An effective leadership can help to tackle infections

Tuesday, February 10, 2009

The hospital represents a unique meeting ground for the natural and social sciences, and this generates many challenges, successes, and indeed failures associated with healthcare. If these sciences are properly integrated, there can be synergy within and amongst individual, team and organisational efforts leading to desired outcomes and further development. On the other hand, where they are not integrated, efforts at integration are unbalanced, or indeed, where they work in opposition, systems failures such as healthcare associated infection may arise.

The most pressing example of opposition is with hand hygiene. There is a clear message from the technical dynamic, the natural sciences, that effective hand hygiene significantly reduces occurrence and spread of pathogens such as MRSA. This can be contrasted with the behavioural dynamic, from the social sciences, that despite technical knowledge of infection and the value of hand hygiene, employees may still not comply with hand hygiene requirements. It would be simplistic to suggest that our greatest resource, the employee body charged with key value creation at the point of care, should deliberately subvert efforts to protect patients and themselves. This meeting place of birth, death, of joy and sorrow, of quality and finance, is ultimately an organisation charged with the business of healthcare delivery, and an organisation is in itself a social construct.

The thesis advocated here is that it is a lack of integration of the natural and social sciences within a hospital that leads to the observed employee behaviour noted above. Another consequence of this lack of integrated efforts is limited organisational learning so that the prevention of infection is not in the mindsets of employees; rather there are only reactive approaches.¹

The challenge for us in the health services is to pull together the technical drivers for preventing hospital infection such as antibiotic controls, availability of hand decontaminating agents and hospital cleaning, with behavioural drivers such as the desire to provide a quality service and to have job satisfaction, and within an overall organisational context. This analysis is what led to the first creation of the post of Director of Infection Prevention & Control (DIPC) in Cardiff by this author in December 2001 (board minutes on file), with two imperatives: leadership for employee empowerment, and management authority for employee enablement^2,3. The post was created by applying two major academic bodies of knowledge – leadership and quality management – to the context of a hospital, and the need to prevent and control hospital infection.

Most proposed health reforms since the DIPC post was first created have focused on quality management with a performance management emphasis, and hence the targets that we must all meet in the NHS. However, problems of hospital infection, including major outbreaks, have occurred when a narrow focus on targets leads to an unbalanced organisation, and hence unbalanced organisational efforts. This is not to argue the possible failings of performance management or of targets as drivers of continuous improvement, but rather to suggest that a balance in efforts must always be kept, and this could be achieved by effective leadership. The DIPC post, as subsequently rolled-out by the Department of Health in December 2003, significantly did not emphasise leadership⁴. This omission, and the subsequent NHS emphasis on performance management, suggests a need to reinvigorate the role by re-establishing its original leadership credentials. Consider again the technical and behavioural drivers of hospital infection within an organisational framework: this leads to a model, also first developed in Cardiff, named the Organisational-Behavioural-Technical (OBT) model, which facilitates the integration of efforts needed for effective infection prevention and control. Leadership is what is required to keep a balance in views and efforts in all these domains, and this is where the DIPC post is vital. By corollary, the OBT model provides a very useful tool when considering the genesis of a problem, whether a sporadic patient safety incident or an outbreak. Its use predates the more formal root cause analysis (RCA) advocated by the National Patient Safety Agency, and it may be helpful at both the start of an investigation and when summarising the findings of such formal RCAs. Use of the OBT model could lead to insight and understanding of organisational dynamics and lead to more organisational learning.

Operational management in a hospital may be considered to be effective but could still lack a broad perspective – we may achieve good results, but still lose sight of the bigger picture, and hence failures may arise in neglected areas. What leadership does is to keep alive a sense of effective questioning and also to seek the best ways to answer these. Leadership affects organisational culture, that oft mentioned driver of proper or improper organisational and employee behaviour⁵. Effective leadership also recognises the value of other business fields and tools, including marketing and quality management, which, when implemented, could lead to better operational management and outcomes⁶. It was internal marketing research on hand hygiene with 2,000 healthcare workers in Cardiff in 1993 that led directly to the mass introduction of alcohol gel at UHW. Also, it was the application of quality management thinking that led to a change of discipline name from infection control to infection prevention and control also at UHW in 1994⁷. These innovations arose from effective leadership and are believed to have been the first such types in the UK.

Thus, we come to another key attribute of effective leadership and its role in shaping organisational culture, the desire for justice at all times. Just leadership is not only about ensuring justice for patients, employees and the organisation, but also for the roles of the natural and social sciences. Waiting for consensus in decision-making when a crisis demands immediate interventions with technical inputs, eg. cleaning and antibiotic restrictions, may not be effective in achieving crisis control. When using the OBT model, the balance of the scale may tip to a more favourable input amongst O, B and T depending on a given situation. Thus, the DIPC position is in itself a meeting place of the sciences, and this then means that the DIPC must lead within a just self-leadership framework in order to make, at times, difficult choices in actions and to inspire others.

The analyses now bring us to a central question of leadership: the need for one leader or many? The DIPC post, as originally created by this author, revolved around the key attributes of vision setting, justice and facilitation. The post was there to inspire all within the organisation to achieve more, to ensure that justice was considered in all actions for infection prevention and control, and critically, to facilitate leadership creation throughout the organisation. The immediate concern is that of effective leadership to deal with preventing and controlling infections but, as can be deduced from the above analyses, the DIPC post, if effective, can lead to an overall better organisational culture, with leadership throughout an organisation driving clinical quality assurance and overall patient safety.

Ticking a box on attendance at a course on leadership does not in itself lead to effective leadership; it must come from within: within an organisation, within a team, within an individual. A course may facilitate self-discovery but cannot itself drive the inner struggle for just conduct in the individual and just decision-making in an organisation. Equally, ascribing leadership authority to those who may only be self-interested, who do not hold the just goals of the NHS at heart, who neither understand nor share the vision of a modern NHS, can lead to the lack of integration noted above and, ultimately, more patient safety incidents, including hospital acquired infections. From the analyses and discussion above, challenges for the NHS, then, in the struggle against infection are to:
• Promote the role of organisational leadership in this endeavour;
• Bring back the leadership emphasis to the DIPC post;
• Select and develop those with the right attributes for leadership positions;
• Develop the leadership potential in all employees.

1 Hosein I K (2002) 'Emphasising Infection Prevention', British Journal of Infection Control, Editorial, June 2002; 3:3:5
2 Ibid
3 Hosein I K (2005) 'Prevention versus Cure', Health Director, March 2005
4 Department of Health (2003) 'Winning Ways', DoH, December 2003
5 Brooks I (1996) 'Leadership of a cultural change process', Leadership & Organisational Development Journal 1996; 17: 5, 31-37
6 Hosein I K (2005) 'Prevention versus Cure', Health Director, March 2005
7 Hosein I (1996) 'MRSA in wounds and control of spread', Journal of Wound Care 1996; 5:388-390

The author developed the ideas herein whilst at the University Hospital of Wales from 1992-2008. He started at NMUH as DIPC on March 1st 2008.