Management / Leadership question

Question 1

define Sepsis

Answer 1

Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death.

Question 2

what are the 6 stages of audit

Answer 2

1) Identify an issue or problem
2) Identify a standard
3) Collect data on current practice
4) Compare current practice to standard
5) Implement change to address any shortfalls
6) Re-audit§

Question 3

what indicators are there that someone is septic

Answer 3

High temperature
HR >90
RR >20
Low systolic BP <100

Question 4

what is research

Answer 4

Aims to create new knowledge that can be used to develop new standards of care

Question 5

What is an audit?

Answer 5

Audit is a systematic quality improvement tool comparing current practise with set standards to maintain quality of patient care

Question 6

You have received your rota and find yourself scheduled for more on call than others. How would you approach this?

Answer 6

balance between training and service provision

1. seek information
   - are you actually or does it just appear that way?
   - is it rota gap? sickness ? someone not able to do on calls?
   - ?discuss with other trainees
2. Patient safety
   - patient safety compromised if you are over worked
   - prevents learning
3. Initiative
   - Discuss with others ?swaps
   - see if issue can be resolved informally
   - see if you can increase your own learning
4. Escalate
   - speak to rota coordinator and CS / ES
   - training programme director
5. Support
   - Clinical governance meeting
   - report ot TPD
   - reflect

Question 7

what is clinical governance

Answer 7

“a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Question 8

what is duty of candor

Answer 8

legal duty to inform and apologise to patients if there have been mistakes in their care that have led to significant harm. Aims to help patients receive accurate, truthful information from health providers.

Question 9

You are about to perform a myringoplasty on a child. The child is anaesthetised and in the operating room. You notice that the ear that is marked is different to the consent form. How would you manage this situation?

Answer 9

Wrong site surgery is a never event

1. immediately raise concerns to team
2. Check with:
   - Marker
   - Consent form, letters, imaging
   - Consultant
   - Parent
3. has it just been wrongly marked? check with the team that they are happy. If not happy you would have to wake the patient up.

elective surgery: if any doubt cancel

WHO Checklist in place to avoid this.

is this a recurring problem.
escalate, Apologise to patient, duty of cantor, datex, CG meeting, M&M meeting, offer PALS, critical incidence form, audit / QIP

Question 10

what are the CEPOD categories

Answer 10

1. Life or limb saving
2. Emergency
3. Urgent
4. Elective

Question 11

Your FY1 tells you that they have lost a USB stick, which was unencrypted with patient data on it. How would you manage this situation?

Answer 11

1. Is it actually lost
2. Whos information & what information
3. patient confidentiality issue and property issue
4. Duty of candor to inform patients
5. offer PALS
6. Escalate
7. CAldicot gardian
8. Critical incidence, CG meeting, M&M meeting,

Question 12

what is NCEPOD

Answer 12

national confidential enquiry in to patient outcome and death

Question 13

You are at work and you notice that one of your fellow CT2 drops a packet of white powder, which you suspect may be cocaine. How would you proceed?

Answer 13

1. find out the facts: is it there’s? what is in it? - see if they give an appropriate responce
2. do they appear like they are on drugs
3. immediate patient safety issue
4. they should be removed from the clinical environment
5. escalate to senior saying the individual is unwell and had to go home
6. Needs to be felt with sensitively
7. liaise with team and ensure work load covered

Clinical governance, Reflection, support for individual

Question 14

Your consultant does not appear to be interested in providing teaching. How would you approach this?

Answer 14

1. Seek further information
   - discuss with the consultant
   - issues relating to self, consultant, system
   - discuss with others if they have had the same issues
2. Patient safety
   - will impact if you are not appropriately trained
3. initiative
   - yourself - improve knowledge and skills independently
   - systems - discuss with consultant and booking office to see if you can get training lists etc.
   - consultant - discuss with consultant
4. Escalate
   - escalate to CS/ ES / TPD
   - in the meantime try and complete competencies
5. Support
   - give feedback to TPD
   - support for consultant
   - reflect

Question 15

You are scrubbed in theatre with your registrar and the list is running behind. The last patient has not been consented. The registrar asks for you to de-scrub and consent the next patient. You however have never seen or done this procedure before. How would you proceed?

Answer 15

You are not able to consent the patient as you do not have sufficient knowledge of the operation.

1. Seek information
   - make the registrar aware you cannot consent
   - do we need to consent now? can It wait until after this procedure
   - how many cases need consenting
   - de-scrub and find someone else to consent (go with them to learn)
   - finish case and go with reg to consent
   - finish procedure whilst registrar consents
2. Patient safety
3. escalate
   - if recurrent issue you will have to escalate
   - if registrar not happy that you can’t consent you have to escalate
4. support:
   - discuss at CG meeting
   - audit consent process
   - reflect

Question 16

One of the nurses has performed a stock check and finds that three knee prostheses are missing. Earlier in the day you saw some prostheses in your consultant’s locker. How would you proceed?

What are the key points

Answer 16

1. You need to find out more information e.g. are there any knee replacement operations listed for today, are there enough prostheses to continue, if not do we need to pause/cancel the operation?
2. Are the stock figures correct
3. if they are missing, discuss with the consultant
4. patient safety
   - Immediate risk to patients that day and patients in the near future
5. initiative
   - can we get hold of any for the operations today
   - Talk to consultant
6. Escalate
7. audit, CG meeting, M&M meeting
8. reflect

Question 17

What is the difference between leadership and management.

Answer 17

Leadership is setting a new direction for a group and developing colleagues in a team
Management is directing people or resources according to principles or values that are already established.
For example, leadership was when I noticed there was little teaching on burns and that members of the team felt challenged by these patients, I created and lead a teaching programme on burns. Managment for example is the distribution or jobs to juniors on the ward or the creation of a rota, ensuring the correct number of people are due to be working each day.

Question 18

You are working in the ENT department. Your FY1 has performed an audit, which has shown the deafness rate for middle ear surgery in the department was 30%. How would you manage the results?

what are the key points

Answer 18

1. Validate audit results - check method and sample size used
2. if they are true how do they compare to the standards
3. what is the cause?
   - is it a surgical technique
   - is it a particular surgeon
4. if figure correct - patient safety issue, may need to stop the operations
5. discuss with individual consultant your findings prior to presentation (if a consultants to blame)

present results at audit meeting, CG Meeting, M&M, critical incidence form, Escalate to head of department, QIP / Audit project

Question 19

What are the 7 pillars of clinical governance

Answer 19

P - Patient and public involvement
I - IT 
R - Risk Management
A - Audit 
T - Training and education 
E - effectiveness (clinical and research) 
S - Staffing and staff management

Question 20

Do surgeons have to be leaders:

Answer 20

Surgeons have multifaceted roles. They lead the team in theatres, bringing the team together to ward round and clincs but they also have to be a leader with regards to managing the departments to ensure effective care is provided and future care is safeguarded.

Question 21

Tell us about a time when your leadership was challenged

Answer 21

Previously no material was provided but a brief introductory lecture was given by the registrars. Feedback had highlighted they felt unprepared following this I created a introductory booklet highlighting the workings of the department. This was questioned by the registrars who felt this was unnecessary. Following this I discussed with both the registrar’s junior doctors Md consultants to identify areas that needed prove ents and areas that overlapped. Taking on board the thoughts of the team. A booklet was created which complimented the existing face to face induction. This experience highlighted the need to listen to all members of the team and to take on valid points of others and allow. Common goal to be achieve

Question 22

what is bullying

Answer 22

bulling is where an individual or group abuses a position of power or authority over another person or persons that leaves the victim feeling hurt, vulnerable, angry or powerless

Question 23

Define caldicot guardian

Answer 23

A Caldicott Guardian is a senior person responsible for protecting the confidentiality of people’s health and care information and making sure it is used properly.

Question 24

Tell us about a time you made a mistake

Answer 24

During a busy night shift during my F1 year, I was asked to see an unwell patient on the ward. Following assessment of the patient and discussion with my senior I prescribed IV antibiotics for a chest infection. During this time I had received a number of further bleeps to see unwell patients. When reviewing my documentation and prescription before leaving the ward I noticed I had prescribed the oral dose of antibiotics to be given IV. I was able to rectify the dosage before the patient received any medication and so no harm came to the patient. Following this I reflected on the impact distractions such as bleeps had on the accuracy of documentation and prescribing, discussed the event with my clinical supervisor and undertook an online module on managing under stress.

Question 25

You are sitting observing in clinic. Your consultant manages a patient against a well-known guidelines recommendation. How would you proceed?

Answer 25

1. Seek information
   - find out rationale behind going against guidelines.
   - do they not apply to this patient
   - have the guidelines changed
   - have they refused the recommended treatment
2. Patient safety
   - if deviating form the guidelines this is a potential patient safety issue
3. initiative
   - Further reading
4. Escalate
   - Clinical supervisor / educational supervisor
5. Support:
   - reflect
   - discuss at clinical governance

Question 26

The registrar asks you to alter a patient’s notes, what are the key points.

Answer 26

1. you cannot do it as It is unethical to change patients notes
2. Why the notes need to be altered? has a mistake been made?
3. does this impact on patient safety?
4. Proberty issue - the doctor is being dishonest
5. Document the conversation

Clinical Governance, Audit, Reflect

Question 27

What is PALs

Answer 27

The patient advice and liaison service.

This is a point of contact for patients and their families offering confidential advise, support and information.

Question 28

You are currently operating in theatre in a training list. You have had several of these cancelled in the past. Management approach you as they have noticed the on call CT bleep has not been covered. How would you approach this?

Answer 28

balance between service provision and training

1. Seek information
   - Is there anybody else who can cover (on call or in theatre)
   - are you needed in the list? are they able to finish the list without you / can anyone cover you in theatre
   - why is the on call not covered / is it genuinely not covered
2. Patient Safety
   - Clear patient safety issue
   - is it just this shift or future shifts
   - loosing training opportunities in theatre
3. Initiative
   - if unable to leave theatre, alternative cover will need to be found
   - if able to leave, cover the shift but need to look in to why this has happened and ensure it does not happen again
4. Escalate
   - ES / CS
5. Support
   - CG meeting
   - discuss with rota team and see if you can have a theatre session in leu
   - audit
   reflect

Question 29

You are on call and a patient needs an emergency procedure but you have only ever observed this procedure and not performed it. The registrar is unable to help as they are busy with another patient at a different site. It the patient does not undergo this procedure they will suffer significant harm.

Answer 29

You need to work within your own competences

1. seek information
   - is this the only treatment available
   - discuss with on call consultant or reg for help
   - can someone else help e.g. non on call reg or consultant
   - can nearby hospital take patient is stale
   - if no help available, need to make a decision on what Is the least unsafe procedure.
   - Document
2. Patient risks:
   - risk if they do not have procedure
   - risk if operation done by someone who is not competent
   - risk to future patients if this happens again
3. Initiative
   - stabilise patient
4. Escalate
5. support:
   - Clinical covernance meeting
   - critical incidence form
   - M&M Meeting
   - QIP / audit
   - Reflect

Question 30

You are about to perform an emergency theatre case with your consultant. The patient is already anaesthetised and is in the operating theatre. Your consultant walks in late and smells of alcohol. How would you manage this situation?

Answer 30

1. Find Facts
   - are they drunk? have they been drinking? Non alcoholic beer / spilt drink?
   - look for signs of intoxication
2. Patient safety
   - if they have been drinking there is a risk to patient safety
   - Property issue
3. Initiative
   - need the consultant to leave the hospital now
   - inform head of department and see if another consultant is able to help to prevent cancelling the operation
   - aim to cover duties where possible
4. Escalate
   - head of department
   - if in theatres make anaesthetic and nurse in charge aware consultant is unwell and has had to go home
5. Support:
   - The consultant may need support - occupational health, GP, firends and family
   - reflect

Question 31

Tell us about a time you did not display good leadership

Answer 31

During my F2 year I was on call in a busy SAU, part of the role of the registrar was to be called to A&E to resus situations . During this time I had to run the department and lead the F1. On my first shift where this occurred, despite ensuring patient safety throughout, I did not feel that I had optimised my team and had not communicated effectively. On finishing the shift I asked the registrar for feedback and advise on how I could improve. I reflected on this event in my logbook and did an online module on leadership. As a result, I implemented these new techniques in subsequent shifts and improved my leadership qualities.

Question 32

You notice that one of the fellow CT2 doctors is consistently late for work by 20 minutes every day. How would you manage this situation?

Answer 32

1. seek information
   - are they actually late or does rota start at a different time
   - why are they late (personal problems, child care, transport etc)
   - if there is no reason ?proberty issue
2. Patient safety
   - lateness may cause harm to patient safety
   - impacts on team (delay others with clinical commitments)
   - safety of night team
3. Initiative
   - Talk to the person
   - is it temporary?
   - recommend talking to ES and CS if more longterm
   - discuss with senior
4. Escalate
   - your CS / ES
5. Support:
   - offer to help if personal problems
   - show flexibility
   - clinical governance

Question 33

what is proberty

Answer 33

property means being honest and trustworthy, acting with integrity.

Question 34

what is harrassment

Answer 34

harassment is any behaviour which has the purpose or effect of violating an individuals dignity or creating an intimidating humiliating or offensive environment for that individual

Question 35

You are assisting your registrar when you sustain a needle stick injury whilst operating. The registrar tells you to ignore this and carry on. How would you manage this situation?

Answer 35

1. Seek information
   - inform registrar you have a needlestick injury
   - if able to de-scrub, find someone to take your place
   - if unable to descrub (I.e vital part of operation), finish operation and call occupational health
   - are you not needed but the registrar is not concerned about the needlestick - proberty issue
2. Patient safety
   - you may be required to finish operation to ensure patient safety
   - must initiate treatment for needlestick injury
3. Initiative
   - discuss with registrar afterwards regarding views on treatment of needlestick
   - discuss with patient (duty of candor)
4. Escalate
   - escalate up the medical chain
5. Support:
   - Clinical governance meeting
   - sudit
   - reflect

Question 36

You are the ENT core trainee and asked to do routine tracheostomy change on the ward but there are no dilators on the ward. The hospital policy is that all patients with tracheostomies should have one at the bedside. How will you manage the situation?

Answer 36

Patient safety issue

1. this is not an emergency, you would not proceed without the correct equipment
2. Is it actually missing? or can you not find it? ask the nurse in charge where to locate one / can we locate one
3. Do all tracheostomy patients have one
4. escalate to consultant and nurse in charge
5. CG meeting, Critical incidence form, M&M meeting

Question 37

You are about to start an elective theatre list, however the theatre manager informs you that there are no beds available. How would you proceed?

Answer 37

1. Bed availability
   - are there none available at all or just HDU?
   - will any become available later pending discharge,
2. List:
   - Are there any cases on the list that can be done as a day case procedure
   - can we reorder the list to give us more time to find beds
   - what is on the list? e.g. cancer operations, day case, routine elective, emergency
3. Patient safety:
   - Patients will have delay in treatment
   - some patients are diabetic
4. discuss with consultant in charge and bed manager
5. initiative
   - can you help with discharge summaries on the ward.
   - prioritise patients on the list.
   - talk to patients if any need to be cancelled and offer another date. Offer support
6. Critical incidence form, CG meeting, M&M Meeting
7. Reflect

Question 38

You are the on call CT2 at handover and the night registrar has not turned up and is not answering their phone. How would you approach this?

Answer 38

1. Seek information
   - Try and contact doctor
   - need to establish if the shift is covered - check rota, speak to site manager, is there a Locum
   - escalate to management
2. Patient safety
   - patient safety issue if this is not covered
   - patient safety issue if you stay as you will be tired
   - ensure sick patients are seen
3. Initiative
   - See if anyone else can cover / cross cover
   - stay late and ensure jobs are done
   - see if day reg can cover with a rest period
4. Escalate
   - inform consultant on call
   - discuss with ES / CS after shift
5. Support
   - support them if there is a reason they are late
   - discuss in clinical governance meeting (well being of staff)
   - if short staffed offer support (check the rota and look for shifts that are uncovered)
   - reflect

Question 39

what score would you use to assess likelihood of appendicitis

Answer 39

Alvarado’s score

Signs:
RLQ tenderness (2)
Temperature >37.3 (1)
Rebound tenderness (1)

Symptoms
Anorexia (1)
N&V (1)
Migratory pain (1)

WBC >10 (2)
Neutrophillia >75% (1)

1-4 = 30% chance of appendicitis 
5-7 = 66% chance of appendicitis 
8-10 = 93% chance of appendicitis

Question 40

why surgery

Answer 40

Clinical -

• Surgery is a challenging, varied and rewarding career which challenges you physically and intellectually.
• Active approach to treatment of disease
• being able to perform an operation and see a patients life improve almost immediately is a privilege and enormously satisfying

Academic -

• Plenty of opportunities for audit and research in rapidly evolving areas of surgery
• opportunities to work with allied specialties

Management -

• opportunities to be involved with management roles both in departments in a wider field
• this is a key skill for surgeons to possess and without good management you cannot progress

Personal -

• underwent surgery as a child and know the importance and life changing results it can produce.
• I have worked with some inspiring surgeons through my career who have reinforced my decision