Doctors as leaders and governors.

Doctors working in healthcare are operating in complex adaptive systems that are unpredictable and have complex problems requiring new and unique skills. The Medical Council of New Zealand has specified a scope of practice for doctors involved in health system leadership, and there are several programmes of study that exist in Aotearoa New Zealand (Aotearoa NZ) to gain skills in this domain. It is crucial at this time of change that we understand why doctors as leaders and governors improve outcomes, the importance of training future medical leaders and how we validate these skills as well as the environment in which they operate. As we begin to reorganise our health system, the question we ask is when will we organise our system to recognise, develop and value these skills?

Leadership and governance-what is needed to deliver the Aotearoa New Zealand health reforms.

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Suitability of emergency department attenders to be assessed in primary care: survey of general practitioner agreement in a random sample of triage records analysed in a service evaluation project.

OBJECTIVES: To assess the proportion of emergency department (ED) attendances that would be suitable for primary care and the inter-rater reliability of general practitioner (GP) assessment of primary care suitability. DESIGN OF STUDY: Survey of GPs' agreement of suitability for primary care on a random anonymised sample of all ED patients attending over a 1-month period. SETTING: ED of a UK Hospital serving a population of 600 000. METHOD: Four GPs independently used data extracted from clinical notes to rate the appropriateness for management in primary care as well as need for investigations, specialist review or admission. Agreement was assessed using Cohen's κ. RESULTS: The mean percentage of patients that GPs considered suitable for primary care management was 43% (range 38-47%). The κ for agreement was 0.54 (95% CI 0.44 to 0.64) and 0.47(95% CI 0.38 to 0.59). In patients deemed not suitable for primary care, GPs were more likely to determine the need for specialist review (relative risks (RR)=3.5, 95% CI 3.0 to 4.2, p<0.001) and admission (RR=3.9, 95% CI 3.2 to 4.7, p<0.001). In patients assessed as suitable for primary care, GPs would initiate investigations in 51% of cases. Consensus over primary care appropriateness was higher for paediatric than for adult attenders. CONCLUSIONS: A significant number of patients attending ED could be managed by GPs, including those requiring investigations at triage. A stronger agreement among GPs over place of care may be seen for paediatric than for adult attenders. More effective signposting of patients presenting with acute or urgent problems and supporting a greater role for primary care in relieving the severe workflow pressures in ED in the UK are potential solutions.

Laboratory sample turnaround times: do they cause delays in the ED?

OBJECTIVES: Blood tests are requested for approximately 50% of patients attending the emergency department (ED). The time taken to obtain the results is perceived as a common reason for delay. The objective of this study was therefore to investigate the turnaround time (TAT) for blood results and whether this affects patient length of stay (LOS) and to identify potential areas for improvement. METHODS: A time-in-motion study was performed at the ED of the John Radcliffe Hospital (JRH), Oxford, UK. The duration of each of the stages leading up to receipt of 101 biochemistry and haematology results was recorded, along with the corresponding patient's LOS. RESULTS: The findings reveal that the mean time for haematology results to become available was 1 hour 6 minutes (95% CI: 29 minutes to 2 hours 13 minutes), while biochemistry samples took 1 hour 42 minutes (95% CI: 1 hour 1 minute to 4 hours 21 minutes), with some positive correlation noted with the patient LOS, but no significant variation between different days or shifts. CONCLUSIONS: With the fastest 10% of samples being reported within 35 minutes (haematology) and 1 hour 5 minutes (biochemistry) of request, our study showed that delays can be attributable to laboratory TAT. Given the limited ability to further improve laboratory processes, the solutions to improving TAT need to come from a collaborative and integrated approach that includes strategies before samples reach the laboratory and downstream review of results.

Enhancement of medical interns' levels of clinical skills competence and self-confidence levels via video iPods: pilot randomized controlled trial.

BACKGROUND: Designing and delivering evidence-based medical practice for students requires careful consideration from medical science educators. Social Web (Web 2.0) applications are a part of today's educational technology milieu; however, empirical research is lacking to support the impact of interactive Web 2.0 mobile applications on medical educational outcomes. OBJECTIVES: The aim of our study was to determine whether instructional videos provided by iPod regarding female and male urinary catheter insertion would increase students' confidence levels and enhance skill competencies. METHODS: We conducted a prospective study with medical trainee intern (TI) participants: 10 control participants (no technological intervention) and 11 intervention participants (video iPods). Before taking part in a skills course, they completed a questionnaire regarding previous exposure to male and female urinary catheterization and their level of confidence in performing the skills. Directly following the questionnaire, medical faculty provided a 40-minute skills demonstration in the Advanced Clinical Skills Centre (ACSC) laboratory at the University of Auckland, New Zealand. All participants practiced the skills following the demonstrations and were immediately evaluated by the same faculty using an assessment rubric. Following the clinical skill evaluation, participants completed a postcourse questionnaire regarding skill confidence levels. At the end of the skills course, the intervention group were provided video iPods and viewed a male and a female urinary catheterization video during the next 3 consecutive months. The control group did not receive educational technology interventions during the 3-month period. At the end of 3 months, participants completed a follow-up questionnaire and a clinical assessment of urinary catheterization skills at the ACSC lab. RESULTS: The results indicate a decline in skill competency over time among the control group for both male and female catheterizations, whereas the competency level was stable among the experimental group for both procedures. Interaction results for competency scores indicate a significant level by group and time (P = .03) and procedure and group (P = .02). The experimental group's confidence level for performing the female catheterization procedure differed significantly over time (P < .001). Furthermore, confidence scores in performing female catheterizations increased for both groups over time. However, the confidence levels for both groups in performing the male catheterization decreased over time. CONCLUSIONS: Video iPods offer a novel pedagogical approach to enhance medical students' medical skill competencies and self-confidence levels. The outcomes illustrate a need for further investigation in order to generalize to the medical school population.

Doctors as teachers: what do they think?

AIMS: To assess the views of senior medical officers (SMOs) at Auckland City Hospital (Auckland, New Zealand) in the areas of teaching, supervision, and feedback for resident medical officers (RMOs). METHODS: All SMOs at Auckland City Hospital were asked to complete a survey regarding postgraduate medical education. Data was then collected and entered into a Microsoft Excel spreadsheet and was statistically analysed. P values were calculated using Chi-squared testing and Fisher's exact test. RESULTS: 237/730 surveys were received giving a response rate of 32.1%. There was a statistically significant difference between SMOs self-rated competence (SRC) and their perceived required competence (RC) in the domains of 'Teaching' (SRC=3.74; RC=4.36 - p<0.0001), 'Supervision' (SRC=3.78; RC=4.37 - p<0.0001) and 'Feedback' (SRC=3.55; RC=4.36 - p<0.0001). Ratings were done on a 5-point Likert scale where a score of 1 was poor and a score of 5 was excellent. SMOs were then asked whether they required further information around various postgraduate medical education topics. 79.9% requested information on 'managing the poorly performing RMO'. Dual employees (i.e. SMOs employed by both the University of Auckland and Auckland City Hospital) were more likely to have attended a 'Teach the Teacher Course' (66.6%) than those SMOs only employed by Auckland City Hospital (43.3%, p=0.0083). A number of factors were also identified as barriers to conducting effective teaching. These included a lack of time, high clinical workload, poor continuity between trainees and SMOs, and a lack of recognition for teaching roles of SMOs. CONCLUSIONS: Our study showed a gap between the perceived self-rated competence and required competence in SMOs in their role as teachers. There is also a perceived gap in support for SMOs in their role as teachers and the expected educational outcomes for trainees within the New Zealand clinical setting.

Passing the buck: clinical handovers at a tertiary hospital.

AIMS: To survey house officers and nurses regarding timing, structure and content of clinical handover and compare these results. Secondary aims included the development of an 'on-call' sheet and the development of guidelines for handovers from the results collated. METHODS: 60 house officers (post graduate years 1-3) and 60 nurses working at Auckland City Hospital were asked to complete a survey covering various aspects of clinical handover in their current department. RESULTS: This study showed that nurses have more handovers than house officers in a 24-hour period. Nurses had an average of 3.2 handovers compared with the 1.2 handovers reported by house officers. Nurses rated their handovers as 'good', with a mean score of 7.8/10, while house officers rated the standard of their handovers as only 'average', with a mean score of 5.1/10. This was noted to be a statistically significant difference with a p-value of 0.01. Our study found that 60.9% of house officers reported that they had encountered a problem at least seven times in their most recent clinical rotation that they could directly attribute to a poor handover. However, nurses reported a much lower incidence of problems relating to poor handover standards, with 37.5% of this group indicating that they had experienced a clinical problem with a patient related to a nursing handover. CONCLUSIONS: In this study, we identified that health professionals perceive that clinical problems can be attributed to poor clinical handover. The majority of respondents in the study felt that an effective handover system should include a set location for handover, a standardised 'on-call' sheet and training related to handovers.