Clinical Leadership and the delivery of sustainable change

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Date: Thursday 19th September 2019

Venue: The Caledonian Club, London

On Thursday 19^th September, Practicus ran a roundtable discussion for CEOs, COOs and Senior Directors and Chief Nurses to focus on the challenges of delivering sustainable change from a clinical perspective. The event was well attended and chaired by Andrea O’Connell, Executive Director of Nursing.

Notably, Andrea recently worked across Suffolk transforming the way the system works to support adults at risk. She was instrumental in leading the development and implementation of a new Vision, Mission and Values as well as a Multi-agency Safeguarding Adults Framework that focuses on the adults at risk, prevention and local action.

Andrea has spent most of her career in the NHS. She was a Director of Nursing & Quality in a CCG before moving on to Executive-level projects and studying at the Institute for Healthcare Improvement in the USA.

WHAT IS GOOD CLINICAL LEADERSHIP AND ENGAGEMENT?

Andrea began the roundtable by asking, “In your experience, what makes good sustainable change?”

Views from around the table:

VISIBLE LEADERSHIP

• “For me it’s visibility for your staff. They need to know you care about them. You need to know your staff, say hello to everyone on the ward, be genuine and give a ‘I do care’ message. Therefore, for me, it’s simply about embracing the basics.”

• “When I leave on a Friday after work, I make sure that I have seen at least five patients within that week. This might involve following up on a complaint, or just showing my face as it’s all about visibility for both staff and patients.”

• “A Senior Director at a psychiatric hospital I visited told me to ‘walk the site’ on a regular basis. I ensure I do this at my own hospital, I agree visibility is key.”

• “I think it’s about valuing the staff. Don’t just hear them, listen to them. That way they will be engaged, so support them with their ‘wild and wacky’ ideas!”

• “I went from Hospital Director to Director of Nursing, so the type of leadership I used had to change to adapt to this new role. As a result, my methods of communication had to be adapted and how I came across as a clinician. One of the things they do at BARTS is a ‘Grand Round’ where senior leadership invite all the nurses from all levels to raise subjects or topics so they can be heard.”

• “One of the challenges we have is ‘how do you get active participation from your clinicians to improve their quality in safety and care?’ They are all busy and there’s that semi-dysfunctional gap between the Board and the Ward.”

• “Yes, we need to work as a multidisciplinary team. Ultimately, our goal is the health of the patient. Therefore, doctors, nurses, physios, cleaners, porters… everybody contributes to this! We need to find a way to motivate the staff so together we have one combined objective.”

EMPOWERING STAFF

• “One of the most important things is to empower the staff further down the line. Organisations under pressure struggle with this.”

• “In our own careers, how many failings have we had and what have we learnt from them and taken into practice? I think we’ve forgotten that. For organisations that are challenged, we often find leadership pulls that control back into the Board area. We lose the real vision and opportunity of using the junior clinical leadership that’s in the organisations to make the difference and sustain the change.”

• “Overall, it’s about having a clear vision and being able to clearly articulate that direction of travel. But it’s also about having a good degree of resilience. How we deal with things sends a very clear message to our team.”

EDUCATION OF CLINICIANS

• “There is a skills gap when training nurses. How do we rapidly upskill them in the ‘business world’ because that’s what they need? If we don’t, we’re not driving that integrated workforce that we require to meet the NHS’s long-term plan. How do we address that skills gap in nurse education as we move forward?”

• “I’d like to share an anecdote from when I was Director of Nursing. One of the things we kept seeing is we were losing good staff when they got to a managerial position in Nursing. As soon as they reached this position they struggled and fell flat on their face. They were falling flat on their face because we simply hadn’t prepared them for that next level. This included not being able to read a spreadsheet, managing staff, that might involve HR responsibilities such as staff sick leave or maternity leave, and stock checks to name a few. Therefore, we put together a business course for our clinical managers and used our own expertise to give them a practical course they could use over the space of one year. The change in their leadership was significantly different, and it worked and is still running now in our Trust. The absolute loyalty they have to us was so worth it as they give it back to you tenfold.”

• “I was asked to set up a management course at our Trust. Our clinicians learn 70% on the job, 20% through coaching and mentoring and only 10% in the classroom. I agree that clinicians need to be shown how to use these business skills in practice and all Trusts should offer these courses.”

Andrea summarised what good clinical care is based from the discussion. The main areas that came up were:

• Visibility
• Valuing staff
• Listen and take action
• Involving clinicians from the beginning
• Measuring impact
• Connecting the system, health doesn’t work in isolation we’re part of a bigger system
• Gaps in training to help support staff

HOW CAN WE USE GOOD CLINICAL LEADERSHIP TO SUSTAIN CHANGE?

“We’ve talked about what is ‘good’ clinical leadership and engagement, and now we are going to discuss ‘how’ we can use this to sustain change.”

• “We’ve never been ‘out’ of change. Not only do we sustain a current changing environment, we must be adaptable about looking at the next phase of change. It’s a continuous improvement journey. Change has never ‘landed’ it’s just moved on again so for me it’s about how do we actually sustain this?”

THE ELFT MODEL

“The East London NHS Foundation Trust (ELFT) has long been recognised as a centre of excellence for mental health care, innovation and improvement. It has been rated ‘outstanding’ by the CQC. Can we learn anything from their methods?”

• “At ELFT, they have trained over 3,000 staff in QI and it really is everybody who gets trained. It’s all about good workplace culture. They allow their staff freedom to train in whatever they like or are struggling in and it’s all lead by the staff. Sustainable change is driven by the bottom up.”

• “The Chief Exec and Director of Nursing go to every new induction to meet new staff and say ‘when you work at ELFT you have two jobs: one job is on your badge and the other is to improve on that job. It’s about continuous improvement.”

• “I found that the Director of Nursing was very active and visible on social media platforms, especially Twitter and I have been following his work. It was refreshing to see his team on Twitter and it really looked like a great place to work and emphasised that they know their community.”

• “I noticed that they also have no agency staff and no temporary staff on the ward. Clearly this shows that people really want to work there and that their workforce has a great retention rate. Why are other trusts or organisations not embracing this model?”

PATIENT SELF-HELP

• “We need to recognise that although we provide services, fundamentally those services need to empower patients to manage their own health. If we embrace this, it changes the dynamics slightly on how we think about clinical leadership.”

• “I did some work with a Community Trust and those patients would be accepted onto a programme without an end point. How do we empower these patients to seek the right help at the right time to avoid a crisis while not knowing how long they will be in the service for? We talk about clinical leadership, but we need to remember it is for the patient.”

• “I think mental health is ahead of physical services. If you listen to the patient’s story about their mental illness, it is such a different narrative to a professional’s. You end up having a complex health system with lots of big words and the poor patient doesn’t have a clue what is going on. Why are we doing this? We need to make it simpler.”

• “What change is it that we want to sustain? Is it change around efficiency, is it change at pathway level? There are many ways of sustaining different parts of an organisation. There’s a lot of discussions now about the public taking ownership of their own health. Ultimately, that takes clinical leadership.”

THE QI MODEL

• “The QI model is very important and organisations need to implement and embrace it. This model needs to be embraced from the bottom up and this will empower our staff.”

• “If you don’t have the culture that is driven from the top, it will not work and won’t enhance sustainable change. That culture is about the values and behaviours.”

• “There is a slight danger with QI as our professionals will decide what is best for the patient, how do we do ‘QI with the patient?’ How do we provide the time for our staff to have these conversations, and can we help them move out of our individual disciplines?”

GOOD WORKFORCE CULTURE

• “We talk a lot about cultures but people are still feeling worried about owning up to mistakes when things haven’t gone well. However, people do make mistakes as they are human, so we need to work in a trusting environment. This also goes for the patient and relatives. If we can get that culture right, that it’s ok to own up to mistakes, This would help us to maintain sustainable change.”

• “What do you do with a small town or city that wants to recruit staff? How do you retain them? Ultimately care is at risk.”

• “There’s problems with recruitment and retention everywhere. Workforce culture is the key, recruitment and retention are the most important ways to sustain change. If a staff member is feeling bullied or discriminated in any way, they will not feel valued and will look elsewhere for work and we lose those skills and talent.”

• “Happier staff make happy customers, and in our case, happy patients! It’s that simple really.”

• “Exactly, Richard Branson even mentioned this ‘If you invest in your staff, you’ll have happy customers’ so where are we still going wrong with this?”

• “Consider clinical job adverts. After submitting an application, most of the time, you don’t hear back from them to say you have been unsuccessful. How am I made to feel valued and engaged in applying for a role in their trust if I don’t even receive a human answer? What we should do is host workshops with unsuccessful candidates to go through their applications and areas they could develop. This would make clinicians feel valued and they might feel empowered to reapply at a later date.”

• “I like the phrase ‘culture eats strategy for breakfast’. It’s the culture that clinical leaders need to embrace as it triumphs all areas of retaining your workforce. Staff need to be happy in their working environment.”

• “We had a nurse who put something about a patient up on her social media channel, which is strictly against our policies and would have resulted in her immediate dismissal. However, our Director of Nursing challenged me back which showed the fantastic culture of our Trust and said, ‘She will be your biggest advocate and training experience.’ Instead of dismissing her, we asked her to write a reflective piece on her actions and it worked! After the process she felt understood and valued by our trust and learnt her lesson.”

• “We can learn so much from non-clinicians too, whether that’s around training or discussions. If we sat down around a table together, like today, we can achieve so much more. Nursing is simply too hierarchal, we need to make it more inclusive which will benefit the patient. It’s clear we’re still very traditional about which profession will handle what in a scenario.”

• “People don’t just want money they want to feel valued. They want to be invested in making a difference. The NHS plan is focused on our People strategy but we need to be thinking differently. We need to be smarter.”

CONCLUSION

The main takeaway from the discussion was that the best way to generate good engagement to support change is to create the right culture so you can sustain your workforce. The right culture has to be driven from the top. It is also important to remember to empower the front-line staff to improve and, if staff are loyal, then we can sustain change long-term.

Our Chair asked the room what they will be taking away from the discussion to utilise in their own organisations:

• “The clinical leadership is the ‘golden thread’ that holds a trust together, this needs to be acknowledged.”

• “Visibility within my workforce.”

• “The patient voice and how important it is to listen.”

• “Sense of responsibility of sharing the lessons I have learnt today, I will share with my peers.”

• “Consolidated by thoughts about work culture and I will be driving this forward within my trust.”

• “Visibility for my executive team, ‘walk the ward!’”

• “Being the advocate for our workforce, our services are under a lot of pressure so let’s empower our staff on the ground as they are the answer!”

• “Culture is what I’ll take away from today. I want to get away from the ideology that ‘Senior nurses eat their young for breakfast!’”

• “Take the opportunity that’s created by risk to make a difference for our patients.”

• “You can’t always lift something from a previous organisation and put the same idea into a new role – one size does not fit all.”

Thank you to everyone that attended this roundtable discussion. If you would like more details, including an anonymised transcript, please contact jon.webster@practicus.com.

About Practicus

Practicus provides problem solving and recruitment. To find out more about the company, see here

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