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Creating a culture for improvement

Posted by admin on January 17, 2017

The last four years as CEO at University Hospitals of Morecambe Bay have been one of the most rewarding periods of my career.  When I joined the Trust back in August 2012 it had a poor reputation following serious failures in care and the loss of 11 babies and a Mother, which have been widely reported over the last few years.

Fathoming out how to develop a vibrant culture across the hospitals, repair relationships and trust and build a healthcare organisation which would not only survive but thrive and flourish was uppermost in my mind.

Having been an NHS CEO for 15 years I have developed a keen nose for diagnosing underlying issues for performance and quality problems. I have used a 5 point framework for “scanning” and locating the “hotspots” which has served me well over the years. The five headings are illustrated in diagram one below.

Diagram One – Framework for continuous development - strategic pillars for improvement

Five pillars.jpg

There is nothing sophisticated about this – it simply allows for a more thorough diagnostic.  I have used these five “pillars for improvement” in a number of CEO roles. They are useful in diagnosing and identifying gaps. I also use them to “frame” conversation with staff, patients, public and so on to describe the work we are doing and explaining why we are prioritising particular issues at particular times.  Running through the pillars continually ensures we are paying attention to the spectrum of issues and challenges we face. Without getting into more detail, this approach has stood the test of time. My teams work on a 12 week cycle and constantly agree and focus on our priorities, reflect what is happening as a result and refine what we do next. Things move so quickly that 12 weeks seems to be the optimum timescale. The only other point worth making here is that it is essential the pillars are underpinned by values. I mention these later – our values were defined and agreed through an extensive process led by staff. I hope that the evidence demonstrates that we try to live these in all we do and everyday this can be seen. What the framework doesn’t do of course is to provide the answers – if only life were so simple.  This framework is useful in “framing” the issues and it allows the conversation to begin about what should then be done. There is of course no substitute for getting out and about and talking with people.  This includes staff, patients, partners, the public, MP’s and councillors and so on – all of whom will tell you from their perspective “what’s really going on”.

When I started to have that conversation at Morecambe Bay – my heart sank.  Relationships were poor between the Trust and its staff, between partners, and the confidence had been lost with patients and the public.  At its most basic level, and with the benefit of hindsight, the reasons for this were apparent over a number of years before the Morecambe Bay Inquiry.  The purpose of this article is not to look in-depth at the reasons why, suffice to say they included leadership failure by those trusted with public services and evidence of complete lack of connectivity with staff at all levels.

For the most part – the staff seemed beleaguered, a minority were indifferent, but most were “lost” – wondering how a change could come about.  I detected a sense of helplessness.

Where to begin

I am in many ways a more traditional CEO – I worked “through the ranks” having started my career as a nurse.  In my early career I was privileged to work with a number of great leaders who oversaw my “apprenticeship”.  I learned some important lessons in overseeing the operations of a busy hospital, on creating momentum and a winning mind-set among staff and on developing great relationships across a system.  All of these well used tools came out of the toolkit at Morecambe Bay and have stood the test of time.

However, Morecambe Bay demanded more. 

It’s all about the people – creating momentum

Over the last few years I have developed a fascination about how to accelerate change and grown to appreciate that as leaders we must focus on two main operating systems.  These are best described by John Kotter in “Accelerate”.

The idea in brief is …”that although traditional hierarchies and processes – which together form a company’s ‘operating system’- are optimised for day to day business, they can’t handle the challenges of mounting complexity and rapid change.  The solution is a second operating system, devoted to the design and implementation of strategy, that uses an agile, network like structure and a very different set of processes.  The new operating system assesses the business and reacts with greater agility, speed and creativity than the existing one.  It complements rather than overburdens the hierarchy, thus freeing the latter to do what it’s optimised to do.  It actually makes enterprises easier to run and accelerates change”. 

When I joined the Trust system one wasn’t working effectively and system two didn’t exist.  I often refer to these two systems as the “art and the science”.  System one is the science, ensuring there is an effective Board assurance framework in place, effective risk and performance management systems, tight financial controls etc. The CQC domains and in particular the “well led” domain all take Boards and leadership teams through the mechanics of how to get these right. Effective governance systems are so important and as a new Board we spent a lot of time ensuring these were put in place and then evolved and strengthened.  I don’t want to belittle system one operating systems as they are fundamental and require a lot of discipline, the appropriate structures and processes and continual maintenance  and upgrading. These two systems are illustrated in diagram two below.

Diagram Two – The Two Operating Systems

                     System 1                                                              System 2

The two operating frameworks.jpg

However, evolving a vibrant system two is a wholly different challenge.  I think I knew intuitively that creating this system was important at Morecambe Bay.  I knew from previous experience that simply putting in place the discipline and structure of system one would not be sufficient and certainly not to accelerate much needed change at pace.  So I began to personally lead a number of Trust-wide “initiatives”.  I don’t like the word “initiatives” and I don’t think staff do either – so I tried hard to not refer to them as such.  I ran a number of campaigns in the early days including Listening into Action (LiA) which has been used successfully by many Trusts nationally.  I also developed local campaigns which sought to surface poor behaviour – e.g. “it’s not OK to behave that way”.  I began to bring staff together in different groups around areas of mutual interest.  An early request through my weekly “Friday Message” was for “leadership activists” to work with me to support staff to come forward and get involved.  It felt as though we were enlisting an army of volunteers – all willingly giving their time and commitment to get involved.  This group of staff worked with me to develop a set of values – which were tested and refined through a lengthy process involving many staff.  These were (and are) as important as signalling the change we wanted to see. 

What I began to notice about working in this way was that it gave us additional momentum. Not only that there was a “feel good factor” to day-to-day work, staff who had worked in the Trust for years met with colleagues for the first time – it created a solidarity and joint commitment to improve.

Over the four plus years, the leadership team and I have continued to work on developing both system one and system two.  System two is known locally as “The Bay Way”.  Each year, as well as agreeing our operational delivery plan, we also discuss the work in system two which complements our efforts and we are continuously listening to staff and looking with them to create new and innovative ways of working.

Having reflected on the past few years it is possible to pinpoint a number of important components about system two working.  At the core of system two are social movements.  They assert new values (vision), form new relationships through organising and mobilise power to translate their values into action. These structures of participation allow staff to celebrate collective identity and assert their voice.  This has been so important given our organisational history.  It gave back the ability for staff to take control and create a different future.

Leadership was all important.  When I joined the Trust there wasn’t a comprehensive leadership structure; this reflected the centralist – control and command culture that was in place at the time.  So - When I joined, leaders were appointed, supported and developed – we owe much to the collaboration with Mike West and Lancashire Business School and also to the North West Leadership Academy for their support.  Appointments were made on the basis of skills and expertise but also on a values base.

There are a number of other points worth highlighting about the approach we took to building system two:

    1. The importance of building “relational fabric” (Marshall Ganz) – we invested heavily in why the commitments between people were important.  We wanted to do more than simply ‘engage’.

    2. The importance of telling our story – past failures included many wrongs that needed to be put right.  Storytelling was important because it helped to explain how we should make decisions. The stories provided a framework to help us understand the choices we had in a moral context based on values.  It helped staff make sense of what had happened, express regret and importantly agree and commit to making the necessary change.  So we engineered as many opportunities as possible for different groups to come together and talk.  Through the discussions and “stories” we were teaching – deploying stories to make a point (how to act) and evoke a response (hope).  Ultimately these stories inspired action.

    3. The relevance of developing a public narrative. It was important to rebuild relationships and trust outside the organisation.  It allowed us to communicate what we stood for, our commitment to change and to reinforce the learning.

    4. Taking time to really understand significance of the “moments”.  Timing is a really important part of strategy. Opportunities exist when the environmental context changes.  I can think of a number of these “moments”; they include being placed in “special measures” following a CQC inspection, coming “out of special measures”, the creation of Bay Health & Care Partners and our strategy “Better Care Together”, publication of the Kirkup Report of the Morecambe Bay Investigation and the extensive floods experienced a year ago.  I can also point to other “moments” involving the families who we had failed and their ability to forgive and signal a willingness to work with the Trust and staff differently – taking great courage and humility on their part.  All of these “moments” created fresh opportunities and momentum for change. One of these “moments” was eloquently captured in this clip which followed a visit by Roy Lilley (Health policy analyst, writer, broadcaster and commentator  on the National Health Service and social issues) following a visit to the Trust and the Bay.

  5. Relentlessly keeping a Focus – given the past fragility it would have been easy            to avoid further conflict and say “yes” to everyone.  This diffuses efforts and                    causes confusion.  Ensuring strategic focus to our efforts was key.

  6. Taking Action – mobilising and deploying resources to achieve outcomes is                  crucial.  Power may be built through the relational, motivational and strategic                work – but the bottom line is action. Social movements are, in the end about                  changing the world, not yearning for it or thinking about it.

Looking back over the years there are a number of initiatives and approaches which added value in a host of different ways. Here’s a list of a few:

  • Listening into Action
  • Creating a “Behavioural Standards Framework”
  • Buddying between parts of the Trust and teams
  • Leadership activists
  • Friday message, Vlogs,  Morecambe Bay TV, Twitter and Facebook
  • Flourish campaign
  • Diversity and Inclusion champions and networks
  • Patients safety summits
  • Speak up for safety – freedom to speak up guardian
  • Sustainability partnership – Maternity and Paediatrics
  • Morecambe Bay Leadership tree
  • Quality Ambassadors
  • Our “FLOURISH” programme to support staff Health and wellbeing

The journey continues

2017 brings further challenges, some new and some age old.  What I feel more confident about is that today we are supported by two operating systems, each working in concert and creating the benefits of both.  Here at Morecambe Bay, through living and experiencing of past events, I think we have created the systems and belief in a vibrant and hopeful future where we can be confident of providing the highest quality care – compassionately.  This is “perpetual” and this work will never be done. Constantly reflecting, looking back, learning and applying that learning to change and improving our future is what we do and must continue to do.  Staff have moved from a fragile state to vibrant, self-starting staff with a “can do” mind set.  Remembering the past will be a fundamental part of our approach to patient safety and we are this year developing ways to ensure that this approach is built into the fabric of our workplace and the way our employees work.  In doing so, we hope to create an environment where staff and the safety of our patients can “Flourish”.

Sources

Kotter, John. (Harvard Business Review, 2012)

West, Mike (Lancashire Business School)

Northwest Leadership Academy

Lilley, Roy (2016)

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