Michael West: developing cultures of high-quality care

The most important influence on cultures, and I mean when we talk about cultures it’s a kind of an amorphous topic, cultures are the way we do things around here. What we have to do is nurture them. They are more like clouds than clocks. But leadership is a really, really important influence on the shape and the development of those constantly changing clouds. So what I want to address is how can we, as leaders in this great health care system, this great health care sector, act to create cultures that deliver really high quality compassionate care for patients. What can we do? And I want to talk about in broad terms six areas that I think are really important. The first is making sure that we communicate an inspiring vision of the work that we do. The problem is that that number one issue is very often articulated by all of those levels of this sector that we call the NHS but very often what happens is that that vision is not enacted with the same priority that we give to it in terms of the words that we use so there is slippage. Productivity becomes more important, targets like, you know, a really compelling target like £20 billion of savings - it’s a really compelling target - becomes prominent in people’s thinking and people’s awareness. Boards inadvertently can spend a lot of time talking about cost cutting and productivity and targets and finances so you know an inspiring vision is important but it needs to be an inspiring vision in practice and behaviour as well as in terms of articulation.

What can Boards do, how can they radically introduce new and improved ways of doing things that will deliver higher quality safer patient care. So that’s the first point and I think the second really important point in terms of how we create these cultures as leaders is that we have to translate visions into objectives. We need clear objectives that are aligned with the objectives of the organisation in each directorate, in each department and in each team and those need to be limited in number. We don’t want, we don’t need, we can’t cope with, 20 or 30 objectives, we are talking about the need for may be six or seven clear priority objectives. One of the characteristics of our health service is that there are so many priorities that people no longer see any priorities because there are so many of them. They must be challenging. We know from research on goal setting that the motivational aspect of goals is fundamentally affective by how challenging those objectives are so it is no use setting objectives we are all going to achieve anyway. And ideally they need to be measurable because when we set goals what we need to do is give people feedback on performance. How am I doing in terms of my progress at achieving these goals? So those are the first two that I wanted to talk about.

The third is about I think the third really important element of culture is about people managing. I had the privilege of being involved in running the national staff survey for 7 years and we were able to relate the data from the national staff survey to various national outcome data sets which has just been a wonderful treasure trove from a research point of view. But it’s also revealed to us really profound messages about culture in health care organisations, so I’m not going to go through all of the findings but I just want to show you briefly some of them. We know that there is a strong link between how staff are managed and what patients say about their experience. It seems obvious that there would be but we have the data to support that. That staff views of their leaders are strongly related to what patients say about the quality of care that they experience. Staff satisfaction and commitment predict patient satisfaction and that the extent of staff reports of positive experiences, positive feelings at work is related to staff satisfaction as well.

When staff report high work pressure that there is too much work for them to do patients say that there are too few nurses and that they don’t get the quality of care, they don’t get the respect etc that they would like to experience within the organisation. And poor staff health and well-being and high injury rates reported by staff are associated with poorer care in the Care Quality Commission ratings of care provision within NHS Trusts. It must be 11 years ago now that I and my colleagues published a paper showing the relationship between human resources what’s been called human resources management practices and patient mortality but what we have been able to show in a subsequent paper published in 2006 is that those results held and using a completely different data set - the National Staff Survey - we’ve been able to show that within Trusts as the spread these human resource manager practices increases across staff within the organisation, subsequently mortality falls. So in other words, when we are introducing and applying good people-management practices, it has an effect on important performance outcomes. You know the most powerful way after leadership, I think, of affecting an organisation’s culture is how we manage staff, how we induct people and socialise people and how we select people so what messages do we give out about the kinds of culture that we are wanting to create through our recruitment processes? When people arrive in the organisation that’s a really, really auspicious moment in terms of communicating the values of the organisation. Are we ensuring that the messages that they get both in terms of what their told and what they see with their teams that they join that high quality compassionate care challenging the unsafe practice, challenging rudeness and incivility, is what’s valued within this organisation. Working with colleagues, one of whom is Mary Dixon Woods sitting at the back there, we’ve conducted a literature review of all of the literature on cultures of high quality care in health care settings around the world and the one culture which emerges as inimical to really high performance is command and control cultures. Across countries command and control cultures seem to be about the worst in terms of how we can deliver high quality care and so there is a real challenge I think about how we can change high quality cultures to high involvement cultures where staff are contributing their ideas for new and improved ways of doing things, where they are involved in decisions, where they are involved in identifying what the problems are in their organisations in terms of delivering high quality care.

I was also involved in a piece of work that was funded by The King’s Fund looking at engagement and leadership in the NHS and we were asked to look at the relationship between the engagement and outcomes and from all of the variables in the national staff survey, the one variable which was most powerful above all others in predicting performance of NHS Trusts (Mental Health Trusts, Ambulance Trusts, PCTs, Acute Trusts) was the level of staff engagement. This case I am showing here the outcomes for Acute Trusts but it was the same in the other sorts of Trusts as well.

From a leadership perspective again it is recognising that a key role of leaders needs to be consulting staff, learning from them. I always think you know the NHS workforce is one the most extraordinarily skilled, extraordinary intelligent, extraordinary well trained and, I mean, kind of super extraordinarily motivated workface in that you will find in any sector. Why on earth are we not spending our time consulting with them to find out what their definition of the problems is and what their solutions are and what their innovations are instead of adopting hierarchical cultures where we command people and control people. Team working is the fifth area I want to talk about as we begin to look at how we can integrate health and social care then we need to develop really effective ways of working in teams and we know that team work in general is really good in health care and in the NHS, in the staff survey, the data we have show that 91 per cent of staff say that they work in a team and that feels great cause for celebration and then we asked three simple questions. ‘Does your team have clear objectives?’ Because that is the best predictor of performance in teams we found in the NHS and outside the NHS as well. ‘Do you work closely together to achieve those objectives and work as a team?’ and ‘Do you meet regularly to review your performance and how it can be improved?’ And we think those are kind of core conditions for what teamwork is about so if you apply those core conditions there is only about 40 per cent or slightly more, maybe 41 per cent, of people in the NHS who work in what we would call a real team so we have got about nine per cent of people who say they don’t work in a team, about 40 per cent of people who we think what we would call real teams and about 50 per cent who say they work in a team but we think there are in a pseudo team.

This is some data from primary care trust showing the relationship between real team working, pseudo team working and organisational health and safety and what it shows is that the more people working in real teams the lower the levels of injuries to staff in the previous year, the lower the levels of potentially harmful errors that staff witness and the lower the levels of physical violence and bullying and harassment. The more people working in pseudo teams, the higher the levels of those things. The data suggests to us that real team working is associated with higher quality safer working and that pseudo team working in addition is associated with harm. You know the implications of this in terms of leadership are about we really need to make sure that when we talk about team working in the NHS that we are really clear about where is the team? Who is in it? What are the objectives of the team? And let’s make sure we get these teams meeting together regularly. The data on mortality also indicate that the more people within the NHS working in real teams and the acute sector the lower the levels of patient mortality and these figures here look pretty small 5% more staff working in teams a 3% drop in mortality rate that’s 40 deaths per year in an acute hospital but if you multiply that 5% up to the 50% I’m saying working in pseudo teams then that figures goes up to 400 and if you multiply that by the number of acute trusts there are let’s say 190 to 200 then these figures start to become pretty powerful in terms of the message that they send.

Now I want to talk about six very briefly core values that characterise human communities that are required by human communities. The first is wisdom and learning. It’s important in every community and culture that we have a commitment to wisdom and learning. For us, as leaders, it’s about which of these values are important to me and how can I bring that value to my leadership and wisdom and learning is really important in any community and I believe that we need to be learning within the NHS from all of the good practices that are going on in other NHS organisations and actually getting outside those NHS organisations and going to the huge number of other organisations that have got great good practices around encouraging staff engagement, building innovation and so on. But we need to be committed to learning and that requires time and commitment in order that we can make a long term contribution and the second is around courage. The courage to have a vision of the difference we want to make and the courage to be persistent about trying to change cultures, to innovate. And the third that I think is really important, and it’s important in any culture, is humanity and within the NHS it feels like humanity should be core. And the fourth is justice of, you know, the role of leaders in creating just organisations where they is transparency and honesty and people are treated fairly and equally. You know one of the dangers of leadership and we are all guilty of it is that we have favourites. People who are like us, people we get on with more easily and so we end up spending more time with them.

Part of justice is about making sure that, as leaders, we are fair and we have a commitment to lead effectively all of the people we interact with. And the fifth is prudence. Prudence and self-regulations are really important in human behaviour and prudence is important within organisations and the NHS, more than most I think, needs to learn to be prudent in what we see in NHS organisations is just a plethora of change effort and initiatives you know about this and people complain. So many initiatives and so many change efforts going on that people get overwhelmed and the final value that’s important across cultures and across communities is wonder and spirituality and this might sound odd in the context of leadership but, you know, part of wonder and spirituality is gratitude and humour. Gratitude immensely powerful in human behaviour and part of the role of leaders is to create a sense of appreciation to express appreciation to encourage appreciation in people so that you create a culture within which people do appreciate each other’s contribution. It has such a powerful effect. I think that the challenges that we face as leaders to create cultures are profound. But actually, everything I have said today, I believe, is a much easier way of leading than leading by command and control and punitiveness and toxicity and is better for us as individuals as well now is the time, there is a receptiveness from the very top right down to making a difference as a result of the Francis Enquiry. So thank you very much for giving me the privilege of sharing my thoughts with you.