Cultural change depends on engagement, not political gestures

Much has been written in recent years about the importance of staff engagement in helping to create cultures that deliver sustained high quality, safe and efficient health services.

‘Medical engagement needs to be part of an overall organisational approach from board to ward’

The King’s Fund’s annual leadership reports, from 2011 to 2014, have all stressed the importance of leaders creating organisational cultures where staff including doctors feel engaged and empowered to contribute to a collective vision of delivering higher quality care.

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Studies using the medical engagement scale – a measure of the extent that doctors are involved in leading the design, improvement and delivery of services in an organisation – have confirmed the strong link between medical engagement and clinical and organisational performance. However, little has been written to date that describes what good medical engagement looks and feels like in practice.

Pegging progress

Last week, the King’s Fund published Medical engagement: a journey not an event based on case studies of four foundation trusts with high levels of medical engagement:

• Northumbria Healthcare Foundation Trust;
• Salford Royal Foundation Trust;
• Southern Health Foundation Trust; and
• University College London Hospitals Foundation Trust (see box below).

The trusts were identified using data from the NHS staff survey and the medical engagement scale, where available, and by getting feedback on their performance.

‘The real benefits for patients and staff occur when medical engagement is part of a wider organisational and cultural process’

Interviews with a range of managers and doctors at the trusts helped draw out key themes and develop a checklist to allow organisations to assess their progress in developing medical engagement.

None of the organisations studied would suggest that they have fully realised their vision but the research offers some powerful messages about what can be achieved if there is a genuine and sustained commitment to medical engagement as part of a wider process for creating an organisational culture of quality improvement.

One strong conclusion from our research is that medical engagement needs to be part of an overall organisational approach from board to ward, and it needs time to evolve. It is a journey, not a one-off event, which motivates doctors to become engaged as “shareholders” and for executives and managers to work in partnership with, and support, clinical colleagues.

Common themes across all four trusts

• Each has enjoyed long term, stable leadership, creating a firm foundation for cultural change based on improving quality and safety. It is this focus that motivates clinicians to contribute and lead.
• They all have clear strategies to embed quality throughout their organisation and involve all staff, not just clinicians. These strategies are not separate programmes or projects, but are real and pervade everything the trusts do.
• Each trust has embraced a strong medical leadership structure with doctors in leadership positions at divisional and departmental levels, supported by managers. Dedicated time is given to those doctors in positional and project lead roles, and leadership development is taken seriously not only for those leading, but also for those seen to have the capability to move into leadership roles.
• Authority is genuinely devolved to, and accepted by, divisional and departmental leaders. Senior managers see their role as supporting them and creating a culture that encourages innovation and decision making. With this comes accountability and two-way performance management.
• Each trust puts considerable effort and resources into selecting senior staff, including consultants. This includes using psychometric tests and simulations against the organisation’s values and competency frameworks. There is an expectation that all consultants will offer more than just their clinical expertise to the organisation.
• Well developed appraisal and revalidation processes exist in all four trusts. Talent management, succession planning and leadership development are all deeply engrained, and are supported by a broader focus on education and training. These are not fads but integral to the way the organisations work.
• All the trusts encourage junior doctors to participate in service improvement initiatives and provide opportunities for leadership development. This means many junior doctors were keen to acquire consultant posts within the trust.
• All four trusts looked nationally and internationally at best practice, and many staff had been encouraged and supported to learn from other high-performing organisations.

While medical engagement should lead to better clinical and organisational outcomes, the real benefits for patients and staff occur when it is part of a wider organisational and cultural process.

We have developed a checklist that might help organisations and individuals in medical leadership roles assess the extent to which medical engagement is actively sought and developed.

For organisations

• Is there an organisational culture strategy that includes medical engagement as an explicit component?
• To what extent are the board and executive team fully committed to medical engagement? What activities provide the evidence that this engagement gets translated into the way the organisation functions? 
• How is medical engagement promoted and brought to life by the chair, chief executive and other senior staff?
• Do the governance arrangements and organisational structure reflect a culture that seeks high levels of medical engagement?
• Is there an organisational goal for engaging doctors in positional and quality improvement leadership roles?
• Is there a talent management and succession planning process for medical leaders?
• Are junior doctors offered leadership development opportunities, particularly in quality, safety and service improvement?

For medical leaders

• What activities are in place to attract, recruit, induct and develop consultants and medical leaders?
• To what extent do these processes connect and reflect aims, values and goals at an organisational and divisional level?
• To what extent are doctors at all levels involved in planning, prioritising and organisational decision making?
• How does the organisation ensure it has the capacity and capability for developing leadership and supporting quality improvement?
• How seriously are job planning, appraisal and revalidation taken? 
• Is dedicated time given to doctors in positional leadership roles?
• Are all consultants, other senior doctors and medical leadership roles appointed through a competitive and values based process that reflects the organisation’s values?

Medical engagement makes a critical contribution to achieving innovation and improvement for patients. Transforming the NHS depends much less on bold strokes and big gestures by politicians than on engaging doctors, nurses, other staff and patients in improving services. This requires doctors, boards and all staff who contribute to patient care to work together to create organisational cultures that meet this challenge.

It requires a sustained programme of cultural change based on clear and explicit values; this needs to be supported by investment in service and quality improvement, engagement, leadership development, education, training and appraisal, and governance arrangements that facilitate and promote the desired culture. It is too important to be left to chance.

John Clark is senior fellow and Vijaya Nath is assistant director of leadership development at the King’s Fund. Vijaya Nath was one of the women on the HSJ Inspirational Women 2014 list.