Changing organisational leadership culture: focus on values changes culture
ABSTRACT
In 2006 Guy's and St Thomas' NHS Foundation Trust not only had a financial challenge but also a cultural one: only just over half of staff would recommend the Trust as a place to work or receive treatment. This prompted the leadership team to embark on a journey spanning almost a decade, developing a values-based culture. The Trust values framework spans four levels of the organisation and sets out the values and behaviours expected of everyone, through to the strategic leaders in the organisation. This focus on leadership and behaviours at all levels has been underpinned with an appreciative inquiry approach to embedding the values and culture change. In this article, chief executive, Sir Ron Kerr, and OD colleagues, Sarah Morgan and Carolyn Norgate, detail the journey that Guy's and St Thomas' has undertaken, its impressive results, and the next stage in the Trust's journey.
There is a growing body of evidence1 that suggests a focus on values and behaviours, leading to better staff engagement, makes a significant difference to patient care. Guy's and St Thomas' has been on this journey for almost a decade, building a strong values-based ethos and collective leadership model, with positive results to the experiences of both patients and staff.
In 2006 when the change was initiated the Trust was financially challenged and had poor national NHS staff survey results with only 54% saying they believed that the care of patients was the Trust's top priority. Only half stated they would be happy for a friend or relative to be treated within our hospitals, leading to the recognition that things needed to change. One of the starting points was the realisation that culture needed modification in order to improve performance. While there was minimal literature focused on health to guide us, Schein's2 view that ‘[the] dynamic processes of culture creation and management are the essence of leadership and make one realise that leadership and culture are two sides of the same coin’ indicated we should start by examining our leadership development programmes. It became apparent that a set of values within which to anchor them was required, particularly given Schein's perspective that leaders impose their values and assumptions on groups, thus forming a culture, which in turn defines the future leaders within it.
The Trust's medical director noted that he could feel our values – he had a clear sense of ‘how we do things round here’ and a good sense that most of our staff and patients would too if asked. What was required was an agreed set of values to be at the heart of our cultural shift, owned by staff, patients and partners and through which we could be held to account. Collins and Porras3 identified that long-term success of an organisation requires clarity on such core values: ‘the organisation's essential and enduring tenets, not to be compromised for financial gain or short-term expediency’. As they found in their research, visionary companies do not ask ‘what should we value?’ but rather ‘what do we actually value?’3
With this in mind, a move from a narrow focus on leadership development to a wider culture development process began. It might have been tempting to invent a set of new values for a new culture; however, mindful of paying attention to what the organisation already actually valued we set about discovering what the core values were. This involved talking to staff, patients, visitors, foundation trust governors, staff-side representatives and the board, using focus groups and interviews. From this, the Trust's five values emerged and were agreed in 2006, and remain true today (Box 1).
The intention at this time was to use the values to help develop a culture of individual responsibility and continuous improvement, thereby increasing staff engagement and enabling excellent patient care. Staff, patients and partners alike felt a sense of authenticity about the values, and liked the fact that they were not just created but were emergent and ‘discovered’. However, after the initial energy and enthusiasm behind the development or rediscovery of the values, little was actively done to embed them. It became clear that more support was needed to help leaders and staff interpret the values consistently.
Consequently, 2008 saw the next stage of the process, which concentrated on embedding the values. Based on Wheatley's4 exhortation that ‘we need to learn how to engage the creativity that exists everywhere in our organisations’, over 200 staff were identified who were considered to exemplify our values and asked to engage in discovering what ‘living the values’ meant across the Trust.
The outcome was a set of behaviours organised into four levels shown in Box 2, set out in the values and behaviours framework.5
This simple, yet comprehensive, framework shows how each level builds on the previous one and provides clear descriptions of the behaviours we demonstrate in living our values. The internal research showed that, when people were performing at their best, leadership was already distributed across the organisation.
In the set of behaviours for all staff we found exemplars of personal leadership that we now ask all our staff to model and key leadership behaviours within the population of staff we would have classically called leaders (Fig 1).
The progression of values from ‘everyone’ to ‘strategic leader’ acknowledges not only the complexity and growth in expertise at each level, but also the core tenet of distributed leadership theory: that the ‘action and influence of people at all levels is recognised as integral to the overall direction and functioning of the organisation’ (Bolden6). So, while on first examination this framework may seem overly detailed and hierarchical, one of its advantages is that within it ‘leadership…is seen as an integral part of the daily activities and interactions of everyone across the enterprise, irrespective of position’.6
At the time, as well as our highest performing staff intuitively living the principles of distributed leadership, there was an increasing external evidence base that distributed leadership makes a positive difference to organisational outcomes .7 This combination encouraged the next phase of embedding the framework across all our staff as the ‘way we do things around here’.
Embedding the values into the organisational leadership culture became the core remit for an organisational development (OD) function, set up at the end of 2008. The concept of OD in acute trusts was a fairly radical one at the time and having this framework to embed gave the team a clear ‘licence to operate’.
The whole process of discovering and developing the values and the resulting framework hinged on engaging staff at all levels. In order to engage them with their own performance, staff were encouraged (and are now required in personal development reviews) to inquire into their own practice measured against the framework. Staff self-assess each behaviour, rating their performance as red, amber or green, and discuss this with their manager in the appraisal conversation. The OD team runs monthly workshops for leaders at all levels to introduce them to the framework, enable them to experience the self-assessment process, examine how well they role model the values and plan how to engage their staff in the process. So far over 1200 leaders have experienced this process, up to and including the board.
This process has been run alongside a range of other interventions to embed the values and develop a leadership culture; values now underpin recruitment, induction, development programmes (especially relating to leadership) and a culture change programme for teams and their managers.
While embedding the values has been central to the change process, the underpinning principles have been generated through appreciative inquiry (AI). AI advises that problem-solving approaches can exacerbate the problem trying to be solved, and research8 has demonstrated it to be an effective way to bring about change. AI supplies an alternative process to change the social fabric or culture via a social process: organisations are changed and developed through conversations during which those engaged people inquire appreciatively, trade stories and, crucially, generate new ideas together9. Philosophically AI, with its roots in social constructionism, fits with the notion of distributed leadership, a post-heroic leadership model in tune with ‘new science’ ways of seeing and thinking: ‘living systems theory, quantum physics, chaos and complexity theory [which suggest], we observe life's dependence on participation’.4
AI was used in the development of the values and behaviours framework by asking staff how, when at their best, they lived our values and subsequently influenced our leadership culture development. In 2011, the Trust integrated with community health services in Lambeth and Southwark and to support this integration, a process was designed to engage community staff with the development of a modified, combined culture focusing on the best of the pre-existing cultures in both organisations. Community health leaders facilitated AI-style workshops for over 350 staff in which they identified existing behaviours and mapped them to the Trust values framework, which was adapted to reflect the organisational change and to ensure relevance and meaning to both hospital and community staff and patients.
After the Francis Inquiry findings were published in 2013,10 leaders were asked to run listening exercises with staff. Again AI was used, so that conversations were forward looking and inspirational rather than focusing on problems to be solved. Instead of asking ‘what prevents staff from always being able to put patients’ interests first?’ we asked the following questions.
At your best, what do you do now to put patients and their needs first?
What should we do to put patients and their needs first all the time?
The 2013 listening exercise was followed by the launch of a Fit for the future programme, with a tripartite focus on quality, safety and efficiency. This programme was as much about culture change as hard deliverables and the leadership had to embrace different ways of thinking and working. AI was an effective counter-cultural process to use with the leadership to develop and review the programme and enabled a creative space for the whole team to work together in a different, more collaborative way. It also allowed us to engage staff in a new way with designing and delivering innovative change to meet the financial challenges facing the Trust, leading to significant savings of £79 million in 2013/14 and a further £64 million in 2014/15. So how is Guy's and St Thomas' performing today? Box 3 provides the answer. Today 86% of our staff think care of patients is the organisations top priority and 85% would recommend us as a place to receive treatment. As Fig 2 shows, there has been a direct correlation between the embedding of the values and behaviours and our focus on leadership and our staff engagement scores. While we cannot show a definitive causal link to our current performance, this strongly concurs with West and Dawson's11 research that staff engagement has many significant associations, including patient satisfaction, patient mortality and infection rates: ‘the more engaged staff members are, the better the outcomes for patients and the organisation generally’.11
Bringing all of these elements together, what is next for Guy's and St Thomas'? As our organisation becomes bigger and increasingly complex, we must seek ways for the leadership to work on a more devolved basis, by creating the conditions for distributed leadership at all levels, so that staff are able to innovate, thrive and continue to deliver excellent patient care. Organisational values, distributed leadership and culture together provide the compass by which to navigate the increasing complex world in which our patients are served.
- © Royal College of Physicians 2015. All rights reserved.
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