Leadership, culture & safe, quality health services

This article is based on an interview Fi Mercer, Founder Governance Evaluator, recently conducted with Dr Sue Mathews, CEO of the Royal Women’s Hospital.

I first heard her speak at the 2016 VHA conference. She shared compelling stories about her work towards creating and sustaining a genuine culture for safe, quality and inclusive health services. These were not only inspirational; they highlighted key concepts that are relevant across all sectors, not just health.

I was delighted to have the opportunity to interview Sue and to be able to share her generously offered experience and tips. She provided insight into the simple but genuine and authentic activities she leads with in her organisation to drive a safe, quality and inclusive culture. These simple, highly effective steps are easy to implement no matter the size of your organisation.

In early 2010, the Ontario (Canada) Ministry of Health introduced mandatory quality reporting. At that time, Sue was CEO of a hospital in that province. All organisations had to review and report annually from the board down to see how they were tracking in relation to the quality indicators.

This audit had three elements:

  1. Narrative, which was written information
  2. Indicators, some of which were set and others that could be selected depending on the particular organisation
  3. Choose relevant indicators for your organisation and then review Board, Executive and staff

This process was Sue’s first experience of a genuine increase in the level of awareness of quality leading to a change in culture that enabled a lift in quality. Sue observed a clear evolution of the attitude of most organisations (Board through to staff) as they progressed through the three‑year process:

  • First year: the response of all organisations to their results was that ‘the data was wrong’
  • Second year: many organisations started to justify their results by saying things like, “We are special and different”, “It couldn’t apply to us due to our very special circumstances,” etc.
  • Third year: organisations started to say, “We get it.”

I found Sue’s observation fascinating, as Governance Evaluator has observed the same pattern with Boards throughout Australia. The universality of this experience reinforces the value of and need for Boards and Executive peers to openly discuss and share their experiences.

The key outcome, Sue noted, was that the process gave everyone involved time to pause and reflect on what was really happening. She derived her signature motto – Stop, pause, and reflect – from this formative experience: it underpins much of her work in her current role at The Women’s.

Since starting at The Women’s, Sue has adapted this concept, and created strategies that support each stage, to:

She leads adoption of this approach by visibly and regularly practising it herself. She leads a mix of casual and more formal ‘walk around’ processes. Her strategies for achieving this are:

  • Schedule time to do the activities regularly across the year
  • Physically meet and deliver message – you can’t lead culture from behind a desk
  • Be genuine in your meetings: speak the language of other disciplines and clients across the organisation
  • Be authentic in your engagement: provide details about what has been done to address feedback from the last walk around.

These walk arounds are of particular value to Board Directors because they provide context (rather than content). Directors gain a qualitative perspective across the organisation, and on feedback such as people matters surveys.

A key element that drives Sue’s success with this process is authenticity. It’s a key strength of hers and one that she teaches her executives. Different styles of leaders lead the rounds, but whoever does needs to understand their own style and how to communicate authentically. The value of authenticity is that it makes people feel safe and secure, and therefore comfortable providing the good or bad news about what’s happening in their area.

Sue places language at the core of her approach to authenticity. “It’s our responsibility as health care leaders to speak the language of the groups we meet with on our rounds, e.g. finance, medical, politics. It’s hard to learn to speak some other languages, but making the effort to listen and pick it up demonstrates you’re genuinely committed.”

Sue has found that the key for high value, quality rounds to work is to teach the language of authenticity to the next level of executives. This equates to a form of succession planning. To lead rounds successfully requires the leader to understand how to adapt their language.

Sue leads a mix of casual and more formal ‘walk around’ processes

Four questions are always asked on the formal leadership rounds:

  1. Are there any patient safety issues? If staff are not available during the walk around, they now leave lists of issues they have noted
  2. Are there any staff safety concerns?g. The #1 issue for nurses (from international research) is a lack of adequate working supplies and equipment – not having enough to do a good job
  3. What’s working really well?
  4. What can we do better?

Sue uses the walk arounds as a way to help Directors engage across the business. Usually 1 or 2 Directors are included in each walk around. They have two key benefits:

  1. Directors can learn in a way that can’t be described in reports, i.e. moving from ‘knowing’ something in their minds to ‘experiencing/feeling’ it in their hearts. They see things like addicted babies and mothers in the Drug and Alcohol centre.
  2. It enables them to be seen to lead the culture.

She has developed an approach to the walk arounds that ensures they are of maximum value.

Preparation for the walk rounds sets expectations

Boards used to see these walk arounds as a ‘tour’. Sue is very clear that this is not the reason. She conducts a 10 minute briefing prior to each round to explicitly state its purpose. Establishing these parameters – context setting – makes for an effective use of time.

Sue also notes that “We don’t own every problem.” Some can be fixed at the time by management and aren’t appropriate for escalation.

Conclusion of the walk arounds

Each walk around ends with a 10 minute debrief. Key issues and observations are discussed. A manager from the area/division visited attends each round and associated debrief to be accountable for feedback of things that can be fixed immediately.

Outcomes of the walk arounds

The data from each walk around is analysed by the quality team who look for themes across the organisation. They then go and look at the themes across the multi-disciplinary areas.

Sue debriefs about the feedback/themes at her monthly executive meetings. Her next step is to provide feedback about what has been done in relation to those themes. These results come back to the quality committee who repost the themes and actions up to the board. The board agenda has leadership walk arounds as a standing item.

While boards have an important role to play, all levels of management must be engaged in a safe, quality and inclusive culture so they can, in turn, engage their staff. Middle management in particular must be empowered and supported. Sue achieves this by bringing all managers (who have direct reports) together quarterly for a half day. The purpose of this half day is to be inspired and engaged in the culture and strategy so they can lead their teams accordingly.

Sue noted that the number 1 challenge to the maintenance of their culture is workload. “You need to avoid a culture that glorifies being busy, whilst at the same time, not diminishing the reality of the volume and complexity of work.” This is an ongoing challenge in such an intense environment, e.g. The Women’s broke its record for the number of births in one day, with a high volume of critically ill babies. Those newborns and their parents are fortunate to experience the quality culture and associated safe, quality health service that Sue has nurtured.

Thank you so much Sue for a great interview and your brilliant insights for how we can positively effect our own organisations culture.

Fi Mercer Founder, Governance Evaluator