Kate Grimes – Autonomy and Patient Care in the NHS

Nicky Stone: So this is Kate Grimes. Kate started at the NHS as a porter and she's worked her way up and now she's been Chief Executive of St Mary's and now Chief Executive of Kingston NHS Trust, and she's here to tell us how you can put this in place, even in places like hospitals. Kate?

Kate Grimes: Thank you very much. In the NHS, we've, we measure whether people are happy at work by whether they're engaged with their work. And, this is lots of words, a definition of whether staff are engaged or not. The bit that, I find particularly interesting is whether people are actually, focused on their work and, interested in what's happening.

And I think about when I did a Saturday job. When I was very young, working in a handbag shop, selling handbags to match people's shoes. And, time went so slowly, I'd watch the clock and it just went so slowly. And now I'm at work, and there's not enough hours in the day, days in the week, minutes in the hour.

And the day's gone before I know it, so I know I'm engaged, with my work. Now, why is it important in the NHS? I thought I'd just show you a bit of the evidence about this. So, one of the ways we measure outcomes in the NHS is to look at mortality. So if you look at mortality in a hospital, the average hospital should have a mortality ratio of 100.

So if your mortality ratio is above 100, more people are dying in your hospital than they should be, than the average hospital. And if it's lower than 100, then you are miraculously saving lives that should otherwise die. So I'm sure you've all heard of Mid Staffordshire Hospital. That had a mortality ratio of 127.

So, when you look at mortality ratio and you, measure it against whether staff are engaged or not, you can see that, low staff engagement scores, hospitals with low staff engagement scores have much higher, mortality ratios. And there's a very clear link. So if you are engaging your staff successfully at work, then you're going to have much better clinical outcomes for patients.

You also have better patient satisfaction. You have, lower hospital acquired infection rates. You have lower sickness rates for your staff and happier staff. Every measure you can think of, of both, staff well being, but more importantly, quality of care for your patients. There's, there's a very clear link with, more engaged staff.

So if I want to improve the quality of care for my patients, which is, my prime aim in my job, one of the things I really need to focus on is making sure that, my staff are engaged and happy at work. Now there's, been quite a lot of research done in what it is in the NHS that leads to, high staff engagement.

And I've summarised it here into these four things, which actually, link across really nicely to the happy manifesto. and I thought I'd just talk a bit about what we're doing at Kingston in those, four areas. Starting with leadership that builds trust. Now, There's lots of different ways to look at trust.

Again, there's been some studies done on trust and how you build trust as a leader. It says that you need to be, competent at your job. I think that's a, I think that's more a measure of if you're not competent, people don't trust you. So I think it's a kind of one of those foundations. You have to be competent.

You've got to be, benevolent, which means being kind and empathetic. You've got to be reliable. People need to be able to predict how you're going to react to something, and you got to demonstrate integrity. And we've also got to have a clear strategic narrative. So again, the evidence would say leaders with a clear strategic narrative so that people know where the organization's going, that have, stronger trust measurements.

And something which I don't think is thought about very much in the NHS, I think is how long your manager's been there, how long the chief exec has been there. I don't know if any of you know that average, Number of days a chief exec in a hospital is in post in the NHS in England. Does anyone know that?

700 days. That's not quite two years. It's a bit like, football managers. So people, as a chief exec in the NHS, if you run a hospital, it's, it's very easy for something to go wrong and the chief exec, to lose their job. But I think that it's very hard for staff to trust a, a leader, a chief exec if they think they're going to be gone, the next day and someone else come in.

So I think this is a key issue for the NHS is the stability we have in our, leaders. So secondly, and we've talked a lot about this today, exceptional, people management by line managers. which is not something, which is not something we do well in the NHS, I think because we don't, often we promote people into management positions because of their expertise and they're seen as being expert as opposed to being a good manager of people.

There's two things that we're doing at Kingston to try and strengthen this. So first of all, we are giving feedback to all line managers on their people management skills in their appraisal. Someone over here said the appraisal, this is never discussed at the appraisal, I think it was someone over here said it.

Yeah, it was Hugh. So that's something that we've started, we're starting doing, we've been doing for two years now at Kingston. And the second is developing coaching style. So I'll talk a little bit more about that. This is our questionnaire. So, this Every person that manages someone, and that's three to four hundred people in my organization has to give this questionnaire to the people they manage, and then it goes they, they answer it, and it goes back to HR and is collated, and then is fed back to you as part of your appraisal.

So, it's appraisal round time at the moment, and all of my direct line reports, I have filled in one of these questionnaires about me, and it's been fed back to me by my manager about how well I do these things. And there's also a free text bit. It's it's anonymous, yes. And so you've got to line manage enough, enough people to make it anonymous.

I manage probably more people than I should, so there's, there's quite a few people People, uh, answered about me. There's a free text box as well which asks what does your manager do really well that you want them to do more of, and what could they do differently that would make it even better.

And actually you get most, you get most value from the free text box. And then that's built into your personal development plan, something to work on over the next year. So you'll, the, and these questions are evidence based about what are the kind of behaviors you want from a manager if they're going to create engaged staff.

And you'll notice that one of those is act as a coach. And I think there's quite a lot in the Happy Manifesto actually about coaching, adopting a coaching style. I'm sure you will know what coaching is. But here's the definition of coaching, which I'm beginning to try and get well understood across the organization.

And it's moving from telling people what to do, directing to helping them to think for themselves about what they what they could do to help solve their problem. So if you have a coaching culture in the organization, then it becomes the predominant style of management across the organization. Not only in one to ones, but team meetings, but also in how you interact with people in the corridors, how you develop your strategy, um, and, and therefore how you make sure strategy is well aligned across the organization.

So how are we working at Kingston to create a coaching culture across the organization? Well, first of all, we're building a cadre of accredited coaches. So I trained as a coach a few years ago now. I trained at Ashbridge and one of the reasons I did it was I wanted to expand my management style so that I moved from being less directive to having a broader group of coaches.

tools and techniques I could use. And I found when I did it, that that I, that I did get better results from the people I'm line managed, that I listened better, that I heard a whole load of things in team meetings that I hadn't even heard before. And my staff, my, the people I managed in particular were were better engaged.

So I sent two of my directors on a, on a course. I got a free place and I managed to move it to two free places and they went off on a course. And they came back a few months later saying very much the same thing, how it was expanding the way they operated, particularly in one to ones. So we're now commissioning bespoke courses.

So, um, when everyone has finished going through, I've got three bespoke courses going on in the organization at the moment. Every director. Is either trained or is on the way to getting trained now as an accredited, accredited coach. And quite a lot, I've got quite a lot of doctors in leadership positions, and I'm training, I'm training them to do it as well.

And some middle managers, and we're now we're now, I'm now moving to actually people that are particularly interested in the organization. We're integrating it into other development programs. So we've got management development programs that have got coaching in it. We're doing a leader, big leadership development program for 80 top leaders at the moment, and coaching is a fundamental part of that.

We've had I've had a coach. I've employed a coach in the organization a day a week to coach people that need coaching for five years now. So coaching is seen as something that is given as a reward, is something positive to help people get better. It's not seen as only given to those that are struggling as some kind of remedial act.

And then we're talking about it a lot more. We're still, I think, probably at quite the early stages of this. And but, but it's something that I think is going to make a really big difference. So thirdly mechanisms to empower staff to, to, to ensure people have control over their working lives. And this is often really difficult to get in a hospital setting because there's so much bureaucracy in a hospital a whole load of that imposed on us from above.

But we've introduced something called service line management. So what, what we've done is we've split the organization into clinical areas that make coherent sense for those that work in it. So we've got small service lines GU medicine is an example, sexual health. So there's a small team of people running a sexual health service in a building on the edge of the site.

They're, they're actually, they're, they're commissioned differently. So they're commissioned from local authorities rather than through the NHS. And they're caring for a very discreet section of the population. And so they're a service line turnover only about 5 million. And then we've got big service lines like maternity, turnover of 35 million, running a really big service delivering 6, 000, babies every year.

So we've restructured into meaningful business units. I think often, the NHS has tried this, but they often chunk them into equal sized groups and then put a manager in the group. But if you put GU medicine alongside rheumatology and diabetes and, and , and pain management and lump them all together so they make a big sized unit, the doctor that's leading it, so we put a doctor in charge, If they're a rheumatologist, they don't know anything about sexual health, they're not interested in sexual health.

I want people that are, to feel part of the business unit that they're working in. And then I've managed to remove a layer, so we've got 18 service lines and then the executive team. And that's, and that's it. Each service line is headed by a doctor and they're supported by a manager and a, a nurse or a midwife or, or a, a radiographer or whatever the profession is.

And that's, so that's created a, a group of about 80 p who are then having a, we then commissioned a development program. It's an 18 month program that's very much about helping people to have the skills and understand their role in leadership across the organization. It's changed the. perception the corporate departments have of their role.

So their role is now to support the 18 service lines. Their role is not to develop information and hold onto it. Their role is to, to provide the service lines with the kind of information that they want and need. And they're finding that really difficult. So it's a big change in behavior for them. It's a change in behavior for me and my team.

We have to let go and create and create a framework rather than taking a command and control approach. To do this, we've created, we've put people into their 18 service lines and we've created accreditation process with defined freedoms once people are fully accredited freedom from, mainly freedoms from bureaucracy.

And we will get to the point where we might have a kind of bank in the organization that people can go and get loans from to do bits of work they want to do. over time, I envisage it really being 18 little service lines, each running their own little business. And that is That, that is, completely changed the dialogue in the organization.

It's completely changed the the feedback, particularly from clinical staff who often feel very done too in a hospital and got them all got engaging all their energies and enthusiasm, which will really help because you know, our money's going down in health service with the hospital, hospitals, money is cut by 5 percent each year.

We have to do the same or more for 5 percent less money each year. And you can't. Just take that amount of money out top down. You have to, you have to engage the people that are running the service in the best way to take that money out and still deliver quality care for their patients. And finally, lived values.

So in 2011, I started thinking about values and I, and I, and the trust didn't have any values. Actually, we did have some values. We had about 10 on a bit of paper that I found on the shelf somewhere when I kind of shook the dust off it. But they weren't, they weren't lived in the organization at all.

And so, we had a conversation through the organization to define the values. So I do a monthly team briefing. And I turned that into a workshop. So the people that I brief, we had a workshop to begin to say what are the values that define us as an organization. And then they went and had, ran workshops with their staff and so on.

And then flowing back up through the organization were the four values, or the nascent four values that we've got in the organization today. You can see them actually along the bottom bottom there. So we defined four values and the behaviors That we would expect to see if people will live in the values.

So they are caring safe, putting safety as our prime priority, taking responsibility and valuing each other. And we're now promoting them, communicating, promoting, embedding them through the organization. So someone talked about recruiting to values. We recruit to the values. We appraise them.

So our appraisal process has got three bits in it. It's got did you achieve your objectives? Did you achieve them in line with the values? So we rate people on a, on a, on a scale like that. Did you do the values and did you achieve your objectives? Then you can put yourself on a. It's a 12 point. You can put your across in a box where you, where you hit them.

And then we've got the manager feedback for those people that are managers. And we reward them. So we have a scheme each month where people nominate people who've lived the values. And we get a whole load of nominations from staff, sometimes from patients too. And each month the exec team is supposed to pick one.

We often struggle to pick one and we end up having more than one. And then I turn up in the working area. Everyone else knows except the individual getting the reward. And I turn up and, and, and, you know, Read the nominate, present them with a certificate and some vouchers and read them the nomination.

And they usually, I think the last time I did it, I turned up in reception. One of the receptionists had gone well above and beyond in looking after a patient. And so I walked into the reception back office and said, I'm looking for Maria. Maria immediately looked completely freaked out. Oh my God, what's the chief exec doing here?

And then I was able to present her with her reward. And we role model them. So Actually, I was going to say this under, under trust, but I forgot. So let me say it now instead. So the, so in our hospital we have double the rate of dementia in an average hospital. So 48 percent of the patients over 75 in beds in our hospital have dementia.

And actually most patients in our hospital are over 75. So on some of my wards, almost all the patients have dementia. Which means they need a lot of help at mealtime. because patients with dementia can't, need help to eat their meals. So we've trained dining, dining companion volunteers. So I'm trained as a dining companion, volunteer, and all the members of the board are trained and a whole load of staff, as well as I'm actually John Lewis in Kingston, some of their staff are trained and local local schoolchildren in the sick form they're trained.

And So we're trying to make sure that every ward has got at least one volunteer on it for every meal time, breakfast, lunch and dinner, seven days a week. To help give out the meals, encourage people to eat, help people to eat where they need help. Which means that I am on a ward once every, at least once every three weeks.

And I'm not on a ward doing a walk around. We do do walk arounds, but actually it's quite difficult to engage with staff and patients. When you go in and walk around and interrupt them when they're in the middle of looking after a group of patients. You get a quite different interaction with staff if you're working alongside them on the ward, helping at a meal time.

Only takes half an hour, three quarters of an hour. So you get a feel for the patients they're looking after, how frail they are. I don't know how many of you have been on a hospital ward recently, but it's really changed in the last ten years. That patients are so old and so frail and and often very, very thin.

And they need a lot of help to eat, eat just a little bit of food. So you get a feel for the demands on staff. The staff are much more relaxed, so they'll talk with you quite differently, particularly in the evening, at the evening mealtime towards the end of the working day. You can see the things that get in the way.

So, I was trying to help someone who only wanted ice cream, and I realized that you can't get ice cream. You have to go down to the canteen, which is a long walk, fill in a form, um, They saw me and they didn't make me fit in the form, but everyone else has to fit in a form. then take the ice cream back up.

So we've now bought little fridges for each ward because I don't know if you know, but patients with dementia, the last taste that goes is sweet, the taste of sweetness. And so ice cream is often something that people, if they don't want anything else, they'll eat, at least take a bit of ice cream.

So we've now got fridges on every road with ice cream, so we can give people ice cream without having to trek miles and miles away. When when, also you have to fill in the documentation, so we try and keep a record of how much people are eating, so you get to look at the documentation, whether it's filled.

You can get to see so many things just by doing this initiative. But it also role, role models the values. And I, I think I've got time for one more story. Christmas time. So, yeah. Yeah. Usually in hospitals at Christmas, we've had a change of nurse director, and our previous nurse director wouldn't let us put Christmas decorations up because they were an infection control hazard.

But we've got a new nurse director who said we could. So we thought, let's get a Christmas spirit going across the organization. So our linen supplier gave us some money for Christmas trees and decorations, and we ran a Christmas tree Decorating competition and we had 45 entries. It wasn't just the wards.

It was departments. It was the nursery. It was all over the hospital had had decorated their area and then wanted us to come around and we had to judge what was the best decorated area, which is very difficult. So we went round giving a box of chocolates to everybody. But as we went round these 45 areas, we found people had put the values on their trees.

So we had numerous values Christmas tree, where they'd taken the values and they created decorations out of the values. And here, this is this is the midwifery led unit. And they'd even made mobiles out of the values and hung them up from the ceiling. And our linen supplier was, was saying, how do you manage to get your values so embedded in the organization?

He went back to head office and he got them to agree to an extra award living your values. Award. And I think that's a really good example of how the values, I think because we've done them with staff rather than to staff are truly owned by the organization and there's something that we try and live by every day.

I'm going to stop there. I think I've got some references here. West and Dawson have done lots of research on the link between quality of care and, engage staff. If you get a chance to listen to either of them or you want to look them up, there's lots of papers of research they've done.

Actually, you asked me to do, have a question, didn't you, Henry? I have got a question. So given that we've got all this evidence about the, the link between engaged staff and better quality of care. I'm interested in why. We don't even know what the evidence is mainly across the NHS, and we certainly don't, we certainly don't approach it in a proactive way, in the way that I've described, looking at those four areas and looking at what we might do.

I'm wondering if you've got any ideas about why we, why we don't do that. So if I think about, well, maybe you've NHS Chief Executives. Why isn't this fundamental to their quality strategy?

Henry Stewart: Okay, so three minutes out of your tables, what advice for NHS executives to make this, or people working in the NHS, because not all the NHS are chief execs.

Audience Member 1: The thing that I was thinking is that as soon as you to make a change that is against the norm. You're making yourself vulnerable. So people aren't keen to do stuff that makes change. So in the NHS, someone who wanted to implement something that would be much easier and something that's probably done in informally in the organization would be too scared to do it because there'd be too much to answer for or too much bureaucracy.

Henry Stewart: Do you want to put your other question?

Kate Grimes: I'm very happy to.

Henry Stewart: Okay, Kate has a challenge.

Kate Grimes: So, you know, I talked about splitting the organization into service lines. We're starting to, but we're starting to find that we're losing some control of the organization. So we're having overspends when we haven't had overspends previously or bits of targets that we're supposed to require to deliver that we're not, we're not delivering.

I'm interested in how I might make sure that I regain control because if I don't, then I'll be in trouble without going straight back to command and control, which is an instinct that is natural in me, which I'm trying really hard not to give into. So I'd be really interested in any advice anyone's got about how I might try and regain control.

Henry Stewart: Any thoughts? How to keep control without commander control? There's one over there, and one over here.

Audience Member 2: Thank you. We're a, a social enterprise company that we spun out of the NHS two and a half years ago and we've got just over 400 staff now, we providing community services. And we split up into business units as well and they were essentially clinicians, senior clinicians who are providing services.

Put into these business partner roles. We've given them autonomy to run their business unit. Some of them have been managing clinical services for a number of years, and they're really skilled at that, but they weren't so skilled in the finance and resources of managing that. So we've put them through a program like a modular program to help develop those, the business acumen.

And some are doing really, really well and some are needing a bit more support. So every month our MD and one of our non execs goes out and meets with them, and they go through all of their performance their quality metrics. the budgets if they want to and it's more coaching. How you doing? How can we support you?

We're very lucky we've only got eight and you've got obviously a lot more than we have, but it's working really well and we, we've had only one casualty through, through the process.

Kate Grimes: That's really good to know.

Audience Member 3: Hi, we were talking about benchmarking and competition perhaps. So where there are some of the units that are maybe doing really well, buddying them up, sharing what's working well, but then also perhaps introducing some kind of competitive nature around who's going to meet the targets best this month and how are you doing it, making it relative because some units are bigger than others.

And in specifically in this area, what generally seems to work is transparency. A lot of transparency about actual performance, transparency about others benchmarking transparency about what is good performance good descriptions of what good performance looks like, and a lot of transparency.

Transparency in itself very often helps people to, you know, to run faster than setting daft short term targets or budgets.

Henry Stewart: Okay. That's a good note to close on. Thank you very much.