Background
Clinical excellence refers to the capacity to deliver evidence-based and satisfying care in methodically to the appropriate recipients. A clinician who strives for professional excellence can administer care efficiently and effectively in highly coordinated institutions.1 Clinical excellence is an integral goal of clinical governance. There has been no universal consensus on the specific metrics for clinical excellence.2 Therefore, some models have been proposed, typically in the advanced world. These models often fail to identify the peculiarities in the different regions of the world. Despite these, there are global concerns about the dwindling quality of care rendered to patients, and this unease is more pronounced in the developing world.3,4 In sub-Saharan Africa, this lacuna calls for an emergency approach from all stakeholders.
A theoretical framework should be innovative yet simple and generalizable.5 However, the few proposed models of clinical excellence do not meet these fundamental benchmarks. The five-step model of professional excellence, which will serve as the foundation of the proposed BALM (Brilliance, Attitude, Leadership, and Materials) framework, has been applied to clinical nursing with magnificent results.6 As shown in figure 1, it depicts a spectrum of abilities, ranging from the novice level to the expert level. A professional clinician is supposed to aspire to mastery by going through the steps upward. However, the model, by itself, does not specify what domains of excellence are assessed using the hierarchy of professional adeptness. Besides, it was proposed and adopted in resource-sufficient areas, and its generalizability to less developed countries, as found in sub-Saharan Africa, is still debatable. The aim of this paper is to propound the BALM framework, a simplified model for clinical excellence, and describe how it could be useful to the health sector in sub-Saharan Africa.
The importance of clinical excellence
In virtually all professions, it is a statutory obligation for the practitioners to demonstrate occupational proficiency not only for their standing but also for the professional group’s reputation.7 Without clinical excellence, clinical governance becomes mere wishful thinking. Excellence and integrity are the cardinal driving forces of professionalism. These attributes define the value a professional is creating for his/her clientele. Factually, mutual trust between the client and the professional is premised on the assumption of the accomplishment and expertise of the professional.8 This is even more relevant in clinical practice where the sanctity of human lives is at stake.
In various countries and sub-national provinces, there are strict regulations guiding the conduct and behaviors of medical professionals. Typically, the regulatory bodies also demand clinical excellence to guarantee accreditation and licensure.9 So, continuous professional development programs are often implemented to ascertain that each professional is given adequate leverage to achieve proficiency. Mentoring is a key ingredient for succession plans in clinical practice.10 Obviously, unattained clinical excellence cannot be transmitted to the upcoming professionals. The clinician who will serve as a mentor must have attained a degree of vocational distinction before the mentoring process can be efficient.
The current speed of technological innovations and scientific discoveries is unprecedented since the advent of civilization. In a rapidly-changing world, a clinician is expected to be up-to-date in evidence-based practice, and it takes a commitment towards excellence to meet this challenging requirement.11 It is only excellent professionals that would be relevant in the near future based on the momentum of modernization. The professional environment is now highly competitive, and health institutions are deliberate in their recruitment exercises. It is the survival of the fittest. Clinical excellence, therefore, has become the rule to guarantee an enviable career pathway in a complex health system.12
Clinical excellence in sub-Saharan Africa: the present and the future.
Clinical excellence is of significant relevance in sub-Saharan Africa for many reasons. The indices of health status, such as infant mortality, maternal mortality and under-five mortality, are still abysmally poor in sub-Saharan Africa.13 The prevalence of non-communicable diseases such as cardiovascular disease is rising, yet the frequencies of infectious diseases such as HIV/AIDS, tuberculosis and malaria are still substantial in the region.14 In combating this ugly trend, there is a need for superior manpower of clinical excellence. The quality of healthcare is low in most African countries, and lack of clinical excellence is a principal contributor.15
Interestingly, different models of clinical excellence previously proposed have not considered the peculiarities of the sub-region.16 In sub-Saharan Africa, there is a dearth of top-notch clinical research that forms the basis of evidence-based medicine which is a strong pillar for clinical governance.17 So, the importance of fortifying infrastructure and re-strategising to build capacity and strengthen clinical excellence so as to meet the health components of the sustainable development goals cannot be overemphasized.
The BALM framework of clinical excellence
BALM is an acronym that stands for brilliance, attitude, leadership and materials. The BALM framework is a proposed model to invigorate the tenets of clinical excellence. It is a simplified configuration to evaluate the execution of clinical excellence efforts. It is designed to have a universal applicability, but the scope of this paper is limited to its adoptability in the sub-Saharan African region. An excellent clinician has adequate mental capacity, attitudinal disposition and leadership potential in a supportive environment that provides sufficient and modern paraphernalia to render cutting-edge clinical services. The BALM framework is an attempt to adapt the five-step model, in a simplified manner, to the art and science of clinical practice. The framework has four domains, whose first letters constitute the acronym (brilliance, attitude, leadership and materials). Each stage of professionalism (novice, advanced beginner, competent, proficient, and expert) is applied to each domain of the BALM framework (brilliance, attitude, leadership and materials), as shown in figure 2. In each domain of the BALM framework, the clinician, in order to attain clinical excellence, strives to move up from being a novice to being an expert. The grand aim of a career clinician is to be an expert in each of the domains. At this peak, the clinician is not only professionally superior but also experienced enough to train, mentor, and evaluate the upcoming clinical professionals. Each of the domains is further discussed in the paragraphs below. Table 1 is a summary of the domains and the attributes of each level of the domains.
The brilliance domain
This has to do with the mental capacity and intellectual prowess of the clinicians. It is simply about the knowledge base of the clinician. There are terms of reference and validated curricula that guide the training of medical professionals, ranging from undergraduate to postgraduate or residency level, and an excellent clinician is expected to have gained a reasonable mastery of these syllabuses. Additionally, the profession also requires that the practitioners are familiar and comfortable with clinical practice guidelines which are derivatives of evidence-based clinical practice.18 There are examinations, licensing evaluations and continuous in-service assessments that are equally essential in strengthening the knowledge base of an excellent clinician.19,20 So, the brilliance domain attempts to grade how a clinician is performing in this regard.
It is also pertinent to highlight that some clinicians with natural flair may not be doing well solely because they have made a wrong career choice for various reasons.21–23 The lack of interest affects how keenly the clinician acquires the requisite knowledge in his/her field. In other words, the brilliance domain is not only about the innate talent or intelligence quotient of the clinicians but about the efforts made to accumulate proficiency. A clinician who does not practice loses what has been learnt very quickly.24,25 Wisdom is sometimes described as the correct application of knowledge. The brilliance domain evaluates how a clinician can apply theoretical principles to practical situations.
Studies have found the overwhelming benefits of continuous medical education.26–28 The advent of COVID-19 has even expanded this horizon by unearthing the multiple advantages of e-learning in boosting the intellectual sophistication of clinical practitioners.29,30 Therefore, the opportunities for a clinician to expand his/her brilliance domain are unprecedentedly enormous. The use of case studies, on personal or institutional basis, has a tremendous impact in upgrading one’s knowledge base too.31,32 So, experience is not only defined by what you have seen but how you have studied what others have seen. All these have redefined the medical education landscape. There are now e-libraries that clinicians can benefit from to make them better professionals.33 Artificial intelligence has also enhanced learning and aided clinicians in mastering how to handle the equipment.34
The attitude domain
Attitude refers to a positive or negative personal predisposition to situations or things.35 It reflects one’s peculiar outlook on someone or something.36 Among the medical professionals, attitudes towards the patients, the profession, professional guidelines, the organization administration and inter-professional relationships are assessed. An excellent clinician is not one with a mobile medical dictionary and encyclopedia in his/her brain but a person who also displays the right attitude despite how much is known (or unknown, sometimes). Attitude is contagious.
The profession demands a lot of empathy from the practitioners.37 An empathetic clinician demonstrates a sound insight into the individual experiences of the patients.38 Empathy is an essential skill for a clinical professional as it approaches communication from behavioural, cognitive and emotional perspectives.39 A clinician has to have the right inclination to work hard. The job, by its nature, is demanding and requires endurance and tenacity.40 The clinician has to practice, impact knowledge and engage in meaningful research. It takes the right attitude to excel in all these areas. Resilient clinicians have a robust capacity to react appropriately to stress without impairing personal health or social responsibilities.41
The old saying, “honesty is the best policy”, is not more relevant in any profession than clinical practice. A clinician must be open and truthful at all times to gain the confidence of the patients, colleagues and society at large.42 It is ethical to be sincere and honorable to be upright in one’s engagements. An excellent clinician has the moral obligation to be candid and reliable in actions, words and behaviors. Inquisition is the bedrock of modern medicine. An inquisitive attitude is one of the most important characteristics of an excellent clinician. Behind medical innovations and therapeutic advances is the undying curiosity of clinicians and researchers.43 An enthusiastic and probing mindset is a fundamental ingredient of clinical excellence. Importantly, a clinician needs to be favorably disposed to working with other colleagues both within and outside the health sector.
The leadership domain
Leadership simply means an ability to inspire and convince others to achieve a common objective. A clinician has to be involved in leadership. Stoller described a clinician as an inveterate leader.44 They are mostly situational leaders who apply utmost pragmatism in overseeing patients as they go through the different phases of their ailments and health challenges.45 Healthcare is a dynamic sector with incessant transformations, and innovations and the practitioners are expected to lead the stakeholders in the face of these infinite changes.46 A leading and excellent clinician has substantial insight into the technicalities of the profession, industrial trends, sectoral regulations, and administrative acumen.47
Leadership entails taking responsibility, which is a sign of reliability and transparency. When the going gets tough, the leaders always show up. So, clinicians are supposed to be exemplary in conduct and bold enough to take tough decisions.48 Leadership starts with the right mentality of problem-solving, and it continues with the thrust to get involved in teamwork to make a difference. Excellent clinicians have cultivated the habit of accountability.49 It is not about who is wrong but what is wrong so that the deviations or inadequacies can be swiftly and aptly fixed. The clinician must support his team members, mentor junior colleagues and be organically embroiled in solving the organisational or practice-related problems. There is no island of knowledge, therefore, leadership also encompasses humility and willingness to rationalize with other people’s views and ideas.
Clinical leadership necessitates training and mentoring.50 An excellent leader can support and encourage others to maximise their potential through training and mentoring. Currently, there is a shortage of effective mentoring in healthcare globally, especially in Africa.50–52 Clinical excellence demands that this gap is urgently bridged. Trainees and mentees require genuine feedback and recommendations from sincere and dependable clinical leaders so that they can be empowered enough to navigate their way through complex and difficult situations. Productive training and successful mentoring require effective communication. So, an excellent clinician must hone his/her communication skills to function optimally in the sector.
Primarily, clinicians were not being trained in management, but the tides have changed. Clinicians now have to manage resources and get the best possible outcomes.53 Clinical excellence requires that professionals must intentionally learn how to administer an institution, coordinate a group, and manage available resources.54 Management cannot be divorced from patients’ safety and outcomes, and no one else can do it better than the trained clinicians. Healthcare funding has become so limited and complicated that clinicians must be able to manage the funds available to his/her organization as a core attribute of clinical governance.
The materials domain
This domain describes processes, procedures, methodologies, devices and instrumentations. It entails medical technology. Every professional needs the appropriate tools to practice effectively and efficiently. Healthcare is not different in this regard. In fact, the health sector is associated with myriads of equipment, materials, devices, processes, and instruments. Medical technology is central to clinical excellence.55 However, human beings need to operate the devices. Even robotic technology and artificial intelligence emanate from primary human input. Therefore, a clinician must be familiar with the relevant devices, how to operate and how to interpret the outputs. Additionally, an excellent clinician must be able to guarantee the accuracy of the output and the safety of the device or the procedure to the patients.56
Furthermore, medical technology is advancing continually, and clinical excellence means that a clinician should be familiar to the latest technology to optimize patients’ care. Medical innovations and digital revolution have radically transformed health care and centers of excellence are expected to be up-to-date- in these advancements.57 A modern medical practitioner must be willing to learn newer things and ready to incorporate innovations into his/her practice. The skills in handling devices must be polished through continuous training in order to optimize services provided to the patients. Moreover, technological innovations help improve patients’ participation in their care through the adoption of information technology.58
The relevance of the BALM framework of clinical excellence
The BALM framework is easy to use, simple, and concise. A model that will be adopted in a clinical setting should be succinct and easy to use.59 The simplicity encourages users to apply it thoughtfully and appropriately. Additionally, the BALM framework is multidimensional in approach. It addresses clinical excellence from four different but important domains- brilliance, attitude, leadership and materials. All these domains directly or indirectly cover all that is required for a clinician to be described as being excellent. A multidimensional approach ensures inclusivity, practicability and generalizability.60 An assessment of clinical excellence or health care quality has to be comprehensive and in-depth. This is a major advantage offered by the BALM framework. Furthermore, it has multidisciplinary applicability. It takes cognizance of the fact that the clinical setting is multifaceted yet, collaborative.61 The BALM model can be adapted to any discipline. This is a pointer to its reproducibility and reliability
Sometimes, frameworks are designed without considering geographic peculiarities. If clinical excellence is appraised only with sophisticated devices, then low-resource settings such as sub-Saharan Africa would be inequitably judged.3 However, the BALM framework has circumvented this by considering divergent domains apart from machinery. So, it is not enough to be proficient with instrumentation and procedures, but one must equally have the right attitude and demonstrate effective leadership on a background of intellectual refinement.62 This allows flexibility which ultimately influences its adoptability in different settings.
Limitations of the BALM framework
The framework is novel, so it still needs time for it to be thoroughly validated across different settings.
Conclusions
Clinical excellence demands that healthcare professionals can render first-rate clinical services. However, there are operational and technological peculiarities in poor-resource settings like sub-Saharan Africa. So, there is a need for a framework or model that is all-encompassing, concise and multidimensional to evaluate clinical excellence in such settings to put the necessary measures in place to optimize care. The BALM (brilliance, attitude, leadership & material) framework of clinical excellence is a novel model for appraising the quality of services rendered by healthcare providers and is considerate of regional eccentricity.
Author contributions
TAA contributed to the conception, data collation, writing and editing of the manuscript.
Ethical approval and consent to participate
Not applicable
Funding
No external funding was received
Availability of data
Not applicable
Competing interest
None.