To download a pdf click here  berwick

A day dream about what Prof Don Berwick might include in his report to the government after the second Francis report

Build teams – especially at the front line. Make frontline teamwork an organisational priority and devise ways of meeting other requirements (such as EWTD) that don’t sacrifice this. Ensure shift patterns support this ( probably means an end to 12 hour shifts and three day weeks for nurses).

Educate all trainee health care professionals ( HCPs) about the nature of organisations . Currently organisationally illiterate they are (and feel) helpless in the face of behaviours, politics, systems, structures and rule books that are an inevitable part of organisational life. Help them to diagnose and treat organisational malaise in the way they would a patient.

Research your care. Use the oodles of data you already spend time  and money generating -and currently ignore. Patient and staff surveys, complaints, disciplinaries, grievances, HSMR – all the returns you make, all the statistics that other people derive from your data. Take clinical coding seriously, get your HCPs, especially doctors, to see coding and the use of statistics as a core part of their professional role. Encourage routine, animated conversations about ‘how are we doing?’

Watch what is happening, listen, touch, taste, use all of your senses to  feel what is going on. Don’t try to  know using complicated data dashboards – use these to frame the questions you ask when you are out and about sensing how things are going. Develop your ability to smell trouble, to recognise good teamwork and bad, and happy purposeful staff from the complacent and self righteous. Feel how things are going . Get out of your office and onto the wards and into the departments.

Inquire and investigate all the time but especially when things go wrong –with the aim of understanding rather than blaming. Encourage reflection on what has gone well at the end of every shift (preferably in teams) and on what could be done better. Expect and reward people for identifying where improvements can be made , and for making them. Support quiet innovations to everyday routines as much as the flashy and hi tech ones.

Conversations, conversations, conversations: make sure everything happens through these. Especially ensure that ALL staff (including and especially the front line, including and especially doctors) have frequent, face to face conversations with someone more experienced (we might call these managers, they will almost always be other clinicians) to agree what they are expected to achieve, ensure that they are (and feel) confident  that they have the skills and resources to be able to deliver that, and have feedback ( positive and negative) on how they are doing –five times as much positive as negative.

Make your organisation a constant buzz of conversations between patients and staff, staff and each other, staff and their ‘managers’ ,between teams, and between the Board and the organisation . And rehabilitate management as a vital, personally engaging, enjoyable role that everyone undertakes whenever they are relying on anyone else.

Know that in many situations you won’t  know, and will never know for sure – you won’t know for sure that an action will have a specific outcome, you won’t know for sure how your organisation is performing. Learn to use your wisdom rather than your knowledge. Learn to use your judgment to ‘muddle elegantly’ through a complex situation – and remember that this is what your staff are doing for some of every day. Sure, standardise , systematise, and write protocols where this adds value or reduces costs (without sacrificing efficacy) but leave scope for professional judgment where it is needed. Encourage this throughout the organisation, and when people who are muddling through elegantly get it wrong (as they occasionally will) help them to reflect, spread the learning from their experiences, and don’t  fuel the risk aversion mentality by dishing out blame (Francis team please note!).

In all these ways help people in your organisation to feel purposeful (that they have a meaning and purpose and are working towards that), to feel capable and supported instead of helpless, to feel that their organisation and they share the same goals and that they are not fighting a faceless and persecutory bureaucracy.

Valerie  Iles April 2013

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