Lilly lecture 2015: Leading cultures that deliver high quality care
Professor Michael West, senior fellow at The King’s Fund, delivered this year’s Lilly lecture – on Leading cultures that deliver high quality care – to an audience of esteemed guests including royal college presidents, academics, senior doctors, trainees and medical students.
From the outset Prof West outlined the challenge: there are around 1.4 million people working in the health sector in the UK, all devoted to caring for other human beings, so how do we create the conditions in which they can consistently deliver high quality, compassionate and effective patient care?
We know that target-setting and regulation has become an enormous industry which can deliver some positive benefits, but also has some negative side effects; the main one being that it distracts people from the principal issue of care. So, how do we create the right conditions? The answer is always the same: it’s all about establishing a safe, supportive, challenging yet nurturing culture shaped and communicated through leadership at all levels.
The NHS uses evidence to decide how best to help care for people, so it’s vital that the evidence base for leadership is such that we can be reasonably confident that what we’re doing will have a positive impact on high quality compassionate patient care. FMLM, The King’s Fund and the Center for Creative Leadership spent more than two years researching which factors are important in leadership overall, with health care in particular, and looked at a number of major studies and surveys, notably the NHS staff survey. All provided details of various cultures, where trusts had both ‘dark and light spots’, but even in the light spots there was evidence of dark practice.
If leadership is so important to culture and culture is so important to the care given to patients, then these are the areas we should be looking at to reduce cultural variability across the sector. Good leadership produces commitment and inspiration, so it is hugely important that leaders are focused on the core mission and communicate the vision, objectives and values through every part of the organisation.
Due to the many priorities set by inspectors and regulators, staff reported they no longer knew what was important. Probably the most axiomatic finding was that when people set clear, challenging goals for themselves and their teams, and sought feedback, their performance tended to be much higher. It is the setting of clear goals and objectives for themselves and their teams that deliver, because people want to feel and be involved, rather than having priorities imposed. Interestingly, it’s the challenge-setting that is important, not the achievement of goals, and quality improvement should also be part of the objective-setting process with five or six objectives as the maximum.
If we want staff to treat patients with compassion and dignity, then we’ve got to treat staff with compassion and dignity, and compassion has three components:
- Paying attention
- Having an empathetic response
- Taking intelligent action to deal with the source of stress
When stressed, we are less able to give compassion or make intelligent decisions, so it is disturbing that nurses, the givers of care, are the most distressed group in any staff group survey. A key element is the level of staff engagement, or, in other words, the extent of humanity brought to the role. In the NHS, we’re asking people (staff) to bring of themselves to their performance every day. People only do that when certain conditions are present. This is where leaders need to focus their attention and enable front-line staff to continually improve quality, adapt and build teams focused on quality improvement, for example where teams are focused on performance data collected in real time, two or three times a day.
The level of trust in an organisation is key to the engagement issue. Continued findings of staff from BME backgrounds in the NHS not being promoted to leadership roles impacts negatively, while positive impacts are those where health trust CEOs have been in place for longer than the average 18 months, and generally where more medical staff are involved in leadership. It is these latter cultures where it is the more likely that a greater presence of trust among staff is delivering high quality, compassionate care.
Happiness and positivity are very important; personally, individually and in teams. People feel more positive and creative when they are happy and produce higher quality work.
Leaders need to be genuine, open, curious, focused, kind and appreciative. When leaders deliver these qualities, the output of their teams multiplies considerably. Also, they need to have the courage to deal effectively with intimidating and aggressive behaviours, because not dealing with them is as damaging to patient care as dirty wards. This is where accountability and clear standards are essential so everyone knows what the consequences will be if behaviour or performance falls below those standards.
Prof West pointed out that humans are uniquely structured to work in teams, working with cooperation and integration – we’ve been doing it since our earliest hunter-gathering years. The problem is that we’ve created large, complex organisations and multi-level, cross-organisational working too, and these have given rise to a combination of ‘real’ and ‘pseudo’ teams. Pseudo teams occur when there are no clear objectives or role clarity and where members do not support one another; these fail where 'real' teams achieve because the quality of team work is as important as cleanliness in wards to the delivery of high quality, compassionate care.
Ultimately, command and control cultures have been revealed as the worst, and cultures centred around the ‘charismatic leader’ are outdated. The time has come for a culture of shared, collective leadership, which shifts according to task and situation. A culture where people will speak up and be supported by their teams when errors are identified and the success of patient care overall is prioritised. If we are to create cultures of compassion, these need to extend to staff and that means we must pay attention to ourselves and be leaders to ourselves before we can lead others.