Leadership

Increasing age is associated with reductions in kidney function and increasing polypharmacy. Most medicines are eliminated through the kidney, meaning older patients are at risk of medication accumulation and toxicity. This scoping review synthesised: (1) the prevalence at which older patients with reduced kidney function in primary care are exposed to inappropriate prescribing; (2) its associated harms; (3) the reasons for this occurring; and (4) the interventions used to improve prescribing practices.

This scoping review searched ‘Medline’, ‘Embase’, ‘PsycINFO’, ‘CINAHL’ and ‘Web of Science’ for publications before October 2024. References were managed on EndNote V.X5 and thematic data analysis was undertaken on Microsoft Excel. Common themes were identified, summary statistics were calculated and insights were summarised through a narrative technique.

43 relevant studies explored the scale of inappropriate prescribing, estimating prevalences of patient exposure ranging from 0.6% to 49.1% (median 24.9%). Five studies explored the associated harm from inappropriate prescribing, but only one study assessed harm as a primary outcome. Eight studies that assessed difficulties in following prescribing guidelines in reduced kidney function suggested that a lack of awareness and trusted guidelines are fundamental problems. While 13 studies evaluated interventions for improving prescribing in reduced kidney function, only two demonstrated evidence of effectiveness and only one intervention was theoretically informed.

Despite significant heterogeneity in study characteristics, it is clear that the prevalence of inappropriate prescribing for older people is uncomfortably high. There is a lack of evidence linking this to associated adverse outcomes, as well as identifying the causative issues driving this behaviour and the preventative interventions that could prevent harm.

Student-run clinics (SRCs), in which medical and health professions students take responsibility for operational and logistics management of charitable clinics,2 are a powerful expression of service-based learning: students hone clinical and administrative skills while communities receive essential medical services that might otherwise be unavailable. Yet over the past 20 years, these clinics have begun globalising^2–5 and increasing in complexity.5 This is happening within a landscape of limited evidence,^{5 6} growing concerns about ethics and substandard care,^7–13

Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.

The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.

Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.

Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals.

Physicians in participating programmes.

Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.

The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.

The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of ‘Organisational learning’ increased significantly from 35% (26%) to 54% (23%), p=0.00, ‘Response to error’ 37% (24%) to 52% (22%), p=0.025 and ‘Communication about error’ 36% (28%) to 64% (42%), p=0.016 after implementation.

Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.

NCT05365516.

To capture experiences of people self-reporting harm and contrast responses and actions between those who do or do not take formal action.

Semi-structured qualitative interview study.

People self-reporting harm experienced in the National Health Service (NHS) or their family/friends identified from a general Great British population survey.

49 participants.

There were commonalities in experiences after harm whether formal action (including making a formal complaint or litigation) was taken or not. Many participants reported raising concerns informally with NHS staff, trying to access explanations or support, but were usually unsuccessful. Decision-making on action was complex. There were multiple reasons for not pursuing formal action, including fears of damaging relationships with clinicians, being occupied coping with the consequences of the harm or not wanting to take action against the NHS. NHS advocacy services were not regarded as helpful. Knowledge of how to proceed and feeling entitled to do so, along with proactive social networks, could facilitate action, but often only after people were spurred on by anger and frustration about not receiving an explanation, apology or support for recovery from the NHS. Those from marginalised groups were more likely to feel disempowered to act or be discouraged by family or social contacts, which could lead to self-distancing and reduced trust in services.

People actively seek resolution and recovery after harm but often face multiple barriers in having their needs for explanations, apologies and support addressed. Open and compassionate engagement, especially with those from more marginalised communities, plus tailored support to address needs, could promote recovery, decrease compounded harm and reduce use of grievance services where other provision may be more helpful.

The 2017 Paediatric Research in Emergency Departments International Collaborative (PREDICT) Bronchiolitis Knowledge Translation (KT) Study, a cluster randomised trial in 26 Australasian hospitals, found targeted interventions provided over one bronchiolitis season effectively de-implemented five low-value practices (salbutamol, glucocorticoids, chest radiography, antibiotics and epinephrine) by 14.1% (adjusted risk difference, 95% CI 6.5% to 21.7%; p<0.001). A 2-year follow-up study found de-implementation was sustained. This process evaluation aimed to identify factors that influenced sustainability of de-implementation of these five low-value practices in PREDICT Bronchiolitis KT Study intervention hospitals and examine fidelity and/or adaptation of the targeted interventions over 4 years post intervention delivery (sustainment).

Semistructured qualitative interviews were conducted, over 2021 and 2022, with a purposive sample of emergency department (ED) and paediatric inpatient clinicians. Data were analysed thematically into facilitators and barriers using the Consolidated Framework for Sustainability Constructs in Healthcare (CFSCH). The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies was used to explore fidelity and adaptation.

50 clinicians (nurses: n=26; doctors: n=24) from 12 intervention hospitals were interviewed. Eight themes were identified and mapped to three CFSCH domains: (1) organisational setting; (2) initiative design and delivery and (3) people involved. Facilitators were a culture of evidence-based practice, ongoing multimodal education, strong clinical leadership as unofficial champions and the previous effectiveness of the PREDICT Bronchiolitis KT Study interventions. Barriers were lack of paediatric trained ED staff, assumptions by senior clinicians that junior doctors can provide evidence-based bronchiolitis management, bronchiolitis not a current improvement priority and lack of bronchiolitis education sessions. Use of the targeted interventions reduced over time and, when used, was adapted locally.

This study provides insights into factors influencing the sustainability of de-implementation of low-value care in acute care settings. Fostering an evidence-based practice culture, supported by senior leadership and ongoing multimodal education, supports sustainability of improvements in this setting.

Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Healthcare education must evolve to address one of the greatest public health challenges we face in delivering care that allows future generations to meet their own healthcare needs. The integration of sustainable healthcare practices into medical education is a key step towards environmentally responsible healthcare delivery. Educational leadership plays a crucial role in transforming curricula in a way that prepares our future workforce to better understand and contribute to addressing emerging healthcare challenges.

The integration of sustainable healthcare principles into primary care education requires strategic leadership to navigate institutional complexities and ensure meaningful change.

Our team at Imperial College London, comprising both faculty members and student partners, examined the undergraduate primary care curriculum, drawing on the Medical Schools Council sustainable health framework and practical case studies, with the goal of incorporating sustainable healthcare principles.

In this paper, we share the process and our framework for integration of sustainable healthcare principles into our curriculum. For educators looking to embark on similar transformations, we share our reflections on the challenges, our solutions and top tips from our experience.

We hope our experience and reflections will give educational leaders and institutions a roadmap to prepare future doctors for the challenges of delivering environmentally sustainable healthcare.

This article evaluates the impact of the allied health professions (AHPs) leadership within the Oxleas NHS Foundation Trust AHP Preceptorship Programme on early career professionals. Preceptorship, defined as structured support during career transitions, is recognised as crucial for developing confidence and autonomy among healthcare workers. While extensive research supports the benefits of preceptorship in nursing, limited evidence exists for AHPs.

To explore the effects of the Oxleas AHP Preceptorship Programme on early career AHPs.

Using a mixed-methods approach, the study surveyed AHPs enrolled in the programme to explore its effects on retention, confidence, continuing professional development and AHP leadership support.

Key findings include the positive influence of a community of practice in reducing feelings of isolation and creating a sense of belonging, with 92.3% of participants reporting that the programme contributed to their retention. The leadership of AHP-specific preceptorship leads, external to clinical teams, was identified as pivotal in providing tailored support.

Despite its limitations, including a small sample size, the study highlights the value of a dedicated AHP preceptorship programme in improving early career support and development. The findings emphasise the importance of structured support for AHPs and suggest that further research is needed to explore the broader impact of such programmes across different healthcare settings.

Effective leadership is necessary across healthcare systems to ensure person-centred safe and effective care delivered by a workforce that is empowered to flourish. Similarly, research is essential to underpin evidence-based clinical practice to optimise the quality of care provided. It is important to develop the capacity and capability of the healthcare workforce to become effective clinical and research leaders; however, there are challenges. The creation of fellowship programmes such as the Director of Nursing and Allied Health Professions (AHPs) Fellowship was inspired by this need to support the skill development of these clinicians.

To report the experiences of nurses, midwives and AHPs (NMAHPs) completing the Director of Nursing and AHP Fellowship programme; a 1-year development programme focussing on leadership, research and quality improvement. To describe the broader impact of the fellowship on NMAHP leadership. To consider the implications of the fellowship on the fellows and the wider organisation and healthcare system.

The evaluation consisted of surveys and focus groups with fellows and mentors supporting them. These included clinical mentors, academic mentors, quality improvement advisors and improvement partners.

The following four themes were identified from the survey and focus group data: leadership development, networking and relationships, collaborative working and communication.

Fellows’ development within the programme translated into multiple clinicians securing new job roles in clinical leadership positions, and key learning has been incorporated into future iterations of the programme.

High-quality patient care relies on the support of research and implementation of evidence-based practice. Investment in the leadership of clinicians is key to promoting a culture of high-quality patient care and evidence-based practice. The Director of Nursing and AHP fellowship contributes to the development of nurses and AHPs implementing national priorities optimising patient care.

Healthcare leaders’ attention is stretched in healthcare organisations due to the large number of issues that they must respond to. Effectively attending to legitimate attentional demands, which involves deprioritising less important demands, is a defining feature of competent leadership.

This piece summarises key findings from research in the attention-based view, integrating its key findings with insights from conversations with healthcare leaders in executive education settings.

The attention-based view develops three premises that explain how organisations structure and channel attention in ways that shape what organisations do: (1) given the scarcity of attention, where leaders focus their attention shapes what they do, (2) people’s attention is situated (eg, in the work they do and the meetings they attend) and (3) organisations structure roles and communication channels in ways that shape who pays attention to what. Five lessons drawn from these premises are that leaders should: create an architecture that will address critical issues; be mindful of attentional networks; cultivate opportunities for voice; create attentional capacity and embrace creating attentional coherence as perhaps the core task of leadership.

Given the diverse issues, people and demands that characterise contemporary healthcare organisations, effectively focusing attention on what matters is essential if organisations are to function well. A critical task for leaders is to prioritise for themselves and for everyone in their organisation the key issues that should be fundamental to, and hence merit attention from, everyone.

English National Health Service (NHS) Trust Hospital board members are collectively responsible for ensuring high-quality care and organisational performance. Integrated performance reports support boards by tracking key performance indicators, supporting quality improvement and providing assurance to NHS England. Statistical Process Control (SPC) charts can support leaders to distinguish signals (special cause variation) from natural fluctuations in data (common cause variation). The Making Data Count (MDC) Programme has effectively increased the use of SPC methodology in NHS Trusts. This study explored board members’ experiences of MDC and SPC, and SPC use in public board meetings.

14 semistructured interviews were conducted with executive directors and non-executive directors across five NHS Trusts. 13 board meetings were observed, and quantitative data were coded and extracted to evaluate if SPC outputs supported assurance and decision-making.

Board members generally expressed positive views towards the MDC Programme and SPC, recognising their value as a supporting tool to monitor interventions, guide investigations and highlight performance issues. Board members noted insufficient training and instances of inappropriate use or overuse of SPC charts. The observations showed that of the 99 statements made by board members, 71 (72%, 95% CI 62% to 88%) were supported by a relevant SPC chart. Unsupported or unverifiable claims made by executive directors were more likely to be statements of improvement (p=0.054). Six decisions were made for further investigative work, and all six were supported by an SPC chart.

MDC SPC charts are seen as a helpful tool, and their outputs are used reasonably effectively in a board environment. However, consistent and repetitive training is necessary to optimise SPC use and prevent misuse or overuse. Training may only partially prevent misuse of SPC charts due to managers’ tendency to try to demonstrate improvement to other staff members.