Introduction. Sources

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1 The Essential Leadership Pre- requisites for Innovation and Best Practice: A Paper developed by the Leadership, Culture and Employee Engagement Workstream Introduction The Health and Wellbeing Best Practice and Innovation Board ( the Board ) has been set up by the Minister for Health and Social Services to make recommendations on how the health and social care system in Wales can accelerate innovation and the adoption of existing best practice. Public services in Wales face unprecedented challenges associated with economic pressures, social change and technological advances. Developing creativity at all levels in organisations, building the leadership capacity and capability to operate on a cross sectoral basis, and being ruthless in the adoption of what works best has never been more important. This paper is the first product from the workstream established by the Board to look at the importance of leadership, culture and employee engagement in the delivery of the wider goals identified by the Board. The Board recognises the critical importance of the environment within which leaders operate. While the role of the Board is concerned specifically with public service leaders there are broader issues around the political and regulatory context that need to be taken into account. Within the context of this paper the term innovation is used in its broadest sense, seeking to drive different behaviours and opportunities, rather than being confined to technological innovation and commercial opportunities. Sources There is a great deal already known about the nature of high performing organisations and the management and leadership approaches that underpin their success. An initial literature review has been carried out to help understand the key themes and to create a platform for discussion about the practical steps that can be taken in Wales. In parallel to this work, the authors have also drawn on the work of the NHS Wales 1000 Lives Plus team which have been working on the concept of high reliability in organisations and the leadership characteristics that underpin innovation and best practice. Other sources of information include: the summary evidence of the Employee Engagement Task Force developed by Bruce Rayton at 1

2 the University of Bath; the summary of key sources provided by Tim Heyward; the emerging findings of the Call for Evidence undertaken by the Board during early 2013 workforce strategy intentions; the results of the NHS Wales staff survey 2012, and the requirements set out in Working differently Working together, the Welsh Government workforce and organisational development framework. Finally, the paper has drawn on the findings of the Francis Inquiry into the catastrophic failure of care at the Mid Staffordshire NHS Trust. The sources are set out in the bibliography appended to this paper. Emerging Themes The most obvious conclusion to draw from the evidence reviewed is that the right leadership is critical. Organisations that focus on quality and delivering best practice display consistent characteristics that can be developed and are replicable across different settings. Leaders have a pivotal role to play in: Creating a fertile, dynamic and supportive culture that: (i) makes knowledge easily accessible and promotes its exchange, and this calls for a systems approach to knowledge management and organisational learning; (ii) is person centred, with service modelling based on co-production between citizens accessing services and the professionals delivering those services; (iii) operates across sectoral boundaries, with the confidence to create systems which move away from being permission based. Ensuring clarity of purpose at an organisational and system level and develop an infrastructure that can continually evolve to ensure fitness for its purpose; Describing a clear narrative that describes where the organisation has come from and where it aims to be; Delivering shared values and beliefs that are lived in practice and underpin authentic leadership behaviour; Aligning high level aims with an executable strategy and clear priorities; Acting as role models for learning and innovation; Paying attention to developing the infrastructure and culture that supports learning and innovation; Encouraging experimentation, rewarding success and tolerating failure, generating a culture of risk and return; Taking the time to build a sustainable organisational culture in which innovation flourishes and best practice is the norm so leaders must look beyond short term priorities in building the conditions for long term success; 2

3 Working across sectors to tackle key issues and to adopt a growth mindset that sees the system as something bigger than individual organisations or sectors. More specifically leaders need to: Develop a distributive leadership model with leadership skills at all levels of the organisation and leaders who are comfortable in letting go. This does not undermine the role of Boards and CEOs and the importance of effective governance but does require a shift from command and control to organisational stewardship and collaboration across the system; Commit time and energy to understanding the views of staff. There is compelling evidence that more engaged staff, working in partnership with senior management, deliver hard outcomes, including both service quality improvement and financial benefits; Empower staff to get on and do without the need for permission. Clarity of purpose and priorities helps establish a framework in which staff can operate; Be open to a wider range of influences and, in particular, service quality as driven by the stories and experiences of service users and citizens. Citizens and patients have to be at the centre of concerns, and putting things right; Emphasise measurement for improvement as part of the development of a culture of improvement; Be willing to personally unlearn their experience, and be open to imagination, self inquiry and adaptability, recognizing that new futures require new approaches. Be transparent in everything they do. This is critical and central to the development of trust and authentic behaviour. Transparency requires leaders to explain strategy and priorities in terms service users and citizens understand, to use open data and information about that performance and to make the rationale for key decisions clear. Action/Recommendations The recommendations set out below result from the key findings that have emerged in the evidence review; they represent practical proposals for both the short and longer term. 1. Sharpening the focus on action to support innovation and adoption of best practice within the core accountability frameworks for senior leaders. This would include reviewing competency frameworks, job descriptions and performance criteria, specifically seeking direct evidence of 3

4 engagement with staff and those who access services, and the learning from this that has been used to influence outcomes. The Minister might include this directly within the performance and appraisal arrangements for NHS Chairs, non executive and executive Board members and encourage the development of appropriate arrangements for senior leaders 2. Ensuring that existing and future leaders and managers, at all levels, understand the underlying factors that create cultures within which innovation and improvement are nurtured, and are given the knowledge and skills to apply within their own organisations. Academi Wales should be asked to review all existing programmes delivered at a national level and to confirm that they provide for these components and to ensure all future programmes include the development of these competencies, including ensuring arrangements are in place to learn from others, Academi Wales should also through its networks, specifically that of the Assistant Directors of Organisational Development group, ensure that local organisations delivering leadership programmes also incorporate these competencies. 3. Many leaders and managers are only just beginning to explore the importance of Social Media; the demographic profile of social media users suggests that there is a significant generational gap emerging between the ways in which top leaders and younger staff communicate. Social media offer new opportunities for horizon scanning new developments, for the rapid sharing of innovation and best practice and also increasingly for service delivery. Current ICT policy in Wales remains problematic with many public sector staff restricted from work based access to social media. Access to social media for NHS staff through NWIS should be reviewed urgently with a view to securing such access and the learning from individual local authorities that have adopted a more liberal approach e.g. Monmouthshire and Flintshire. Urgent attention should be paid to offering training in the use of social media for senior executive and non executives across Wales 4. The literature is clear that recognition matters in creating cultures that promote innovation. There are a number of award schemes currently in place, including the First Minister s Awards, Social Services and NHS Awards. There are also excellence awards systems in place for NHS medical staff that formally recognise excellence in service innovation and research, NHS/life sciences related recognition via the MediWales Innovation Awards, and a variety of local schemes run by individuals. The Board s Incentives and Investment Workstream will be reviewing all current schemes to assess their reach and making recommendations to assist public service bodies in broadening the approach to recognition and tailoring existing performance schemes to encourage innovation and curiosity. Leaders have a specific 4

5 responsibility to bring in new ideas from outside; this Stealing with Pride should also be reflected in Award schemes and included in formal performance and appraisal arrangements for top leaders and managers. One specific initiative that can be utilised in this way is the proposal to grant University status to NHS bodies if they meet certain criteria, recognising that three health boards already hold University status. This initiative should reflect the need for organisations to demonstrate what they have up in place to support creativity and innovation. 5. Arrangements are already in place across NHS Wales and social care to promote research and development through NISCHR work. Leaders need to ensure that R&D remains a corporate priority and that everything is done to ensure that Wales develops an international reputation in this field and is successful in capturing research funds into Wales, delivering impact and positive outcomes through turning evidence into practice. This responsibility should be reflected in the accountability framework. 6. Regulators/inspectorates have an important role to play in supporting experimentation and in understanding the role of failure in supporting innovation through risk taking. There is a clear balance to be struck between the rooting out of poor performance and the supporting of knowledge management and learning, through an analysis of innovations that have failed. The current default position for any regulator is to check against a given defined set of criteria and also to seek out and respond to failure. A more rounded process to draw lessons from failure, and one that does not prompt a lock down of innovation or risk taking is fundamental, and this should be recognised in the forthcoming review of regulatory machinery. 7. Leaders should secure local resources to support improvement. A target already exists to train 25% of the NHS workforce in improvement methods, and the Call for Evidence responses from local government identify similar requirements for the social care workforce. This should be strongly supported as a key means of creating the organisational culture and capability to deliver continuous improvement and adoption of best practice, and extended to the social care workforce. The impact of the target to date, and the lessons learned from implementation should be considered as part of the ongoing development of the workforce in improvement skills. Effective involvement of staff and citizens is essential to the creation of a culture of innovation and best practice. Put simply experts do not have all the answers and many of the solutions to problems we face will come from learning about the experience and views of 5

6 staff and service users. The 1000 Lives Plus team will shortly produce a white paper on Listening Organisations and the Board endorses the approach set out in the paper for adoption within and beyond the NHS. 8. Cross organisational effort on innovation and best practice should be strongly encouraged. Many of the wicked issues that hinder progress in delivering desired outcomes for Wales require agencies to work together and to learn from each other. A more systematic approach to cross sector innovation and learning from others, both within and outside of Wales, should be pursued and the Board will be exploring the development of Innovation Hubs more fully. Innovation Hubs would bring together partners from across agencies to participate in exploration, learning and the adoption of new ideas. The Hubs would utilise expertise from existing action on R&D and improvement within agencies rather than seeking to replicate but considerable benefit could flow from better coordination across agencies and the creation of a focus on innovation and improvement as a high level shared goal Conclusion The actions recommended in this paper set out a number of practical steps that can deliver the Minister s goal of creating a culture of innovation within health and social care and accelerating the pace of adoption of best practice. The challenging financial context in which public services in Wales currently operate is recognised, but, more than ever, innovation needs to be hardwired into the fabric of organisations and people. Creativity comes from exploring difference and organisational and personal resilience is supported by diversity. There is a healthy tension to be managed between the requirements for compliance on the one hand and the need to explore new ground and take risks on the other. Innovation often stems from initial failure and the health and social care regulatory model needs to change to reflect this The shift the Board is seeking to support can perhaps best be described as a move from a culture of compliance to a culture of commitment, in which staff can innovate within the strategic frameworks established by collective efforts and beliefs, and challenge those boundaries safely, with the interest of citizens, patients and service users at the centre of those efforts. Senior leaders across the health and social care system should be held collectively accountable for developing and implementing a standardised system for the identification and dissemination of innovation and proven best practice. Reflecting this, the workstream will, during the next phase of work, design a template that describes a knowledge management and learning strategy and the implications for leadership. 6

7 BIBLIOGRAPHY The following papers have been used as sources of information in the development of this Paper. Assuring the Quality of Senior NHS Managers. Department of Health, Assuring the Quality of Senior NHS Managers: the evidence base. Price Waterhouse Coopers, Balancing innovation and risk in social services. The Institute for Research and Innovation in Social Services, Coproduction of health and wellbeing outcomes: the new paradigm for effective health and social care. OPM, Creating the Culture for Innovation: A Guide for Executives. NHS Institute for Innovation and Improvement, Creating the Culture for Improvement: A Practical Guide for Leaders. NHS Institute for Innovation and Improvement, Cross sector working to support large-scale change: an evidence scan. The Health Foundation, Culture change in the public sector. The Institute for Research and Innovation in Social Services, Leadership at all levels Leading public sector organisations in an age of austerity. Deloitte, Engaging boards: The relationship between governance and leadership, and improving the quality and safety of patient care. King s Fund, Employee engagement and NHS performance. King s Fund, Facilitators and barriers to leadership and quality improvement. King s Fund, How good is our leadership? The Institute for Research and Innovation in Social Services, Improving access to research for social services. The Institute for Research and Innovation in Social Services, Investigation into Mid Staffordshire NHS Foundation Trust, Commission for Healthcare Audit and Inspection, Key challenges facing public sector leaders. Ashridge Public Leadership Centre, Leadership and engagement for improvement in the NHS. King s Fund, Leadership for Patient Engagement, King s Fund, Leadership for Whole Systems. King s Fund,

8 Medical Engagement. King s Fund, (2012. The Instrumental Value of Medical Leadership. King s Fund, Leading Networks in Healthcare: Learning about what works the theory and the practice. The Health Foundation, Nailing the Evidence: A Report of the Engage for Success Task Force, NHS Wales Staff Survey 2013, Welsh Government, Quality, Development and Leadership - Lessons to learn from Jönköping 1000 Lives Plus Improving Healthcare White Paper Series No. 4, 2011 Improving Healthcare White Paper Series No. 4 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Chaired by Robert Francis, QC, Volume 1: Analysis of evidence and lessons learned (part 1) Volume 2: Analysis of evidence and lessons learned (part 2) Volume 3: Present and future & Annexes Shared Leadership for Change. The Health Foundation, Step into leadership. The Institute for Research and Innovation in Social Services, Strengthening leadership in the public sector. Cabinet Office, Strengthening Leadership and Accountability for Innovation in the NHS. Innovation, Health and Wealth Implementation Board Seminar, The Gwent Frailty Project: From vision to implementation of Phase One. Unpublished paper, The Health Foundation submission to The King's Fund Commission on Leadership and Management in the NHS. The Leadership Foundation, The Report on The Call for Evidence, Health and Wellbeing Best Practice and Innovation Board, not yet published. Transparency and Scrutiny Vital for the Future of the NHS. Welsh Institute for Health and Social Care, Who s leading? The Institute for Research and Innovation in Social Services, Working differently, Working together a workforce and organisational development framework. Welsh Government,