How engagement and communications can

be used to both accelerate improvement

within the NHS and increase its

sustainability

Andrew Kliman

NHS Improvement

14.03.16

‘If the sector is going to respond to all of the challenges

that face it, then all of the staff need to be involved in

developing new and improved ways of doing things

and in implementing change.’ Michael West, (Dromey, 2014) and member of

NHS Improvement’s, Faculty of Improvement

There is a problem across the NHS that staff do not

feel empowered to make improvements

• The NHS Staff Survey (2015) found that only 30% believe feedback will

be acted on, only 32% believe senior managers try to involve staff in

important decisions, and only 38% think communication between

managers and staff is effective (three important subsets of engagement

focusing on the belief staff have that they can make improvements)

• 84% of services rated inadequate overall by CQC were also rated as

inadequate for leadership. Potentially very many staff do not feel engaged

• The CIPD Employee Outlook survey (2015) of engagement across the UK

showed that between 35% and 39% of employees indicated positive

engagement.

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Data shows that urgent and emergency care

systems with poorer staff empowerment have

poorer performance

• A breakdown of the NHS

Staff survey by Emergency

Care Improvement

Programme (ECIP)

systems (worst performers

against the 95%

emergency care standard

Q4 2015 and Q1 2016),

High Risk systems (next

worst performing group),

and all others shows a

clear difference

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• The 95% standard is used

as a proxy for effective

processes across an

emergency care system

This correlation holds firm across different staff

empowerment identifiers

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Data also shows that improvement is difficult to

sustain when introduced from outside an organisation

• Those staff that do make change, for example when ECIP show them

how to do it, don’t maintain it for long and behaviours revert to the norm,

e.g. – Colchester SAFER 3-4-3 ECIP sponsored campaign (Oct 2015) reduced medically fit

patients by 50% and hit the 95% standard. Since the end of the three week campaign

performance has slipped back to pre event levels

– 2015 NHS Staff Survey, Colchester Hospital University NHS FT – ‘Senior managers act

on staff feedback’, 23% agree and 8% strongly agree (31%)

• The ECIP Safer Start Campaign, targeted at improving performance in

ECIP systems in the first week of January, demonstrates the same

pattern.

• ECIP survey of communications and engagement leads (2016) found

only 17% of respondents included information about Safer Start in their

internal bulletins

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ECIP Safer Start Campaign results – difficult to

maintain improvement when externally introduced

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ECIP systems’

performance against

95% waiting time

standard to date

Safer Start effect

Disempowered staff have a negative effect on

patient safety and outcomes

• There is a strong body of evidence that demonstrates the more

engaged staff members are, the better the outcomes for patients

and the organisation generally

• Prins et al (2010) gathered data from a sample of 2,115 Dutch

resident physicians, and found that doctors who were more engaged

were significantly less likely to make mistakes

• A study of 8,597 hospital nurses by Laschinger and Leiter (2006)

found that higher work engagement was linked to safer patient

outcomes

• Leaders who don’t listen to staff or don’t demonstrate they are

listening to staff undermine the NHS Constitution.

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The NHS Constitution pledges that ‘all staff will be empowered to put

forward ways to deliver better and safer services for patients and

their families.’

There is evidence to show that empowering staff as

part of a wider engagement package has significant

organisational benefits• (West & Dawson, 2012):

– In trusts where a large percentage of staff felt they could contribute towards

improvements at work, infection rates had decreased, reinforcing the value

of staff involvement in service improvements and of creating cultures of

engagement and innovation

– Higher rates of engagement have a direct relationship with lower mortality

rates

– high levels of engagement were associated with much lower absenteeism

than low or moderate levels of engagement.

– Staff engagement is also strongly linked to turnover, with turnover rates

approximately 0.6 per cent lower in trusts that have a one standard

deviation higher engagement score, all else being equal

– Finally, patient satisfaction is significantly higher in trusts with higher levels

of employee engagement

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Engaging with patients can also drive improvement

• A complaint from a patient called Gerry prompted South Warwickshire NHS Foundation Trust

to invite him to come in and talk to them about his experience. Gerry spent eight days with

them in total. Whilst his experience of the clinicians was excellent, there was no co-ordinated

approach to his care and communication between specialities was poor.

• The Trust process mapped Gerry’s journey through the hospital and discovered that, during

his entire eight-day stay, there were only 34 hours’ of value-added time. The rest of the time

was spent waiting... for decisions, for tests, for results, for To Take Out Medications (TTOs) to

be written up.

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ECIP case study: South

Warwickshire NHS

Foundation Trust –

consistently amongst

highest performers

against 95% standard

www.ecip.nhs.uk

2015 NHS Staff Survey,

South Warwickshire

NHS FT– ‘Senior

managers act on staff

feedback’, 24% agree

and 10% strongly agree

(34%)

Barriers to empowering staff can come from the

top down

• An example from outside of health demonstrates that perceived and

actual regulatory and political pressures and a top-down approach to

improvement have a negative effect on staff empowerment and

therefore patient experience and outcomes

• Local leaders who are trying to please the centre (perceived or

otherwise) develop a false understanding of risk within their

organisation.

– Analysis by the NAO in 2013 found the effectiveness of Monitor’s

interventions to be inconclusive (NAO 2014)

• Maintaining this false understanding means leaders not listening to

staff who might tell them otherwise, with negative affects on patient

experience and safety.

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Planning and targets … got a bad name from Stalin’s five-year plans

because in that infamous case the targets were unashamedly top-

down and those involved in implementation manipulated the data to

fit the plan and distorted the truth to (appear to) succeed.” Michael

Barber (2015)

“…it’s a question of whether, when you

do tell somebody about some problem,

they’re delighted to hear about it and they

say “Tell me more” and “Have you tried

such-and-such?” or they say “Well, see

what you can do about it”— which is a

completely different atmosphere. If you

try once or twice to communicate and get

pushed back, pretty soon you decide, “To

hell with it.” Richard Feynman (1988)

In Jan 1986 The Challenger Space

Shuttle exploded killing its crew.

Richard P Feynman, Nobel prize

winning physicist was asked to be on

the Presidential Commission

investigating the disaster. Feynman

found NASA's organisational culture and

decision-making processes had been

key contributing factors to the accident

Top down working increases isolation from staff

driven improvements – experience from NASA

Feynman’s three key points

1. Perceived and actual pressure from the top causes senior

managers to hugely underestimate risk “to the point of fantasy”.

In order to maintain this viewpoint they must closet themselves

from those on the front line who have a more realistic view of risk

2. If you work in an organisation where the higher-ups don’t want to

listen then you are disempowered and disengaged from making

suggestions for improvements

3. When you work from the top down you create barriers to change

by making it difficult to fix the individual components one by one

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Communications and engagement (C&E) can be used to

accelerate and sustain improvement

• Market improvement tools to staff when introducing improvements

from outside of the organisation in order to increase uptake and

sustainability

• Use campaigns to promote behaviour change through evidence of

improved performance and improved outcomes for patients in

language appropriate to that group (nurses, doctors, managers, etc.)

• Harnessing C&E channels (such as social media and face-to-face

events) to increase outreach, capture staff and patient ideas, enable

better strategic decision making, and demonstrate impact

• Empower staff through effective involvement in decision making, with

visible buy in from senior managers (role models)

Communications and engagement (C&E) can be used to

accelerate and sustain improvement

• Co-create and signpost tools for C&E teams that encourage staff to

take the initiative in improving current circumstances

• Incentivise staff engagement through recognition and awards

• Encouraging greater use of data transparency as a tool for

improvement and honest conversations – supported by the regulators

and Department of Health

• Reviewing the organisational culture and behaviours framework with

staff to embed more effective empowerment processes

Recommendations

1. NHS Improvement should focus on helping organisations to

empower staff in order to accelerate improvements and make them

more sustainable

2. Externally delivered improvement interventions should have

additional marketing support for staff to embrace them

3. NHS Improvement should sponsor an HSJ Award for empowering

staff to deliver improvements

4. NHS Improvement should support organisations in using various

empowerment techniques, such as crowdsourcing, and work with

them to measure the outcomes

5. NHS Improvement should shift focus away from top-down planning

and support organisations in having honest conversations,

increasing transparency, and Chief Executives in visibly leading from

the front to empower staff

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References

• Barber (2015), How to Run A Government: So that Citizens Benefit and Taxpayers Don't Go Crazy.

Penguin Books

• CIPD( 2015), Employee Outlook survey, Factsheet. http://www.cipd.co.uk/hr-resources/factsheets/employee-

engagement.aspx#link_4

• Dromey (2014) Meeting the Challenge – Successful Employee Engagement in the NHS IPA. http://www.ipa-involve.com/resources/publications/meeting-the-

challenge/?Employee%20Engagement%20in%20the%20NHS

• Feynman RP (1988) "What Do You Care What Other People Think?": Further Adventures of a Curious

Character. W.W.Norton

• Laschinger HKS, Leiter MP (2006). ‘The impact of nursing work environments on patient safety

outcomes: the mediating role of burnout/ engagement’. Journal of Nursing Administration, vol 5, pp

259–67.

• National Audit Office (2014). ‘Monitor: Regulating NHS foundation trusts https://www.nao.org.uk/wp-

content/uploads/2015/02/Monitor-regulating-nhs-foundation-trusts.pdf

• Prins JT, Hoekstra-Weebers JE, Gazendam-Donofrio SM, Dillingh GS, Bakker AB, Huisman M, Jacobs

B, van der Heijden FM (2010). ‘Burnout and engagement among resident doctors in the Netherlands: a

national study’. Medical Education, vol 44, pp 236–47.

• West & Dawson, Employee engagement and NHS performance, pub. 2012, The Kings Fund http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership-review2012-

paper.pdf

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