Stuck on the Culture Change Springboard

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06 / 8 / 2014 12.51pm

The greatest challenge leaders and managers in health care face is to change the cultures of NHS organisations so that they deliver high quality, compassionate care and so that all staff are focused on continually improving that care. Starting that journey of change and then sustaining it requires leadership from the top that is prepared to leap into the unknown by relinquishing their power and releasing the creativity and innovation of all staff.

The starting point for that leap of faith is asking staff and patients to say what the values of the organisation should be, to give voice to their vision for the organisation and to sculpt collectively the mission and strategy that emerges from that vision and those values. Then every leader, formal and informal, can take on the responsibility for the values being enacted and the vision being relentlessly pursued. A vision such as ensuring step changes in health or health equality for whole communities or of providing integrated, preventative care that relentlessly promotes better health and human flourishing across a town or city. A vision that reaches ambitiously for the kind of health services we want for all.

Springing from the board also requires developing a shared, consistent strategy for ensuring that all staff feel respected, valued, supported and justly treated by those who lead and manage and then implementing that strategy. It means adopting a shared, organization-wide value of compassionate care for staff – listening, supporting, empathising and taking intelligent action to help staff by ensuring they are enabled to function effectively, healthily and innovatively. 

The courage to step off the safe platform of hierarchy also requires leaders and managers from Board level to front line supervisors to empower staff to innovate and to create the space for them to reflect and learn. It requires to nurture and practice shared leadership, where expertise and motivation determine leadership in any moment not status or profession. It also requires determination to address long-standing issues of lack of leadership representation of BME staff, of bullying of staff, and of chronically high levels of staff stress across the NHS. Creating a high-engagement community of shared leadership requires leadership that is perceived as just, inclusive and caring, where there is consistency between espoused and enacted leadership values.

And the leap from the safety of the board requires a commitment to implementing the basics of good management. Ensuring everyone, every team and every department has a small number of clear, challenging objectives – aligned around the vision – and that measures are built in to provide feedback on performance against these objectives. And quality improvement must be intrinsic to such objectives.  This is quite different from the proliferation of targets and priorities that asphyxiates health service organisations currently. 

And basic good management is constructing teams around core tasks in the organisation. Teams with the skill sets to complete the task effectively. Teams with clear, challenging objectives aligned to the vision of the organisation. Teams with a commitment to working supportively together and cooperatively with other teams. Teams that meet regularly to review their performance and plan for how to improve. Teams that see improving and innovating as core to their practice. And, above all, teams that embody shared leadership where leadership in any given situation is dependent on who has relevant expertise not on hierarchical power or professional status. The evidence is clear that, in whatever sector, such shared leadership in teams predicts team effectiveness and innovation. 

And innovation is the best barometer not only of effective teamwork but also of healthy organisations. There is much innovation within NHS organisations but overall, the level is disturbingly low. Command and control, fear, conflict, work overload, system blockages, inertia and poor management create sterility rather than sparkling fountains of innovation (Dixon-Woods et al., 2013). We need sustained and fundamental culture change. How can leadership be propelled off the safe environment of command and control to cultures of collective and compassionate leadership?

It requires planning the steps and then following through to that leap of faith. And research evidence consistently demonstrates it is a leap that can be safely made if we jump with conviction and integrity. And the OD and HR communities have the responsibility and opportunity to enable that journey to begin and to be sustained. It starts with a discovery of  each organisation’s current state – its strategy, culture, leadership capacity, leadership needs, dark spots of performance, bright spots of care; its future needs in terms of numbers of leaders, backgrounds (BME, medical, other clinical, specialties); organisational performance (CQC ratings, patient satisfaction, complaints); quality of appraisals; levels of employee engagement; quality of leadership – in short a detailed assessment of culture (and we have the tools to do this). 

Such a discovery process will reveal the gaps between current and desired future state and enable the identification of leadership styles and qualities required including more participative, supportive, enabling leadership styles; the need for leaders and managers to see their roles as serving staff; the need for all leaders and managers to deal effectively with disruptive or aggressive behaviours and poor performance; the need to ensure leaders see their role as taking responsibility for the quality of patient care overall not just their individual areas of clinical practice; the need for leaders to work together across boundaries within and across organisations to deliver high quality patient care. 

Identifying those gaps is the first step along the board and the second is designing OD interventions, culture change processes, in-house leadership development activities and collective norm development that ensures the creation of a collective leadership culture. No more scratching around the edges of change or peering over the edge of the board apprehensively or retreating by simply sending leaders away on courses (however well-run) as the first solution. 

The third step involves moving resolutely from design to implementing the plans for developing collective leadership that supports and enables continually improving, high quality patient care. Shared leadership, innovation, listening, reflective practice, positive, supportive, compassionate cultures and clear quality improvement objectives and methods are required to deliver the health care our communities need. It is the responsibility of OD and HR practitioners to work collectively to achieve that. 

Our two publications from The King’s Fund and the Center for Creative Leadership (Developing Collective Leadership for Healthcare; Delivering a Collective Leadership Strategy for Health Care) offer coaching manuals for making that walk along the board and taking the leap. But the real skill development in supporting cultural change will occur as we all work together - managers, leaders, HR, OD practitioners, patients, staff and communities - to commit to that journey. My personal commitment is to work with all and any of you who want to make that leap to creating cultures of continually improving, high quality and compassionate care. 

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