprising a longitudinal pre-post design using mixed methods. Ethics approval was obtained from the University Ethics Committee prior to the start of the evaluation study. Measures: Intermediate outcomes It was assumed that there would be some intermediate outcomes in terms of leadership and quality and safety skills that could be measured quantitatively. The quantitative measures were gathered from participants using pen and paper questionnaires with validated scales to track changes in self- assessed leadership skills, and quality and safety attitudes and skills among the participants.

Based on the literature outlining leadership skills among clinicians, we chose five quantitative measures. The first was the Leadership Practices Inventory (LPI), 22 which was used to measure self-reported Leadership ability. The LPI has been used in a large number of studies related to health professional leadership. 23,24 This scale has 30 items and given the Cronbach’s alpha of 0.958, all items were included in the analysis.

This scale contains five subscales, four of which had acceptable Cronbach’s alphas:

Challenging the process (0.832), Inspiring a shared vision (0.900), Modelling the way (0.847), and Encouraging the heart (0.898).

Enabling others to act had an alpha of only 0.673 but this was not improved with the removal of any of the scale items and so all of the items were retained in the analysis.

Various studies have identified the link between empowerment and quality of care. 25 Therefore, the second measure was Psychological Empowerment, measured using Spreitzer’s 12-item scale 26 that comprises four components: competence (Cronbach’s alpha 0.846), impact (Cronbach’s alpha 0.822), meaning (Cronbach’s alpha 0.893), and self- determination (0.846). The Cronbach’s alpha for the 12 items was 0.861 and all items were retained. The third measure was Self-efficacy, measured with the 10-item Schwarzer and Jerusalem scale 27, with a Cronbach’s alpha of 0.881. Emotional Intelligence was suggested through the program planning processes 18 as a key characteristic for clinical leaders and was the fourth measure using the Assessing Emotions Scale. 28 The Cronbach’s alpha for the 33 items was 0.899 and all items were retained.

The final intermediate measures related to patient safety attitudes and skills. These were measured using the Patient Safety Attitudes and Patient Safety Skills. 29 The Cronbach’s Service Delivery C linical leadership 140 A ustralian and New Zealand Journal of Public Health 2016 vol . 40 no. 2 © 2015 Public Health Association of Australia alpha was an acceptable 0.757 for the five skill items, but even with a substantially reduced number of items in the attitude scale, the alpha was only 0.645, suggesting that the attitude scale was not a useful measure of patient safety attitudes.

Participants completed pen and paper questionnaires with the five scales and demographic information. The data were entered into SPSS 30 and cross-checked for accuracy. The negatively worded questions were reversed coded. SPSS was used to calculate descriptive statistics and t-tests to determine whether any reported changes on the scales were statistically significant. Measures: terminal outcomes The final program outcomes were measured using qualitative data gathered from program participants and their organisation sponsor who was able to judge the ongoing contribution of the clinical leader. A sample of 28 program participants and 24 of their organisational sponsors were contacted by an independent evaluator and all volunteered to participate in the semi-structured interviews.

This analysis took place a year after the first cohort in 2011/12 and at the end of the 2013 program. Most interviews were conducted by telephone, with a few conducted face-to-face, and comprehensive notes in relation to the structured interview questions were made during the interviews by two interviewers and later typed for analysis. Illustrative quotes are provided to show the qualitative findings below.

In addition, a formal exercise of validation of the curriculum was completed by independent academics. This involved a review by three senior academics in the fields of health leadership, management and clinical governance. The academics concerned had considerable experience as educators, health system practitioners and researchers. Each assessed the curriculum and provided their feedback independently of the other.

Results Quantitative findings The curriculum was assessed by the independent academic reviewers as meeting the desired learning outcomes to a high standard. 31 The overall course was considered soundly structured, the theoretical frameworks on which the curriculum was based were well chosen and the approach was seen as thoroughly researched and evaluated. It was also noted that the educational approach had built on and improved previous learning models.

The intermediate outcome questionnaires were completed by the majority of the participants in 2012 and 2013, as outlined in Table 1. The pre-intervention questionnaire was completed by 60 of the total 62 participants (97%) and the post-intervention questionnaire was completed by 52 of the 62 participants (84%). This ensured a representative sample of participants. Intermediate measures Prior to the start of the program the Leadership Practices Inventory mean score was 46.02. This increased to 50.32 at the end of the program, which was a significant improvement (t=4.216; df=102.7; p=0.000).

This compares favourably with Nurse Practitioner Candidates who increased from a mean of 47.03 to 49.33 following a formal mentoring program. 23 The participants reported significant improvement in all five of the LPI subscales with p <0.01 between the start and the completion of the program. The t-test statistics and p values for each of the subscales are outlined in Table 2.

The participants also reported significant improvement in Emotional Intelligence 28 between the start and completion of the program at p <0.05. The mean of the pre scores was 3.73 and the mean of the post scores was 3.91 (t=2.923; df=109.7; p =0.004) Table 3 outlines the t-test analysis for nine of the 33 (27%) Emotional Intelligence scale items with statistically significant improvement. The Emotional Intelligence items with reported improvement were largely related to recognising the emotional aspects of interactions with others.

The participants also reported significant improvement in Psychological Empowerment. The mean of the pre responses was 3.95 and the mean for the post responses was 4.17 (t=2.670; df=108.8; p =0.009). The participants reported improvement in two of the Empowerment sub-scales of Competence and Impact with p <0.05. Table 4 outlines the t-test analysis for each of the four Psychological Empowerment subscales. Items with statistically significant differences between the start and the completion of the program are bolded.

There was no reported change in General Self-Efficacy between the start (mean 3.13) and the completion (mean 3.24) of the program. There was improvement in the Patient Safety Skills score (t=3.776; df=101.2; p=0.000), with the improvement noted in ‘analysing a case to find the causes of an error’ (t=2.386; df=106.5; p =0.019) ‘supporting and advising a peer who must decide how to respond to an error’ (t=3.510; df=108.9; p =0.001), and ‘disclosing an error to a patient’ (t=4.207; df=102.2; p =0.000). There were small but insignificant changes in accurately entering a Risk Man Table 1: Participants who completed pre- and post-intervention questionnaires. 2012 2013 Pre-intervention Post- intervention Pre-interventionPost-intervention Female 171731 25 Male 656 5 Total 232237 30 Table 2: Leadership Practices Inventory subscales.

LPI subscale TdfSig p= Challenging the process 3.773107.97 0.000 Inspiring a shared vision 4.068106.89 0.000 Enabling others to act 3.078104.96 0.000 Modelling the way 3.876107.70 0.000 Encouraging the heart 3.442104.66 0.001 Table 3: Emotional Intelligence items with significant change.

Item TdfSig p= Other people find it easy to confide in me 2.364109.00.020 I am aware of the nonverbal messages I send to others 2.944108.90.004 I present myself in a way that makes a good impression on others 2.423109.00.017 By looking at their facial expressions, I recognise the emotions people are experiencing 2.161109.10.033 I know why my emotions change 2.060107.10.042 I have control over my emotions 2.773109.00.007 I easily recognise my emotions as I experience them 2.899108.40.005 I know what other people are feeling just be looking at them 2.109108.40.037 I can tell how people are feeling by listening to the tone of their voice 2.331108.60.022 Leggat et al. A rticle 2016 vol . 40 no. 2 A ustralian and New Zealand Journal of Public Health 141 © 2015 Public Health Association of Australia Service Delivery C linical leadership report (t=1.851; df=107.6; p=0.067) and no change in disclosing an error to my supervisor (t=1.257; df=99.5; p =0.212).

Although there was a small change in the reported attitudes towards Patient Safety between the start and the completion of the program, it was not significant (t=1.782; df=109.5; p=0.077) and none of the individual items recorded a significant difference.

Qualitative results The program was regarded by the clinicians who participated and their organisational sponsors as exceptionally valuable. They viewed it as making a significant difference in two major ways. First, it strengthened their knowledge and skill in the field of quality and safety, their understanding of the thinking and rationale behind quality and safety initiatives and the evidence regarding their importance and impact. In addition, the interview participants reported a new-found appreciation for the importance of the patient and consumer in assuring quality and safety.

It completely changed the way I practise medicine and interact with each patient. – Participant, metropolitan health service Second, they reported that the program, often for the first time, helped them appreciate why all this mattered and how to go about it. In other words, the program took them out of their clinical silos and opened their eyes to the organisational and broader system context in which everything happens and equipped them with many of the skills to effectively navigate that context. In some cases the shift to a leadership mindset and personal growth was viewed as profound. The growth I saw … and the confidence …She had no idea about the clinical governance structure of the organisation before CLiQS … [She is now] a champion with her peers.

– – Sponsor, metropolitan health service With respect to quality and safety understanding, the interview participants stated the participants now had the capacity to back up their proposals, interventions and arguments because they were founded on a credible evidence base. This enabled them to act as more effective advocates for quality and safety practices and engaged them as clinicians in leading quality and safety, rather than finding themselves as reluctant players in initiatives they did not really understand or have much ability to shape.

I have the evidence to back up the leadership.

– Participant, metropolitan community health service Made our staff understand quality versus compliance. A spin-off was lots of staff asking, investigating, doing quality activities, especially as it is coming from a clinical leader. – Sponsor, rural health service With respect to the second broader system outcomes, the interview participants reported that the participants had developed an organisational and systems literacy that enabled participants to understand the bigger picture and engage constructively with the imperatives contained within it. This enabled them to collaboratively influence outcomes, rather than avoiding or resisting involvement or giving up when encountering barriers. This was identified as a critical factor in both clinician engagement and promoting projects that had clear organisational impact.

Consistent with the quantitative results, the interview participants reported that the participants had acquired skills in strategic thinking and planning, communication, project management, reflective practice and change management. Has helped me see how my work and leadership fits with strategic plan; that I am working to something bigger, how the health service works and how I can work in it. – Participant, rural health service I work a lot less in a silo and have a broader view of how the health service and system works. I have a picture of what others are doing and a sense of the bigger team. – Participant, metropolitan health service Organisational impact on quality and safety In most cases, participants perceived the workplace projects to have a significant impact in terms of early outcomes, impact and reach. The majority had plans to extend the project or use it as a starting point for other quality improvement initiatives. Almost all participants and sponsors indicated they would continue to work on or support the project and its extension or evolution and many had specific plans to do so. Some organisations had the projects already built into their strategic and operational program indicating evidence of early embedding. This suggests the program has contributed to the type of capacity building that results in sustainable outcomes Participants reported that many projects, with their focus on practical improvement and change, had resulted in distinct and recognisable changes to practice. They addressed a wide range of clinical practice and service provision and often focused on areas of practice highlighted in the Australian National Safety and Quality Health Service Standards. 32 All located the consumer at the centre of the care process, marking a major shift in thinking for these clinicians.

The projects reflected the variety of health settings in which participants worked ranging from large metro acute hospitals, rural health services, aged care facilities and community health services. The project outcomes included:

• significant reductions in medication errors accompanied by a decrease in readmissions Huge benefit for organisation, the initial data of 60 audits, 14% avoided error – had interventions implemented and prevented because of the form developed. There have been no re-admissions due to medication problems. – Sponsor, rural health service • improved performance information in oncology services including active consumer engagement • the development of an allied health competency framework that has resulted in cross disciplinary interest within and beyond the hospital • a reduction in clinical incidents due to ineffective handover We went from nothing to something.

The foundations are there [now] and we have built capability [in] multidisciplinary handovers. – Sponsor, metropolitan health service • improvements to clinical assessment and intake in aged care resulting in better patient flow and relationships with acute services • better information provision to engage consumers in oncology services • improved infection control practices and outcomes • changes to surgical practice resulting in better patient outcomes • introduction of interdisciplinary case conferencing, resulting in better integrated client services and satisfaction.

It was clear from the longitudinal evaluation that the program’s focus on clinical leadership Table 4: Psychological Empowerment items. Subscale TdfSig p= Meaning 1.297109.00.198 Competence 2.674103.57 0.009 Self determination 1.104109.62 0.272 Impact 2.191109.96 0.031 142 A ustralian and New Zealand Journal of Public Health 2016 vol . 40 no. 2 © 2015 Public Health Association of Australia and how to enact this aspect of the clinical role did not cease at the completion of the program or the workplace project.

Participants and sponsors reported that their involvement in the intervention had resulted in a sustained capacity to exercise clinical leadership in quality and safety that is progressively becoming embedded in the practice of participants and is influencing how quality and safety is approached in their organisations.

Some participants and sponsors reported the projects had not developed quite as far as initially envisaged, but all of these indicated that a strong foundation had been established and they anticipated the projects would be fully implemented and/or rolled out more broadly or become part of a larger project. In fact, virtually all sponsors indicated that the very least the workplace projects had done was to lay the groundwork, providing a sound platform for moving forward.

Discussion There is substantial literature lamenting the lack of clinical leadership in ensuring efficacious and safe health services and systems. 33,34 This study reports a successful intervention to engage health professionals in clinical leadership and illustrates that practising health professionals can develop leadership knowledge, skills and competencies that have a positive impact on the quality and safety of health service and care delivery in their organisation. The evaluation of the Clinical Leadership in Quality and Safety intervention comprised quantitative measures of intermediate individual indicators of leadership, associated psychological constructs, quality and safety skills, as well as qualitative opinions of the program participants and their organisational sponsors. We found that the intervention was effective in assisting 60 practising health professionals to develop leadership skills that had a positive impact on the quality and safety of health service and care delivery in their organisations.

The program participants reported significant improvement in the Leadership Practices Self-Inventory Scale overall, and for each of the subscales of Challenge, Vision, Enabling, Modelling and Heart, 35 suggesting they were more aware of and possibly more able to practice recognised leadership activities at the conclusion of the program. Improvement was also noted for Emotional Intelligence, 28 largely in items related to recognising emotion in others and having control over one’s own emotions, and Psychological Empowerment with improvement related to their perceptions of their competence and impact within their organisation. Finally, the participants indicated greater confidence in understanding and responding to errors, as measured by the test of Patient Safety Skills. 29 There was no significant change in the reported attitudes towards Patient Safety between the start and the completion of the program, and this may be because the participants were already strongly committed to patient safety and the tool was not reliably designed to pick this up.

In the interviews, the participants confirmed what the scales had measured, indicating they felt they were in a stronger position to take on leadership roles in their organisation and across organisations within the broader health system. Most importantly the organisational sponsors and other contacts reported a visible change in how these clinical leaders went about their work, resulting in measurable improvements in the achievement of organisational strategies to improve quality and safety. The identified changes in behaviours were still apparent in those of the first cohort who were interviewed 12 months after completion of the program.

The intervention was designed to reinforce behaviours, skills and use of knowledge essential for effective quality and safety practices in the workplace through learning both content and process. Participants were required to work in cross-discipline, cross-sector and cross-organisational teams to analyse and propose solutions to the quality of care simulation in the fictional community, and apply these lessons to their individual workplace projects. Although the need for an interdisciplinary approach to quality enhancement has long been recognised, 36,37 there are few educational opportunities for health professionals from all disciplines, and from all health system sectors, to study together. This interdisciplinary and inter-sectoral approach was seen as an important strength of the program and suggests the potential for similar approaches in pre-registration education for health professionals.

This method of self-directed learning was new and somewhat threatening for many of the participants. In the first workshops, the participants were troubled that there were no lectures where the faculty would tell them the right answer; tell them what they should read; and tell them what they needed to know. However, by the end of the program, the participants showed they could find the appropriate evidence, evaluate the strength and applicability of the evidence and put it together with the system, organisational and consumer information to both solve the simulation and complete their own workplace projects. The development of these skills bodes well for future evidence-based system initiatives in the public health care system in Australia.

Limitations Although the outcomes were reviewed a year following the program for the first cohort participants, more time is needed to observe whether the longer-term organisational and system outcomes were maintained.

In addition, given the nature of the health systems in different states, this program may need further modifications to be relevant in other states in Australia. Conclusions and implications While there is substantial literature on the importance of clinical leadership to improve the Australian health care system, there is little understanding of effective approaches to promote this leadership. This paper provides evidence of an effective clinical leadership program for enhancing health system quality and safety.

Acknowledgements The Clinical Leadership for Quality and Safety Program was conceived and supported by the Victorian Department of Health.

The authors would like to acknowledge the assistance of Geoffrey Leggat in the preparation of the data.

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