Presentation on theme: "Professor Brendan McCormack"— Presentation transcript:
1 Professor Brendan McCormack Preventing ‘Francis II’ – using practice development for culture changeProfessor Brendan McCormackDirector, Institute of Nursing & Health Research and Head of the Person-centred Practice Research Centre, University of Ulster.Professor II, Buskerud University College, Drammen, Norway;Adjunct Professor of Nursing, University of Technology, Sydney;Visiting Professor, School of Medicine & Dentistry, University of Aberdeen.
5 The ‘Big Agendas’ Safety Quality – of the patient/family experience Staff competence and wellbeingPerson-centred outcomes
6 Lack of a systems-wide commitment to person-centredness “… I don't think the <service name> nurses I encountered were uncaring. They were ill prepared for the tasks they faced, sometimes insensitive, unsupported by the structures and ethos of the service and very overwhelmed, but I wouldn't say they didn't care or that they didn't, for the most part, work hard. They reminded me of the adage 'the road to hell is paved with good intentions' and even if they had known more … or at leasthave been aware of what they didn't know, they still couldn't have functioned adequately within the structures and systems”[‘Prof Faith Gibson, 16th October 2011].
8 What went Wrong in Mid-Staffs Lack of basic care across a number of wards and departments at the TrustCulture at the Trust was not conducive to providing good care for patients or providing a supportive working environment for staffAn atmosphere of fear of adverse repercussionsHigh priority was placed on the achievement of targetsMedical staff dissociated themselves from managementLow morale amongst staffLack of openness and an acceptance of poor standards;Thinking dominated by financial pressures and achieving FT status, to the detriment of quality of careManagement failure to remedy the deficiencies in staff and governance that had existed for a long timeLack of urgency in the Board’s approach to some problems, such as those in governance;Stats and reports were preferred to patient experience data, with a focus on systems, not outcomesLack of internal and external transparency regarding the problems that existed at the Trust.
9 Warning Signs Loss of star rating – In 2004 Poor peer reviews Health Care Commission review of children’s servicesAudit reports – poor risk managementSurveys – staff and patientsWhistleblowingProfessional body reportsTrust’s financial recovery planApplication for Foundation Trust status – focus on targets and finance only
10 The Trust’s Culture“The Trust’s culture was one of self promotion rather than critical analysis and openness. This can be seen from the way the Trust approached its FT application, its approach to high Hospital Standardised Mortality Ratios (HSMRs) and its inaccurate self declaration of its own performance. It took false assurance from good news, and yet tolerated or sought to explain away bad news”.
11 Key Characteristics of the Trust’s Negative Culture lack of openness to criticism;lack of consideration for patients;defensivenesslooking inwards not outwards;secrecy;misplaced assumptions about the judgements and actions of others;acceptance of poor standards;A failure to put the patient first in everything that is done.
12 “It cannot be suggested that all these characteristics are present everywhere in the system all of the time, far from it, but their existence anywhere means that there is an insufficiently shared positive culture”.“To change that, there needs to be a relentless focus on the patient’s interests and the obligation to keep patients safe and protected from substandard care. This means that the patient must be first in everything that is done: there must be no tolerance of substandard care; frontline staff must be empowered with responsibility and freedom to act in this way under strong and stable leadership in stable organisations”.
13 290 Recommendations! Changing the Culture Patient Voice Developing compassionate and enabling Leadership
14 “To achieve <a change in culture> does not require radical reorganisation but re-emphasis of what is truly important:Emphasis on and commitment to common values throughout the system by all within it;Readily accessible fundamental standards and means of compliance;No tolerance of non compliance and the rigorous policing of fundamental standards;Openess, transparency and candour in all the system’s business;Strong leadership in nursing and other professional values;Strong support for leadership roles;A level playing field for accountability;Information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation.”
16 Person-centeredness“Person-centeredness is an approach to practice established through the formation and fostering of healthful relationships between all care providers, service users and others significant to them in their lives. It is underpinned by values of respect for persons, individual right to self determination, mutual respect and understanding.It is enabled by cultures of empowerment that foster continuous approaches to practice development”.
17 Principles of person-centredness Treating all persons as individualsRespecting rights as a personBuilding mutual trust and understandingDeveloping healthful relationshipsIn practice, the concept of person is played out through a set of principles that support the delivery of person-centred care.It is an approach that:treats people as individuals with their own life historyrespects their rights as a personis built on mutual trust and understandingand fosters the development of therapeutic relationships.These ideas are not new to nursing and indeed if we were to look back over several decades in the nursing literature we would see these principles embedded in many models and theories, and indeed I could argue further, are reflected in the knowledge base of other health care professionals.
18 The Four Elements of Flourishing ChallengeConnectivityAutonomyUsing your valued competencies(Gaffney, 2011)
19 Person-centred Moments Care & CompassionSympathetic presenceEngaged with her as a personTried to involve her in shared decision makingBut was it person-centred care?
20 Person-centred Practice Framework (McCormack & McCance 2010)I would like to introduce the Person-centred Nursing Framework, which has been developed by myself and Brendan over a number of yearsThis Framework is offered as a tool to facilitate nurses to explore person-centredness and has been used by nursing teams to provide a lens that enables them to recognise the principles of person-centred care in practice.
21 Prerequisites Professionally competent Developed interpersonal skills Commitment to the jobClarity of beliefs & valuesKnowing ‘self’
22 Care environment Appropriate skill mix Shared decision making systems Effective staff relationshipsSupportive organisational systemsPower sharingPotential for innovation & risk takingThe physical environment
23 Person-centred processes Working with patient’s/families beliefs and valuesEngagementHaving sympathetic presenceSharing decision makingProviding Holistic Care
24 Outcomes Satisfaction with Care (experience of good care) Involvement with CareFeeling of Well-BeingCreating a Healthful Culture
25 Workplace Culture The way things are done around here ResultsActionsPatternsAssumptionsValues and BeliefsThe way things are done around hereSignificance of beliefs, values and assumptionsActors in the field create and re-create culturePatterns reveal the underpinning cultureWe are each shaped by the cultureExternal factors
26 Characteristic of a Person-centred Culture Shared values – respect for all personsSituational leadershipCollaborative care processesCommitment to shared and participative learningShared governance/non-hierarchicalProcess and outcome orientedInnovation to enable human flourishing
27 So how do we make it real? Person-centered care Evidence-informed care Collaboration & integrationBreaking habitsExperiences of good careRights and responsibilitiesSo how do we make it real?
28 Five Principles for a Service to ‘say’ it is Person-centred We adopt a caring approach to how we meet needs.We nurture effective relationshipsWe promote social belongingWe create meaningful spaces and placesWe promote human flourishing
29 Practice development is a continuous process of developing person-centred cultures. It is enabled by facilitators who authentically engage with individuals and teams to blend personal qualities and creative imagination with practice skills and practice wisdom. The learning that occurs brings about transformations of individual and team practices. This is sustained by embedding both processes and outcomes in corporate strategy. (McCormack, Manley & Wilson, 2009)
30 Shared Values and Vision Developing shared valuesDeveloping a shared visionRole ClarificationCreative engagementAssessment of Practice ContextLeadership DevelopmentDeveloping engagement of stakeholdersShared Values and Visiontransforming individuals and contexts of carePerson-centredCultureFacilitatedActiveLearningAuthenticEngagementFacilitationAction PlanningRole modelingCritical CompanionshipReflectionAction LearningWorkshopsWBL(adapted from McCormack & Garbett, 2004)
31 Person-centred Outcomes Experience of good careInvolvement with care.Feeling of well-being.Existence a therapeutic culture.
32 What can we do to ensure service users are more satisfied with care? Acute Surgical Unit Nurse Manager: Review of complaints‘inconsistent care decisions’Local evaluationObservations of practice (e.g. case reviews; rounds; handovers; patient/family consults)Review of care plans: the patient’s voicePractice development project focusing on ‘consistency of multidisciplinary decision-makingChanges made:Care planning reflectionsTemplate for ‘patient voice’ in care plansChanges to ‘rounds’Follow-up evaluation:Stories; observations; care plan review
33 What can we do to ensure that team members feel involved in care? Community Care Team Manager:complaints of care assistants not doing what they are asked to do.Lack of RN authorityPatient/family complaints of ‘attitudes’ of staffMeeting with Care Assistants:Claims, concerns & IssuesKey finding:lack of involvement in decision-makingCorroboration:Observations of practice; 1: 1 discussionsAction Plan:team building work: involvement of care assistants in handovers; consistent assignment with service users; participation in care planning and role clarification activities.Leadership development
34 What can the organisation do to ensure patient and staff wellbeing? Outpatient Dept. doing ‘Releasing time to Care’Used Service Improvement Processes and Emancipatory PD ProcessesStaff feeling like ‘pawns’ in a management game (e.g. despite improvements no replacement of staff)Significant changes to waiting times but patients still spent a lot of time ‘hanging around’‘Communicative spaces’: where staff spent time together regularly expressing emotions and feelings about their work and how this impacted on their sense of well-beingSchwartz Rounds and narratives
35 Mental Health inpatient unit What can a leader do to determine the extent to which a therapeutic culture exists in a care setting?Mental Health inpatient unit‘18-month cycles’ evaluating ‘essentials of care’Action plans drawing on practice development and service improvement methods.Mapped to the Person-centred Practice Framework (McCormack & McCance 2010)Reported to Trust Board – outcomes against strategy and resource requirementsInforming education commissioningModel of good practice
36 “The constant tussle between conflicting priorities … and the desire to live out person-centred values in practice was evident from the data … while acknowledging that everyday practice is challenging, often stressful, sometimes chaotic and largely unpredictable, it is important to ask how we can ensure person-centredness becomes an everyday cultural norm.” (McCance et al 2013)