continuous improvement, Leadership

Listen with fascination – How to get more love into the workplace – part 8

When was the last time you really listened to someone? Not just listened to give advice or to respond; not half-listened but really listened? Apparently we only retain 25% of what we hear as we are not actively listening. That’s 75% of what others tell us, we miss.

Giving your full attention to another person, is an extremely compassionate and human thing to do. We talk about compassion as a significant part of how we treat our patients in the NHS, however we talk about it less so in relation to how we treat each other.

To me, building a culture of compassion is crucial to ensuring that organisations enable people to bring their whole selves to work. If we truly want to build cultures of continuous improvement, where staff are enabled to make change in their own areas, then leaders and managers must learn to really listen to staff and support them to make that change. As Andy Stanley warns, “Leaders who do not listen will eventually be surrounded by people who have nothing to say.” This is a dangerous situation to be in as groupthink can creep in.

Recently I had the privilege of talking to Professor Michael West about our leadership development programme ‘Leading for the Future’; due to be launched by our Chief Executive in the Autumn. The aim of the programme is to support our most senior leaders to create the enabling environments within every directorate that will allow staff to make the change they want to see. We have identified the competencies we believe our leaders will need to create the right conditions for staff to take the organisation forward. We have categorised these competencies into our three pillars of leadership with the first and foremost being Culture of Compassion.

During our conversation West talked about the importance of leaders really listening and told me a fact that I found alarming which was that it has been proven that the more senior people become the less they listen. This appears to me to be paradoxical as surely the more senior you become, the more you need to listen so that you really understand your people and your organisation. There is a real danger that leaders become fixated in their own social construct and rely on their memory of what life was like when they were on the frontline earlier on in their careers. This can lead them to become out of touch; lead from a place of fear and put forward directives or initiatives that are based in historical success rather than on what the organisation needs today.

West identifies that compassionate leadership, the type required to enable a culture of continuous improvement to flourish, is supported through:

  1. Attending – paying attention to the other and ‘listening with fascination’
  2. Understanding – finding a shared understanding of the situation they face
  3. Empathising – feeling how it is to be in their situation
  4. Helping – taking intelligent action to help them achieve their purpose

This can really only be achieved well through visible leadership; that is leaders going out and about meeting with and listening to their staff to really understand their views.

So, next time you are talking to someone in your organisation, I urge to you to stop, pay attention and listen with fascination. What you learn may surprise you.

 

 

With thanks to Professor Michael West, Head of Thought Leadership for The King’s Fund and Professor of Work and Organisational Psychology at Lancaster University

 

About the author

Sarah Morgan is the Director of Organisational Development for Guy’s and St Thomas’ NHS Foundation Trust and passionate about building more human organisations

Follow Sarah on Twitter @SarahMorganNHS

 

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culture of compassion, Leadership, Organisational development, Staff development

How to get more love into the workplace – Part Two

What better day to talk about love in the workplace than Valentine’s Day? The day when we profess our undying love for the focus of our affection; we can choose to keep our identity a secret or reveal all; we wear our hearts on our sleeve and chance rejection. We take that risk in the name of love.

The workplace can be a minefield to navigate. There are different ‘tribes’; power dynamics and unsaid rules. It often takes courage to say what you really think; stand up for what you believe in and wear your heart on your sleeve. The question is why? Why do you sometimes feel psychologically unsafe if you speak out? Why are diverse views shied away from rather than encouraged? I can’t profess to fully know the answers to these questions, but I do suspect that it stems from a need to belong and our tribal instincts kicking in. This can lead to bad behaviour; exclusion and a general lack of compassion towards our workmates. There’s an interesting Switch and Shift article on this if you want to read more.

So, if it’s an innate part of us, how do we get more love and compassion into the workplace?

Well to me it’s about appreciating what others have to offer. There’s an old African proverb that says, “If you want to go fast, go alone. If you want to go far, go together.” This sums it up for me. Often we are imbibed with a sense of urgency; short deadlines; stretching targets and the volume of work and weight of expectations is ever increasing. Naturally, this gives us a tendency to lean towards the ‘going fast’. Other people, who may have a valid, but different point of view, could slow us down, and we haven’t got the time to ‘bring them round to our way of thinking’ so instead, divergent views are at best ignored or worse ridiculed and those offering them made to feel inferior or stupid.

Over time, divergent views stop being offered, which gives rise to a different challenge, that of ‘groupthink’. This was described by ACCA in their December 2015 article on the need to diversify Boards as a “psychological behaviour of minimising conflict and reaching consensus without critically evaluating alternative ideas.” Often this is found in highly regulated, performance target-led environments such as banking and healthcare.

The predominant leadership style in the NHS is ‘pace setting’(1) . At first glance this sounds like a style that would get results; sets high performance standards whilst exemplifying delivery themselves; however over time it can have detrimental impact as it depersonalises the work environment, making it all about hitting the targets whilst forgetting about the human aspects.

In healthcare, we talk a lot about the need for compassionate care but often we overlook the need to have compassion in our everyday interactions with our colleagues. We need a more human touch in the workplace. To me this includes treating others as you would want to be treated and showing compassion in meetings as much as on the wards. It also means having honest conversations with people, especially if they are not performing as expected, rather than avoiding the difficult issues and potential conflict and then letting things escalate, potentially leading to festering resentment.

To summarise I think compassion in the workplace involves the following three aspects:

1. Treating people as individuals – acknowledging we are all different and have divergent views and opinions. Building relationships and trust on this basis and being as open and honest as possible.

2. Being open and honest – it’s often much easier to develop a ‘parent/ child’ relationship between manager and staff member than it is to have an adult to adult relationship (2) . Having honest conversations and being open when things are not going as well they might takes quite a lot of courage for some managers. It is far easier to not address issues but this just builds ill will over time. Voicing your opinion and being true to yourself, colleagues and staff, will enable a much more positive and transparent environment.

3. Valuing others’ opinion – as well as voicing your own opinion, allowing others to voice theirs without immediately responding or trying to bring people round to your way of thinking. Often this is more difficult than it sounds, but really listening to other people and opening your mind to other possibilities is the key to working with colleagues from different professional backgrounds, organisations and industries. Working out how to collaborate and work through the net benefit, so there is a shared and collective understanding and an agreed way forward, takes real skill.
I think if we all listen a little more; talk a little less and think of the person in front of us as a fellow human being, we might just start to get a little more love in the workplace.

Happy Valentine’s Day!

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1   Leadership that gets results; Daniel Goleman; Harvard Business Review; March 2000.

2.Eric Berne; Transactional analysis (parent, adult, child model); 1957.

About the author

Sarah Morgan is the Director of Organisational Development for Guy’s and St Thomas’ NHS Foundation Trust and a passionate advocate of creating conditions in the workplace to enable creativity and innovation to flourish

 

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Authentic Leadership, culture of compassion, Leadership

How to get more love into the workplace – Part One

In my last blog post I shared my new years resolution for 2016, which is to get more love into the workplace.  This is part one of my approach.

I’m posting this from a snowy Colorado mountain on Martin Luther King Day; which seems very apt as MLK once said, “I have decided to stick with love. Hate is too great a burden to bear.”

MLK was a truly authentic leader who spoke out for what he believed in and empowered people to think and act in a different way.

It’s been a tricky start to 2016. With industrial action from junior doctors and the continued struggle with waiting times and financials; it’s starting to feel as though the old methods just aren’t working for us anymore and a new approach is needed.

It seems to me what is needed is a new leadership approach that moves away from traditional pace-setting, command and control styles that have dominated the NHS for at least the past decade, to a more authentic leadership style – MLK style. One that supports staff with the right tools and techniques to make the changes needed on a day-to-day basis, without the bureaucracy of committees that are – in some cases – far removed from the frontline.

The NHS has a good track record of supporting staff with training in tools and techniques, but what has always been lacking is a systematic way of improving the services and solving problems as they happen. Many healthcare organisations have trained up hundreds of their staff in various quality improvement techniques, though few have managed to leverage the benefits. What has been missing is the infrastructure and governance that allows decisions to be taken quickly, at the frontline, at the time it’s needed.

In the past, managers such as myself were trained to be ‘heroic leaders;’ i.e. it was their job to solve the problems (otherwise what are they doing?); however the time for this has now passed – if it ever really was the right approach – and it’s time to really think differently about how we support our staff.

In my view, there are three steps that leaders could take to become more authentic and to enable more effective decisions to be taken as close to the patients as possible:

Step One admit you don’t know all the answers and place the decision making in the hands of those who do; especially those at the frontline. That is a very big ask in this world of accountability and takes bravery; however it has been proven to yield effective results in healthcare systems elsewhere in the world.

Step Two give the staff the tools and techniques to make the necessary change. Supporting clinical staff by training them in quality improvement techniques; using data effectively and understanding how to manage change has the potential to make more of a difference in two months than a year’s worth of committee meetings.

Step Three take the governance to them. Don’t expect clinicians to navigate the intricacies of the corporate governance that many of us spend our days steeped in. Work with intention and develop a systematic approach that allows decisions to be taken quickly and easily. If needed, schemes of delegation can be drawn up to keep everyone safe. Knowing that the intention behind the decision is to ‘make things better’ for patients and staff whilst supporting clinicians to understand the constraints will unleash their creativity. As the saying goes ‘innovation loves constraint’. A really successful example of this is the Virginia Mason test: ‘What can you do with half the money, half the staff, half the space?’ This has supported them to radically change how they deliver healthcare at the same time as increasing quality and reducing cost – the holy grail.

In my view, these three steps will go a long way to bring about a more authentic leadership approach which will lead to a better engaged and enabled workforce and overall more love and wellbeing into the workplace. The question is, can we do it quickly enough to make the difference? In reality, do we have a choice?

I’ll leave you with the words of Mark Twain; “There isn’t time, so brief is life, for bickerings, apologies, heartburnings, callings to account. There is only time for loving, and but an instant, so to speak, for that.”

About the author

Sarah Morgan is the Director of Organisational Development for Guy’s and St Thomas’ NHS Foundation Trust

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continuous improvement, patient centred care, Staff development

Back to the floor

On Friday I had the great pleasure of spending a clinical day going back to the floor, reconnecting with our staff and patients.

When I start in a new organisation the first thing I like to do is to get out and about to the clinical areas to get a real feel for the place. This is a habit I developed when I was a graduate and spent three months on my orientation exploring all jobs in the hospital and wider system.

I spent the morning in our children’s hospital, the Evelina London, shadowing their Director of Nursing. We headed onto Savannah ward, our cardiology high dependency ward. Starting out at the top of the ward we examined the stock cupboard and tested the stock system – quite tricky! We examined the cleanliness of the ward – a deep clean was in progress – and checked the kitchen and clinical areas. This gave us a good feel for the management of the ward.

Next stop was to meet the patients and their parents. We met Kayla, a 17 month old little girl with heart failure, who was on the transplant list and had been in our care since Monday. We chatted to Kayla’s mum who told us that she was usually cared for at Great Ormond Street. This presented a great opportunity to find out what we were doing well, but more importantly, what we could improve. Kayla’s mum was hugely complimentary about the nurses and the care they had shown by laundering her clothes, as she was sleeping on the ward on the pull down beds next to the cot. She was also impressed by the deep clean she had seen going on over the past couple of days. It was great to hear about such good care, although we also learned a lot about how we could do better.

We then chatted to the ward sister about her patients and the integrated care record. I asked her what brings her joy at work, at which point she completely lit up and talked about how much she loved her job and the nursing team at the Evelina (she is a Nurse Educator). She spoke about the wards, staff and patients with such love. It really gave me a sense of what a happy team the Savannah ward are.

We then had a further walk through the orthopaedic ward and met the matron who told me an equally heartwarming and heartbreaking story about a little boy – Ewan – who was born with a genetic condition that is severely disabling and means his life expectancy is very short. Whilst on our ward, the staff organised a christening for him. The parents had written to the Chief Executive and Chief Nurse complimenting all the staff on the ward on the care they had given and enclosed a photograph of the family on their Christening Day, which she showed me. It was truly humbling.

As we carried on through the ward I saw our Quality Fellow who invited us to one of the paediatricians’ Safety Huddles. They have developed a 6 point checklist to improve patient safety which they run through every day. This includes examining the Paediatric Early Warning Scores for each patient; highlighting any planned high risk procedures to be undertaken on the ward and flags any other teams the ward need to communicate with, such as Theatres. This only took 15 minutes and gave me a real sense of the team being on top of every patient.

After lunch I headed up to our Theatres suite. We have 44 theatres, 60% of which run 6 days a week and we support our neighbouring hospital with their trauma lists as well.

Kitted out like an extra in Casualty (or more likely Scrubs) I spent a fascinating afternoon in Theatres, starting out with a tour of the day surgery unit accompanied by the Nurse in Charge (NiC). I think it’s really important to not just have a ‘royal’ visit but to see what it’s really like for the staff on the frontline. As we walked around the unit the NiC was approached from all sides with all sorts of problems and requests for information, and I observed him trying very hard to not just take on all of this but support the staff to think for themselves and try and solve their own problems. Not easy in a busy clinical environment!

He was clearly passionate about the development of his staff and talked me through the new clinical educator role they have introduced to quickly train up staff as they have such as high turnover in Theatres. This has proved to be a great success in the last three months.

I was lucky enough to observe a clinical procedure in one of the theatres for a patient with chronic pain. It was great to see the WHO checklist being used to cross check the procedure even as a day surgery. There was an anaesthetist on standby in case the patient went off, but the patient was coping very well so he had the time to talk me through the details of the procedure in-between reassuring the patient, which made it even more interesting. I had to wear a heavy lead apron as interventional imaging was being used as the procedure was so intricate it needed constant images available. I was absolutely in awe of the precision with which the consultant worked.

It is twelve years since I was last in theatres as an observer and it was incredibly interesting how much things have moved on. I came out of my time at theatres with a much richer appreciation of the pressure that our theatres teams work under, but everyone I met was friendly, welcoming and made time to speak to me.

My whole day was humbling and awe inspiring. I am proud to work in the NHS and think it’s vital for managers to make the time to walk the clinical areas and speak to staff to see what it’s really like for them day to day.

Get out there.

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Acknowledgements

A big thank you to all the staff, patients and parents that made time to speak to me on Friday 31 July 2015, I really appreciated it and I am in awe of the work you do every day.

About the author

Sarah Morgan is the Director of Organisational Development at Guy’s and St Thomas’ NHS Foundation Trust

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continuous improvement, Leadership, Organisational development, patient centred care, Staff development

What does it take to get truly patient centred care?

“People are not cars”

This week I’ve had the privilege of being part of a team hosting colleagues from the Seattle-based, world renowned, healthcare provider Virginia Mason (VM). VM have earned their reputation through the development and implementation of the Virginia Mason Production System (VMPS), which has enabled them – in a relatively short period of time – to move from being a high cost, average quality provider that was losing money to becoming the US hospital of the decade, with the highest quality, lowest cost and best patient and staff experience. The holy grail for most healthcare providers. So how have they achieved this?

The VMPS has its roots firmly planted in the LEAN-based Toyota Production System, to the point that they even use the Japanese terms in their everyday language. So what has this to do with healthcare? People are not cars! This is true, but as one Virginia Mason senior surgeon observed, ‘if we treated our patients with as much love and respect as Toyota treat their cars, we could become the best health system in the world!’

So what is the VMPS and what can the NHS truly learn from it?

About 15 years ago, Virginia Mason were in financial difficulty. A new CEO, Gary Kaplan MD was voted in and he knew that if the hospital was going to still be there in 100 years time, they needed to ‘change or die’. The Board had also levied a challenge that said, ‘if you’re really patient focussed, why does care look the way it does at Virginia Mason?’ This was a reference to the long waiting times patients were experiencing both before, during and after treatment. The Executive Team knew they needed a systematic improvement methodology if they were going to make the wholesale change they required. After two years of careful study they identified the Toyota Production System as the one they felt would get them the results they wanted – truly patient focussed care.

The team went to Japan to witness this at first hand and were inspired by the Toyota way. With that, the Virginia Mason strategic plan was born and to be honest, it is very hard to argue with.

VM strategic plan

Their strategic plan has remained the same for the last 15 years and as such forms the bedrock of the mindset and approach to everything that VM stand for and are trying to achieve.

The VMPS is not just a set of LEAN tools and techniques, it’s a mindset. It’s not an addition to the day job, it’s absolutely how everyone at VM does their work, it’s the management method and decision making framework. The most important factor is its consistency of application. It starts with the Board and flows through the organisation and is adhered to with rigour and discipline.

One of the first things that Virginia Mason did was to develop ‘compacts’ or agreed ways of working for their physicians, leaders and the Board. This defines what is expected of employees at VM and what they, in turn, can expect from the organisation. Showing Respect is a huge part of the culture at VM and they have found that this has gone a long way in supporting their staff to feel confident to speak up with concerns; have ideas and be creative; and bring their best to work every day. All of this has culminated in an improved patient experience at the same time as a reduction in their cost base, generating enviable profits to reinvest in patient care.

Everybody who works for VM is trained in the techniques and they are now starting to train their suppliers and partner organisations as well. All managers and supervisors (clinical and non-clinical) are required to have the more detailed training for leaders and run at least one 2-day improvement event (known as a Kaizen event) every year to remain at VM. All directors and senior clinicians must be certified and run a 5 day rapid improvement workshop every year to stay employed. This means, everyone speaks the same language, everyone knows what to expect including the Executive Team, who are also bound by the same expectation and run at least one 5 day event every year.

The whole system is underpinned by the principle that those than run the business, improve the business. Decision-making is devolved down to the lowest level and the staff that are on the frontline, doing the job, are empowered to make changes as long as they add value to the patient.

Part of this methodology includes a standardised approach to how everyone does their work called ‘the standard work’. This element is a very different way of thinking than we are used to in the NHS. The underlying principle is that the more work that is standardised, the more the time is freed up for creative thinking. Examples of this are: walking the wards and clinic areas (or the Genba as VM describe it) at 8am every morning so problems can be immediately resolved; every Wednesday, recognising and appreciating a staff member who has made an outstanding contribution to patient care or analysing the data regarding your service at 11am every day so you can spot trends early.

Supervisors generally have 75 – 90% of what they do standardised and they are freed up to spend the majority of their time on the frontline supporting and enabling the staff. They ask their staff every day, ‘what is the rock in their shoe’ and take a coach not tell approach by asking, ‘what ideas have you had and how can I best support you?’ The principle is to support staff to start working to solve live problems that may impact on patient experience rather than looking at retrospective data and taking many months worth of meetings to resolve it.

Even directors have 10% of their work standardised. Again, this is also about how often they walk the wards, recognise and appreciate their staff and how much time they spend prepping for meetings etc.

VM describe this as their World Class Management System and it includes the principle of daily management. The 5 principles of daily management are designed with the patient at the centre as set out in Fig 1.

5 principles of daily management

Figure 1: The principles of daily management

This took VM 5 years to develop and they have subsequently realised that this has been their most important work and now recommend other organisations to implement this far sooner to get to the high impact changes much faster.

Their approach can be summarised into 6 words:

  • Go See
  • Ask Why
  • Show Respect

The US healthcare system is very different to ours and although heavily regulated, they have the ability to take decisions about changes to healthcare more easily, so how would this even be accepted as a way of working? How do you manage the risk of not undermining the professional autonomy of your most senior clinicians?

Well, the basic VM approach is about putting the patient at the heart of everything you do and getting rid of the waste in the processes that support the patient experience so you can spend more time caring for patients. Not only is this hard to argue with, it’s also the reason many of the 1.4m people who work in the NHS get out of bed in the morning and continue to choose to work in healthcare.

Understanding how the principles apply in our legislative and regulatory regime is the next key stage, however it is clear that the Secretary of State is a big fan of Virginia Mason so the timing may be right for a change in the way we work.

What is clear to me is that having a cultural mindset of truly putting the patient first and explicitly showing respect for work colleagues is a must do. Our interpretation of what that means needs more careful definition, but starting with the end in mind, I find this a compelling vision of the future. There will be many who say we have this now, but having seen the achievements of VM, in reality we are just at the start of that journey.

It’s not necessary to be a slave to the VM Way but it is important that organisations do have a prescribed improvement methodology and decision making framework so it is clear how clinicians and managers take decisions and make change. Agility is the key. The NHS is not really fleet of foot and hasn’t always been clear about expectations. This has led to cumbersome change management often taking years; a large change programme and many committee meetings.

Having spent time with the Virginia Mason Faculty this week I can absolutely see why people are queuing up to work at VM and their patient satisfaction scores are so high. Today the NHS turns 67 and this is a compelling vision of the future to ensure the NHS is still delivering high quality healthcare for our population in another 67 years.

We’re at the start of that journey and I personally am looking forward to the day we treat our patients with as much care and attention as Toyota treat their cars.

With special thanks to:

Cathie Furman, RN – Member of the Faculty of the Virginia Mason Institute and former Senior Vice President for Quality and Compliance. Cathie was part of the original Executive Team who made the decision to adopt the VMPS

Henry Otero, MD – Medical Oncologist and Faculty member of the Virginia Mason Institute. Henry was the clinical lead for Cancer and an early adopter of the VMPS. He is a Kaizen Fellow.

About the author

Sarah Morgan is the Director of Organisational Development at Guy’s and St Thomas’ NHS FT.  GSTT are currently developing an organisational development strategy to enable the transformation to a culture of continuous improvement.

Further reading:

Plesk P; Accelerating Healthcare Innovation with Lean and Innovation: The Virginia Mason Experience; 2014

Kenney C; Transforming Healthcare: Virginia Mason Medical Centre’s Pursuit of the Perfect Patient Experience; 2010

Web links for more information

http://www.virginiamasoninstitute.org/

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