Pengembangan Pengembangan kepemimpinan klinikkepemimpinan klinik

(Development of clinical leadership)(Development of clinical leadership)

Tjahjono KuntjoroTjahjono Kuntjoro

The scepticism barrierThe scepticism barrier

• Hospital performance ?....Who Hospital performance ?....Who cares ????cares ????

• Anyway, It is not my unit in the gunAnyway, It is not my unit in the gun

• It is not my teamIt is not my team

• And…….. It is not meAnd…….. It is not me

Doctors’ perceptions, Doctors’ perceptions, attitudes, behaviorsattitudes, behaviors

• Lack of awareness of “error”, what I am Lack of awareness of “error”, what I am doing is always right.doing is always right.

• I must get what I want for the sake of I must get what I want for the sake of my patient, otherwise……. (……ignoring my patient, otherwise……. (……ignoring the scarcity of resources)the scarcity of resources)

• The doctor as an authorityThe doctor as an authority

• The doctor as “hero”The doctor as “hero”

• Allergy of “management terminology”Allergy of “management terminology”

Why we have to change the Why we have to change the medical as well as the medical as well as the institutional culture ?institutional culture ?

• Medical litigation Medical litigation • Consumer autonomyConsumer autonomy• Increasingly complex medical Increasingly complex medical

interventionsinterventions• Resource constraints, scarcity of Resource constraints, scarcity of

resourcesresources• Escalating cost of health care is not Escalating cost of health care is not

sustainablesustainable• Health reformHealth reform

Solution ?Solution ?

• Development of Development of Clinical Leadership ?Clinical Leadership ?• Health professional should be playing a central Health professional should be playing a central

role in making changes to the health system to:role in making changes to the health system to:– Allow the system to offer Allow the system to offer better outcome, greater ease better outcome, greater ease

of use, and more social justiceof use, and more social justice in health status in health status

• Health reform is not changing the surroundings Health reform is not changing the surroundings of care, but of care, but must be changing in the care itselfmust be changing in the care itself

• Clinicians have an opportunity to exercise Clinicians have an opportunity to exercise leadership for the improvement of care, but… leadership for the improvement of care, but… they must first they must first agree to address the aims of agree to address the aims of changeschanges and to and to adopt the agenda of specific adopt the agenda of specific changeschanges in their own work to meet the social in their own work to meet the social needs of changeneeds of change

……what is clinical leadership ?what is clinical leadership ? (Colin Feek, 1999)(Colin Feek, 1999)

• Leadership means: the process by whichLeadership means: the process by which others are others are influencedinfluenced to achieve common objectives in specific to achieve common objectives in specific circumstancescircumstances

• It is not a matter of the relation of leader and It is not a matter of the relation of leader and subordinatessubordinates

• But….But….clinical leadership is the leadership of clinical leadership is the leadership of change.change.

• The role of clinical leader is The role of clinical leader is to navigate at the edge to navigate at the edge of “chaos”of “chaos” where change and stability operate where change and stability operate

• Key words: Key words: awareness, concern, and careawareness, concern, and care (sadar (sadar dan peduli)dan peduli)

Clinical management partnerships for Clinical management partnerships for health service leadership health service leadership (Gaye Tozer, 1999)(Gaye Tozer, 1999)

• Complex system encompass “chaos” and Complex system encompass “chaos” and order, from a system that never settles. order, from a system that never settles. Health care systems risk becoming rigid and Health care systems risk becoming rigid and are therefore unable to meet societal needs. are therefore unable to meet societal needs. The edge of chaos is where both stability and The edge of chaos is where both stability and change operatechange operate

• Clinical leaders should seize the opportunity to Clinical leaders should seize the opportunity to work with government and communities work with government and communities (community partnership) to adopt an agenda (community partnership) to adopt an agenda to improve societal healthto improve societal health

Where am I ?Where am I ?(Malone, et al, 2001)(Malone, et al, 2001)

Low High

• Traditional, command and control• Lack of role clarity• Lack of team work• Authoritative decision, the doctor is always right• Autocratic• Didactic approach• Lack of awareness and concern

• Transformational• Role clarity• Effective teamwork• Decentralized decision• Participative decision making• Empowering others• Aware, concern, care and committed

Flinstone era Clinical governance era

Style of leadershipStyle of leadership(Nellie Yeo & Maureen Bisognano, (Nellie Yeo & Maureen Bisognano, 2002)2002)• Bold aims-clear action-strict deadlinesBold aims-clear action-strict deadlines• Inspiration and motivationInspiration and motivation• CoachingCoaching• Personal examplePersonal example• Drive fear out of the teamDrive fear out of the team• Learning and continuous improvementLearning and continuous improvement• Sponsor role: encouraging and Sponsor role: encouraging and

empowering othersempowering others• Celebration of successCelebration of success• Communication, communication, and Communication, communication, and

communicationcommunication

Attributes of leadersAttributes of leaders (Cartmill, 2001)(Cartmill, 2001)

• Leads by exampleLeads by example• Evaluate team performanceEvaluate team performance• Advises intent before actingAdvises intent before acting• Delegates tasksDelegates tasks• Encourage input from teamEncourage input from team• Responds to inputsResponds to inputs• Set prioritiesSet priorities• High technical competenceHigh technical competence• Involves team in decisionsInvolves team in decisions• Praises good performancePraises good performance

LeadershipLeadership

•Bold aimsBold aims

•Clear actionsClear actions

•Strict deadlinesStrict deadlines

LeadershipLeadership

•Developing shared vision: a Developing shared vision: a patient-centered visionpatient-centered vision

•Develop and deploy strategic Develop and deploy strategic goals (bold aims)goals (bold aims)

•Be a personal exampleBe a personal example

Setting directions

Push Pull

Encouragement.Empowerment

BuildingWill

GeneratingIdeas

ExecutingChanges

Five leadership challenges Five leadership challenges (JCAHO)(JCAHO)• Creating a culture of safetyCreating a culture of safety

• Ethics: professionalism, bioethics, institutional Ethics: professionalism, bioethics, institutional ethics: patient rights, individual clinical ethics: patient rights, individual clinical judgement, fraud,abuse, over-utilizationjudgement, fraud,abuse, over-utilization

• Confidentiality and patient privacyConfidentiality and patient privacy

• Evidence based medicineEvidence based medicine

• Integration of setting and services / Integration of setting and services / coordination of care and assuring continuum coordination of care and assuring continuum of careof care

Roles in clinical settingRoles in clinical setting

•Independent rolesIndependent roles

•Dependent rolesDependent roles

•Inter dependent roles Inter dependent roles (collaborative)(collaborative)

Self leadershipSelf leadership

• Inti kepemimpinan Inti kepemimpinan • Inti dari self leadership adalah self disciplin Inti dari self leadership adalah self disciplin

yaitu menegakkan disiplin atas diri yaitu menegakkan disiplin atas diri pribadi :pribadi :tegas dan adil terhadap dirinya sekalipuntegas dan adil terhadap dirinya sekalipun artinya memberikan hukuman jika artinya memberikan hukuman jika bersalah dan tidak mudah memaafkan jika bersalah dan tidak mudah memaafkan jika keliru meskipun terhadap pribadinya keliru meskipun terhadap pribadinya

• Self leadershipSelf leadership merupakan ciri utama merupakan ciri utama kepemimpinan model kepemimpinan model the top leader in the the top leader in the world : world : muhammadmuhammad

Self leadershipSelf leadership

• Masing-masing kalian adalah Masing-masing kalian adalah pemimpin dan masing-masing akan pemimpin dan masing-masing akan bertanggung jawab terhadap bertanggung jawab terhadap kepemimpinannya kepemimpinannya

Ciri-ciri pemimpin yang belum Ciri-ciri pemimpin yang belum memiliki kemampuan memiliki kemampuan self self leadership :leadership :

• Self excuse (+)Self excuse (+)

• Self punishment (-)Self punishment (-)

New Value New Value the top leadership valuethe top leadership value

• Amanah ( trust) : dapat dipercayaAmanah ( trust) : dapat dipercaya

• TablighTabligh ( kebenaran) : selalu ( kebenaran) : selalu menjaga kebenaranmenjaga kebenaran

• Fatonah (cerdas,cerdik, kompeten) : Fatonah (cerdas,cerdik, kompeten) : memiliki kemampuan lebihmemiliki kemampuan lebih

• Sidiq (integritas ) : mempunyai Sidiq (integritas ) : mempunyai integritas kepribadian, keyakinan integritas kepribadian, keyakinan

Leadership ModelsLeadership Models• Conductor of an Conductor of an

orchestraorchestra

•Conductor as case managersConductor as case managers

•The players as the The players as the professional expertsprofessional experts

•Partiture as the clinical care Partiture as the clinical care pathwaypathway

Leadership modelsLeadership models

• Jazz Jazz PerformancePerformance

• Shared leadershipShared leadership

• Autonomous players, but play in harmonyAutonomous players, but play in harmony

• Rooms for innovation and improvisationRooms for innovation and improvisation

• Shift of leadership responsibility during the Shift of leadership responsibility during the show:show:– Start the play – maybe the drummer’s Start the play – maybe the drummer’s

responsibilityresponsibility– During the play, maybe the pianist, or others During the play, maybe the pianist, or others

will leadwill lead

Leadership modelsLeadership models

•Socker game Socker game playersplayers

• Nobody will say : Why do he take the Nobody will say : Why do he take the responsibility (ball), why not meresponsibility (ball), why not me

• Otherwise, everybody will provide support Otherwise, everybody will provide support and always get ready to accept the and always get ready to accept the responsibility, not to say: why should I ?responsibility, not to say: why should I ?

• Shifts of responsibility during the play to Shifts of responsibility during the play to gain the scores (goal). The players as gain the scores (goal). The players as “day-to-day” “second-to-second” “day-to-day” “second-to-second” leadershipleadership

• The role of the coach is performing the The role of the coach is performing the system leadership.system leadership.

Leadership modelLeadership model

• ………………..paling oyee…… ..paling oyee…… Dalang, sinden, dan Dalang, sinden, dan penabuh gamelan.penabuh gamelan.

Coordination among functions

Leadership modelsLeadership models

• Heru SuHeru Sutimbul timbul SrimulatSrimulat

He is the group managerHe performs as stewardBut …he plays as “batur”

How to get the clinicians How to get the clinicians aboard?aboard? (Berwick, 2001)(Berwick, 2001)• Shared problem: sense of urgency, basic Shared problem: sense of urgency, basic

problemsproblems• Shared vision: best practices, bold aims, Shared vision: best practices, bold aims,

innovationsinnovations• Leadership: patient-centered vision, strategy Leadership: patient-centered vision, strategy

to actionto action• Teach the “how to’s”: trainingTeach the “how to’s”: training• Professional gains: “what is in it for me?” Professional gains: “what is in it for me?”

better results, quality is fun, early adoptersbetter results, quality is fun, early adopters• Quality culture: paradigm of quality no blam, Quality culture: paradigm of quality no blam,

no fear, learning and improvement, valuesno fear, learning and improvement, values

Leadership players in the Leadership players in the service system (Berwick, 2002)service system (Berwick, 2002)

• System and/or subsystem System and/or subsystem

leadershipsleaderships

• Technical expertiseTechnical expertise

• Day to day leadershipsDay to day leaderships

Let us look at the following Let us look at the following case case • In a surgical ward, Five patients were catheterized, In a surgical ward, Five patients were catheterized,

but the catheters were not appropriately in place. but the catheters were not appropriately in place. They were not going through the urinary tract, but They were not going through the urinary tract, but to the scrotums. to the scrotums.

• The surgeon got mad and said that the nurses were The surgeon got mad and said that the nurses were not competent and professional.not competent and professional.

• The chief of ward: Sister Mary call for clinical audit. The chief of ward: Sister Mary call for clinical audit. The result of the audit is: the nurse re-use the The result of the audit is: the nurse re-use the catheter for the third time by sterilizing the catheter for the third time by sterilizing the catheter. Sterilizing for the third time damages the catheter. Sterilizing for the third time damages the catheter (becomes soft)catheter (becomes soft)

• The result of the audit: catheter can be sterilized The result of the audit: catheter can be sterilized twice only. There is a need a person who will twice only. There is a need a person who will control the uses of the re-use catheter. control the uses of the re-use catheter.

• Sister Mary, the chief of ward, She is the Sister Mary, the chief of ward, She is the one who are responsible for the one who are responsible for the accountability of the nursing service in accountability of the nursing service in the ward. She performs micro system the ward. She performs micro system leadershipleadership

• While the other nurses take turns to While the other nurses take turns to perform day-to-day leaderships to perform day-to-day leaderships to ensure that the daily activities be ensure that the daily activities be performed well.performed well.

Getting good players Getting good players signed up is easysigned up is easy

Getting them to play Getting them to play together- that’s the hard together- that’s the hard

partpart

Casey StangelCasey Stangel