Developing cultures of high-quality care: what do leaders have to do to get there?

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At a time when patients, carers and communities are feeling let down by the lack of care in hospitals, we heard an inspirational lecture from Professor Michael West last week on how leaders can change the culture of care in their organisation.

Michael sees culture as something that has to be ‘nurtured, not wound up'. Managing culture is not a dark art, but is linked to really good human resource management. It is nebulous but not unmanageable.

For high-quality care there needs to be a vision for quality at every level of the system: regulatory, board and team. This vision must be translated into clear and challenging objectives, with quality and safety at the top of the list. When teams and individual staff members are involved in co-designing objectives against which they can be held to account, and when leaders provide feedback through well-constructed appraisals, staff feel much more engaged.

During his lecture, Michael drew on his impressive evidence base, including his paper for last year’s leadership review on employee engagement and performance, and his involvement in running the UK NHS staff survey for the past seven years. One of the main messages he gave to leaders was to make sure that they are using good, enlightened HR practices with staff, and are working continuously to remove the obstacles that are stopping staff from doing what they want to do: deliver high-quality, safe patient care. Achieving these good human resource management practices also goes hand in hand with a drop in patient mortality rates.

The real challenge for the NHS is to shift the culture of command and control to one in which staff are engaged in decision-making and fulfil their potential as one of the greatest sources of ideas for innovation and learning. There is evidence from the NHS and other industries, including the oil industry, that top-down command and control cultures are the worst kind of culture for quality and safety. Leaders do sometimes need to be directive but this isn’t the same as allowing a command and control culture to dominate.

The Francis Inquiry report has made clear that the responsibility for ensuring quality of care sits with boards and senior executives. Our experience of working with boards in NHS organisations tells us that boards must pay attention to the behaviours and culture within the boardroom first, in order to model good cultures within their organisation. A solution will not be found without paying attention to the boardroom culture and being open to learning. 

In my previous article on board leadership, I describe the importance of behaviours in the boardroom. To develop a learning culture, behaviours need to include openness, trust, challenge, support and ability to handle conflict in a constructive way. When we are observing boards, we use a template that is based on two powerful models: the behaviours needed to be a learning organisation and the behaviours needed to exercise strong governance as implied by the Monitor code of governance for NHS Foundation Trusts

We also provide organisational development for boards to help them develop a unitary or whole-board responsibility for quality. This means working with them to develop joint understanding of how their objectives relate to quality and how the different roles of non-executives and executives will come together to achieve these objectives.

The real test for the NHS is whether it can bring about culture change and create an empowered and aligned workforce. Michael West’s lecture shows us the anatomy of this culture and what leaders have to do to get there. It is our best chance.

We’re pleased that Michael West will be joining the Fund as a Visiting Fellow to inform our leadership work later on this year. Michael’s lecture is the first in a series of lectures in the run-up to the launch of our 2013 Leadership Review in May.

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chrissie hinde

Occupational therapist,
SHSC foundation Trust
Comment date
17 March 2013
I agree with the above and have been thinking about how ludicrous it is to set targets for care and compassion. We can't make external demands for something that must by it's very nature come from the heart.

A compassionate culture can be nurtured in a system where everyone feels valued, has a voice and is not asked to fulfil time consuming tasks that they don't see the point of. Less form filling and opportunity for staff and patients to share their good ideas would go a long way.

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