Day 65: Wicked Problems

Safeguarding children workshop this afternoon, where I was introduced to Wicked Problems .  These are hard to define problems with no obvious solution and impossible to identify when they’re solved.  Complex problems aren’t new to me, but this concept was.

We are developing a Learning and Improvement Framework for Safeguarding Children .  We will never eliminate safeguarding issues, as we can't guarantee children will never suffer harm in the future.

Solutions are rarely simple and simple ones often impossible to implement.  To resolve this wicked problem we need an open, learning culture and to recognise that we will have to continuously improve.

Day 64: On Call

Today was the end of my first week as CCG Senior Manager On Call: the first port of call for organisations needing to contact the CCG out of hours.  It’s been an interesting experience and first of many periods of on call I will do in this role.

In my first week on call I dealt with three issues: two to do with capacity, i.e. not enough beds for patients; and one to do with a specific patient need.

I think I did OK, but will sleep better tonight now I’ve handed it over to a colleague for this week.

Day 63: Chief Nursing Officer Summit – Part 2

Today was the second day of the annual Chief Nursing Office Summit (see   yesterday’s Blog about Day 1).

Again there’s too much from today to mention in this blog.  See my Twitter timeline and any other #CNOSummit tweets for a flavour of what today was about.  I will break my 100 word rule again today, but normal service will be resumed tomorrow.

I joined the @WeNurses Team for a workshop in the morning to help directors of nursing better understand social media.  We talked about our fears and how we can overcome some barriers to using it more productively.  More information on the workshop is available online.
Right at the end of the day we heard a brief talk from Professor Veronica Hope Hailey of the University of Bath about ‘trust’.  She described the key five features of high trust organisations found through her research.  We should aim to work with patients and staff to achieve this for our organisations in the NHS:

Create a Trust Fund – not a financial fund, but pre-crisis, manage trust as a precious commodity upon which you can draw in times of difficulty.

Leadership as Service – senior leaders should see their roles as serving employees as well as shareholders (for NHS read patients/public/carers) throughout change process

Kill Spin – only have honest communications.  If things are bad for staff or patients, tell them; with compassion, but tell them.

Re-engage the Middle and Local Levels During Change – the local manager is the key trust relationship with the front-line, so engage them in planning and designing change.

Reposition the Employment Relationship – manage employee expectations – treat change as evolution, be open, transparent and make information available to them.

Day 62: Chief Nursing Officer Summit - Part 1

Today was the first day of the annual Chief Nursing Office Summit.  It’s invitation-only for all Directors of Nursing from across the NHS in England.  It’s publicly streamed live online to be accessible to a wider audience.  There was also a lively conversation on Twitter through the hashtag: #CNOSummit.

There’s far too much from today to mention in this blog, but I will break my 100 words rule to share an element of the inspirational talk by @ElaineInglesby about how we improve patient safety through culture change.

There’s been much talk previously about how the culture in the NHS needs to change; today Elaine spoke passionately about some of the practical ways we can make this happen.  She shared a leadership example from the USS NIMITZ, an American Navy Aircraft Carrier.  This isn’t the most obvious comparison to draw for the NHS and certainly differs to commonly used examples from the airline industry.

On the NIMITZ they apply simple principles to bring clarity of role and effective leadership.  This ensures the safety of 5,500+ crew and the aircraft that can take off and land at a rate of every 25 seconds.  Read the principles below, as I think they speak for themselves and the NHS can learn from this. You don’t have to look to hard to see our Culture of Compassionate Care #6C here:

“We are NIMITZ professionals and we apply the following principles all the time, in everything we do.

INTEGRITY:  We expect honesty from all our Sailors.  We expect our Sailors to take responsibility for their actions and to never avoid accountability.  We expect our Sailors to take ownership of their tasks, their spaces and their ship.

FORMALITY:  To accomplish the mission, Sailors aboard USS NIMITZ work as a team.  But they also perform their individual tasks in a manner that contributes to team success.  To do that, each Sailor communicates well by giving precise orders, providing verbatim repeat-backs, listening to repeat-backs and adhering to established NIMITZ standards.

PROCEDURAL COMPLIANCE:  This principle takes formality a step further.  Aboard NIMITZ, established procedures have evolved over many years from the lessons learned following mistakes made by others.  We don’t want our Sailors to re-learn old lessons the hard way, so we insist on using the right procedures for each evolution.  We train our Sailors on what the procedures and we also train them to understand the ‘why’s’ behind its use.”

LEVEL OF KNOWLEDGE: We know that a sound level of knowledge leads to intelligent on-the-spot decisions.  We train our Sailors to understand the how and the why of their contributions to the ship’s mission.  We believe that if we’re not learning and teaching more each day about our job and our ship, then we’re not doing our job right.

QUESTIONING ATTITUDE: A questioning attitude is both a critical thinking skill and an exercise in vigilance.  It is a personal trait that it  learned, yet requires practice to remain sharp.  Aboard NIMITZ, each Sailor is encouraged to have a questioning attitude.  Many of the best ideas on how to improve processes and procedures have come from our junior Sailors.  A Sailor with a questioning attitude is learning more about the ‘why’ and that can help improve their level of knowledge.

FORCEFUL BACKUP: NIMITZ Sailors watch each other’s backs to ensure an evolution is being conducted safe and proper.  The ‘forceful’ part of this principle is tied to integrity.  Being ‘forceful’ when backing up shipmates means our Sailors have the courage to point him or her back on the right path if they’ve started to stray from it.

Day 61: Review of Performance

The CCG’s performance for the second quarter of this financial year (April – March) was reviewed by the NHS England Hertfordshire & South Midlands Area Team today.  I mentioned preparatory work in Day 56’s blog.  The review involved looking back at how we’ve done and also future plans.

The review went well with constructive challenge around our financial plans.  We agreed that we need more people working within the CCG to help us deal with some of this.  Also some healthy debate around how we can make even more improvement this year, as well as our planning for future years’ improvement.

Day 60: Impact MH

Earlier this month we launched a reprocurement of our mental health services.  This means we are using a competitive process to find an organisation, or group of organisations, to provide more personalised services for the people of Luton.

During the time we are doing this it is really important that individuals don’t experience any deterioration in quality or lack of confidence in current services.

I spent some time today with Impact MH, who undertake quality reviews of our mental health services, talking about how we can improve ways to identify early warnings of any quality issues caused by the reprocurement.

Day 59: Mental Health Quality Review

Today was the planned 2013/14 Quarter 2 (Jul-Sep 2013) Quality Review for our Mental Health provider.  This is a process by which we review the performance of mental health services against the quality requirements within the contract.

The review was chaired by the Director of Quality & Nursing for our neighbouring CCG, as they hold the contract on our behalf and are ‘lead commissioner’.  Prior to the review the provider had sent a quality report detailing performance against what is required in the contract.  We had an internal pre-meet as commissioners and had requested further information in some areas before today's review.

Day 58: A Proper Director’s Diary

A member of my team said to me “your diary’s looking like a proper director’s now” in reference to how busy it is and how I regularly have to discuss priorities and delegation with my team.

I’ve passed my honeymoon period where I had some space and time to meet new people and get to understand the business of commissioning better.

Still making time to reflect & learn and of course enjoy things.  This week I probably have one hour in my diary not already committed to something.  Flexibility is also important to me, especially to make time for colleagues.

Day 57: The Council Chamber

I’m late posting my blog tonight following an evening meeting of the Luton Health & Social Care Scrutiny Committee in the Council Chamber.  I attended with my Accountable Officer who presented an update on development of our Mental Health Strategy and our current procurement of Mental Health and Community Services.

Earlier today I spent a useful hour with the Director of Nursing of our main hospital provider for a routine one 2 one update on a number of issues including the report from a recent Care Quality Commission inspection.  Great progress being made in implementing actions arising from the inspection.

Day 56: Planning For Q2 Review

My Monday morning started with a planning meeting for a routine review next week of our Quarter 2 (April – September 2013) performance as an organisation and our future plans.  We agreed the areas to include in our review presentation to the NHS England South Midlands & Hertfordshire Area Team, including those they have requested and those that we want to add.

The rest of my working day was spent catching up with team members; Risk & Governance Steering Group and Informatics & Activity Validation Group meetings; and getting back on top of e-mail from Friday and over the weekend.

Day 55: Hospital Quality Review

I spent another day at our main hospital provider today, where I joined the Chief Nurse and Deputy Chief Nurse for their bi-monthly ward-by-ward quality review.

It was an intensive day; Matrons attended in turn with their senior sisters (or charge nurses) for their wards to discuss successes and challenges in providing safe, effective and valued services to patients.

I was impressed to see the improvements being achieved.  Whilst this bi-monthly process is still relatively new, the quality and consistency of information to support this is also improving.

I’m looking forward to being invited back to join a future review.

Day 54: Staff Well-being

Weekly Executive Committee meeting this morning, followed by our monthly staff meeting.  One of the benefits of working in a smaller organisation (64 staff) is that the logistics of having a regular meeting with all staff is less challenging than in bigger organisations.  Inevitably all staff members can't always attend, but it is a good opportunity to get as many as possible together to interact, to share information and discuss issues.

The well-being of our staff is really important and there have been a couple of recent incidents witnessed by staff near to our office building that have caused us to review security arrangements.  We have agreed a ‘closing time’ for the building to reduce the risk of staff leaving too late at night along with other measures.

Next month we will devote time in our staff meeting to working on our vision and values.

Day 53: Dear Digital Diary…

I'm over half way through the 100 day challenge I set myself at the start of September.  One of the main purposes for doing this was to share my experience of working in an NHS ClinicalCommissioning Group (CCG) with my friends, family, colleagues and anyone who is kind enough to read what I write.

I have a reflective personality and am never short of a few words to say; so writing 100 of them a day about my experiences in a new job and a new organisation has not been difficult.  When asked how I manage to write 100 words a day I’ve always said that the hardest part is keeping down to only 100 words!  As today demonstrates though, sometimes I do write a few more.

I realise I am never going to set the world of blogging on fire with this stuff, but it does provide me with an opportunity to reflect on what I am experiencing and learning every day.  So far I’ve had good feedback that I'm providing an insight into the workings of the NHS and CCGs; I’ve also been reminded more than once how much jargon we use in spite of me making efforts not to (must use plainEnglish!!!).

My Day

Today was spent mainly in preparation for our next Patient Safety & Quality Committee Meeting, which is next Wednesday.  Today was the deadline to get all papers prepared and sent out to committee members.  This is only the second meeting of the committee and the first since we decided to formally separate from a previous joint arrangement with a neighbouring CCG.  The main challenge, as anyone who has tried to co-ordinate reports from many different sources across a number of organisations knows, is co-ordinating common format and structure to a tight deadline.  This was achieved in the main, but we’ve still got work to do in the future to get more consistency in how we present reports.  We need to be brief, but clear and include enough information to help the committee perform its role properly.

Digital Health

Before coming into this role I had worked for over seven years at NHS Direct, who were and still are at the forefront of digital health.  Whilst there I was fortunate to be part of innovative work to use digital technologies to improve patient’s potential and capacity for self-management; including telehealth, web-sites, mobile Apps and social media.  These digital technologies were used to engage with people about services and to support them to make better decisions about their health and care.

Whilst working at NHS Direct I developed an interest in digital engagement and in particular the power of social media to open up the NHS to patients, the public and colleagues for learning and improvement.

Through this interest, I have been lucky to be part of a particular many digital communities; the one I enjoy being part of the most is: WeNurses.  In spite of the name, this community includes far more than nurses and has expanded to develop communities for pharmacists, midwives and paramedics and also worked closely with other nursing communities for learning disabilities and mental health.

The digital community I first really engaged with was #NHSSM.  This is for those with an interest in how the NHS can better use social media for patient benefit.  As I write this blog there is a live chat about how organisations can learn from and use information from patients live tweeting their care?  One of the most powerful things about these live chats is that they are in public and patients, public, health professionals, managers alike all join in and there is no hierarchy, but lots for all to share and learn.

  

My experiences of working in digital health and my interest in social media has led me to write this blog and has also provided me with so much learning and experience from others that there is no way I could have otherwise got.

There is much more the NHS needs to do to unlock the potential of digital tools and to add them to the public’s toolkit to help self-manage their health as far as they can.  Once self-care is no longer an option, digital tools still have a role to play in giving patients, public and staff a voice and a way to engage with professionals and organisations.

Erik Qualman says: “Don’t do social media campaigns; let social media be the glue that helps connect everything”

Day 52: Peter John Foord 1926 - 2013

No work today, as I attended the funeral of my Grandpa, Peter John Foord, and celebrated his life with family and friends.

Feel no guilt in laughter, he'd know how much you care.

Feel no sorrow in a smile that he is not here to share.

You cannot grieve forever; he would not want you to.

He'd hope that you could carry on the way you always do.

So, talk about the good times and the way you showed you cared,

The days you spent together, all the happiness you shared.

Let memories surround you, a word someone may say

Will suddenly recapture a time, an hour, a day,

That brings him back as clearly as though he were still here,

And fills you with the feeling that he is always near.

For if you keep those moments, you will never be apart

And he will live forever locked safely within your heart.

Day 51: O.D.

My first OD (Organisational Development) Steering Group today.  OD is important for us to plan, monitor and shape how the organisation grows, learns and develops and to ensure good succession planning to develop talent for the future.  We discussed our OD plan, which includes our training & development and succession plans.

We looked at the demographics of our staff, what further detail we want to know and how we incorporate this into our Public Sector Equality Duty declaration in the new year.  We reviewed the results of our Board effectiveness survey and how we can develop future GP leaders in Luton.

Later I met with exec colleagues to discuss how we'll develop our five year strategy and more detailed two-year operating plan (2014 - 2016).

I then spent time this afternoon working on our Risk Register and Board Assurance Framework, ensuring that we're effectively managing the high-level strategic risks as well as the more operational ones.

Day 50: Half-time Team Talk

If you haven't read my blog from Day 1 here's a brief introduction (if you've been reading from the start, skip to the next paragraph, or carry on reading for a reminder):  On 1 September 2013 I left NHS Direct after seven and a half enjoyable years to take up a new post as Director of Quality & Clinical Governance with NHS Luton Clinical Commissioning Group (CCG).  With some encouragement from friends on Twitter, I set myself the challenge to write a blog of 100 words per day for the first 100 days of my experience of working in this new role.

I have given myself permission to write more than 100 words today as this is the day 50 milestone of my 100 day blog.  A bit like giving myself a half-time team talk!

In the last 50 working days I have probably learned more than I have in any other 50 day period of my adult life.  I learned an enormous amount at NHS Direct;  I also learned much in the year I was an independent Nurse Board Member with NHS Milton Keynes CCG; however, moving both into the world of commissioning and into my first full-time director role has been a steep learning curve and a great challenge (this is a challenge that I am up to meeting and thoroughly enjoying).

Moving from a provider to a commissioning organisation requires a change of mind-set.  You find yourself changing from being more closely in control of systems and processes for ensuring the safety and quality of services to working with providers through relationships and processes to gain assurance of this.  Many of the same skills required, but a different perspective.

One of the biggest challenges I have found in this role has not been getting to know the technical side of commissioning and what CCGs do, which I had a year's introduction to with Milton Keynes CCG; but getting to know Luton, including the local population's needs, the people who work in the health and social care system and the history of what has gone before in terms of services and people.

Before I officially taking up the role on 1 September I started to get to know key people and it is confirmed every day that the most important thing about being a director and in particular working in commissioning is interpersonal relationships.  I realise this sounds a bit clichéd and applies in many roles and businesses, but working in commissioning we don't have direct 'control' of the services our patients use.  We don't make decisions about individual patients' care on a daily basis.  The power of our role as commissioners is in bringing people together to develop, communicate and deliver a shared purpose to achieve better services for our patients and public.

This can be achieved to a limited extent by individual organisations on their own, but the real impact of CCGs will be integration between organisational boundaries, overseeing the 'system' and achieving outcomes in a genuinely person-centred way. I reflected in a previous blog post that I feel CCGs are a bit like yeast in dough; you can make bread without it, but it needs to be added at the start along with other elements to 'activate' the process of dough rising (I was helpfully reminded in feedback on this blog post that in order for dough to prove properly, it needs to be left alone and not interfered with - another helpful metaphor!).

With people and how I relate to them being so important, and at this half-way stage in my first 100 days, I have been reflecting on the key relationships I need to continue to work on in the next 50 days and beyond. In summary, these are: my own direct team, the Exec team, wider Board and other CCG colleagues; Directors of Nursing and other senior leaders in our main providers; key partners in the local authority with whom we are seeking to more closely integrate through our Better Together programme; fellow CCG Quality & Nursing Directors, senior nursing and quality leaders in NHS England, particularly within the Area Team; and probably most importantly with my wife, Sam, without whose support and direction I never would have achieved what I have in my career so far (she is very patient and tolerant of the time I devote to my professional life, but I will never take this for granted or neglect her).

I am looking forward to the next 50 days and beyond.

Thank you for taking the time to read this; feedback is welcome including ideas for what I should do with my blog after day 100!

PS the 'Word Cloud' is made up from the text of the first 50 days of this blog.

Day 49: Exec to Exec to Exec

Two Exec Meetings today:

This morning we held our weekly internal Executive Committee Meeting where we reviewed: the recently published Care Quality Commission Inspection Reports for two of our main providers; our current financial position; improving the management of Board committees; how we engage with member GP practices; collaborative research opportunities with Luton Borough Council’s Public Health Department and University of Bedfordshire’s Institute for Health Research; and other significant current issues.

This afternoon I joined a bi-monthly ‘Exec to Exec’ meeting with our community services provider.  This is an opportunity for directors and senior managers from both CCG and provider to update each other and discuss significant strategic issues.  We covered a number of areas including: an update on current services; current recruitment to community nursing staff roles; future service integration; and our re-procurement of the service, which has just formally been launched.

Day 48: Quality Schedule Review

A key part of the commissioning cycle is the monitoring and management of quality and performance of providers.  One of the ways this is done through our contracts with providers is the ‘Quality Schedule’.  This is where we specify the key measures for the quality of services they provide to our patients.

We continually monitor how our providers are meeting the standards we set through contracts and formally review this with providers at quarterly intervals throughout the year.  Today we held our internal panel meeting to review Quarter 2 (July – September 2013) for our main hospital provider.

They provided a wealth of evidence of compliance with this element of our contract with them and we’ll meet with senior clinicians and managers from the provider later this month to discuss their successes and areas for further development.

Day 47: ‘Going Forward’

Firstly, this is my public commitment to say ‘going forward’ less, when I simply mean ‘in the future’!

Significant step taken today in the transition of the Quality Team into the CCG: We held our last joint Patient Safety & Quality Committee meeting with the CCG who previously hosted the shared Quality Team .

Time was mainly spent agreeing some finer transition details, of which we are in the latter stages, to help achieve our aspirations for quality.

Next steps include: assurance to our Governing Body (Board) of progress made; further work on our risk register to ensure it properly reflects our more significant risks to quality; and refinement of processes, such as annually agreeing CQUINs (see Day 38!).

Day 46: Making the Dough Rise

I had two significant conversations today about the role of CCGs as health system leaders:

The first was with the Chief Nurse from a provider who had raised a difficulty about staff serving patients who could be managed better in other services.  They can’t resolve this alone, as the issue needs leadership across a number of organisations to best serve patients.

The second with another CCG Director of Quality about similar issues.  We agreed that we need to bring together local providers' nursing directors to identify areas of greatest patient benefit to improve access to services, where these services are delivered and how to achieve the best possible outcomes with them.

Maybe I’ve been watching too much Paul Hollywood (of Great British Bake-off fame) but this made me think of CCG Directors of Quality acting as the yeast within a local health system; whereby providers can do a lot alone, without commissioners, but with them the dough can rise and activate the component parts to work together to make the most out of the ingredients.

Day 45: Catch Up

A bit of a catch-up day today: catching up with people, catching up with e-mail and catching up with some reports that I haven’t had time for earlier this week.

I had a very constructive initial meeting with the Director of Quality of one of our providers.  I’m still getting round to meeting with many people who are new to me.  We got on well and agreed a plan to meet regularly in the future.

This relationship is particularly important, as we’re about to go out to the market to re-procure these services.  During this process, this relationship will be important as we both look to ensure safety and effectiveness of services for patients through a period of potential change.