Leadership in Surgery for Public Sector Hospitals in Jamaica: Strategies for the Operating Room
Shamir O Cawich, MBBS, DM; Hyacinth E Harding, MBBS, DM; Ivor W Crandon, MBBS, FRCS; Clarence D McGaw, MBBS, DM; Alan T Barnett, MBBS, DM; Ingrid Tennant, MBBS, DM; Necia R Evans, BSc; Allie C Martin, MBBS, DM; Lindberg K Simpson, MBBS, DM; Peter Johnson, MBBS, DM
Perm J 2013 Summer; 17(3):e121-125
The barriers to health care delivery in developing nations are many: underfunding, limited support services, scarce resources, suboptimal health care worker attitudes, and deficient health care policies are some of the challenges. The literature contains little information about health care leadership in developing nations. This discursive paper examines the impact of leadership on the delivery of operating room (OR) services in public sector hospitals in Jamaica.F
Delivery of OR services in Jamaica is hindered by many unique cultural, financial, political, and environmental barriers. We identify six leadership goals adapted to this environment to achieve change.
Effective leadership must adapt to the environment. Delivery of OR services in Jamaica may be improved by addressing leadership training, workplace safety, interpersonal communication, and work environment and by revising existing policies. Additionally, there should be regular practice audits and quality control surveys.
Several publications refer to differences in health care delivery systems between developed countries and those that are still developing.1-6 Unique problems in the Caribbean have been explored, particularly underfunding, limited support services, scarce resources, suboptimal attitudes of health care workers (HCWs), and inadequate health care policies. However, little has been published about health care leadership in developing nations. A deficiency in any of these areas can cripple the delivery of surgical services; this is probably most evident in the daily function of the operating room (OR).
Operating Room Services In Jamaica
Jamaica is the largest of the anglophone Caribbean islands, with a population of 2,709,281 persons.7 The government of Jamaica offers free basic health care to residents through a network of public sector hospitals across the island.2
Two public sector hospitals, Kingston Public Hospital and University Hospital of the West Indies, serve an estimated 826,880 persons residing in and around Kingston, the capital of Jamaica.7 These facilities also act as tertiary referral centers for the entire island. Together, they have a combined capacity of 194 general surgical beds, 13 general operating theaters, and 24 multidisciplinary intensive care unit beds. However, this capacity is often unrealized because of many deficiencies in health care system funding, staffing, and management.
Health Care System Funding
According to the latest available figures from the government of Jamaica, only 4% of the national budget is allocated to health care.2 Apart from donations from nongovernmental organizations, there is no source of financing for public sector health care. This creates many barriers to surgical care and optimal functioning of ORs, including scarcity of monitoring equipment, ventilators, operating tables, personal protective equipment, drugs, surgical disposables, and hardware.
Termination of the public sector health care system is not an option, because the majority of the population cannot access private health care.1 Therefore, the public sector health care delivery system continues to function, with impromptu solutions bypassing problems as they arise. This commonly results in cancellation of OR lists; postponement of treatment of major cases; and HCWs working without personal protective equipment or performing operations with insufficient high-dependency care, intensive care unit backup, blood products, and support services.
Health Care System Staffing
The University of the West Indies (UWI) offers undergraduate and postgraduate medical education in the region.8 UWI trains almost all categories of HCWs, gearing them for independent practice in the anglophone regions of the Caribbean. A basic degree from UWI is generally accepted as the minimal qualification for licensure in these countries. Non-UWI medical graduates are required to pass licensing examinations before being granted practicing privileges in the region.
Despite admission of more than 300 medical trainees at UWI's Mona Campus in Jamaica for the 2012 academic year,9 there is still a shortage of trained personnel. This is because of the well-documented problem of emigration to developed nations.10-12 The entire Caribbean is plagued by the brain drain phenomenon: it is reported that 70% to 90% of educated persons end up emigrating to North America.13-14 Plummer et al2 reported that the attrition rate for nurses from anglophone Caribbean was 8% per annum and was primarily caused by emigration. But the phenomenon affects all categories of HCWs, making it difficult to retain high-quality staff within health care delivery systems.
Health Care System Management
Health care system management is a complex science that requires oversight of institutional resources and professional groups to promote the health of the population. Jamaica's public sector health care system has several managerial positions and titles. Individuals appointed to these positions are given control over institutional resources in order to direct health care delivery.
One of the problems in small developing nations is that the cadre of candidates is small. To compensate for this, experienced staff members are often selected to fill formal management posts on the basis of seniority rather than formal training in management of health care systems. Because they lack formal training, persons appointed to managerial positions are frequently unequipped to effectively steer ailing health care systems.
A unique combination of factors strains the public sector health care delivery system in Jamaica, making it very different from those in developed nations. Although the good work performed despite deficiencies is not to be discounted, there is room to improve surgical care in this setting.
A discussion of all barriers to surgical care delivery in public sector hospitals in Jamaica is beyond the scope of this article. We have chosen to focus on an area that has not been addressed in the literature: attributes of good leadership that are needed in this environment. More specifically, because the OR is the area most affected in the delivery of surgical services, we focus on leadership for the OR in public sector hospitals. In this context, we refer to a leader as any person or group who has the vision and influence to empower a group to work together for a common goal.
Several authors have defined leadership goals that must be observed in business settings.15-16 We review six leadership goals, modifying them to the context of health care delivery in the ORs at public sector hospitals in Jamaica (see Sidebar: Leadership goals in the context of a Caribbean health care system).
Mandate Leadership Training
Health care management is a complex science. Physicians and nurses are not equipped for it on the basis of experience alone. Coordinating the OR is particularly difficult because it must function with existing, usually outdated equipment; few basic supplies; and limited financial resources.
This requires formal training in management. Effective leaders recognize that they cannot rely on business principles alone15 but must win cooperation from their staff through strong leadership.10 To do this, leaders must master their own personal interactions. They must not rely on coercive power (influence through fear or the ability to punish employees), which does not promote desired actions.16 Instead, leaders should rely more on charisma power (influence through force of character16).
Because of the small cadre of candidates in Jamaica, leaders have been traditionally assigned to their roles on the basis of experience, often without formal training in management techniques. In addition, performance auditing is not prioritized because of a combination of political influences, resource scarcity, and financial constraints that plagues most developing Caribbean nations. Insufficient auditing is also rationalized based on the need to channel scarce resources to address other well-documented inadequacies of health care delivery systems.1-5
Many steps could be taken at an institutional level to improve the current situation. First, leaders must be chosen on the basis of their training in health care management instead of the traditional requisites of seniority, experience, or political affiliation. Otherwise, suboptimal leadership qualities are perpetuated. Instead of solving problems, ineffective leaders may erect further barriers, from low morale among HCWs to flawed decision making. Ongoing development is critical; continuing education should be mandatory for persons occupying formal leadership roles. And auditing and evaluation of leadership roles is urgently needed. Leaders must be held accountable for their performance.
Institutions should also be familiar with their human resources so as to identify informal leaders10 who are not in official management posts but use their own micro-organizational skills to overcome existing barriers to service delivery. Informal leaders should be identified and nurtured so that they maintain interest in and contribute to the health care system.
Commit to Policy Development
Policy development is an important exercise that lays the foundation for successful functioning of ORs. Our leaders are charged with ensuring that OR policies and practice guidelines are based on the best available evidence.17-20 Although most clinical data come from high-volume centers in developed nations, leaders have the responsibility to analyze data and interpret them in context to tailor policies for the environment of their ORs.21
Many authors have detailed the inadequacies of policies at public sector hospitals in Jamaica. McGaw et al5 reviewed existing OR guidelines at a tertiary referral hospital in Jamaica and noted that some practice guidelines were not evidence based. Specifically, they pointed to the requirement for routine face mask use and the requirement to change OR attire at each exit and reentry,5 despite evidence suggesting that these measures are not necessary.22-25
The most important example of failed policy is the failure to implement proven safety measures in the public sector ORs in Jamaica. Consider the universal regulatory standards developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicare and Medicaid Services (CMS).26-27 To be accredited by the JCAHO/CMS, an institution must comply with a three-tiered OR checklist that includes preoperative verification of procedure and background information; marking of operation sites; and an official team meeting to confirm patient identity and the planned procedure.26,27 A survey of public sector hospital ORs in Jamaica revealed that neither JCAHO/CMS protocols nor similar practices are routinely followed.
Another point to consider is that Jamaica's health care delivery system is grossly underfunded. Basic supplies that are taken for granted in developed nations (eg, hand soap, personal protective equipment, OR scrubs, surgical aprons, surgical disposables, puncture-resistant sharp disposal containers, consistent water supply, and uninterrupted electricity supply) are not routinely available at Jamaica's public sector hospitals.1-6 After several decades of constantly facing these barriers, OR staff have become used to functioning in a crisis mode.
A critical leadership goal is to change this culture by developing well-thought-out policies that proactively steer surgical services using existing resources while accounting for barriers to implementation. Often, this requires making difficult decisions on the basis of the appropriate allocation of scarce resources. For example, leaders could either lobby for the state to cease full funding of health care or introduce policy stating that the public sector health care system will not provide modern services such as laparoscopy, despite their proven benefits. Although there is rationale for policy revision, these changes would be unpopular and might have negative repercussions for leaders who implement them.
It may be time to establish a regional body to oversee standards at health care facilities in the Caribbean, similar to the function of the JCAHO. The regional body could commission local studies to provide good quality local or regional data that would then be used to tailor policies.
Prioritize Workplace Safety
The government of Jamaica has legislation in place mandating employers to ensure that workplace environments are safe for employees.28 Safety is especially important in the OR, where HCWs may be exposed to needlesticks, body fluid splashes, blood, and dangerous infections. It is a reasonable expectation that employers ensure employee safety.29
Several breaches of this expectation occur in Jamaica. For example, personal protective equipment, such as waterproof aprons, safety goggles, adequate sharps disposal systems, and properly fitting gloves, is not routinely available. Many times, HCWs simply endure without these in the interest of patient care. This then creates the perception that such conditions are the norm, and the need for change is trivialized. In addition to placing HCWs at unnecessary risk, these circumstances create division between leaders and HCWs, who perceive a lack of concern for their well-being.
Leaders should be made sensitive to the fact that creating a safe workplace is one of their key responsibilities. Even though the system has traditionally worked without an emphasis on HCW safety, the time for change is here. Change must be a priority. The appropriate resources should be allocated to make protective equipment available.
Optimize Communication Strategies
Several groups work in the OR to complete procedures that ultimately benefit patients. Communication, the main tool to achieve this goal, is made difficult in any OR where tenuous personal relationships, poor communication, human conflict, or flawed decision making exist.30,31 These problems are magnified in Jamaica, where public sector health care delivery systems are perpetually in crisis mode and staff must constantly adapt their routines.
Previous surveys in Jamaica identified inappropriate communication (lack of communication and autocratic leadership styles) between leaders and HCWs as one of the main causes of workplace contention.5 Autocratic leadership styles undermine OR function by creating animosity between leaders and HCWs, by fostering negative attitudes, and by reducing productivity.5 This is compounded if HCWs disagree with policy, lack confidence in policy developers, or expect poor outcomes.15,19,32,33 All these issues can be resolved with dialogue.
Autocratic leadership styles are no longer appropriate in modern health care systems. Leaders must engage HCWs in constructive dialogue, relying on charisma power more than coercive power. This may be achieved by forming common interest groups, for example a theater-users committee that incorporates HCWs, giving them a stake in the organization. Regular meetings can give leaders and HCWs a forum to discuss problems and propose solutions.
Nurture a Healthy Work Environment
Success of the public sector health care system hinges on retaining trained, competent, and motivated staff. Unfortunately, the majority of educated persons emigrate from Jamaica.13,14 Questionnaire surveys in the public sector health care systems have revealed that dissatisfaction with the workplace is the main reason HCWs consider emigration from Jamaica, followed by insufficient work-related rewards.5
This is a multifactorial issue, but it lends itself to analysis with Abraham Maslow's hierarchy of needs theory.34 After an individual's most basic physiologic and safety needs are met, the next to be satisfied is belonging (the human desire to be accepted and appreciated by others). This becomes important in the OR, where personnel from many disciplines (eg, nurses, scrub technicians, anesthetists, and surgeons) and at different training levels (eg, house officers, residents, and consultants) interact on a daily basis. Tenuous personal relationships, poor communication, and human conflict can produce hostile environments30,31 not conducive to workplace satisfaction.
Identifying these problems and promoting healthy relationships among OR staff and between leaders and subordinates is an important leadership responsibility. Leaders should strive for fairness in the workplace and nurture freedom of expression while avoiding racial, class, and gender discrimination. The JCAHO/CMS universal regulatory standards26 may be good policies to adopt. The official team briefing could be a framework for structured, healthy personal interactions that foster a team approach and a positive environment.
Fredrick Herzberg adapted Maslow's theory to the workplace35 and suggested that employee motivation depends on reward/recognition (corresponding to the ego-status need identified by Maslow34) and a sense of achievement, satisfaction, and self-fulfillment based on one's contributions (similar to the self-actualization need Maslow identified34).
There are several ways to satisfy HCWs' ego-status needs. Leadership theories discuss organizational reward power, where leaders have administrative control over institutional resources that allow them to reward good service.16 Jamaica does not have the financial resources to allow promotions or bonuses as reward power, but leaders can still use extrinsic motivators as simple as managerial praise, recognition ceremonies, or even increased autonomy on the job. Leaders should harness these subtle institutional reward powers to improve staff motivation.
We can empower HCWs with a sense of self-worth (self-actualization) through continuing medical education. McGaw et al5 reported that 20% of Jamaican HCWs felt inadequate in their knowledge of OR safety practices. Formal scholarships or financial aid may not be feasible in the current economic climate, but there are several other ways to promote continuing medical education. By simply tapping into existing human resources (organizing the large cadre of OR specialists to host regular teaching sessions, for example), leaders could contribute to staff education and development. Alternately, by taking the initiative to approach existing partners in developed nations about arranging fellowships or observer periods, leaders could help increase HCW motivation, self-worth, and workplace satisfaction.
Regularly Perform Clinical Practice Audits
Regular clinical audits are important instruments of quality control. Audits identify ongoing problems in the OR and are prerequisites for solving them. Without these exercises, it is difficult to ensure that acceptable care standards are maintained.
Public sector hospital ORs in Jamaica do not have effective auditing systems to generate good-quality data and objectively evaluate the ORs.5 This is partly caused by the lack of electronic databases in public sector hospitals in Jamaica,2 a lack of emphasis on auditing, failure to appreciate the importance of local data, and low expectations for outcomes from auditing. Leaders must appreciate the importance of these activities and encourage them because in their absence, systemic inadequacies persist. Resource limitations may not allow the use of sophisticated electronic monitoring systems, but clinical audits can still be performed using paper-based systems.
An important task of good leaders is to identify the strengths and weaknesses of their staff. Leaders can identify staff members who are interested in research and motivate them to spearhead this type of work and eventually develop a research culture in the workplace. Partnering with existing educational institutions is another approach to promoting a research-oriented workplace.
Simply implementing quality-control surveys and clinical audits is not sufficient. There must be overt consequences. Quality-control data should be used to hold leaders accountable when pre-set performance goals are not met and to reward them when appropriate. This may work at several levels. For example, awareness of ongoing monitoring may be sufficient in itself to bring about positive behavior modification by HCWs, even without the immediate threat of penalties.36
Several unique cultural, financial, political, and environmental factors influence the delivery of surgical services in Jamaica; this context is different from that of developing countries. Effective leadership must adapt to its environment. The delivery of surgical care in this environment may be improved by attention to leadership training, workplace safety, communication, work environment enrichment, and revision of existing policies. Practice audits and quality control surveys should be conducted regularly. v
The author(s) have no conflicts of interest to disclose.
Leslie Parker, ELS, provided editorial assistance.
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