empowering staff presentation 23.03.16 v4
TRANSCRIPT
How engagement and communications can
be used to both accelerate improvement
within the NHS and increase its
sustainability
Andrew Kliman
NHS Improvement
14.03.16
‘If the sector is going to respond to all of the challenges
that face it, then all of the staff need to be involved in
developing new and improved ways of doing things
and in implementing change.’ Michael West, (Dromey, 2014) and member of
NHS Improvement’s, Faculty of Improvement
There is a problem across the NHS that staff do not
feel empowered to make improvements
• The NHS Staff Survey (2015) found that only 30% believe feedback will
be acted on, only 32% believe senior managers try to involve staff in
important decisions, and only 38% think communication between
managers and staff is effective (three important subsets of engagement
focusing on the belief staff have that they can make improvements)
• 84% of services rated inadequate overall by CQC were also rated as
inadequate for leadership. Potentially very many staff do not feel engaged
• The CIPD Employee Outlook survey (2015) of engagement across the UK
showed that between 35% and 39% of employees indicated positive
engagement.
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Data shows that urgent and emergency care
systems with poorer staff empowerment have
poorer performance
• A breakdown of the NHS
Staff survey by Emergency
Care Improvement
Programme (ECIP)
systems (worst performers
against the 95%
emergency care standard
Q4 2015 and Q1 2016),
High Risk systems (next
worst performing group),
and all others shows a
clear difference
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• The 95% standard is used
as a proxy for effective
processes across an
emergency care system
This correlation holds firm across different staff
empowerment identifiers
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Data also shows that improvement is difficult to
sustain when introduced from outside an organisation
• Those staff that do make change, for example when ECIP show them
how to do it, don’t maintain it for long and behaviours revert to the norm,
e.g. – Colchester SAFER 3-4-3 ECIP sponsored campaign (Oct 2015) reduced medically fit
patients by 50% and hit the 95% standard. Since the end of the three week campaign
performance has slipped back to pre event levels
– 2015 NHS Staff Survey, Colchester Hospital University NHS FT – ‘Senior managers act
on staff feedback’, 23% agree and 8% strongly agree (31%)
• The ECIP Safer Start Campaign, targeted at improving performance in
ECIP systems in the first week of January, demonstrates the same
pattern.
• ECIP survey of communications and engagement leads (2016) found
only 17% of respondents included information about Safer Start in their
internal bulletins
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ECIP Safer Start Campaign results – difficult to
maintain improvement when externally introduced
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ECIP systems’
performance against
95% waiting time
standard to date
Safer Start effect
Disempowered staff have a negative effect on
patient safety and outcomes
• There is a strong body of evidence that demonstrates the more
engaged staff members are, the better the outcomes for patients
and the organisation generally
• Prins et al (2010) gathered data from a sample of 2,115 Dutch
resident physicians, and found that doctors who were more engaged
were significantly less likely to make mistakes
• A study of 8,597 hospital nurses by Laschinger and Leiter (2006)
found that higher work engagement was linked to safer patient
outcomes
• Leaders who don’t listen to staff or don’t demonstrate they are
listening to staff undermine the NHS Constitution.
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The NHS Constitution pledges that ‘all staff will be empowered to put
forward ways to deliver better and safer services for patients and
their families.’
There is evidence to show that empowering staff as
part of a wider engagement package has significant
organisational benefits• (West & Dawson, 2012):
– In trusts where a large percentage of staff felt they could contribute towards
improvements at work, infection rates had decreased, reinforcing the value
of staff involvement in service improvements and of creating cultures of
engagement and innovation
– Higher rates of engagement have a direct relationship with lower mortality
rates
– high levels of engagement were associated with much lower absenteeism
than low or moderate levels of engagement.
– Staff engagement is also strongly linked to turnover, with turnover rates
approximately 0.6 per cent lower in trusts that have a one standard
deviation higher engagement score, all else being equal
– Finally, patient satisfaction is significantly higher in trusts with higher levels
of employee engagement
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Engaging with patients can also drive improvement
• A complaint from a patient called Gerry prompted South Warwickshire NHS Foundation Trust
to invite him to come in and talk to them about his experience. Gerry spent eight days with
them in total. Whilst his experience of the clinicians was excellent, there was no co-ordinated
approach to his care and communication between specialities was poor.
• The Trust process mapped Gerry’s journey through the hospital and discovered that, during
his entire eight-day stay, there were only 34 hours’ of value-added time. The rest of the time
was spent waiting... for decisions, for tests, for results, for To Take Out Medications (TTOs) to
be written up.
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ECIP case study: South
Warwickshire NHS
Foundation Trust –
consistently amongst
highest performers
against 95% standard
www.ecip.nhs.uk
2015 NHS Staff Survey,
South Warwickshire
NHS FT– ‘Senior
managers act on staff
feedback’, 24% agree
and 10% strongly agree
(34%)
Barriers to empowering staff can come from the
top down
• An example from outside of health demonstrates that perceived and
actual regulatory and political pressures and a top-down approach to
improvement have a negative effect on staff empowerment and
therefore patient experience and outcomes
• Local leaders who are trying to please the centre (perceived or
otherwise) develop a false understanding of risk within their
organisation.
– Analysis by the NAO in 2013 found the effectiveness of Monitor’s
interventions to be inconclusive (NAO 2014)
• Maintaining this false understanding means leaders not listening to
staff who might tell them otherwise, with negative affects on patient
experience and safety.
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Planning and targets … got a bad name from Stalin’s five-year plans
because in that infamous case the targets were unashamedly top-
down and those involved in implementation manipulated the data to
fit the plan and distorted the truth to (appear to) succeed.” Michael
Barber (2015)
“…it’s a question of whether, when you
do tell somebody about some problem,
they’re delighted to hear about it and they
say “Tell me more” and “Have you tried
such-and-such?” or they say “Well, see
what you can do about it”— which is a
completely different atmosphere. If you
try once or twice to communicate and get
pushed back, pretty soon you decide, “To
hell with it.” Richard Feynman (1988)
In Jan 1986 The Challenger Space
Shuttle exploded killing its crew.
Richard P Feynman, Nobel prize
winning physicist was asked to be on
the Presidential Commission
investigating the disaster. Feynman
found NASA's organisational culture and
decision-making processes had been
key contributing factors to the accident
Top down working increases isolation from staff
driven improvements – experience from NASA
Feynman’s three key points
1. Perceived and actual pressure from the top causes senior
managers to hugely underestimate risk “to the point of fantasy”.
In order to maintain this viewpoint they must closet themselves
from those on the front line who have a more realistic view of risk
2. If you work in an organisation where the higher-ups don’t want to
listen then you are disempowered and disengaged from making
suggestions for improvements
3. When you work from the top down you create barriers to change
by making it difficult to fix the individual components one by one
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Communications and engagement (C&E) can be used to
accelerate and sustain improvement
• Market improvement tools to staff when introducing improvements
from outside of the organisation in order to increase uptake and
sustainability
• Use campaigns to promote behaviour change through evidence of
improved performance and improved outcomes for patients in
language appropriate to that group (nurses, doctors, managers, etc.)
• Harnessing C&E channels (such as social media and face-to-face
events) to increase outreach, capture staff and patient ideas, enable
better strategic decision making, and demonstrate impact
• Empower staff through effective involvement in decision making, with
visible buy in from senior managers (role models)
Communications and engagement (C&E) can be used to
accelerate and sustain improvement
• Co-create and signpost tools for C&E teams that encourage staff to
take the initiative in improving current circumstances
• Incentivise staff engagement through recognition and awards
• Encouraging greater use of data transparency as a tool for
improvement and honest conversations – supported by the regulators
and Department of Health
• Reviewing the organisational culture and behaviours framework with
staff to embed more effective empowerment processes
Recommendations
1. NHS Improvement should focus on helping organisations to
empower staff in order to accelerate improvements and make them
more sustainable
2. Externally delivered improvement interventions should have
additional marketing support for staff to embrace them
3. NHS Improvement should sponsor an HSJ Award for empowering
staff to deliver improvements
4. NHS Improvement should support organisations in using various
empowerment techniques, such as crowdsourcing, and work with
them to measure the outcomes
5. NHS Improvement should shift focus away from top-down planning
and support organisations in having honest conversations,
increasing transparency, and Chief Executives in visibly leading from
the front to empower staff
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References
• Barber (2015), How to Run A Government: So that Citizens Benefit and Taxpayers Don't Go Crazy.
Penguin Books
• CIPD( 2015), Employee Outlook survey, Factsheet. http://www.cipd.co.uk/hr-resources/factsheets/employee-
engagement.aspx#link_4
• Dromey (2014) Meeting the Challenge – Successful Employee Engagement in the NHS IPA. http://www.ipa-involve.com/resources/publications/meeting-the-
challenge/?Employee%20Engagement%20in%20the%20NHS
• Feynman RP (1988) "What Do You Care What Other People Think?": Further Adventures of a Curious
Character. W.W.Norton
• Laschinger HKS, Leiter MP (2006). ‘The impact of nursing work environments on patient safety
outcomes: the mediating role of burnout/ engagement’. Journal of Nursing Administration, vol 5, pp
259–67.
• National Audit Office (2014). ‘Monitor: Regulating NHS foundation trusts https://www.nao.org.uk/wp-
content/uploads/2015/02/Monitor-regulating-nhs-foundation-trusts.pdf
• Prins JT, Hoekstra-Weebers JE, Gazendam-Donofrio SM, Dillingh GS, Bakker AB, Huisman M, Jacobs
B, van der Heijden FM (2010). ‘Burnout and engagement among resident doctors in the Netherlands: a
national study’. Medical Education, vol 44, pp 236–47.
• West & Dawson, Employee engagement and NHS performance, pub. 2012, The Kings Fund http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership-review2012-
paper.pdf
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