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

Nil.

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?

The context and influences of safety: An exploration of social networks, actions, and behaviour.

BACKGROUND: Safety systems are socio-cultural in nature, characterized by people, their relationships to one another and to the whole. This study aimed to (i) map the social networks of New Zealand's quality improvement and safety leaders, (ii) illuminate influential characteristics and behaviours of key network players and (iii) make recommendations regarding how networks might be optimized. METHODS: Instrumental case study was done using mixed methods. Purposeful sampling was applied to collect survey data from delegates at two national safety and quality forums (n = 85). Social network questions asked respondents who influenced their safety work. Key network players were identified and invited to participate in a semi-structured interview (n = 7). RESULTS: Key players described safety systems in humanistic terms. Safety influence was determined to be a responsive relational process. Adaptive leaders broker relationships between multiple perspectives and contexts, which is essential for safe healthcare. CONCLUSION: Influential safety approaches appreciate the human contribution to safety. Designing the health system to adapt and respond to the needs of people, teams and communities, rather than the unilateral needs of the system, is essential. Adaptive leadership will assist in achieving these aims and will likely be embraced by New Zealand health professionals.

The state of quality improvement and patient safety teaching in health professional education in New Zealand.

AIM: To investigate how quality and patient safety domains are being taught in the pre-registration curricula of health profession education programmes in New Zealand. METHODS: All tertiary institutions providing training for medicine, nursing, midwifery, dentistry, pharmacy, physiotherapy, dietetics and 11 other allied health professions in New Zealand were contacted and a person with relevant curriculum knowledge was invited to participate. Interviews were conducted using a semi-structured interview guide to explore nine quality and safety domains; improvement science, patient safety, quality and safety culture, evidence-based practice, patient-centred care, teamwork and communication, leadership for change, systems thinking and use of information technology (IT). Transcribed data were extracted and categorised by discipline and domain. Two researchers independently identified and categorised themes within each domain, using a general inductive approach. RESULTS: Forty-nine institutions were contacted and 43 (88%) people were interviewed. The inclusion and extent of quality and safety teaching was variable. Evidence-based practice, patient-centred care and teamwork and communication were the strongest domains and well embedded in programmes, while leadership, systems thinking and the role of IT were less explicitly included. Except for two institutions, improvement science was absent from pre-registration curricula. Patient safety teaching was focused mainly around incident reporting, and to a lesser extent learning from adverse events. Although a 'no blame' culture was articulated as important, the theme of individual accountability was still apparent. While participants agreed that all domains were important, the main barriers to incorporating improvement science and patient safety concepts into existing programmes included an 'already stretched curriculum' and having faculty with limited expertise in these areas. CONCLUSIONS: Although the building blocks for improving the quality and safety of healthcare are present, this national study of multiple health professional pre-registration education programmes has identified teaching gaps in patient safety and improvement science methods and tools. Failure to address these gaps will compromise the ability of new graduates to successfully implement and sustain improvements.

Procedural and examination skills of first-year postgraduate doctors do not improve with clinical experience alone.

AIM: To look for factors mitigating for or against first-year postgraduate house surgeons (PGY1) gaining experience in examination and procedural skills. METHODS: Ten PGY1s at Hutt Hospital (Lower Hutt, New Zealand) filled in self-reporting questionnaires to assess the impact of 6 months of on-the-ward training on their baseline competence in clinical examination and procedural skills. Opportunities for skills acquisition, and barriers (if any) towards gaining experience were assessed. RESULTS: The small numbers of PGY1s limit generalisation of the findings, however certain trends are evident. Improvements were seen in commonly carried out procedures, though gaps in these areas could still be present after 6 months. Commonly performed examinations such as auscultation of heart sounds and murmurs improved, though in the area of intimate exams and fundoscopy there was little confidence gained. Log diaries show that opportunities for practice of clinical procedures were limited and that regular weekly practice only occurred with arterial blood gases and intravenous (IV) cannulation. A discussion group analysis revealed that competition with other PGY1s for the limited number of opportunities and the random occurrence of practical procedures were barriers to gaining skills. CONCLUSIONS: Clinical on-the-ward experience is not always enough to gain clinical skills and perhaps alternate means such as simulation need to be explored.

Procedural and examination skills of first-year house surgeons: a comparison of a simulation workshop versus 6 months of clinical ward experience alone.

AIM: To assess the impact of a simulation workshop prior to starting clinical work, on the practical and examination skills of first-year postgraduate house surgeons (PGY1s) starting at Hutt Hospital (Lower Hutt, New Zealand) and to compare this to 6 months of clinical ward experience alone. METHODS: Self-reporting questionnaires on clinical examination, and procedural skills were used to compare a 'control' group of 10 PGY1s who had 6 months on-the-ward training only, to a second 'intervention' group of 10 PGY1s who underwent training in a simulation skills workshop prior to starting clinical work. RESULTS: The small numbers of PGY1s limit generalisation of the findings, however certain trends are evident. The skills workshop improved self-rated competence scores in clinical procedural skills, and was significant for lumbar punctures (LP) and spirometry. Scores were comparable to those of 6 months of clinical exposure alone. Self-reported confidence scores in picking up abnormalities of clinical examination improved in all areas taught and were significant for fundal, prostate, and rectal abnormalities. Scores exceeded those achieved with 6 months of clinical exposure. CONCLUSIONS: The findings suggest that a skills workshop prior to starting clinical work may approximate 6 months of clinical experience and improve baseline procedural and examination skills.