2. Culture: where do we start?
Start where you are, Use what you have, Do what you can (Arthur Ashe)
This work came about following a casual conversation I had with an acquaintance at a professional development event. The hospital where she worked provides specialist services for people from the immediate local area as well as regionally. The hospital is part of a larger healthcare organisation but has a clear identity of its own, and a workforce of around 450.
As part of its strategy to become a national centre of excellence, my colleague told me about a raft of developments underway at the hospital regarding modernising the estate, exploring new care models, developing new roles and securing investments in leading-edge equipment. The worry she shared with me was ‘but nobody seems to know what to do about the culture. And it needs seriously thinking about.’
Fast forward a few weeks, and she had introduced me to the person leading the strategy work, who had persuaded the leadership triumvirate/trio – the Medical Director, Ops Director and Nurse Director - to jointly meet with me. I listened to their take on the whole situation. I heard an acknowledgement that they knew there were ‘cultural issues’ but they weren’t really sure what the problem was, nor whether anything could be done about it. Whilst quality of care may be holding up for now, issues of recruitment, retention, stress, morale and unhappy teams were putting this at risk.
There was nobody in the organisation itself with the breathing-time in their schedule or the capacity in their role to do this work from the inside. They took up my suggestion of some initial dialogue-based inquiry work, to see whether we could discover the nature of ‘the culture problem’ they perceived. They scrabbled around in their budget lines and squeezed out some money to take this first step.
Start where we are
I had 1-1 and small-group conversations with around 120 staff (c25% of the total) from all departments and across a range of roles, experience and seniority, in which they shared with me their personal views about what it feels like to work in the hospital – the good aspects and the not-so-good. Some of the messages I heard consistently were:
Passion, goodwill and commitment to the best possible patient care
In a crisis, people pull together and achieve exceptional things.
On a day-to-day basis, this ‘togetherness’ is less obvious and sometimes absent
Lack of teamliness – not feeling a sense of ‘being in it together’. ‘Divisions’ between staff.
Perceived lack of time for meaningful, supportive, conversations about care quality beyond dealing with the immediate must-do’s.
Consultants seen by many as separate rather than an integral part of MDT working
‘Us and them’ thinking and behaviour across all staff groups and levels
Desire for more caring and supportive working relationships
Managers and leaders perceived as distant, formal and inaccessible
Serious breakdowns of relationships and trust among staff (c40 people) in one department providing safety-critical work to the whole hospital
Little appetite to take up key clinical / professional leadership roles
Use What we Have
When I shared back the themes and data emerging from the conversational diagnostic, the leadership trio recognised the messages, were concerned, yet were very unsure what to do about it. This kind of in-depth OD work was beyond any of their previous leadership experiences. They were open to learning and jointly willing to take a step into the unknown.
Crucially, they also recognised that their own approach, style and leadership practice would need to adapt; they needed to model different ways of relating, demonstrate new ways of engaging with staff and create the conditions for more collaborative working across the hospital.
Cognisant of the pressing problems highlighted by the diagnostic, the leadership trio decided to partner with me on four areas of work:
1. Team coaching for them jointly as a leadership trio, to develop a more collective, inclusive and purpose-led approach to their leadership work. This included them sharing back the gathered data with all colleagues in the hospital, to stimulate conversations and joint work which would help the cultural issues raised. It would also include them applying the concepts and practices of Aim High, Feel Safe, Team Up, Fail Well, Learn Fast - to complement their habitual, formal and largely hierarchical approaches to managing the organisation.
2. Team coaching for the operational management group of 17 people, providing tailored team development, building their confidence and capability to act as a joint leadership group with a clear purpose, rather than the existing bureaucratic management committee.
3. Seeking funding for a wider, hospital-wide piece of culture development work, involving a wide range and large number of staff across the organisation.
4. Some intensive development work with a safety critical department, where relationships had badly deteriorated (this piece of work had positive outcomes, but is not covered in this blog. If you’re interested, feel free to contact me).
There was no allocated budget for this work. A pragmatic approach was needed, which involved flexibility and goodwill on both their side and mine. They were persuaded by the power of the diagnostic data that in the short term, ‘Doing Nothing’ would risk further declines in staff morale and well-being, more recruitment and retention problems, further safety concerns regarding care and poor results against key performance indicators. In the longer term, the transformation of care required for the hospital’s strategic aims to be achieved was dependent on effective collaborative working across disciplines, so unless attention was paid to this, the strategy itself was at risk.
On my side, the priority was to build capability, confidence and skills into the system so that new ways of interacting, communicating, engaging and collaborating moved from being ‘developmental activity’ to being ‘the everyday way we work together’. Given the tight resources, hourly pressures on the service and the depth of trust-building needed, this felt like rather an over-ambitious hope. I was acutely aware how much this work now mattered to me, and how connected I was becoming to the staff and their work. Holding my boundaries was an important part of being in service to them.
At the same time as commencing the developmental strands of work, I used my own time and resources to research possible funding sources. I also commissioned and paid for a rapid but thorough literature review. I wanted to locate the most up-to-date studies and examples from around the world of how and where the core Teaming concepts had been applied, and what I could learn from these. I discovered some useful insights from this. Mainly, it seemed that very little learning was being shared about roll-your-sleeves-up, practitioner-led work on Teaming, with its warts-and-all-reality, to help anyone else make a small start, take some first steps, or translate wistful dreaming into living, meaningful, developmental action.
My mind was spinning with the possibilities of how Teaming could be embedded into the everyday way of working in the hospital I had partnered with. Out of professional curiosity, I was intrigued to see what we could shape as a potential approach. I realised this may never see the light of day; it was an experiential foray into an under-reported area of practice, without any Big Names or Notable Institutions involved. I did have conversations with several academics in the field in the UK, USA and Canada, but it transpired that none of them could connect me with people exploring the practical application of Teaming in a UK healthcare context. From this, I surmised, perhaps not much work is being done? Or maybe it is, without being recognised or named ‘Teaming’?
I drew an almost total blank on all 4 areas of possible help: nobody in my extensive network was actively exploring Teaming as a systemic, focused area of practice; no funding seemed likely; no ‘academic’ interest was forthcoming and I had found nothing much to guide me from published case studies or literature, beyond the classic bestsellers and peer reviewed papers I had already digested.
The only thing I felt we were left with was to believe in ourselves – the colleagues within the client organisation and me, together. I realised I needed to derive courage from our own skills, insight, wisdom, instinct, learningfulness and experience. I needed to stop imagining that someone else, somewhere else, might have the key, golden nuggets of essential learning to share which would make our work more likely to succeed. I realised what we did would be as good as it could be.
We didn’t have enough money or enough time. But we did have other invaluable ingredients for change. We had a rapidly-developing rapport as partners, based on trust, honesty, a growth mindset, a shared purpose and a belief in the difference this work could make. And from our very early work, we heard people talking with hope and optimism about the chance to do things differently, and the chance to pay attention to areas of the work which had long been neglected. So we immersed ourselves in the work and did what we could.
Do what we can
I developed a literature-based framework for the development work, adapted from the work of Amy Edmondson, Michael West, Barry Oshry and others. (We have since refined and further developed this framework, and have called it Co-Creating Culture.) The original version of this provided a quick way of explaining to busy clinicians, managers and practitioners the rationale that if their ambitious strategy (AIM HIGH) was to be achieved, some underpinning cultural foundations needed attention:
Staff need to feel psychologically and emotionally safe at work to provide clinically safe care (FEEL SAFE)
People need to be skilled and confident to work collaboratively across teams, services, organisations and systems of care (TEAM UP)
Colleagues need to feel supported to experiment, take risks and innovate (FAIL WELL and LEARN FAST)
These conditions are created (or eroded) through the behaviours and interactions of colleagues together, leading at all levels (LEAD COLLECTIVELY)
Beginning conversations about these 5 aspects of ‘how we work together’ generated interest and momentum in the work among a broad cross-section of people working in the hospital. This new and different kind of dialogue provided the basis for some focused development work. I will share our learning from this in the next four blog posts.
Next up - Collective Leadership: Lessons from a Leadership Trio
Image by JamesDeMers