case study

Leading and managing organisations and systems

In the UK, cuts to health service funding over the previous decade had left a large NHS Foundation Trust - Boxgrove hospital in the West Midlands - with severe staff shortages and financial difficulties, leading to the hospital failing to meet a range of Government targets, and receiving a number of fines as a result. The hospital was in serious danger of being placed under ‘special measures’ following a serious case review into poor practices and high patient mortality rates, as well as consistently failing to meet financial targets.

After an unsettling period of 10 years which saw 3 different CEOs in post, matched with instability in key executive positions, it was decided by the hospital’s Board of directors that the current CEO, Alan Scott who had been in post for 3 years, should step down and that something drastically different was needed. After much deliberation, the hospital appointed Sara Kato for the role. Sara is Japanese but has worked in the UK private sector for 7 years, where she built a reputation as a ‘turnaround’ specialist, improving organisational performance in struggling businesses. Additionally, she had sat on the Board of directors for a smaller hospital in Central London for the last 2 years where she was responsible for workforce planning. Those around her describe her leadership style as charismatic, engaging and that she delivers on her promises.

Sara had a clear view on what she wanted to achieve and set a target of being classified as a high performing trust rather than a failing one within 2 years of her appointment. She communicated this mission in a compelling way to the organisation and the Board of directors on her first day. Her determination to accomplish the mission she set out for the hospital was challenged by a lack of endorsement from some senior managers who viewed Sara as unrealistic, and lacking in the experience needed for the health sector. Sara however has never been known to question herself. She believed she could achieve it and would stick to her word. Privately, she admitted that she aimed to be so successful in the role, that she would be nominated for ‘CEO of the year’.

In order to diagnose the problems within the hospital Sara hired external consultants to run focus groups with employees at all hierarchical levels (from the ward cleaners, to the surgeons, to clinical directors) to gain a wider sense of the issues. Following this period of consultation, it became clear to Sara that there were systemic problems which went back many years revolving around a culture of bullying where people did not feel able to speak up about issues or voice concerns, and a reluctance to change as ‘we’ve always done things this way’.

This was compounded by poor systems for communication, where senior leadership were often hidden and unapproachable, believing everything was ok and the wider system was to blame for the hospital’s failings. Staff commented that leaders only wanted to hear positive messages, and avoided or downplayed any concerns raised. Staff also felt that decisions were made which affected their areas of work, without consultation, and which served to satisfy financial pressures in the short term, but impacting on the quality of care they were able to give, or to overload them with increased work demands.

This left the staff feeling alienated, with an overall lack of trust in leadership. The whole organisation was driven by very traditional views of hierarchy. Additionally, concerns were expressed regarding medical leadership in the hospital, which was viewed as a group of senior doctors who behaved ‘with impunity’ and were not held to account in the same way that other staff were. Poor behaviours included allegations of bullying and a lack of awareness of the need to work as a team, rather than making unilateral decisions.

Following a review of the hospitals accounts it was clear to Sara that Alan had not made the difficult decisions when it came to the budget, often leaving this task to others or avoiding it altogether. Alan was seen as a ‘nice’ character, but was not bold enough to make key decisions, and did not have a clear vision for the organisation, being described as having to ‘firefight’ the whole time. Likewise, he had not worked with his Board, and particularly the Medical Director, to address concerns about medical leadership in the hospital. Staff engagement was low, and absenteeism and sickness rates were high.

Following the initial consultation exercise, Sara immediately outlined a 2 year plan, which she said would address what she saw as a poor culture throughout the organisation. Sara came up with a clear vision for the organisation, and communicated this throughout the organisation along with a small number of clear objectives. These were all prominently displayed throughout the hospital on posters, with the values printed on all lanyards. She encouraged the senior leadership team and the Board to become more active in seeking out ways they could help their organisation, primarily through better lines of communication. She emphasised the importance of delivering the positive message she had created, whilst not shying away from difficult issues, but seeking to solve problems with the staff involved and the senior leadership team. She stressed to the senior leaders the importance of listening to staff as well as to each other. She also provided the senior leadership team with leadership training, provided by a consultancy she had previously used and had found personally very helpful.

In conjunction with the Medical Director, she quickly sacked a small number of senior doctors, who she had privately been advised as being ‘ringleaders’ of the poor behaviour. Additionally, she set up a series of cross-functional teams, across both medical and non-medical staff of all levels, in an attempt to get these two professional groups talking. Each team was tasked with identifying key ways in which they could improve quality in a meaningful way in their own areas, whilst also focusing on delivering cost efficiency or reduction measures.

Sara summoned the teams in a meeting, briefed them on their task and emphasized that they only had two weeks to devise their action plans which she would then review with the rest of the top management team. Many of the staff were resistant and complained that this was insufficient time and not in keeping with how things had previously been done but Sara did not budge. Sara had actually already devised her own major change programme, partly based on her feedback from the external consultants and partly as a result of previous change programmes she had run whilst she had worked in the private sector. However, she wanted individuals to take ownership for the problem and give them the opportunity to come up with their own solutions. Sara believed that all staff had the potential to do this and just needed encouragement, something which had not previously been there.

Indeed, at the end of the two weeks, a number of teams devised a number of innovative, cost saving initiatives. One team from community services came up with a highly innovative idea around improving waiting list times for attendances at a memory centre, and this was subsequently implemented. Using a quality improvement framework to make use of the resources available, they were able to reduce waiting times from 6 or 7 months, to 4 or 5 weeks. For example, one change included introducing reminder calls for appointments, which drastically reduced the number of DNAs (did not attend). This was very helpful given that people attending were likely to have memory problems. The team were clear that the approach worked because the whole team was involved, rather than a ‘top down’ quality assurance project. It was described as a ‘grass roots’ project that ‘everyone was able to get behind’. The team were able to work flexibly towards achieving their goal of ‘meeting the needs of their community with the correct care at the right time’. They were also able to coordinate care with local GPs, carers, and the local authority in order to provide ongoing care where necessary. This was done by identifying key individuals in each organisation who were given the authority and autonomy to be able to operate together on a case by case basis. Staff from all organisations were clear that the service users were central to their treatment plans, and reported patient satisfaction was also dramatically improved. Many of these cross functional teams were so successful that they were reported on in national healthcare journals and periodicals.

Sara celebrated these successes throughout the organisation, holding awards ceremonies for the most innovative team, or initiative – personally presenting the awards. After one year, Sara felt confident and thought she had gone a long way to achieving her aim of turning the organisation around. Many staff who had been involved in the cross functional team initiatives were generally reporting that they were happier, and had more faith in senior leadership, and consequently the organisation. She wanted to show off her successes, and consequently hired the same external consultants to perform another review at the hospital, and planned to use the report to showcase what a good job had been done, and to garner more favourable relationships with her superiors in the regulatory agencies.

However, while the consultants’ report was highly supportive of many improvements, particularly around the cross-functional teams, they highlighted that not all had worked as well as others. They wrote that there were still large pockets of disenfranchised teams and individuals, with some reports of tensions between some groups who had to work across boundaries, or cross-functionally. They heard many comments during focus groups, from staff who said they felt that it was unfair that other teams were given resources and autonomy to make improvements in their own areas, whilst they were not supported in their teams, with training or resources. Senior leaders were also positive about many of the changes, but felt that some of the ideas had not been adequately considered, and decisions made were not inclusive enough. They were keen to not downplay the positive successes, and welcomed clear improvements in the experiences of many staff, but had concerns about the extent to which the changes were reaching all areas and teams within the hospital, and supporting services. Similarly, senior leaders also commented that the turnaround plans were ambitious and admirable, but lacked goals in a number of important areas. When the consultants spoke to external stakeholders, including the local authority, they heard that the relationship with the hospital was strained, and that the hospital was not ‘at the table’ or on board with the integrated approach that was required at a local system level. This was particularly importance as the hospital held a lot of influence and power, and without them, providing integrated care was difficult. However, they did acknowledge that there were some real success stories where partnership working had made a significant difference to the care provided, but that this was mainly a result of the efforts of local teams. A frequent concern was that Sara had very good ideas and was enthusiastic and charismatic, but was too ambitious and had ‘taken on too much’. This prevented her from engaging with the wider system in a meaningful way.

Sara was surprised with the findings of the external report, and did not publish it as she had expected to do. Sara decided that she must renew and revise her efforts in order to deliver the changes needed, embarking on a ‘second phase’ of actions.