The heart of healthcare
How putting people before
process
will delivery outstanding results and
transform
our healthcare
Dr D J Brown, BMedSci BM BS
Praise for “The Meaning of CAREFUL”:
“Dr Brown’s front line experience brings a sharp focus to the leadership challenges now facing the NHS. I recommend this book to anyone interested in improving patient care.” Sir Gerry Robinson
“If you are vaguely aware there are problems with NHS organisations, this book can help you articulate them. If you already know what the problems are, this book can help you solve them. If you have tried to solve them but have become jaded, this book can re-energise you. Highly recommended.” David Griffiths, GP and Clinical Advisor, Commissioning Support For London
As a Chief Nursing Officer it is very easy to become swamped by the demands of the operational aspects of my role. This book is a fantastic reminder that as a leader I am there to make a difference for my staff and my patients and that I have a responsibility to be present and connected all of the time. No small hill to climb but I will be pulling this book out whenever I need a little push back up the hill!”. Sheila Enright, Chief Nursing Officer, Princess Grace Hospital
“Many, many thanks for putting me onto this book; it revived my soul and gave me a boost of energy. I read it this weekend and want to read it again; I am going to get a few copies for our leaders within the service as there are so many areas for improvement with very practical tips here.” Dr Vanessa Crawford, Consultant Psychiatrist / Clinical Director, East London Specialist Addiction Service
THE MEANING OF CAREFUL
Dr D J Brown
Published by HCV Publishing at Smashwords
Copyright 2010 Dr D J Brown
ISBN: 978-0-9563833-1-0
First published by HCV Publishing 2009 (ISBN 978-0-9563833-0-3)
42 Moulsford House, Camden Road, London N7 0BE
This edition published by HCV Publishing at Smashwords 2010
All rights reserved
Editor: Jo Swinnerton
The moral right of the author has been asserted.
All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the author, except for the inclusion of brief quotations within a review.
Contents
Chapter 1: Why healthcare should be more like John Lewis
Chapter 2: Why we should value our human capital
Chapter 3: The CAREFUL Programme: seven steps to creating performance ownership
Chapter 4: Change management and the problem of implementation
Chapter 12: Transforming the NHS
To my father, who encouraged
me
to become a doctor.
Introduction
“ ‘Treat everyone as if they were your mother or father.’ This, according to some, is the very definition of compassion.” With these words I began an article in a national healthcare management magazine last year, exhorting readers to take seriously the need for better measurement of clinical leadership.
I began with that phrase because, as a practising doctor, I find it sad that not all healthcare is delivered with the compassion, humanity and care that patients deserve. Much that should happen naturally in such a caring profession seems to have been lost: unbalanced targets, thoughtless leadership, an emphasis on the short-term, inexpert political interference and seemingly endless reorganisation have all taken their toll. Healthcare has become less caring – both of its patients and its staff.
I mention staff, because in the dozen years during which I have worked both as a front-line doctor and an implementation consultant, helping hospitals and other organisations to implement change, I have seen that if patients are to be properly cared for, we need to have staff who feel fulfilled and motivated. And for that to happen, they need two things.
First, they have a need to be successful. Specifically, they must be able to demonstrate their success by delivering tangible results – both clinical and non-clinical – that they care about.
Second, they, like their patients, want to feel cared for and valued. They want their leaders and their peers to treat them with compassion, humanity and good humour.
These two things, in my experience, are not mutually exclusive. In fact, in healthcare they are mutually dependent. Despite how odd it sounds, to deliver the numbers, we must care for each other – and vice versa.
It is because of this belief – that we need both numerical rigour and compassionate care, and that they depend upon each other – that I have written this book. I hope that in some way it may inspire us as healthcare leaders to redouble our efforts to improve further the institutions in which we and our families are treated.
Because, as my first chapter demonstrates, it is we and our families who suffer, as much as anyone, from our failure to do so.
Dr D J Brown, BMedSci BM BS
Chapter 1
Why healthcare should be
more
like John Lewis
It was a hot, sunny week last summer when my mother started feeling unwell. Up until then she had been a healthy 76-year-old. She played badminton once a week, went for five-mile walks without a problem and enjoyed her keep-fit classes. She had never had a day’s serious illness, had never been hospitalised and was on no medication.
Over the course of several days, she developed a flu-like illness: she had a persistently high temperature and a dry cough and lost her appetite. She didn’t eat properly for about five days and, worse, she didn’t drink enough either. She was in bed for several days, but didn’t sleep well. While none of this was comfortable, it wasn’t too serious.
After a week, though, she noticed a rash on her legs. She went to her GP. It seemed she was becoming systemically unwell, and he thought she should be seen at the hospital. She was admitted via A&E to the Medical Admissions Unit on a Thursday night. She was seen by the admitting physician the next day – within 12 hours as required by the Royal College of Physicians – and was assumed to be merely dehydrated. She had low sodium levels (about 118 instead of the more normal 135–145), so the doctors put her on IV fluids and the nurses encouraged her to drink.
Over the weekend, she was cared for by some lovely people. The nursing and ancilliary staff were friendly and compassionate. However, she was not seen by another senior doctor, and the only doctors available were for urgent cases. They were junior and very overworked.
It was at this point that things started to go wrong. As she was on a drip but also being encouraged to drink, her fluid intake went from 500ml to over 4 litres in a day – from under a pint to over a gallon. No one noticed until Saturday evening, when she started to become breathless and very, very anxious. Her temperature and flu-like symptoms had all disappeared and her rash was receding, but now her ECG – which was normal on admission – developed atrial fibrillation (AF). She felt as if her heart were trying to get out of her chest. By Sunday evening she had fallen into heart failure, frank pulmonary oedema, and was drowning in her own secretions. She was close to death and she knew it.
Fortunately, someone at last noticed the problem, at which point she was grossly fluid-restricted – starved of water – and put on a diuretic in order to reverse the problem. On Monday, for reasons that were not clear, her consultant changed – the person who had seen her on Friday was no longer her doctor. Unfortunately her new consultant did not see patients on a Monday because he had an endoscopy list. So this meant that she was not going to have a review by a senior doctor from Friday morning until Tuesday afternoon – four and a half days – the equivalent of being seen on Monday morning, then not again until Friday.
When she was eventually seen, the consultant ordered a battery of investigations to find out why she had gone into heart failure, including:
• CTPA (X-ray investigation of the pulmonary arteries)
• abdominal ultrasound scan
• several more chest X-rays
• exercise ECG stress test
• echocardiogram
• a battery of blood tests including cultures and various auto-antibody tests, thyroid function tests and so forth
By this time, her hands, face, arms and legs had swelled up. She was unable to walk properly. After several days she was moved to another long-term ward in order to continue her recovery.
She was seen by her consultant only once more – in order to discharge her several days later. She was sent home into the care of her daughter, who flew back from America, leaving her own children, to provide 24-hour care.
At this point, my previously capable mother was unable to look after herself. She developed occasional bouts of AF and was put on beta blockers in order to control this. They made her very tired. She couldn’t walk far.
Slowly, over the coming months, she made progress back to normal. She made several outpatient visits to her consultant and to a cardiologist. Investigations continued as to why she developed AF. Three months later she was discharged from the hospital’s care with a clean bill of health but without:
• a diagnosis – or any underlying reason for her heart failure, pulmonary oedema or AF
• any recognition that her condition may have been mismanaged
• any admission that the hospital may have made a near-fatal mistake
• any phone call or letter from the hospital to ask about her experience
My mother was unwilling to write a letter to the hospital explaining our concerns because one day she may go back to that hospital for another reason, and she doesn’t want a reputation for being ‘difficult’. The fact is, she was grossly fluid-overloaded during a period when her fluid status should have been closely monitored and carefully regulated. The NHS had probably spent £100,000 unnecessarily on her extra stay and her investigations.
The trouble is, no one knows that the hospital nearly killed my mother and no one has learned from it. That means that it could happen again. And maybe it has.
Thankfully, my mother is now fighting fit once again. She has resumed her keep-fit classes and can do her five-mile walks once again without a problem. She has not had another day’s illness since this experience, and is once again on no regular medication.
But she’s given up the badminton.
Caring for the customer
By way of a contrast, I’d like to tell you a story about a saucepan.
I was in John Lewis a few years ago, attempting to buy a saucepan. I was standing in the kitchen department – not a place in which I feel terribly confident – weighing a saucepan in each hand and wondering which would better suit my needs, when a man in brown overalls strolled past me, pushing a big trolley full of… well, full of kitchen stuff. He was clearly a warehouseman.
He saw me and stopped. Did I need some help? It was clear that I did. He offered a few opinions – hefting a few pans and comparing their merits. We discovered that the one I needed wasn’t there. He went off to get some help and came back with one of his sales colleagues. Between the three of us we decided which pan I needed, and a few minutes later the overalls guy went back to pushing his trolley and continued on his way.
In which other shop would a warehouseman even notice that I was there, let alone recognise that I needed help? How many would know enough about their product to be able to help – or consider it their job to help?
Imagine if our healthcare organisations were run like John Lewis. Not only did this person, in a seemingly lowly position, have the confidence and capability to deal with my problem, but he also cared enough about my predicament to notice and do something about it. If we come back to my mother’s story, I wonder who in the myriad of people looking after her in those first few days noticed that she should have had a fluid-balance chart. Did they notice and then not speak up? Or didn’t they care? And how many of the senior doctors cared about the condition of the patients, or worried about how overworked the staff were on their wards at weekends?
When I tell my saucepan story to people, I find that they often have their own John Lewis stories. One person told me he took a faulty camera back to a different JL store without a receipt and was given not only a replacement camera, no questions asked, but also a partial cash refund because the price had dropped since buying it. Replacement camera plus £30. Based on your word as a customer. Nice.
The reason that this is possible is partly because John Lewis as an
organisation is dedicated to – wait for it – the happiness of its
staff. (Of course, this can’t be to the exclusion of profitability
or customer satisfaction – in fact John Lewis acknowledges that
these things are interdependent.)
I say that as if it were
extraordinary – but what is extraordinary is not that a business
should stress employee satisfaction as a driving force, but that
taking such a stand is so rare. When you think about it, it seems
obvious that all businesses – or organisations of any kind –
should be run this way.
It is as a result of this stand that employees of John Lewis demonstrate something that most people – let alone those of us in healthcare – have never really known.
We call it ‘performance ownership’.
Performance Ownership
Performance ownership means having a real care for the reputation and success of the organisation that you work for – a real attachment to its purpose and how well it is doing. At John Lewis, people really do care that they are ‘never knowingly undersold’, and they really do care whether the customer has a good experience in their shop. The reputation of their organisation is actually important to them. They are proud of it – and they feel that they are genuinely part of it.
People tell me that this ‘performance ownership’ is possible only because John Lewis employees ‘own’ the shop (as partners). I reject this for two reasons: there are other examples where employees don’t own the shop (I’ll cover these in Chapter 11), and on a day-to-day basis it’s not the certificates in their pockets that make them do it. It’s what’s in their heads – how they feel about their work. Share ownership may help, but it’s not essential.
My work with healthcare clients over the last few years has been directed towards making performance ownership a reality in healthcare. I believe not only that it’s possible, but also that it’s essential we do this if the NHS is to thrive. Performance ownership is better for the patient – and it’s necessary also for the efficiency improvements and cost savings that we are going to need in the future.
Performance ownership is better for the patient because in hospitals it means noticing not that someone is dithering over a saucepan but that they are in pain, or becoming fluid-overloaded like my mother, or maybe just lost. Patients are not just treated; they are cared for.
Performance ownership is better for efficiencies and costs because it makes people want to improve their organisation. They put in the discretionary effort needed to make things more efficient – and greater efficiency can lead to better clinical outcomes as well as reductions in costs.
And finally, it is better for staff because working in such an organisation gives them a real sense of satisfaction and happiness in their work.
So far, so obvious, you might think. But the question is, how do we develop performance ownership in our healthcare organisations?
Transforming healthcare
To some extent, my mother’s story provided the impetus for me to write this book. But the idea for the book began much earlier, when I left the NHS myself 10 years ago. I wasn’t always a doctor: I once worked in city institutions, then re-found my childhood vocation to become a doctor. I trained for five years, but once in the job, I quickly lost my faith in medicine. I found myself working for organisations that seemed hell-bent on breaking me. I remember the surge of anger I once felt when I was asked by one of my well-meaning patients: ‘Don’t you ever go home?’ I was sleep-deprived and gently bullied for several years until I gave up. My colleagues and friends must have been made of sterner stuff. Or maybe they just didn’t think they had a choice. Either way, I was pleased to leave behind organisations that I felt were profoundly in need of change.
I left medicine when I was given the opportunity to work as an implementation consultant whose job it was to help change organisations. That seemed pretty appropriate, considering. I soon learned how hard it was to really change such things – to help people modify en masse the way that they work. People, it seems, have a strange way of resisting change, even when it is in their best interests. (I’ll talk more about that in Chapter 4.)
Over the years I became interested in how cultural change comes about, particularly within the healthcare industry. I set up a company called Human Capital Valuation, which aims to transform hospitals, making them better places to work and better places to be treated as a patient. As the company’s name suggests, it focuses primarily on helping organisations to gain maximum value from the people who work for them.
The problems that prevent such excellence tend to be the same whether you work for a bank, an oil company or a hospital – an unbalanced focus on profit and too little emphasis on what makes staff feel successful, motivated and committed. Yet we all know that people are the key to everything – to your success as well as your failure.
Drawn back by that childhood vocation, I returned to medicine in 2004 and now work in A&E, as well as running my company. The NHS changed while I was away. Junior doctors seem less overworked and better cared for, although it often seems to be at the expense of their seniors. There is much more computing power in evidence. Investigations have improved and treatment has continued to accelerate. Yet there is much still to improve, as my mother’s example showed.
But what I did realise, and still know, is that healthcare is teeming with talented staff – extraordinary individuals of the very highest calibre. Most industries would give away half their assets to get their hands on staff of the quality – highly trained, intelligent and self-motivated – that is enjoyed by healthcare organisations. So if that is the case, why aren’t our healthcare organisations more successful?
It’s true that there are some great examples of fantastic places to
work – world-leading organisations filled with happy and motivated
staff. Yet the sad thing is that this is unusual. For the most part,
this extraordinary human capital asset is needlessly squandered:
high-quality individuals and teams are often demotivated and unhappy,
with equally unhappy consequences for patients and for the efficiency
and reputation of the places in which they
are treated.
Yet – as this book sets out to prove – it needn’t be so.
Chapter 2
Why we should value
our human
capital
I once worked with an independent hospital where the Financial Director took a particularly extreme view of what was important to success: ‘It’s volume that counts,’ he insisted. ‘Getting the patients through the door. Everything else is just soft stuff. If someone’s no good we should simply get rid of them and hire someone better.’ Given that I was trying to persuade him to develop and nurture the ‘soft stuff’, I had a serious challenge on my hands. It’s true that that we can overindulge in too much ‘soft stuff’ at the expense of good management systems, but I strongly disagreed with him. He – and his ‘hard-nosed’ colleagues – can so easily squander the talented and motivated staff that deliver healthcare to our friends and families. By demotivating them he risks making them, and his hospital, unsafe. His approach verges on the negligent.
To counter this, over the last few years I have developed a way to explain more eloquently why I think this is the case and why, to develop real excellence, you must focus jointly on operations, patients and people.
I called my company Human Capital Valuation because we believe you can put a value on human capital just as easily as on financial capital, and that by doing so, you can drive both growth and improvement. An organisation is not simply a machine into which you put investment in order to get results. It is more complex than that. Each organisation is a finely tuned balance of capital and talent.
In the past, an organisation was measured solely by the value of its tangible assets – work in progress, assets, capital employed and retained profit. So businesses tended to focus entirely on increasing value by building capacity, developing new products, improving efficiency and increasing margins and so on. What that didn’t take into account was the qualities of the people who worked for that company: their motivation, their capability and their willingness to stay in their jobs. Let me explain how this works by referring to the diagram opposite.
The three circles
CIRCLE 1 (left, ‘Financial Capital’): We take money from investors (taxpayers or shareholders) and put it into a budget with which we build capacity to deliver healthcare. This creates demand from patients. The volume of patients largely determines the size of the financial surplus. These are the traditional ‘book values’ on the balance sheet.
CIRCLE 2 (centre, ‘Customer Capital’): The demand from patients is also affected by the reputation of the organisation and vice versa. The better the hospital, the more a patient will want to go there. In commerce, demand and reputation are the ‘goodwill’, the intangibles, which predict the future value of a company.
CIRCLE 3 (right, ‘Human Capital’): The reputation of your hospital is, however, principally dictated by the quality of the care it delivers. This quality is largely determined by the capability of your staff, which is influenced by levels of staff retention, the talent that can be attracted and staff motivation. Critically, motivation is itself largely determined by quality and reputation: everyone wants to do a good job, working in a great hospital.
These qualities of human capital are not traditionally used to value companies and yet, in a service environment, and especially in healthcare, it is these qualities that determine the long-term success of an organisation.
For simplicity, I have abbreviated this complex model into something more manageable (see overleaf). It is easy to see that these circles feed off each other. Motivated, capable staff deliver a high-quality service which creates a good reputation, which not only causes patients to demand more services, but also has a positive impact on motivation. This demand then generates cash that can be used to build more capacity and deliver more services. It is also easy to see that demotivated and poorly trained employees can destroy your reputation, causing a fall-off in demand and a fall in volume.
It is common for organisations to neglect or merely pay lip-service to the human capital circle and concentrate instead on measuring financial capital. As we shall see, measuring customer/patient capital as well as human capital is not difficult, and it helps us to improve financial and operational results.
The ideas and the programme that I outline in this book are based on the need to balance these three circles and at the same time to ensure that all staff have the right mix of challenge and support (see page 28). Without this, they won’t provide the efficient and effective levels of care that are being demanded by patients and investors.
Valuing your human capital is the key to transforming your organisation.
Chapter 3
The CAREFUL Programme:
seven
steps to creating
performance ownership
Let me tell you about two hospitals. They could be two hospitals in which you and I have worked – or indeed in which we and our families are being treated.
Hospital A provides healthcare in a poor and unhappy part of the country, but it is nonetheless a good place to work. You wouldn’t think it would attract many people to work there, but you’d be surprised. Vacancies don’t remain unfilled for long, and many of the staff have been there for years. The training and development of staff is well renowned. Patients have nothing but praise for the way they are treated, and the hospital is at the top of the national league tables in all its clinical specialities and measures of patient safety. It attracts funding for its research and audit programmes without much difficulty because it’s renowned for being innovative. In fact, it was one of the first to install electronic patient record (EPR) systems, which make its systems and processes very efficient. The hospital is building a new wing to house a new unit with investment secured to develop a wider range of services. But above all, Hospital A is a friendly place. Staff are courteous to each other and to patients, and they are outwardly happy. The CEO and exec team are all familiar faces on the wards and clinics.
Hospital B, on the other hand, is less happy. The main feature of working here is the stress, caused mainly by frustration with systems and processes that don’t work. The EPR system was rushed in without consultation and that doesn’t work either. Despite being in an affluent area, the hospital has difficulty retaining staff – vacancy rates and staff turnover are high, so agency staff are the norm – making the management of wards and clinics even more frustrating. There is no real research and development budget, which means good clinicians stay away, and managers have little time to develop the skills of the staff that do remain. A recent announcement has said that funding for a much-needed extra wing has been put on hold. Patients seem to have become more demanding and complaints are on the rise, which is taking up valuable management time and effort. A recent high-publicity patient safety scare has added to management’s problems, and several of the exec team have been summarily replaced. None of the staff would recognise the CEO or the board if they bumped into them. In short, it’s an unhappy place to work. Morale is low, and it shows.
I’ve worked in both of these hospitals – and I know in which one I would rather be treated.
The CAREFUL programme
In the remaining chapters, I’m going to explain how you can turn Hospital B into Hospital A in seven stages. These stages are the components of a cultural change programme that I have developed and delivered, with the help of colleagues and clients, over the last decade while working across healthcare and other industries.
This programme has evolved into what is now called – for ease of mnemonic as well as for its compassionate overtones – the CAREFUL Programme.
Each letter of CAREFUL represents a quality that you will find in well-run organisations, from Commitment to Leadership. Each stage of the programme is concerned with one of these qualities, and for each stage I explain how it is possible to nurture that quality in your organisation.
The stages work together – and they necessarily overlap. They also reinforce each other. My recommendation is, not surprisingly, that you start at the beginning and work through to the end. But in the spirit of ‘virtuous circles’, the quality defined by the last letter reinforces the first, and so we have a programme that is itself a continuous effort at improvement – a continuous attempt to move Hospital B into the realm of Hospital A.
Briefly, the seven letters stand for the following:
COMMITTED: The organisation is clear and consistent in its pursuit of excellence. It knows what it excels at, which we call a ‘first or best’ position. Leaders know what that position is and how to measure it. They also behave in a way that clearly supports that position.
ACTIVE: Staff work together to solve problems in teams that are flexible, efficient and well supported. Everyone in the organisation understands how to collaborate rather than compete in order to make improvements.
RESPONSIVE: The organisation listens to patients and to staff and takes note of what it hears. It looks at its behaviour from the point of view of its patients and works to improve their experience. It responds also to staff and their needs, to enable them to be more efficient.
ENERGETIC: Leaders work constantly to improve the way in which they lead the organisation. They use their skills to positively influence and energise the people who work for them. The organisation recognises leadership development as being as important as clinical development.
FOCUSED: Everyone in the organisation sees beyond what is happening today and strives for goals that may seem impossible. The organisation does not tolerate unacceptable behaviour or attitudes that work against this effort.
UNIFORM: The organisation is an efficient machine where repetitive tasks are done right first time, every time, freeing up time for staff to provide ‘service on top’. It properly documents, controls and improves its processes.
LEADING: A leading hospital knows where it stands – it knows its first or best position. And being good at one thing makes everyone in that hospital want to do more of it, to sustain that reputation. As a result, they do everything else well, too. They are proud of and work hard for their hospital – they have found performance ownership.
You will find the description of each stage and each quality in Chapters 5–11. In each chapter I explain why this quality is necessary and what it means for your organisation. I explain how to achieve this quality in your organisation, starting with the bare essentials – the things that you must do – then I add further ideas for ways in which you can turn Hospital B into Hospital A.
Before I do, though, I’m going to offer you a small challenge. I would not be surprised if, at this point, you are thinking one of several things:
‘We already do that.’
‘That’s not possible.’
Or maybe just: ‘I can think of several reasons why he’s probably wrong.’
I know this, because I have heard all of these many times before. It’s just sheer resistance. It’s common, it’s obstructive – and it’s time we dealt with it.
Chapter 4
Change management and
the
problem of implementation
I once worked for a client that needed to redesign its supply chain in order to save millions of pounds in wasted costs. The company needed to renegotiate contracts with all its main suppliers and work out better ways for goods and people to be delivered to its many sites. This was a hugely complex programme of change that required immense technical skills as well as the ability to influence a wide range of people.
The person responsible for this programme had recently been appointed to the role of ‘procurement manager’, a title that didn’t do justice to the immensity of the challenge that he faced. His team was very junior and had no experience of managing change on this scale. His boss hired us, a small team of experienced consultants, to help him to create and execute a plan to save all this wasted money.
Over the course of several weeks, it became clear that the procurement manager was doing everything underhand that he could in order to get rid of us. His aim was to undermine our credibility and to get us out of his department. He avoided all contact with us and spent time trying to make out that his department’s work – which was of terrible quality – belonged to us. He spent time bad-mouthing us to his colleagues, who were working with us on other projects and had made up their own minds. His tactics became more obvious as the weeks went by. Eventually, the tension rose to such a point that his boss took the only step available.
He sacked his new procurement manager.
What was going on here? Instead of welcoming us as a way to improve his team’s capability and reduce his own workload, this man acted consistently against his own interests and paid the price by losing his job. Such behaviour is hard to understand – especially if you are new to change implementation.
The answer is fairly simple. We’re all human and hold strongly to our ideas of what sort of person we are, how good a job we do, and what is important to us. If someone comes along and says ‘This all needs to change’ or even simply ‘It looks like you could do with some help’, it can be uncomfortable and a threat to our security, our identity and our pride. People do not actually resist change per se – on the contrary, most people welcome change. What they resist is being changed. It is the emotions evoked by being changed that will cause problems when you set out to transform your organisation.
As I said at the end of Chapter 3, suggestions of change often meet with resistance. Here are six reasons why your staff – or you – might resist the changes needed to transform your organisation.
1. Threat to security A fear of losing what you have. This can be your job, position, sense of direction, territory or work relationships. Any threat to move people around and change these things, particularly job descriptions, is so unsettling that it easily overrides reason.
2. Threat to identity A need to maintain what you are (rather than what you have). This can be a real or perceived threat to self-esteem, competence or established position. Our procurement manager clearly felt this acutely.
3. Conflict of values The ‘over my dead body’ issue. Change may appear to undermine the current value system or culture of the individual or of the organisation by implying that they’re not good enough, even if this is not necessarily the case. A good example of this would be clinicians faced with cost savings, if they felt that the savings would be dangerous or that they might threaten their judgement and professionalism.
4. Inherent problems with change The ‘Whoa! Slow down’ problem. Stability is more important to some people than others – and a lot of people think that going in a new direction will be too difficult or too terrible. Many have difficulty embracing the magnitude or speed of change, or the fact that it is irreversible.
5. Lack of belief The ‘here we go again’ syndrome. If a person has been subjected to lots of previously unsuccessful changes in their organisation, they will, naturally, be suspicious of yet another set of initiatives. They will lack faith in any new changes and will be unable to see the likely benefits.
6. False optimism ‘Oh, we’re doing all that.’ This was the response of an HR director of a hospital I talked to recently about some of the concepts in this book. I had worked in his hospital and I knew they weren’t doing ‘all that’. The place was deeply dysfunctional. Of course, no one can get away with this if they are measuring their results, something I insist upon frequently throughout this book. In fact, this last objection is the hardest to overcome, because you do have to install measurement systems, which is hard, just to face up to reality.
I suggested in Chapter 3 that you may feel some of these ‘resistances’ yourself. That’s normal. But how can you and your staff overcome them? There’s no single answer, but there are some things that I have learned about how to make change easier which may help you as you work through the CAREFUL Programme.
1. Be positive and visible Repeat the benefits. Be encouraging and compassionate. Smile (genuinely).Never berate or blame someone for a problem – it will come back to bite you. Never announce an initiative then retreat to your office and wait for someone else to deliver it. It’s your challenge too.
2. Let the people do it for themselves Find ways for staff to make their own changes. Set up Action Teams (see Chapter 6) rather than ruling by decree, so that staff create and implement their own changes rather than being changed from ‘above’. Then congratulate, reward and recognise their contributions.
3. Recognise and understand resistance Don’t get cross or frustrated when staff resist. Get closer. Find out what’s bugging people and deal with their concerns. Negotiate. Give them time to understand. Involve them.
4. Only believe the numbers Time and again throughout this
book, I emphasise the need for installing systems to measure and
manage what you are trying to implement. A verbal report is quick and
easy, but often worthless. A doctor won’t accept that a heart rate
is ‘reasonable’: they demand the number. Equally, a target isn’t
meaningful unless it has a number attached. (Saying that ‘staff
absenteeism is down to 3%’ is vastly more meaningful than ‘staff
absenteeism is down’ or
‘is acceptable’.) Remember the
adage ‘In God we trust, all else bring data’. Have command of the
evidence.
5. Work hard on alignment Resistant members of staff will set other members of your team against each other. Don’t let them. Make sure that everyone in the senior team is completely aligned with the overall vision and targets. Help them learn how to articulate these aims.
6. Do one thing well Don’t bite off too many things at once. If you can address one problem at a time, it helps you to concentrate and move faster. Succeed at one thing, then move on.
7. Persist A friend of mine has a saying: ‘Persistence pays the bills.’ He’s right. You will have to become an expert at persistence. Persistence at different stages needs different skills (see ‘The cliff face of implementation’, page 32).
While you are thinking about persistence, it is important also to understand how to balance challenge and support as you encourage your staff to change the way they work. Challenge alone or support alone are not enough – you need both, and in the right quantities (see below), if staff are to be motivated and successful.
To support the seven principles above, I want to suggest that you develop three simple skills – leadership rounds, talking up and thank-you notes – which I have described on pages 29–32. Do these before you do anything else in this book, as a foundation for what is to follow.
Challenge and Support
To persuade anyone to change the way they work requires a fine balance of challenge and support. Challenge – which must be willingly accepted by the individual rather than imposed on them – can be anything that requires extra effort or capability. Support consists of those things that help to develop or nurture the necessary capabilities. Creating the right mixture of these two things is the key to success.
Apathy: With too little of either challenge or support, jobs are meaningless. People find excitement and motivation elsewhere in their lives. A good example might be a night watchman: nothing much happens and no one much cares.
Comfort zone: Too much support without any real challenge may seem pleasant for a while but soon becomes cloying and seems a waste of time. It also rarely produces excellence. Many ‘support’ departments – almost by definition – suffer from this.
Stress: Too much challenge without enough support may cause short-term exhilaration, but soon causes burnout, even fear and isolation. The Apprentice, anyone?
High performance: With the right mixture of challenge and support, people grow: their capabilities and their motivation both improve and they derive real satisfaction from their jobs. Because they are helped to deliver, they deliver.
It’s important to realise that the nature of ‘support’ required by high-performance staff – much of which we discuss in this book – is totally different from that enjoyed by those in the ‘comfort zone’: it means more hands-on training and individual coaching and fewer ‘team-building’ exercises and away-days (which may be fun but do nothing to respond to individual needs). Don’t be surprised if moving your ‘comfort zone’ staff into the high-performance box causes stress. It will. But it will be worth it.
The cliff-face of implementation – the stages of persistence
It is worth expanding on the idea of persistence. I have a lot of experience of implementing change, and there is no doubt that it can be difficult – both for those leading and for those coping with the changes. Some of the ideas described in this chapter are easy. The ideas in later chapters become more and more difficult. The common thread is that each new change requires persistence.
To help, here’s an analogy: you decide one day to climb a mountain and ski down the other side. You have to persuade your friends to come with you – all the way. You will need to go through several stages of persistence:
1. Getting started: you need to clearly articulate the end point – how great it will be to reach the top. I call this VISIONING.
2. Back-sliding: when things get tough, early on your friends will try to give up, finding good reasons to go home and watch TV. You need the skills of PROMOTION to keep them with you.
3. The long haul: the tedious, dangerous, exhausting climb will involve making mistakes and – mainly – trying not to fall off. Your job is to support your friends. This is COACHING.
4. The view from the top: when you make it to the top, you should rest a while and take in the view – and you should phone home and tell people how good it is. We call this IMAGING.
5. On the other side: you need to continue the good work, having got to the top. This is DEMONSTRATING the benefits so your friends will come with you again.
Three Simple Skills
Visibility of leaders is vitally important to staff. As I said earlier, it is no good delivering an initiative and then disappearing while someone else implements it. You, as the leader, need to be right there, helping, encouraging and rewarding results. Leadership rounds, talking up and thank-you notes are three small but significant ways to impress upon people the seriousness and strength of your own commitment as their leader.
LEADERSHIP ROUNDS
It is essential for senior leaders to be visible and approachable on a regular basis if staff are to feel engaged with their organisation. After all, how can leaders know what is really going on unless they spend time visiting and talking to their staff? It would be rather like a doctor treating a patient by email without ever meeting them.
Leadership rounds must focus on the positive and on the individual, otherwise staff will think you are there to catch them out. I recommend that you ask three questions:
1. What’s going well?
2. Who’s doing a great job?
3. What tools or equipment do you need to do your job?
Then take it from there. You must impose a proper structure on this part of your work; write down what your staff tell you, file and monitor the information and follow it up.
Avoid the temptation to fix problems during the rounds – that’s not what they’re for. Their chief purpose is for you to listen to and talk to your staff. If a problem comes up, note it down and deal with it later, otherwise it will feel like an inspection.
Making time for leadership rounds can seem difficult, but it pays dividends. You will better understand and respond to the day-to-day needs of staff; you will be viewed more positively; and, properly executed, leadership rounds will reduce ad hoc requests because staff can rely on having face-to-face time with you in the future.
Such leadership behaviours are difficult to introduce into an organisation – for some people they require a change in entrenched habits. But leaders do need to change their frame of reference and start thinking more readily about the work environment from the point of view of their staff.
THANK-YOU NOTES
I recommend that leaders write regular letters of thanks to individual staff to acknowledge their work and the effect that it has on the organisation. Leadership rounds will provide all the material you need to decide who should be thanked and for what. Don’t get your PA to write them and sign them on your behalf. And don’t use email. The best thank-you notes take the form of a simple, hand-written greetings card, explaining what the person contributed, who passed on the information, and how their contribution improved the experience of patients and staff.
Experience tells us that maintaining enthusiasm for thank-you letters can be difficult. As with all implementation, it requires commitment from senior leaders and persistence. This means measuring and monitoring what letters are written by which leaders to whom – and making sure every leader is doing their bit. But if you are in doubt about their worth, I can tell you that I have seen staff laminate their thank-you notes and place them next to their work area, so proud were they to have their efforts praised.
Here’s an example of a thank-you note:
Dear Kate,
Tony tells me that while you and your team were on duty this weekend, you helped him reorganise the stock rooms as required by our last inspection. He tells me that this means we now won’t lose any theatre time this week, as we feared. I really appreciate the extra effort and help that you put in because we know that cancelling theatre time can be very traumatic for patients and their families. Thank you.
TALKING UP
Another skill you need to develop is ‘talking up’. This combats the pernicious ‘us and them’ syndrome that builds up in large organisations. It’s easy for one department to blame another when things go wrong, but it’s damaging to staff morale and discourages collaboration between departments.
Talking up means describing your hospital, your colleagues and your peers in a positive way – that is, telling other staff and patients how good they are or how well qualified or successful. For example, it’s reassuring to patients and staff to hear that your hospital has the newest equipment or the highest success rate in a particular area. Talking up sets a good example, becomes part of the culture and reinforces the positivity we need.
CASE STUDY: Follow the leader
A CEO in one hospital I once worked in had a reputation for being aloof and constantly in his office dealing with email. A recent staff survey had been scathing of his style, so he adopted daily leadership rounds, choosing a different area of the hospital each day.
He soon discovered a lot about the day-to-day work of the hospital that had been hidden from him – and staff found that he was much more approachable and capable than they thought. Because he kept a log book, he was able to hold his leadership team to account for following up on the things he had discussed with clinical staff. He reckoned that by being proactive his rounds saved him several hours a week.
How people learn and the importance of numbers
I’d like to finish this chapter with an important point about adult learning. I mentioned in the introduction how success – the opposite of resistance – can only really be demonstrated through numbers. I continually emphasise in this book the importance of numbers and systems as a way to help people measure, and therefore demonstrate, their success.
So, the groundwork has been done. Leadership rounds, thank-you letters and talking up have all started – and so we have begun the journey from Hospital B to Hospital A. Now for the seven stages.
Chapter 5
Committed
‘Be clear’
A friend of mine recently had minor surgery on her hand. She had skewered herself trying to remove an avocado stone. Thankfully no lasting damage was done, so she makes light of it. She makes her friends squirm by describing the accident in gory detail, but she’s never considered telling her employer about her mishap. Who would? However, if she’d worked for the international company DuPont, she’d have been sacked for not doing so.
Sound extreme? Before you pass judgement, there’s one thing you should know about DuPont: they are the undisputed world leaders in industrial safety. The safety record of DuPont puts every other organisation in the world to shame.
The story of this goes back to the inter-war years. At that point, the company was already forward-thinking in industrial safety. However, it made munitions in the First World War and during that time a lot of people were killed in its factories. The graph showing the number of fatalities in its manufacturing sites shows an enormous blip between 1914 and 1918. Because of that, DuPont committed itself to eliminating fatalities and serious injuries entirely.
One of the most notable things it did was to place the house of every factory manager inside the factory. By putting the manager’s home, family and possessions into the same position of risk as that of his employees, DuPont ensured that the manager had a vested interest in preventing the place from exploding. By the time the Second World War came along, the same graph showed not a murmur: major incidents continued to fall throughout.
By the end of the 20th century, the company could no longer use ‘fatalities and serious injuries’ as a measure. Any disturbance from zero was too rare to be useful. It started measuring other things, which predicted the likelihood of an accident – including accidents at home. As a DuPont employee you are contractually obliged to report accidents at home. The company has worked out that accidents are not random. They happen to unsafe people, and if you’re unsafe at home you’re probably going to be unsafe at work – hence the need to report avocado-related stabbings. And if you do something demonstrably unsafe at work (like standing on your desk), you’re not welcome – just in case the next shortcut you take causes an explosion.
The key elements of the DuPont philosophy are:
• Managers at every level are responsible for preventing injuries and illnesses.
• Safety must be a part of every employee’s training.
• People are the most important element of a health and safety programme.
There is much more to the DuPont philosophy and practice, and I do it an injustice by summarising it so briefly. For a complete description, see Industrial Safety Is Good Business: The DuPont Story by William J Mottell (John Wiley & Sons, 1995). It is a masterclass in commitment.
Therein lies the reason I use DuPont as an example in this chapter. It exemplifies what commitment means in an organisation:
• Be clear about your ‘first or best’ position. What makes you worth working for or doing business with? Are you the safest, the cheapest, the fastest; do you have the best technology or the best customer service?
• Set clear numerical targets at every level.
• Make sure that your leaders behave in a way that supports the first or best position.
DuPont’s first or best position was simply to be the safest company in the world. Its target was zero accidents. And its behaviour backed that up – the safety rules were clear, strict and enforced absolutely at every level, from trainee to CEO.
The last point – demonstrable behaviour – is important. Commitment is not just a decision. It’s also a process. Once you have stated your aim, you must back it up with appropriate behaviour.
Take, as a simple example, a man who wants to pass his driving test. He books a test date, which is the aim. But he backs that up with supporting behaviour – he takes driving lessons, he learns the Highway Code, he practises driving with friends and family, he checks with his instructor how well he’s doing and works on his weak points. It is this behaviour that shows he is committed to passing. Merely saying ‘I want to learn to drive’ is not in itself proof of commitment, in the same way that a vision statement – ‘We want to be the best!’ – is meaningless without measurable targets and behaviour to back it up.
What is a committed organisation?
A committed organisation has a clear FIRST OR BEST POSITION.
A committed organisation underlines this with DEMONSTRABLE BEHAVIOUR.
A committed organisation has targets that are BALANCED across the Three Circles (see page 17).
A committed organisation has targets at EVERY LEVEL of leadership.
The importance of balance – the four-hour wait
For a target to be meaningful, it must be pursued with some thought for balance within your organisation. This cautionary tale will demonstrate how things can go awry.
In 2003, amid growing public concern about long waits in A&E, the Blair administration introduced draconian penalties for any hospital that failed to see, treat or dispatch within four hours every patient that entered A&E. (‘Dispatched’ could mean sent home or admitted to the hospital.)
The government exerted pressure on hospitals to meet the target by simple but drastic means; each breach of the target could lead to severe penalties of several thousand pounds of reduced spending in the hospital. This filtered through the CEO/board members, divisional directors and department managers to the nurses and doctors on the shop floor.
I experienced the effects of this first-hand when I returned to work in A&E after taking a few years out of medicine, just as the targets began to bite. I came back from seeing my first patient and was approached by the ‘Throughput Nurse’ – or, to put it more simply, ‘Nurse in Charge of Making Sure That No One Stayed More Than Four Hours in the Department’.
‘What are you doing with this patient?’ she asked.
‘I’m going to wait until I get his blood tests back to decide whether he needs to be admitted or not.’
Without hesitation, she replied: ‘Oh, no you’re not, Doctor. You’re going to make up your mind right now. If we need to admit him, we must make that decision right now. If he goes home, then he goes home now.’
I was taken aback. I insisted that I couldn’t judge the clinical need until I knew what his results were. ‘That’s irrelevant. If there’s any chance we might admit him, then he needs to come in.’ And so we admitted him.
I quickly learned that for every breach, someone got a kicking – and that very soon translated into a change in behaviour. If you didn’t want to be humiliated or quite literally shouted at, you got the patient out of the department – whether they’d been treated or not. You handed them over, sometimes mid-treatment – never a great idea when everyone’s busy, tired and prone to errors – and hoped that nothing would go wrong. It worked, to a point. Patients generally were ‘dispatched’ within four hours. But they weren’t necessarily treated in that time, and often they were admitted unnecessarily, only to be sent home hours later.
Let’s examine this in the light of the Three Circles in Chapter 2. This is a well-managed target executed brilliantly, but it’s completely unbalanced. On the whole, it doesn’t take into account clinical need. It creates demand from patients (because they know they’ll be seen the same day, so they come to A&E instead of going to their GP) and yet creates no satisfaction in the staff.
Targets work – if they’re balanced
After reading this, you may be surprised to discover that I am an ardent supporter of targets. It’s true that they can have unintended consequences. The unbalanced nature of the four-hour wait can have a negative impact on patients and staff, as we have seen. Nonetheless, it has caused a sea-change in the way in which patients are seen in A&E. Most consultants in this area agree that targets have done more good than harm by helping people to focus on the way in which demand is managed. We should be rightly proud of the efficiencies of our A&E departments. Targets are good in principle, providing they are balanced. We actually need more targets, not fewer.
The problem is that many of the targets demanded of senior leaders in healthcare these days are handed down either by the Department of Health or by shareholders. They tend to change with the political and financial climate. Most targets concentrate on finance and operations because investors (DoH or shareholders) are primarily interested in Circle 1, finance and operations. Leaders do need to meet these targets, of course, but it is vital that they keep the wider needs and aims of their organisation in mind, and not allow every new target to unbalance those things.
In summary, balance, across the Three Circles, is vital if you are to sustain your commitment and have targets that are meaningful. In the above example, operations benefited – but patients and staff did not.
What’s the benefit of commitment?
Commitment helps to align everyone from top to bottom. Everyone knows the key targets and priorities, what their organisation stands for and how to behave. At DuPont, no one is in any doubt about whether to stand on their desk to change a light bulb. Safety always comes first.
But commitment has a wider importance. Setting out the intent of the organisation helps people to solve problems in context. This is where a clear ‘first or best’ position helps. There is one airline, for instance, that is ‘best’ at being the lowest-cost airline. Staff are, allegedly, banned from charging their mobile phones at work because it wastes electricity. This may not be true – but such stories help staff to decide how to behave in other situations.
Commitment motivates staff. Commitment makes it clear why their organisation is worth working for. If staff are motivated, the rate of staff turnover and absenteeism goes down, which in turn improves clinical quality and patient care.
What happens if an organisation lacks commitment?
Working in an organisation that lacks commitment can be a demoralising affair. Here are a few examples of the many ways in which commitment can be lacking. Having talked to many people about this over the years, I would guess that everyone has experienced some of this, in one form or another. The boxes on pages 41 and 42 provide concrete examples.
Download this book for your ebook reader.
(Pages 1-32 show above.)