Improvement Story One

Contributor: Justin Daniels, Consultant Paediatrician and Deputy Medical Director

What aspects of culture did you focus on, why, and what changes did you make

The spur to change was external scrutiny – the CQC had downgraded leadership in obstetrics to inadequate. The hospital executive team reacted by dismissing the divisional medical, midwifery and divisional operational leads and appointing interim leads. At the same time, the hospital commissioned a public sector consultancy visit to better understand the problems.

The consultancy found a culture of bullying, harassment and racism across all aspects of the multidisciplinary team, with much of the racism being between people from different groupings within the same geographical area. Wards and departments often had a significant number of staff from the same grouping and this led to a lack of trust between different clinical areas. 

We focussed on listening to concerns, staff rotation and making it ok to talk about issues that were bothering staff and affecting safety. We looked at our safety indicators and claims records. There did not seem to be a clinical problem, but there were concerns that this might happen and that adverse outcomes were being avoided by ‘heroic’ efforts rather than having correct processes in place.

We also recognised that almost all staff within the NHS come to work to do the best job that they possibly can, the thing that stops them is poor systems and poor leadership. Where there were poorly performing leaders, we put in support and coaching for those individuals who we thought would benefit from this. We invested in training courses and national initiatives. Interestingly many poor leaders who were perceived as being not capable became good leaders.

What effect has this had on your team culture?

Team culture did not change overnight but did change gradually. There seemed to be less heroic saves and more of a culture of getting it right first time. The CQC returned and changed the leadership rating to good- it’s unusual to go up 2 steps in one go. This in turn led to further improvements in team dynamics. The trust also invested in governance – this happened as the CNST rebate scheme was introduced, which not only meant this was the right thing to do, but also was financially beneficial. 

What barriers have you had to overcome?

The first barrier was the one that says, ‘we’ve always struggled, we’re an underfunded hospital with not enough staff serving a deprived population so we can’t improve’ – it’s hard to change the narrative but it can be done.

The second was breaking down the racial dividing lines – ‘this ward is mostly staffed by staff members from this background’ – staff rotation was essential, talking about the importance of diversity was necessary (for anyone who doesn’t get this please read Rebel Ideas by Matthew Syed).

The third barrier was not accepting that Manager X was someone who was not able to do their job, it turns out with the right leadership and inspiration many of the ‘failing’ managers were extremely competent.

What helped to make this successful?

The CQC findings led to the need to look more deeply at the problem. The consultancy was able to independently ask difficult questions and come up with unpalatable answers. The wish to improve across all staff groups was essential. A small amount of investment, for example in the governance team, was also vital.