CAREFUL Leadership: How Your Leadership can Create Safe, Compassionate and Effective Healthcare

Contents

Preface

Acknowledgements

Introduction

CAREFUL leadership

Your Leadership Challenge

The seven CAREFUL qualities

Part ONE:

The Art of Leadership

Watch your language

Soothe the inner animal

Learn to be positive

Above all, be kind

Part TWO:

The seven qualities of CAREFUL leadership

Committed

Active

Responsive

Energetic

Focused

Uniform

Leading

Notes

References

for Melene

Preface

The bulk of the first version of this book was written during September 2014. I remember the time clearly because I spent most of a two-week holiday in Majorca working steadily on the text, largely in isolation in the dining room of a rented house. Which, of course, sounds nice.

In reality, it was a difficult time. My wife had been told that the baby she was carrying had died at ten weeks gestation – the third time that something similar had happened in as many years – and we were waiting for this to be resolved either by a spontaneous abortion or, once we returned to England, through a surgical termination.

You might reasonably conclude that I should have been more attentive to her needs and less focused on writing. Don’t worry, I am reminded often enough, but time seemed qualitatively different during that holiday, as if we were waiting between worlds. Writing seemed suitably liminal as we moved around the house and made occasional forays to a local beach.

When we returned to England, my wife accepted the necessity of a surgical termination. She was taken to theatre one morning, directly from the local early pregnancy unit. She spent a few hours regaining her strength and balance and was sent home that evening. A couple of days later she began to bleed more heavily and by the following morning we knew that something was clearly wrong. We returned to the same department.

She was examined by a doctor who declared her fit to return home. A bit of peri-operative bleeding was to be expected. I remember both the inscrutable look on the faces of the staff and the trail of blood-spots on the floor as she left, sent home, a woman visibly haemorrhaging, shivering in the early stages of shock.

Thankfully, I was a senior emergency doctor. I took her directly to my own emergency department where she was scanned. She had 400 millilitres of fresh blood in her uterus – roughly ten per cent of her circulating blood volume. I still feel a surge of gratitude for the kindness shown by our emergency nurses during those few hours and for the competence of the doctors who treated her. She was admitted, given tranexamic acid, IV antibiotics and some fluids. Despite a fall in haemoglobin she avoided a transfusion and was discharged after a couple of nights.

That this extraordinary contrast in both humanity, and basic clinical acumen, could exist so close together in the journey of one patient, sums-up the reason for this book, namely the need to address very directly the importance of healthcare leadership in creating safe, caring and effective clinical services.

That the two groups of clinical staff could work in such close proximity and yet offer such different experiences and outcomes is, in my opinion, a shining example of the impact of first level leaders. First level leaders are the most numerous leaders, closest to the base of a traditional organisational chart. They are the people who most strongly influence the quality of care through their role-modelling and their support, direction and inspiration of the staff around them. Their leadership capability, more than their technical expertise, or any other factor, is critical to the quality of care delivered day-in day-out in busy departments across the world. It is towards these leaders that this book is directed.

I should stress that through this story I do not intend to find fault – either with the institution or with the individuals involved. I have had too much experience examining and unpicking the Swiss-cheese effects that combine and create serious harm to patients. Blame is neither a useful nor correct response. The systems of work which are created within each department by first level leaders are what need strengthening. It is these systems which persist as individuals come and go through these departments. I tell this story purely as a pertinent image to reinforce the overarching premise of this book:

... first-level leadership is of paramount importance to patient care;

it can be learned – and should be widely taught.

A few months after this incident, I put the finishing touches to the manuscript, and then had the book typeset, which seemed an easier task than finding an agent and a publisher. By then, my enthusiasm for the project had waned – and so the book never really saw the light of day. The following year, I was promoted in my clinical work and then appointed to a Group Medical Director role in the private sector. In 2018, I left the UK to help lead an expanding group of hospitals and clinics in China. By that time, my wife and I were fortunate to have had another child – a fact which provides something of a happy ending.

But the China job, my most recent and most fascinating leadership position, ended abruptly because, well, because now it is 2022. The coronavirus pandemic rages across our world and we are in the middle – possibly only at the beginning – of a wave of suffering, death and disability that will be with us for years to come.

As a result, healthcare professionals are being been put under strain in ways previously reserved for war. I have no war stories for this period since I have taken the view that the world is better served if I am late to the battle than an early casualty. As a result, my clinical practice and my leadership positions have for the last few months been put on hold.

In that time, I have moved to create impact through med-tech* rather than my clinical work. And I have unearthed this book, which has been lurking in my subconscious and my hard drive for more than seven years.

On re-reading, I realise that it has many faults and is in some places seems somewhat out-of-date. It fails to draw on any of the many experiences and mistakes that I have made, and from which I have learned, during the last few years. It would undoubtedly benefit from a re-write – but my calculation is that better would then become the enemy of good.

What this book tries to tell, however inexpertly, is the importance of being both kind and rigorous. It may have been intended for a different time but perhaps this message is even more relevant now than it was seven years ago.

It is therefore with the firm intention to benefit as many of my fellow healthcare leaders as possible, that I commend this book into your hands, your mind and your heart. I hope that it can have relevance to your struggle to be a better healthcare leader, and to improve the care of your patients. Its many imperfections are mine alone. May its benefits give you support, encouragement and inspiration in this most difficult time.

DJ Hamblin-Brown

East Sussex

May 2022

* see www.careful.online

Acknowledgements

This book would not have been possible without the longstanding encouragement of my wife. Emily, your forbearance of my own behaviour, generally, is clear from the preceding story, and your support for all our endeavours has been both unending and yet tempered with realism and sound advice. I owe you a debt of gratitude for much else besides.

I would also like to thank many of the people who read and critiqued various versions of this book over the years: Jo Swinnerton, Nina Lyon, David Bond and Victoria Millar – you have all been hugely helpful at different stages.

Within the book itself, I have made reference to several inspiring individuals and friends, as well as many investigators, researchers, authors and practitioners. I hope that the passages in the book will stand in acknowledgement of my gratitude for your work. Like everyone else, I stand on the shoulders of giants.

My thanks also go to the many attendees and administrators who contributed to the Art of CAREFUL masterclasses that I have run intermittently over the years. From you, I learned a great deal; from your stories of success and failure and from your enthusiasm for excellence in patient care. I hope sincerely that – if this book ends up in your hands – you recognise some of your own contributions to it.

I also want to acknowledge the debt of gratitude that I owe to the many colleagues who have provided me with examples of great leadership over the years. Not all of you work in healthcare – but many of you do. We all recognise the superb examples of clinical and administrative leaders, without whose courage and persistence our hospitals and healthcare institutions would not run at all, let alone well. You are, as we are finding out during this pandemic, the heroes of this unwelcome war.

Finally, I want to acknowledge the dignity and courage embodied by my mother Melene, to whom this book is dedicated. In her final months, she was an exemplary patient, cared for by some exemplary people, most notably my brother Jeremy and my sister Jackie. From you, my family, I have learned most.

Thank you.

Introduction

CAREFUL leadership

Compassion binds us to one another.

– Nelson Mandela

[1]

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