Sally Howard

We are all now impacted by COVID-19, where we work (if we are able to do so), what we wear to work (or would like to wear if we had PPE), how we work as teams and how we communicate with each other. Day to day activities need different routines so we can look after each other. In particular, working in a new clinical environment requires bravery and extra special support so everyone can give of their best. This blog offers reflections and pointers to help as we move into the next phase of the journey and towards the first steps of recovery. Whilst certain colleagues, sometimes called ‘they’ will be tasked with recovery planning, ‘they’ will do it a whole lot better with you on board. Transitioning Whilst we cannot put the clock back - our version of ‘normal’ has left the building - we can focus on things we can change that will make a huge difference and things we can do to influence for a better future. John Kotter in his brilliant book ‘The heart of change’ identifies 8 steps of successful large scale change: 1. Creating a sense of urgency. 2. Pull together a guiding team with the credibility, skills, connections and reputations and formal authority required to provide change leadership. 3. Create a sensible, clear, simple uplifting visions and sets of strategies. 4. Communication with simple heartfelt messages so you develop a gut-level commitment liberating more energy from groups of people. 5. Empowerment, removing obstacles not giving power. 6. This empowerment then gives us short term wins and momentum. 7. Keep going - momentum builds after the first wins – early changes are consolidated. People shrewdly choose what to tackle next –and they don’t try to do too much at once. 8. Finally in the best cases leaders throughout the organisation make change stick by nurturing a new culture – a new group of norms and behaviours. So where do we all fit in this and how can we play our part? Here are 3 keepers to consider: Keep practising the new routines For a lot of people, the daily routines have changed and each one requires practice for example: If you are working in Personal Protective Equipment you not only need to know how to put it on and take it off, you won’t have the normal cues available as you work with the team - see Claire Cox’s brilliant blog on this (1); For anyone doing virtual meetings these do take practice. Otherwise you risk a game of virtual ping pong with 2/3 players going great guns (or not so great) and others reduced to being ineffectual bystanders. We do behave differently in virtual interactions and if we aren’t careful we may sway towards a more negative, aggressive line. It’s called online disinhibition. There are two Harvard Business school articles on the art of virtual meetings (2) (3). My take aways were; keep still, banish any niggling desire to get on with something else and focus 100% on the conversation and how you can add something helpful. Keep looking out for each other More so now than ever, understanding the work/home issues of colleagues is key. Home schooling and long clinical shifts do not make good bedfellows and you will have a range of other examples. My current twitter feed is filled with stories of clinical colleagues supporting and looking out for each other in their practice, so everyone can give of their best. Keep the good things that are working for staff and patients We have seen collaboration, support and flexibility across teams and organisations, mentorship in areas of practice logged as important not a nice to have. We’ve also seen some better systems of access for patients through virtual consultations, an agility that has enabled logistical challenges to be overcome. With greater levels of trust and co-operation there are many good things to nurture. Make a mental note of the brilliant new practices that you would like to keep going forward – and if you are not being asked to share these, find out when you will be invited to contribute. We are on the cusp of a culture change. It’s amazing what people can do when we empower them, so make your voice heard now and going forward. ‘If you think you are too small to make a difference, try sleeping with a mosquito’, the Dalai Lama. (1) Cox, C. Working under pressure – a nursing perspective – Interview with Claire Cox, 2020. Patient Safety Learning. (2) Thompson, L. How to foster positive virtual interactions against all odds, 2020. Harvard Business Review. (3) Littlefield, C. How to Be a Respectful and Empathetic Remote Coworker During the COVID-19 Crisis, 2020. Harvard Business Review.

My original plan for this blog was to explore why change is a bit Marmite – some of us love change (the ‘bring it on’ group), and others less so. Then the COVID-19 jar was opened and everything changed. We are all impacted in different ways, both staff and patients. Whether it’s even more time at work, less time with those we love, wanting to be at work but having to self isolate, loss of our identity as the one who always does x or y, how as patients we interact with our NHS, or the loss of those we love. Transitions are challenging William Bridges says it isn’t the changes that do you in, it’s the transitions. Change is something that happens to people, even if they don't agree with it. Transition, on the other hand, is internal. It's what happens in people's minds as they go through change. Change can happen very quickly, while transition usually occurs more slowly as we internalise and come to terms with the details of the new situation that the change brings about. Stages of transitioning include: Ending - letting go of the old ways and the old identity. The neutral zone - going through an in-between time when the old is gone but the new isn’t fully operational, when the critical psychological re-alignments and re-patterning take place. New beginnings – when we come out of the transition and develop a new identity, experience a new energy and discover a new sense of purpose. 3 tips for dealing with transition So what can we do to ease the transition? Here’s my three As for the day: Acceptance Accept that we will each make our transition at different paces. For some shock and denial through to acceptance and hope is rapid, for others it may take longer. So more than ever looking after each other is key. Steve Covey’s talks about making a deposit in the emotional bank account: understanding your friend, your colleague, a small act of kindness. What will be a deposit for you, may be a valuable withdrawal for them. Appreciation There’s already a zillion examples of people moving hell and high water to do what needs to be done to best respond to COVID-19, positive energy is thriving. Appreciating this is just as important. We can show our appreciation locally in our teams, on an individual basis or by joining the nation in clapping those who are helping to keep our world turning,. Awareness Be aware of high levels of anxiety and exhaustion in yourself and those around you. We are all stressed by different things. For some it’s spending too much time alone. Others ambiguity and uncertainty. Some will struggle most with decisions they think are illogical, last minute or require super human endeavours. Knowing our own limits and triggers and those of people around us is key. When you spot them, pause just for a vital moment, take a brief step back before anyone keels over and think through next steps. Explore information and ideas and talk them through with others. And where you can see that someone isn’t in a good place, give them permission to re-charge their batteries so their brilliance can continue to shine. “Not in his goals but in his transitions man is great.” —Ralph Waldo Emerson References William Bridges, Bridges Transition Model, 1988. Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990. Previous blogs by Sally Leading for improvement Immunity to change How a single piece of paper could help solve complex patient safety issues The art of wobbling: Part 1 The art of wobbling: Part 2

So, you have a network in place, a few allies and that’s working well. Your curiosity means that you are asking great questions. Then you hit a brick wall Push a few boundaries and you may find yourself in the middle of a disagreement, whether that’s you as a leader sharing power with your team or as the one brave soul who says "you don’t have the full picture". Whilst it may seem that people ‘in authority’ must find this easy to handle, otherwise they wouldn’t be in charge, at the end of the day this can be scary stuff wherever you sit within your team and the wider system. You could turn back at this stage, but I hope that you don’t. Top tips for dealing with conflict Here’s a few more tips from me, all drawn from my experience of working with individuals and teams wanting to make the right difference for their patients: Pause and take a long hard listen to what’s being said. Stephen Covey says that most people do not listen with the intent to understand, they listen with the intent to reply (1). Take a moment to reflect on how you listen. Empathic listening is not listening until you understand, it’s listening until the other person feels understood. Combine this with patience. Rome wasn’t built in a day and a big shift in the way things happen may take time. Use this opportunity to grow your network of people who share your passion for making a real difference. Last time I talked about power; from our formal positions, expert power derived from our knowledge and experience, and personal power. There’s also a wonderful power expressed through appreciation (2). Nancy Kline recommends a 5 to 1 ratio of praise to criticism. Researchers studied how appreciation effects blood flow to the brain. Less flows when we are thinking critical thoughts. Appreciation is necessary for optimal brain function. It moves to the heart to stimulate the brain to work better. Infectious, it goes a long way especially when someone may be quietly wondering whether something was the right thing (3). And, unusually, emails and texts can be the unsung heroes of appreciation. Being appreciated for what you did that day, that week makes a real difference. So far so good but what if you really cannot agree with the direction of travel? Well you can disagree respectfully and politely. There is a time and place for agreement and disagreement (4). And finally seek some feedback. One of the real benefits of building a network of support is that it can help you hone your practice and build your confidence. It can be difficult to fully engage, give your best and then know how you landed. Was I clear in that meeting? Could people understand what I was trying to say? Was I too forceful? But you can identify a trusted colleague and ask if they will give you some feedback. I often suggest people set this up ahead of time, you receive richer feedback as a result. The Healthcare Leadership Model is also a brilliant tool (5). It’s not just for people with leader in their title. It’s made up of nine leadership dimensions that you can explore at your own pace and then, if the time is right for you, seek feedback from others using the online tool. In return you receive a comprehensive 360 report along with a session with a trained facilitator to help you get the best out of your report. Thanks for reading this – let me know your experiences. Next time I am going to be talking about our responses to change and why it really is a bit Marmite – some of us are wired for change, others less so. But it’s a little more predictable than you might think… References 1 Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990. 2 Video: French and Raven's Bases of Power. YouTube. 2017. 3 Nancy Kline. Time to Think: Listening to Ignite the Human Mind. Ward Lock, 1999. 4 Peter Khoury. How to Disagree Respectfully, magneticspeaking.com 5 Healthcare Leadership Model. NHS Leadership Academy.

If you are of a certain generation you may remember Weebles, the roly-poly toys that wobbled but didn’t fall down. Tipping an egg-shaped Weeble causes a weight located at the bottom-centre to be lifted off the ground. Once released, gravity brings the Weeble back into an upright position. This blog is the first of two, where I’ll be discussing the 'art of wobbling'. We all have a wobble now and again. A lack of confidence in our own abilities and what we have to say. Unsure whether we should say anything or concerned we won’t get our points across when we do. All of which is not helped by other factors that may be outside of our immediate control. So, what triggers our wobbles as we take forward improvements in our service? And what are some of the go-to strategies you may want to have in your back pocket to help you get up again? Research over many years, led by Amy Edmonson, Novartis Professor of Leadership and Management at the Harvard Business School, identifies a recurring theme of ‘self protection’.[1] Don’t want to look stupid? Then don’t ask questions. Don’t want to look negative? Then don’t criticise the status quo. One of the most common themes I come across through coaching is genuine fear. Fear of not being listened to, being misunderstood or no longer being part of the main group. Sometimes a genuine fear of saying anything because it’s just expected that we keep quiet and carry on. Well, that takes us down the rocky path of missed opportunities – opportunities for prevention of harm, learning together and continuous improvement. Taking that first step can be the hardest part but people often don’t realise the power they have. Power isn’t just from formal positions. We all know people who we value because of what they bring to the table. Back in the 1960s, French and Raven identified six sources of power.[2] Yes, there’s legitimate power from formal positions but there’s also expert power, derived from knowledge and experience and personal power (when others believe you have desirable qualities and traits). You have more power than you think. The trick is in how you use it… and that takes practice. So, here’s my starter for ten: Build yourself a network of trusted confidants and go on the journey together. You may not be the most senior person but you have your experience and knowledge – it’s too good to keep to yourself. Be curious. It’s rare we know everything – check what may be missing. This puts any fear on the back bench. The more curious you are, the braver you’ll become. And as you get curious, listen with your biggest ears. The attention we give is key. As Nancy Kline says in her brilliant book ‘Time to think’,[3] get interested and listen. Be really clear about what’s expected of you and whether it’s actually possible. It may not always feel safe to speak out but sometimes you must do so to get that clarity. Once you have this you can start to focus your time on the key things that will make the right difference. Look after yourself. You cannot push a few boundaries without getting a bit of push back. Steven Covey in ‘The seven habits of highly effective people’[4] says we can be ‘response-able’. We all have the power to choose our response. It’s not what happens to us but our response to what happens that hurts us. But it doesn’t have to. Don’t let those knock-backs disable your brilliance, learn from them. And lastly, back to those Weebles. One way to keep upright is to do some preparation and build resilience (resilience is a mixture of personal characteristics and learnable skills). The Robertson Cooper I-Resilience tool[5] is great for this; it’s also free and easy to use. Give it a go, talk it through with your boss or a colleague, identify and work on two or three things that will help build your resilience. So, expect surprises on the journey – some good, others less good but this is all about practice. Celebrate the good times, learn from the not so good. "The greatest glory of living lies not in never falling but in rising every time you fall": Nelson Mandela, 1998. Happy wobbling! References 1. Amy Edmonsaon. Video: Building a psychologically safe workplace. TEDxHGSE. YouTube. 2014. 2. Video: French and Raven's Bases of Power. YouTube. 2017. 3. Nancy Kline. Time to Think: Listening to Ignite the Human Mind. Ward Lock, 1999. 4. Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990. 5. The Robertson Cooper I-Resilience tool.

Often, there are many perspectives that we need to consider before we have a complete picture. 'The Blind Men and the Elephant', and earlier versions of this parable, show us the limits of perception and the importance of complete context. This also applies when we are facing a difficult or complex issue in relation to patient safety. As part of the Patient First programme at Brighton and Sussex University Hospitals NHS Trust, we used A3 problem solving. Many others do too. It’s a structured problem-solving tool, first employed at Toyota and typically used by 'lean' manufacturing practitioners. Flexible and succinct, it captures everything you need on a single piece of paper – A3 in size, hence the name. It also brings together some widely used improvement tools – cause and effect diagrams (fishbone diagrams) the 5 whys and small change cycles (Plan, Do ,Study, Act). Most recently, I've had the pleasure of using it with teams wanting to improve elements of their services such as time to triage, discharge or wanting to minimise avoidable harm (e.g. patient falls). I have also used it with families and clinical teams wanting to take forward a key service change. Its’ real power is that, rather than jumping in with solutions in hand (which are, more often than not, shopping lists of resources required), you don’t move forward until you have absolute clarity on what the ‘problem’ is you are trying to solve. Plus, this is a team activity. It is rare we know everything about our issue and the power of an A3 derives not from the report itself, but from the development of the culture and mindset required for its successful implementation. There are several formats around – just google A3 problem solving. I have summarised the first 4 steps below: Step 1: Problem Statement Set out why this is important? A couple of sentences about the size of the issue, how long it has been going on, impact on patients, their families and staff. For example Over the last 4 months we've seen a reduction in patients triaged from X% to Y%. There was a near miss event last week that would have been averted had triage been in place on that shift and staff are concerned that there is no single process for them to follow. OR Our surveys over the last 6 months indicate that only X% of our clients are fully engaged in the development of their care plans. We need to address this urgently in order to ensure best outcomes for our clients and support family members and carers who are willing and able to participate. This is your call to action – if it isn’t making your staff and clients sit up and want to engage then it needs more work. Step 2: Current Situation What you know about the issues, what staff are saying, what patients and their families are saying (small surveys are great), what the data is telling you, any protocols or algorithms, and anything else that you need to know. Step 3: Vision & Goals Vision: A softer statement of quality AND Goal(s) : Measurable goal(s) and when you are aiming to deliver, for example: From June 2020: ‘X% of patients to be triaged within Y minutes of arrival‘ AND ‘Y % of patients triaged to the correct clinical pathway’ Step 4: Analysis: Top Contributors & Root Causes Use a cause and effect (fishbone) diagram to ensure you are capturing the many causes For example, the methods in place that may not be working quite so well, things to do with the environment, equipment and the people, both patients and staff. Once these are all out on the table then you can use root cause analysis to get underneath them. It’s only at steps five and six that you start to think about the actions that you will take forward and how you might fix some of these big issues. The full A3 is pasted below: And finally, it goes without saying that step nine, ‘insights’, is key. In my experience, people get best benefit if they complete this as they go along. There is always learning, for example people you might have engaged sooner, early identification of others who are already on top of the issue and able to share their work with you so you can adapt for your own use – we used to call it ‘assisted wheel re-invention’ when I worked for the NHS Modernisation Agency. Please leave a comment below or message me through the hub @Sally Howard if you want to know more. I'm very happy to talk further about this approach.

Over the Christmas period I caught up on ‘interesting emails’, the ones with content that needs you to put thinking time aside to inwardly digest rather than cramming it in between Christmas baking. One of these was from Mike the Mentor, one of the great people who trained me as a coach a good few years ago, asking a very simple question: How is it that, despite being committed to change, we so often fail to make the changes we are committed to? He offered a great answer, taken from from Kegan and Lahey's book, Immunity to Change: How to Overcome It and Unlock the Potential in Yourself and Your Organization. If you are just following a simple recipe there’s no need for this but if you are going to take advantage of new opportunities and deliver a bigger change then this is worth a look. Just as with New Year’s resolutions, we often look at the behaviour that we want to eliminate as bad. This book is all about growing into your aspirations, knowing what makes them possible and what is getting in the way. There is a four step process to understanding the space between the change to which you are committed and actually making it happen, then a journey of a few months to make that change either with your team, with a coach or in quiet contemplation. Step one Identify your improvement goal. The thing you are really motivated to change, the one that is worth getting out of bed for, that scores five out of five, and its simply no longer tolerable to leave things as they are. For example: I am absolutely committed to improve x in our system. Step two Take an honest look at the things that you are doing or not doing that work against that goal. The more concrete you can be the better. Be honest, you don’t have to share this with anyone. But, if you can, seek out people who you trust who can add things that they see you do or don't do that are getting in the way of this being delivered. These are your hidden competing commitments. For example: I don’t actively engage. When I engage I tell people what needs to happen OR I rush through what I have to say. Step three Well done. Now confront these. What are your fears behind them? Identify that loathsome feeling lurking in the background, what would be the biggest risk for me in this? For example: I worry that people won’t take me seriously. Step four Behind step three will be one or two big assumptions that you hold to be true. These need to be identified. For example: I assume that if I don’t get this right others will reject what I hold dear because they know more than me. These steps then become the route to changing your mindset that is working against your goal. Do take a look at Kegan’s TED Talk ‘An evening with Robert Kegan and Immunity to Change’ and take a moment to reflect on the space between you deciding to do something that’s important to you now, and actually doing it. You can also go to the Harvard website where you'll find a helpful immunity mapping tool to download. Please leave a comment below or message me through the hub @Sally Howard, I'm very happy to talk further about this approach.

We know from our own experiences and those of others that patient safety fears are growing daily across the NHS and social care. Staff shortages and burnout are all taking their toll on patient satisfaction, safety and standards of care. I had the pleasure of joining a webinar arranged by the Health Foundation last week where the National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey, outlined the up and coming improvement framework for the NHS. A good framework provides a skeleton on which to build. His presentation included the importance of: leadership both at the Board and at the front line people who are empowered and engaged a culture built on collaboration and continuous improvement, where it’s safe to learn co-production – engagement, empowerment and ‘lived experience’. Workshops, seminars and conversations across social media will follow in 2020 to build the thinking. So, be ready to contribute and help make sure patient safety is coming through as the top priority. And as you do, keep a copy of Roy Lilley’s latest blog in your hand. For those who don’t follow him, Roy is a health policy analyst, writer, broadcaster and commentator on the NHS and social issues. He recently posted this summary, outlining NHS electoral promises. Please do as he suggests – pin this up and bring it out every time you see a politician and whenever you have the opportunity. This way we can all ensure that these promises will be delivered.