Chief Executive’s Tale

I have been re-reading the Kings Fund report The chief executive’s tale and was really struck again by what an astonishing insight it is into how a chief executive in the NHS feels and thinks and the aspects that are so very relevant to our work at Sign up to Safety.

Firstly, we have focused on understanding the unique aspects of patient safety (as opposed to quality) related to human error, human factors and the cross cutting, systems approach to safety.  This is often misunderstood, for example, as Jonathan Michael says:

One of the frustrations particularly recently has been the lack of understanding that health care is an inherently risky business but there has been this drive .. to somehow present it as something that ideally ought to be risk free.  Being alive is risky.. being treated is risky… but equally not being treated is inherently risky.. the drive is generating a degree of pressure on clinicians, on organisations and therefore on the chief executive…

Secondly, we have chosen to purposefully not micro-manage from the centre and to build local ownership of self directed safety improvement.  There is already enough of that from regulation and other national mechanisms. As Angela Pedder says, the job of a CEO is ‘holding up an umbrella to keep the stuff that’s coming down from up high away from the people that need to do the really good work day to day with patients’.  The trouble with that is that if you are perceived as part of that ‘stuff’, how do you get through, how do you convince people that you are different? How do you reach the people who are doing the day to day work with the patients? Steve Shrubb describes our approach when he says; ‘the key is to use the power you have to give it away to the leaders in your organisation so that they can actually create the change.. and feel part of it’.  He goes on to say; ‘if you can get the staff feeling engaged, informed, involved and cared for then you will deliver good, efficient care’.

Thirdly, we choose to be a different voice – a positive, caring, kind voice.  This report and those we talk to on a regular basis describe the ‘hostility’ in the NHS.  With the on-going emphasis on reducing avoidable mortality, we believe that we should move as far away as we possibly can from the experience described by Catherine Beardshaw:

I remember sitting on one side of the table with six or seven of my team to talk about… our quality strategy and reducing our avoidable mortality and there were 38 people from other agencies sitting opposite demanding ‘where, why, how’, each of them marking our homework.

Instead we need to do as Steve Shrubb suggests; ‘prepare our talented leaders to lead in a very challenging environment, surrounding them with people who can nurture them and support them from an early stage; we need to apply the same supportive values to CEOs that we seek to apply to the rest of the staff’.

Fourthly, we have focused relentlessly on describing and promoting the right culture of safety; one that is supportive, proportionate and fair (a just culture).  Sadly an experience related to ‘risk summits’  shared by Mark Newbold is so far removed from what a good safety culture looks like.

It was the worst moment, I think, in my professional career. It was like a ritual humiliation and bullying session. And the tone of it was as if they thought that we were somehow now sufficiently concerned about the problems, not trying hard enough to sort them, where here was a highly experienced and deeply committed … team that was living and breathing these issues.

Finally, we are committed to helping people talk to each other about what they know about keeping people safer.  We are doing this by working through different concepts and methods to find ways in which people can speak out, share their stories, truly listen and notice what is being said and what isn’t.  This report is a beautiful illustration of the power of story telling.  In our work we have also been exploring the value of using metaphors to explain thoughts and feelings in order to see if we can get deeper into people’s experiences.  Along with Angela’s umbrella metaphor, there are some great metaphors within the report:

if felt like you were tied to a tree, and each time they just went around with the rope another time, so you were getting more and more tied down (Mark Newbold)

The chief executive’s tale is a very moving report.  As Marcus Powell from the Kings Fund says in his summation; ‘the consistency of commentary should be deeply worrying to anyone who has an interest in health’. He goes on to say that the ‘forces at work to keep any system the same are stronger than people acknowledge‘ … the ‘task is to support and encourage them to adopt the paradigm change that’s now needed and not just reinvent the past’.  Thinking differently about patient safety is a key part of our work and our promise at Sign up to Safety is to share our learning about how we can step beyond the short term and help the frontline, the people who know their own situations better than we do, be the guiding force for change.




Social Movements

There is a lot of talk about social movements at the moment.  Social movements are not created they emerge and they are dynamic.  They often arise as a response to intolerable conditions or societal behaviours.  The leaders of social movements create the conditions for others to achieve a shared purpose (Ganz 2010).  They facilitate trust, motivation and commitment and are in the end about;

‘changing the world, not yearning for it, or just thinking about it’ (Ganz 2010)

Over time they need to be organised. Surprisingly, after a while social movements require specific actions with real deadlines (Ganz 2010).  Without this the initial spark will simply die down and become a distant memory.  These actions need careful thought, one of the main reasons movements avoid committing to them is the fear of demotivating the people who think the movement has turned into a ‘must do’ task.  Being organised reminds people what needs to be done, what’s important and what will happen next.  This requires consistent coaching which avoids both micromanagement and hands off management (Ganz 2010).

Social movements think of time as an arrow. They begin at a specific moment and end at a specific moment.  In the middle is the change.  This ‘time as an arrow’ framework is more generally described as a campaign (Ganz 2010) and is the most effective way to organize the most valuable resource of time.  Campaigns are strategic and motivational ways to target effort and organize change activity; it provides a rhythm for others to follow.  They unfold over time with a rhythm that slowly builds foundation, gathers gradual momentum with a few peaks along the way.  A good campaign can be thought of as a symphony of multiple movements that adapts to the rhythm of change (Ganz 2010).

The solidarity of collaborating with others in a common cause energizes us. Sign up to Safety campaign was formed in order to create a ‘social movement’ to promote and help people build the right safety culture in the NHS in England.  Launched in June 2014, as a three year campaign, it has been built using the experience of a small team who have over twenty years in patient safety, two years of patient safety campaigning and the benefit of time to think about what could be done differently.  In particular Sign up to Safety has used social movement principles to create a locally owned, self-directed approach to improving patient safety.  We know that change is more likely to be successful if locally owned rather than because of instructions from the top so as a campaign we do not tell people what to work on and have not added to the mass of targets and central commands.

History has shown us that central commands are only likely to be complied with in the short term and often fail to embed changes in the long term.  They lead people to feel intense pressure to comply with a set of priorities that are not the same set of priorities that are important to them. The expected interventions move individuals and organisations away from their own priorities and also inhibit the development of local knowledge and ownership of safety.  We have found that by not telling people what to do we have in fact energized them; we have surprised them and some have told us they have found this really exhilarating.

Social movements counter feelings of isolation with a feeling of belonging. Sign up to Safety has created a brand for people not only to trust but to belong to.   We have over 400 members who have something to belong to. Sign up to Safety has used the Ganz model of leadership (Ganz 2009);

the difference between leadership as a position, and leadership as a practice, and accepted responsibility for enabling others to achieve purpose under conditions of uncertainty.

One way of looking at our leadership style is to see how we reach out to mobilize the community and help them turn the campaign aims into their own aims.  It is a form of collaborative and distributed leadership, not becoming ‘structure less’ (as that would be chaos), it’s about creating an interdependent relationship between the central campaign team and the members.

We have purposefully used a particular tone and style and created a brand that is synonymous with kindness, caring and compassion. In today’s stressful and challenging healthcare environment the last thing people need is another stick.  We have shown that kindness works; thanking people, valuing them and being thoughtful of all around us are vital to creating the right culture for safety and are leadership traits that we both embody and promote.

Key to achieving this is being positive, personalized and telling stories with hope. The stories are about why patient safety matters, why we need to act.  This is challenging when there is a great deal of inertia, apathy, change fatigue, and exhaustion. We are exploring a way of giving back some hope and motivation.  Everyone whether providing healthcare, monitoring, inspecting, guiding, commissioning, should do so with a positive purpose, providing hope and energy that inspires rather than crushes.

Hope is what allows us to deal with problems and is one of the most precious gifts we can give each other and the people we work with (Ganz 2009).

We have therefore started to experiment with a method of experiential learning using conversations and storytelling. Stories of powerful personal narratives of individual learning which can inspire people to keep going.  They are not a set of messages or sound bites.  As we listen, we evaluate the story; we hear it in different ways depending upon who we are and who the story teller is.  The story teller will also tell it in different ways depending upon who is listening.  Story telling is therefore an interaction, a shared experience.

For a collection of people to become an ‘us’, requires a story teller, a listener and an observer (Ganz 2010).

We are testing conversations and storytelling by gathering people together and sharing their challenges, obstacles and how they are learning to overcome them.  Stories that demonstrate how they are implementing their plans, stories to illustrate the impact of local activity for safety, stories about how they overcame a challenge and stories of possibility. Stories can make a significant contribution to personal and professional growth as they communicate our values through the language of the heart; our emotions (Ganz 2009).  We look forward to sharing with you what we learn.

Our throughline

When you talk, you are only repeating what you already know. But if you listen, you may learn something new.

  • Dalai Lama

Everything we do should be about keeping patients as safe as we can and the vast majority of healthcare is provided safely and effectively, however, just like any high risk industry, things can and do go wrong.

The science of patient safety is relatively young. Early pioneers identified aspects of safety in the 1850s but the science as we know it today grew substantially from around the mid-1990s.  What followed has been a cacophony of solutions and interventions and the field of patient safety has accelerated over the last two decades.  But the anticipated fundamental and lasting change has yet to be realised.

Safety is not a task or a set of technical interventions, it is not notices on the wall or a risk register; it is a mind-set, it is in everything we do.  Feeling safe means we need to be constantly vigilant, noticing what happens every moment of every day, noticing when it goes right and noticing when it doesn’t.  With that knowledge we then constantly adapt our behaviour and practice.

Our efforts to date have been a touch random; we give the impression that we don’t quite know where to start or what to focus on when. We have also not consolidated our actions; in that we have moved from one thing to another and then another. We have focused on one off interventions rather than creating a comprehensive, system approach to safety. If we were to make a fresh start what would that look like?

We need to go back to the fundamentals. Ask ourselves some questions, the kind of questions that you can only ask in fact after you have tested out some ideas and assumptions. So while we may be disappointed in our efforts so far, perhaps it is only through these experiences that we can we finally see what we might want to do or where we now should be focusing?

We have been asking these questions over the first two years of our work at Sign up to Safety.  Our conclusions? We need to think and act differently in many ways but at the very heart of safety is people.  Yes the system and environment can help people be safer, it can also set them up to fail – but at the very core are people and relationships.  And at the core of people and relationships are conversations.

So as Margaret Wheatley says:

I believe we can change the world if we start listening to one another again

William Schutlz argued in 1979 (Weick 2009),  that learning and understanding progresses through three stages; superficial simplicity, confused complexity and then profound simplicity.

Profound simplicity is achieved when people doubt the completeness of their assumptions, and through experimenting with a wider variety of possibilities may realise that out of that confusion may come a fuller understanding of what they face. This is only achieved by working through the confused complexity and this needs to be lived; experiential learning is therefore vital. Without the experience (or working it through) people have no idea why the simplifications are profound, why they work, or what lessons there are.  Without the experience the borrowing is superficial and typically fails when implemented.

Only now do I think that we are moving into the era of profound simplicity, where we are starting to realise that there are some fundamental and seemingly simple aspects related to how we work in patient safety that could make a profound difference to the safety of patient care.  What could we do differently?

At Sign up to Safety we have recently worked through what our throughline should be for 2016.  What is a throughline?  Chris Anderson in his book (TED talks, the official TED guide to public speaking 2016) says it is the connecting theme (described in around fifteen words) that ties together each narrative element of a talk.  I really like this idea and thought I would use it to construct our third year strategy.  So we spent a day working through what we wanted our throughline to be. We wanted to construct something so great that it would create a strong thread throughout all the elements of our work.  A way of connecting everything together; connecting the pledges and safety improvement plans people are working on, with our work in creating a safety culture and narrowing the implementation gap.  And those fifteen words needed to inspire our members but also focus them on the precise idea we wanted to work on.

The throughline we came up with was:

We want people to talk to each other about what they know about keeping patients safer

Talking to each other; doing less telling, learning to listen, learning to ask the right questions and acknowledging what is being said and heard.

Listening to another human being starts to create a relationship, starts to help us understand them more.  Listening means we hear someone else’s point of view rather than forcing our own on to others.  We move away from our judgments and assumptions towards curiosity.  This means we start to learn more about what could be safer, what could or should be changed.  The reason why I believe this so fervently is that ‘not listening’ or ‘not being heard’ or ‘not being able to speak out’ has led to harm on so many occasions. Harm to patients, harm to relationships between patients and staff and between colleagues.

Good conversations can help us talk about the things we notice, help us understand and learn about how we can achieve the safest and best possible care for patients. Conversations can help us create the right culture for safety; the just culture.  We want to connect with people in a kind and human way that acknowledges the conditions and to help them work and explore together the possibilities for safer care.   Our throughline will help us explore honestly both people’s lived reality and new possibilities; enquiring more deeply into how to make people safer.

This is, we believe, profoundly simple.   Margaret Wheatley talks about how people band together with their colleagues and friends to create the solutions for real social change.  Such change she argues will not come from governments or organisations, but from the ageless process of thinking together in conversation (Wheatley 2009).

Our solution for change? A culture of kindness and a just culture of safety, one which is based on a very simple premise; that we all need to learn to talk to each other; interactions, relationships and conversations.  That if we get this right we will go a long way to transforming the safety for future patients and those that care for them.

  • Weick KE (2009) Making Sense of the Organisation; the impermanent organisation Chichester: Wiley (John Wiley and Sons Ltd)
  • Anderson C (2016) TED Talks; the official TED guide to Public Speaking London: Headline Publishing Group
  • Wheatley M (2009) Turning to one another; simple conversations to restore hope for the future San Francisco: Berrett-Koehler Publishers inc