Michael West speaking at our 2015 annual conference about creating compassionate cultures that lead to quality care.
This presentation was given at The King's Fund annual conference on 19 November 2015.
So I’m going to talk about developing cultures of high quality compassionate care.
Culture’s really important because it’s the most significant influence on the way people behave in countries and in communities and in work organisations, and we have his national treasure at the NHS and I kind of think that national treasure is an expression of a fundamental value of our country which is we believe that we should provide healthcare to people free at the point of delivery no matter what their status, their wealth, their background, their ethnicity, their religion, their sexual orientation, because compassion is a core value of our national, and this is such a powerful value that whenever an election comes along, the NHS is either first or second on the agenda because it is a treasure to the people of this country, and the one point seven million people who make up the workforce of the NHS made a decision at some point in their lives to dedicate a huge part of their precious, mysterious, wonderful lives to caring for their fellow human beings in their communities because they have a fundamental core value of compassion.
The challenge for us as leaders in this National Health Service is how we can create the conditions that will enable them to do what it is they really want to do which is to deliver, to provide, to offer high quality, continually improving and compassionate care to the people they’ve chosen to dedicate their working lives to. That’s, I think, the challenge that faces us.
So I’ve had the privilege of being involved in research over the last 30 years looking at cultures of high quality care across the NHS in England and what’s emerged from that is an understanding that there are at least six, but definitely six really important things that we need to get right in terms of creating these cultures. We’ve just finished a very big international review of all of the research on culture and climate in organisations, internationally and across sectors, and what that review has demonstrated to us is the fundamental key primary importance of leadership as the influence on the culture of organisations. There are other influences, of course, but leadership is absolutely critical. What every leader focuses on, nurtures the culture of the organisation, every interaction by ever leader, every day within our healthcare organisations, nurtures, shapes the culture of the organisation. So what we, therefore, need our leaders to do is to ensure that they stay focused on those cultural elements that are viral and nurturing the cultures that we seek to achieve, high quality care, continually improving care and compassionate care for the people that we serve, and those six elements, the first is prioritising and inspirational vision.
Now this may sound kind of a bit managerial and technocratic and abstract. Those staff who are coming into work every day have a core value of compassion, they want to provide high quality care. They are motivated on a cold, wet November morning to get out of a warm bed. When they see, when they believe, when they feel that their organisation shares that fundamental value of delivering high quality care to the people of their community and that there is a fundamental value of compassion within their organisations, so it makes a huge difference to motivation and to people’s identification with their organisations.
As part of our research, we analysed the minutes of the meetings of 70 Trusts, over the boards of 70 Trusts over an 18-month period of their meetings. 80,000 pages of the most exhilarating material you could possibly imagine [laughter]. You have fun don’t you out there? Too often what we found was when we asked the question “what are they talking about?” was it they were talking about the regulators, they were talking about productivity, they were talking about financial performance, and we saw quality in evidence far too little. Moreover, what we found was that when there was a discrepancy between that core mission vision of high quality, continually improving compassionate care and what they were spending time talking about, the staff survey results for those organisations indicated staff did not feel supported to deliver the care that they wanted to deliver, did not feel so engaged, did not feel so committed, felt frustrated by their work experiences and were more stressed.
So every interaction by ever leader every day has to reinforce that core vision, that core set of values around high quality, continually improving and compassionate care, top to bottom, end to end. The second point is we need to translate values and visions and missions into practicalities.
One of the things we’ve observed across the NHS in England is what we’ve come to call priority thickets. There are so many priorities raining down that people who are delivering care no not what is the priority that they should be focusing on. What we do know from research on human motivation and performance at work is having a limited number of agreed, clear, specific objectives and challenging objectives and getting constant useful feedback on your performance against those objectives is associated with much better levels of performance and much higher levels of motivation.
From the top team of an organisation down to the teams on the front line, they need to have a limited number, five or six, clear, shared objectives and get useful data in relation to their performance because then what we’re doing is ensuring that we’re focused on those activities that will deliver continually improving, high quality and compassionate care. We also saw the vast amount of information that’s collected, very little of which seems to come back to inform staff at the front line on a daily basis about how well they’re doing in relation to those key objectives.
The third point I can sum up by saying if we want staff to treat patients with compassion and respect and care and dignity, then we must treat staff with compassion and care and respect and dignity. Twelve years of running the national staff survey have shown us that there are very clear relationships between what staff say about their experience of work and what patients say about the quality of care that they receive. Staff views of their leaders predicts patients’ satisfaction with the care they experience. When staff report high work pressure or low levels of well being at work, what we see is poorer care quality as rated by the Care Quality Commission and worse financial performance. We published a study in 1997 of levels of stress within the NHS, it was based on a survey of 10,000 staff and 600 clinical interviews with staff, and this showed that 26.8% of NHS staff were categorised as cases in terms of minor psychiatric morbidity, 26.8%, compared with 17% in the general working population. Stress kills people.
So in effect we’re creating work environments for staff which are damaging their health and well being, their wider lives, their family relationships, by the kind of leadership that we’re offering, and it doesn’t need to be that way because there are examples of Trusts around the country that have been very successful in reducing levels of staff stress, promoting joy at work and emotional well being at work, and sustaining those good practices. It doesn’t need to be this way and we know that when people are stressed, when they are anxious chronically, they find it much more difficult to be compassionate because the key elements of compassion are hampered by that stress and that anxiety. Engagement, levels of staff engagement, is the best predictor of a range of outcomes in relation to our healthcare organisations from the national staff survey. Levels of staff engagement predict patient satisfaction, Care Quality Commission indicators of care quality, use of financial resources, staff absenteeism, staff turnover and patient mortality.
So getting staff engagement right is important. What does it mean engagement? Engagement means that I am bringing my humanity, my emotional intelligence, my compassion, my commitment, my professionalism, fully to my work every day and I do that when I trust the leadership within my organisation when I perceive fairness, when I perceive support, when I perceive equal opportunities. The report we published yesterday on discrimination in the NHS between the King’s Fund and NHS England demonstrated the very high levels of discrimination experienced by all minority groups across the NHS. There is huge work to be done to build that level of social justice, morality, ethics, fairness and climates of inclusion and cultures of inclusion, and it’s vital that we create positive work environments for people to come to enjoy at work. People perform better when they feel positive, doctors make better medical diagnoses when they feel positive.
People are less likely to discriminate against dissimilar others when they feel positive. We’re more creative when we’re positive. We lead teams better when we feel positive and we’re in a better position to deal with the inevitable negativities that are associated with the delivery of care to people who are in pain and feeling out of control and suffering, and it means dealing with those behaviours that are intimidating or aggressive among senior members of staff which are still too common across NHS organisations and which are as dangerous to patient care as medication areas or dirty wards because those people who intimidate make it difficult for others to challenge behaviours that they see as unsafe.
The fourth point is the importance of quality improvement in learning and innovation and would I have the temerity to say anything sensible after the presentation of Don Berwick, the world’s guru on this? No, other than to say it’s not enough to advocate quality improvement and learning and innovation, we must give people the practical skills and there are great places around the country doing that, Wrightington, Wigan and Leigh and working with Unipart to adapt lean techniques. There are lots of great examples, but we must give people the skills of quality improvement.
Fifth is the importance of team working that are mentioned. In the national staff survey we ask NHS staff do you work in a team, 91% say yes. We follow it up with three criterion questions, does your team have clear, shared objectives? Do you have to work closely together to achieve them? Do you meet regularly to review your performance and how to improve your performance? The figure then drops to 41%, so about 40% of people working in what we would call real teams, 50% working in what we’d call pseudo or dysfunctional teams and about 8 or 9% who have no idea what they do really. The more pseudo team working in organisations the higher the levels of errors that can harm patients or staff, the higher the levels of stress, the higher the levels of injuries to staff, the higher the levels in the acute sector of patient mortality.
The data from the national staff survey that we’ve been analysing over the last few years have shown us that a 5% increase in staff working in real teams as opposed to pseudo teams – remember 50% of NHS staff working in pseudo teams – 5% more staff working in real teams is associated with a 3%. 3.8% drop in patient mortality which is 40 deaths per year in the average acute. If we could increase that 5% to 25%, half of the people who were working in dysfunctional teams working in real terms in the acute sector, that would be associated with 30,000 deaths a year.
Team working is not a nice to have and the way that we implement team working in our healthcare organisations can be very simply and dramatically improved by the discipline of working effectively in terms and ensuring clear, shared objectives, regular meetings to review performance and ensuring people are working closely together and interdependently to deliver services.
The final point is the importance of collective leadership. I’m struck again and again from work I’ve been involved with across industry, not just in health, by the extraordinary nature of the NHS workforce. 1.4 or 1.3 million people who are incredibly highly skilled and who have motivation that any other industry would be desperate for, why do we seek to manage them with command and control, directive approaches to leadership when all that does is inhibits innovation, improvement, learning? The evidence we have from reviewing all of the literature on leadership and the climate and culture in healthcare across the world demonstrates again and again the importance of creating collective leadership approaches where people can contribute to the leadership process at every level within the organisation, where leadership in terms is shared. So, I don’t know, Andrew may be the team leader, but if Alison has the expertise, it seamlessly shifts to her. We know, not just in health, that shared leadership in teams predicts team effectiveness, where leaders are working together across boundaries, prioritising patient care overall, not just their own, individual areas of practice.
As Jim Mackay said this morning, in relation to territorial boundaries, let’s get over it, and the fourth is the importance of having a shared approach to leadership within our leadership communities. In many organisations there are inspirational pockets of supportive, positive, enabling, participative leadership and then in the next department, there’s a bully and we know that where you have bullying leadership, it permeates down through the organisation. So we need consistent approaches to leadership and that needs a strategic orientation to the development of the leadership of the future in this national treasure.
The last thing I want to say is to go back to what I said at the beginning, I think the core value of the National Health Service is the value of compassion. Let’s provide care to our fellow human beings who need it. If we want to create cultures of high quality compassionate care, then we need to have leaders who embody the value of compassion as part of their continually improving, high quality leadership.
What does compassion mean? If Vijaya is in distress, compassion, I think, has four components. The first is I must pay attention to Vijaya, I’ve got to be present with him, listen to you with fascination, and the second is that I then make some appraisal, ideally with you of what is the cause of the distress, and the third is that I have an empathic response that I feel your distress at some level, and the fourth is that I then take intelligent action to help you. That I think is what compassion means, and I think we have to have a leadership which embodies those principles. Leaders who pay attention to staff, who listen with fascination to what staff have to say, who appraise with them the causes of the challenges and the difficulties that face them, who have an empathic response to the situation of staff and the fact that they’re currently so beleaguered and so under pressure and who take intelligent action to help them to make a difference.
So I think our responsibility of leaders is to nurture that culture of compassion by embodying what compassion means in order that we continue to polish and sustain this wonderful national treasure.
Thank you very much.