Recently, I experienced what care is all about. I became a patient and noticed that my field of expertise, quality of care and patient safety, is not that easy in daily practice. In this Leadership in the Mirror, I reflect on my own experience and describe how four core values of care can hopefully guide the leadership of junior and less junior clinicians. The essay is adapted from the commencement speech I gave in June 2022 at the Faculty of Medicine at KU Leuven University and introduces a new quality framework that highlights the progressions of healthcare towards personalisation of care, with a focus on the whole person as an individual, rather than a restricted view on the patient’s disease.
- clinical leadership
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I would like to take you back in time, to the night of Saturday June 5 to 6, 2021. I was admitted late in the evening as a patient to a local emergency department. That evening I was suffering from severe abdominal pain radiating to my back. This was something that I had been experiencing for about ten years, but the pain and urge to move were never as severe as that evening. The first suspicion was kidney stones. But shortly after the nightly CT-abdomen scans with contrast were taken, it turned out that I had severe acute pancreatitis.
Now, I know what you are thinking. As clinical experts you might immediately jump to a preliminary diagnosis of alcohol abuse. Because indeed, this condition is often seen to be caused by excessive alcohol consumption. With a negative CT and ultrasound for gallstones, it is only natural to consider the second most likely cause. So as was to be expected, a young junior doctor came to my bedside the next morning and asked me how many units I drank on a regular basis. I replied: ‘About three to five.’ ‘Daily?’ she said. ‘No, per week.’ Upon which she flashed me a smile.
The next morning, the same lady came to me again and asked ‘Sir, tell me, how many units are you really drinking?’ Once again I replied with ‘Three to five’. She insisted once more that I surely must mean per day, upon which I again said that I consumed this amount per week. The very next day she came in and asked again. Subsequently I was visited by her supervising consultant. He said Kris, your story and imaging do not add up. I recommend an endoscopic ultrasound under general anaesthesia. After discussing pros and cons, we decided together to do that the next morning. The cause of the pancreatitis was discovered: microlithiases filled my gall bladder, fine stone dust, a ‘starry sky on the ultrasound’ as a radiologist called it. As I, the patient and person had reported by now several times, it turned out excessive alcohol consumption wasn’t to blame after all. Ten days later I underwent a laparoscopic cholecystectomy, after which the friendly top doctor proudly told me he had finished in 15 minutes. Timeliness is a dimension of healthcare quality after all.
I have been teaching quality and patient safety in healthcare for the past decade at Leuven University, a renowned university in Belgium. Along with doctors, nurses, managers, paramedics and support staff, I try to raise quality step by step. I am therefore pleased that quality policy will be taught to undergraduate Medicine students from this academic year onwards within our faculty. This will prepare doctors of the future more comprehensively for the many challenges ahead including the increasing expectations of patients and their kin.
Over the past period, I have learnt once again, thanks to my pancreas, what this field is really about. Quality of care! Over the past 25 years, we have paid a great deal of attention to technical quality. We developed new techniques, procedures and protocols. Knowledge has been shared internationally. I invite you to reflect on where you were 21 years ago, when the book Crossing the Quality Chasm,1 first introduced quality within six dimensions: healthcare had to be safe, efficient, effective, timely, equal for everyone regardless of race, orientation or socioeconomic status. Finally, care had to be patient-centred. In recent years, the focus has been on safety and efficiency. We obtained accreditation labels, established care pathways and quality indicators were reported publicly.2
Today we see that healthcare and quality thinking is constantly evolving in response to the ever-changing systems environment and newly posed challenges. The world has become more complex, patients and staff are raising the bar… and just as well "quality management" is asking more attention from clinicians, policy makers and academics.
Together with Peter Lachman and Paul Batalden, colleagues of the International Society for Quality in Healthcare and the Institute for Healthcare Improvement, we developed an update of the model with the six dimensions, which is now more complex.3
The main changes to this model are threefold:
First, in addition to paying attention to the six original dimensions, we raise awareness to the ecological footprint of our hospitals and primary care practices. Perhaps we could minimise our use of disposable materials and packaging by replacing them with sterilisable and reusable alternatives. Just looking at the waste mountain often left behind after surgeries, poses questions on how we can be more efficient and conscious of the waste we are producing. So let’s make an effort to dim the lights and close the tap, as we try to do at home.
Second, the original patient-centred dimension should be extended to a person-centred one, where we ask for attention not only for the patient and their relatives, but also for the healthcare provider.
The challenge for healthcare management and policy is our human capital. How do we keep our employees in top condition and motivated to keep doing their best work? My lord rector, professor Luc Sels, always reminds me of the three words that determine whether you will enjoy your job: mastery, autonomy and purpose.
And that brings us seamlessly to the third adjustment of our quality model. We need to further operationalise the person-centred dimension into four basic values for good care.
First, treating each other with dignity and respect becomes crucial in every interaction, be it between patient, loved ones and care provider or between care providers. In addition, attention should be put on a holistic frame of mind, focusing on the complete human being as a unique one-of-a-kind person. During my hospital stay I sometimes heard doctors and nurses say ‘the pancreas is calling’. This feels off. I was not just a ‘pancreas’, I was Kris, a 47-year-old man who was anxious, worried about his family and the fact that he could not take his upcoming exams. Next to these concerns, I’m also someone who loves photography, enjoys a good conversation and relaxes by watching television with his 10-year-old son or singing and dancing along with his adolescent daughter to Harry Styles, Billie Eilish, ABBA or Charlotte De Witte … With adolescents, preferences can change quickly, but one thing is certain: I was and am not just the pancreas of room 14 bed 2.
Second, I would like to provide advice to all new clinicians out there. Be aware that if you close the curtain of the patient’s room, it takes away the view but not the sound. In bed, we will still hear what you say about us, or about each other. So think dignity, respect and holism, also when you close the curtain.
A third core value is partnership. Attention to shared decision-making and co-production, like the doctor who, together with me, decided to perform the endoscopic ultrasound under general anaesthesia. Partnership between healthcare providers is equally important. Coproduction between all disciplines without unnecessary hierarchy and with the psychological safety of daring to ask the stupid question. That is the future.
Finally, in addition to dignity and respect, holism and partnership, there is a fourth basic value: empathy with kindness. Kindness is currently the buzz-word at international quality conferences. Kindness to patients and their relatives, introducing yourself clearly with your name and role before examining a patient, making eye contact, offering a heartfelt smile. Saying good morning to your colleagues, including those from all roles and levels within the department.
We have learnt that doing that extra something for the patient or for each other, what we have labelled a ‘Mangomoment’, defined as a small unexpected kind gesture, makes healthcare a little sweeter.4 Although we often underestimate the value of these small acts of kindness and leadership, implementing them is becoming an increasing challenge in our online society where everything must go fast, fast, fast.5
I have already learnt a lot from my pancreatitis. I have seen many aspects of care that could be better. However, I’ve also had the good fortune to feel what good and warm care is.
As clinicians, you have chosen a profession that many look up to. The wonderful things you can do for patients and their loved ones, including the safe, efficient, effective, timely, equal and environmentally sustainable care you will provide. You will be able to experience and witness that every day. Yes, I am grateful to the multidisciplinary team of which you are a member. But the people I am most grateful for are not the professionals who used their expertise and skills to do the correct thing, but the ones who also did the right thing by living out these four basic values. The ones that treated me with dignity and respect, they did not look at me as the pancreas in room 14 bed 2, but instead looked at me as an individual. They saw me as a partner in their quest and they were empathic and friendly, like the professor from another department, who came by every morning at a quarter past seven with his coffee in his hand and asked “and how are you?”, the board member who asked daily ‘tell me your story of the day’ and the cleaning lady who told me her story of the day. It’s in these moments that no pethidine is required. Another unforgettable moment was when a beautiful young nurse came in with blushing cheeks to ask who the handsome junior doctor was who had just visited me… Those were my Mangomoments.
You as young clinicians all have a fantastic career ahead of you. If you are at a party with your colleagues, raise the glass, have a good drink. However, if I can give you one piece of advice, it would be to drink in moderation. See, I wish for you to never go through pancreatitis. You will have to deal with difficult patients, difficult relatives and sometimes even difficult colleagues from time to time. But know that you are the first generation of post-covid physicians. Many of us know that you have not had it easy and have missed out on many things, for which we respect you tremendously. However, as was described in JAMA, there is also something called Post-Covid & Post-Traumatic Growth.6 Growth! The resilience and enduring commitment that your generation has already shown, has the potential to make our whole society stronger.
Realise that you can make a fantastic contribution to our society. Be proud of yourself and, when times are tough, think back to your impressive achievements. However, never stop being humble. Don’t take risks with your patients, because remember that pride or hubris is healthcare’s enemy. Please spread the positive message about our incredible healthcare, but never stop asking questions when you have doubts about something. Dare to address people about their actions when you don’t agree with them, but always do this in a respectful, dignified and friendly manner. It is now and for the rest of your blossoming career that you can demonstrate your leadership by setting an example to your patients and colleagues. Here is your opportunity to become the role models our healthcare needs to thrive.
Data availability statement
No data are available.
Patient consent for publication
I hereby thank the dean of the faculty of medicine KU Leuven, Prof. dr. Paul Herijgers for the invitation to give the commencement speech 2022 and a special thank you to Astrid Van Wilder for the editorial support.
Contributors KV is the main and only author of this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.