Authentic Leadership, culture of compassion, Leadership, NHS Leadership, Organisational development

Move away from fear – how to get more love in the workplace – part 6

Earlier this week research showed that there are high levels of perceived bullying in the NHS workplace.  According to the research by NHS Employers 20% of NHS staff report that they have been bullied by other staff and 29.9% indicated that they had some element of psychological distress. Managers and supervisors were perceived to be the most common source (51%).

This is quite a shocking statistic and one that begs the question ‘why?’. What drives, seemingly normal people, who work in a compassionate profession and are probably lovely outside of work, to behave in a bullying manner in the workplace?

My guess is that it is based in fear.

Fear of missing the target; fear of the ramifications of spending too much money; fear of losing job/ reputation/ career that you’ve spend decades building; fear of rocking the boat or speaking up. What fuels these fears?

Fear is toxic; it creates a unconscious psychological response in our amygdala or ‘reptile brain’ which is fight; flight; freeze. This is helpful when a sabre toothed tiger is bearing down on you but has no place in today’s healthcare environment except in extreme circumstances. We are starting to see some of the unintended consequences such as a recent CQC report awarding a requires improvement rating citing ‘learned helplessness’ as one of the cultural indicators created by the senior leadership team.

So, how can we support our leaders to move away from fear and start to create the right conditions for staff to be able to operate to their full potential?

As we know culture is the shadow of the leadership and if the shadow that is being cast is one of fear; perceived lack of ability to control or influence; driving for results no matter what the cost and an inability to listen to ideas or thoughts that differ from the cultural norms; then the conditions that are being created for staff to work in are oppressive; toxic and limiting.

Having grip and telling staff what to do can work for a short period of time, particularly in a crisis. However, over a longer period will lead to reduced results and a culture of escalation to the organisation as paralysis will seep in and staff will start to fear making the wrong decision and therefore will make no decisions.

To move away from fear takes a huge amount of courage and the ability to trust in others. Although the current regulatory environment means that there needs to be an Accountable Officer so it is clear where the buck stops, this does not mean that this person has to do everything; quite the opposite.

The key to that opposite approach is enabling the Executive Team to feel it is safe to let go. A recent interesting article by the Harvard Business Review (1) on exactly this, highlighted the rules of ‘self organisation’ the main element of which is communicating intent. This is a very different approach to delegation. One which establishes a set of principles and a clear framework from within which all staff are able to take decisions.

Many of the organisations featured in Fredric La Loux’s inspiring ‘Reinventing Organizations’ (2) have in common a clearly set out vision and principles and enable their staff to make decisions based within the simple framework that they have established. All of the organisations have established approaches to dealing with performance issues and with those people who do not make decisions according to the agreed doctrine, quickly and simply. This clear and simple approach appears to be yielding amazing results the world over.

It is often argued that this is much easier in organisations such as Google and Amazon and in healthcare organisations such as Buurtzorg in the Netherlands (3) as they are all start up companies and had the opportunity to set things up right from the beginning.

So how easy is it to introduce this new way of working into a well established; heavily regulated environment such as the NHS where everything that is paid attention to, measured and rewarded is the opposite? Well the answer is that it is not easy – but rarely is anything worth having easy to achieve. If it was we would have done it already!

Collaboration is the key. Today’s healthcare environment is too complex to rely upon the leadership approaches that worked for complicated problems. Complicated problems can be solved through processes and linear solutions. Complex problems are worsened if this thinking is applied as there are too many factors and variables and therefore a more emergent approach is necessary.

The fear many leaders will have to face is that their ‘tried and tested’ methodologies that worked for yesterday’s problems no longer work and they have no more tools in their toolkit to rely upon. This can often be the root of fear that drives the ‘tell’ culture and often leaders struggle to understand why these methods, previously so successful don’t work in today’s technology driven, disrupted environment. They interpret the lack of results as due to the way the staff are implementing their instructions rather than it being the wrong approach and so give further, more detailed instructions.  Thus creating a vicious circle of decline.

The simple truth is we need a new toolkit and manual for ‘letting go’. Bringing together clinicians and giving them the tools and techniques to enable them to improve how they deliver care and trusting them to come up with the answers, is the first stage to truly transforming the culture in the NHS.

We need leaders that can:

  • lead from behind, rather than in front
  • pose questions rather than offers solutions as they recognise wicked problems require emergent solutions
  • truly collaborate with the workforce and inspire them with purpose and commitment.

These are the leaders that will create the right conditions to replace the fear currently being felt in the NHS workplace with love and compassion, both for staff and patients.

(1)   How Leaders Can Let Go Without Losing Control; Mark Bonchek; Harvard Business Review; 2 June 2016

(2)  La Loux F; Reinventing organizations; A guide to creating organizations inspired by the next generation of human consciousness; 2014

(3) Community nursing organisation in the Netherlands based on the principles of self managed teams which achieves high levels of patient satisfaction, improved clinical outcomes and reduced cost. Featured in La Loux’s book as referenced above

About the author

Sarah Morgan is the Director of Organisational Development for Guy’s and St Thomas’ NHS Foundation Trust and passionate about creating happy workplaces

 

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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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Leadership, Millenial Generation, Organisational development, Staff development

All present and correct?

In today’s increasingly fast paced; always connected, always ‘on’ world, it feels as though there are never enough hours in the day to get done what needs to get done. Time feels like it slips through the fingers like sand but suffers from the polarity of being both fiercely protected and recklessly squandered. A way of making the most of the time we have; our precious 168 hours a week; is to improve our work/life balance, but is that as easy as it sounds?

Work/ life balance is something we all talk about, but achieving the perfect balance appears to be the Holy Grail. The Millennial generation (those born between 1980 and 1995) are particularly protective over their work/life balance and as the Deloitte Millennial Survey (2014) highlighted, by 2020 75% of the global workforce will be millennial, and so understanding what they are looking for in the workplace is increasingly important.

An international study published in the Harvard Business Review report from February 2015 (https://hbr.org/2015/02/what-millennials-want-from-work-charted-across-the-world) demonstrated that the term work/life balance means different things in different parts of the world. Many interpret it as work/me time. Interestingly, except for Central/ Eastern Europe, in every other region, over half the respondents said they would give up a well-paid and prestigious job to get better work/life balance.

W150217_BRESMAN_HOWWORKLIFE_1

Source: Harvard Business Review, What Millennials Want From Work Charted Across the World; February 2015

Broadly speaking, most Millennials across the world cited spending time with family and to grow and learn new things as the most important to them, if they could prioritise in life.

W150217_BRESMAN_HOWMILLENNIALSWOULD

Source: Harvard Business Review, What Millennials Want From Work Charted Across the World; February 2015

 

This is great in theory, and companies such as Google and Apple are famous for having mastered it, however many organisations still have a prevailing culture of presenteeism i.e. I have to be able to physically see you to know you are working. Frederic Laloux’s fabulous book Reinventing Organizations tries to tackle this very issue, citing the companies around the world that have moved to self-management; putting the power in the hands of the staff rather than the management. He describes these types of organisation as being evolutionally teal, the characteristics of which appear to be looking after the spiritual well-being as well as the emotional and financial well-being of their workforce.  In reality, these organisations are the exception rather than the rule, so the real challenge is how to move away from a culture of presenteeism to one that values effective outputs.

This demands a different kind of leader; one that is comfortable with a more collective or distributed type of leadership; who moves the power to where the skills, energy and motivation lie and creates the right conditions for innovation to flourish (West and Dawson 2014; Kings Fund).

Enabling staff to have more flexible and agile working practices is crucial to ensuring the recruitment and retention of the best talent. Unusually for an NHS organisation, over half of our staff are under the age of 40 (54% against the NHS average of 41%) and so understanding what is important to different generations, particularly millennials, is an important part of our workforce strategy. We are about to undertake some research looking at what is meaningful to the different generations and different professional groups in our organisation, so that we are better able to tailor our training and development; workforce policies and support different working practices. Moving our managers away from a prevailing culture of presenteeism to one where they are comfortable in treating staff as individuals; interpreting policy and managing staff on the basis of the quality and timeliness of their outputs will require investment in supporting our managers to think differently and will require our leaders to change the ‘ask’ in the organisation.

This feels like the right direction of travel and should enable a different type of workforce to emerge to ensure that we remain one of the best employers in the NHS and are growing a workforce that has the work/life balance they both want and deserve.

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.

 2015-07-31 16.44.39

 

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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