Mid Staffordshire Hospital: Lessons for Organisations
The scandal of lack of care and poor management at Mid Staffs Hospital over a number of years has raised important questions not just about that hospital and the NHS, but also about how large organisations are managed.
Culture and Culture Change
Culture can have an iron grip on an organisation. One of the key recommendations from the Francis inquiry, which conducted an extensive, in-depth review, has been about changing the culture of the NHS: it states that the NHS must have a more patient-centred culture than it has at the moment. However, sometimes we need to look beyond culture. We have just finished a major three year study of the changing role of middle managers in acute care and that group of middle managers includes not just full time professional managers but also ward managers, ward sisters, modern matrons, senior nurses who have management roles. We asked them what their main motives were, what drove them, and their rewards in those roles.
The five main motives were: making a difference for patients, delivering innovation and change, doing a good job, feeling valued and developing others. This emphatically underlines that a patient-centred culture is already there, deeply embedded.
The American psychologist Philip Zimbardo talks about bad behaviour by explaining that bad behaviour can be understood in terms of bad apples, bad barrels and bad barrel makers. A close reading of the Francis report suggests that we need to be looking at the barrel makers not just at the bad apples and bad barrels.
Where motivation is being stifled, first look at management and leadership style: at Mid Staffs it was highly autocratic and not at all supportive. If we review the positive motives of employees in the health service, those motives have been stifled systematically by a number of factors, the first of those and probably the most important, is that the NHS has a top-down, prescriptive and autocratic leadership style; that comes from the top and has been bolstered and reinforced by politicians and the Department of Health. Such a style is automatically cascaded right down the system.
Structural Change and Cost Cutting
However well-intentioned, constant change can have a dispiriting and confusing effect: constant tinkering with structures and with the details of the system means people have to learn how to work with new structures, new relationships and new people all the time. Added to this, the cost improvement programmes that are imposed on acute care in particular, are extremely burdensome. A figure of only four per cent a year in recurring finance cuts can have substantial effects. To a moderate size hospital with a four hundred million pound budget, four per cent translates to sixty million pounds; and with 60-70 per cent of annual spend taken up with payroll, then healthcare and quality has to suffer if that continues.
Changing the Way Things Are
Leadership Style and Management Style
Change has to start at the top with leadership style and management style and a marked change in some of the kinds of commentary that politicians repeatedly make about the nature of NHS staff and the people who manage the health service. The leadership style has to be more supportive, more listening. It would also be useful and would cost nothing to give the NHS a period of relative stability, breathing space that allows some of the innovation that is required to happen and take root.
Performance Management and Feedback
Some classic mistakes were made at Mid Staffs and one of the key ones is how the organisation manages performance. Managers focussed almost exclusively on financial measures, yet we have known for thirty years within the business community that you must look at measures in the round and that to focus on financials at the expense of everything else is a recipe for things going wrong.
The second and important aspect of performance management concerns feedback. Measurement is not a means to force people in what to do, it is about feedback and systematically at Mid Staffs they forgot about the feedback, especially as the soft measures about perceptions of care were not taken into account by the Board. That was a central issue for Mid Staffs because managers just ignored such feedback and did not take them on board at any point.
Regulation a Major Issue
Lastly, over-regulation-sometimes conflicting- can be a real and pressing factor in influencing organisational performance. For the NHS, serious consideration should be given to taking a knife to the regulation regime, perhaps with just two regulators overall, leaving the rest to local implementation. The regulatory regime would benefit from being simplified and streamlined: perhaps to include a shift away from prescription and inspection, so that the Care Quality Commission operates to what is called a "safety case approach" which puts the responsibility on providers, not on acting as an inspectorate agency.
It would be easy to dismiss as unique the factors contributing to the powerful and deadly brew at Mid Staffs hospital. However, in the light of the extreme and disastrous case of Mid Staffs, leaders of every large organisation would do well to review the effectiveness of their own organisation, drawing up a checklist which covers an honest and probing analysis of how it handles:
- Culture and culture change
- Motivation of employees
- Management style
- Cost cutting
- Performance management
- The effects of regulation
Swift generalisations will not suffice. For example, there is a danger of abandoning the concept of targets and performance measures altogether and that would be a mistake. Performance measures and targets communicate to the organisation what the leadership is trying to achieve, but they must be used in the right way. If you use them to terrorise people, people become intimidated and act accordingly. If you use them to learn and improve they will help to get and keep the organisation on track.
David A. Buchanan is Professor of Organizational Behaviour and Mike Bourne is Professor of Business Performance at Cranfield School of Management.
Acknowledgements: The research described in this article was funded by the National Institute for Health Research Service Delivery and Organization programme (award number SDO/08/1808/238, ‘How do they manage?: a study of the realities of middle and front line management work in healthcare’).
Disclaimer: This article comments on independent research commissioned by the National Institute for Health Research. The views expressed are those of the authors, and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.