Creating a Great Culture – Part 1

I’ve recently finished reading the extraordinary book, “Legacy”, by James Kerr. It is a book about the culture of The All Blacks, the most “successful” sports team in the world. If you are involved in leadership, at any level, especially if you are passionate about developing the culture of your team, I would heartily recommend that you buy yourself a copy – it serves as a great manual! As you might expect in a book which flows out of Rugby Union, there are 15 principles to align with the 15 players in the team. I will therefore make this a 2 part reflection, to make it more readable!

 

I’ve written a few blogs on here about the importance of culture (of joy and kindness) in health and social care, and indeed, the IHI so clearly show that building a “Culture of Joy” in healthcare is one of the core pillars to creating a truly excellent, safe and sustainable health and social care system. If we get the culture right, everything else follows. We spend so much time focused on vision, process and measurement, but nowhere near enough time to establishing a really healthy and flourishing culture. So, how do we do it? How do we build a really good culture? Well….I am no expert, but I want to share what I’ve learnt from this book and am learning through the work we are doing here in Morecambe Bay.

 

1) Character – it is everything. Team is not built on good players, it is built on good character, which is far more important than talent. Good character starts with humility. No one is ever too important to do the most menial of tasks. This has to be modelled.

 

2) Adapt – Darwin said, “it is not the strongest species who survive, but those most able to adapt.” In a target driven system, like health and social care, with edicts handed out from on high, we need to develop the kind of culture that is able to take the strain, to bend, to mold and not lose focus at the whim of every new government initiative. Adaptation means we need a compelling vision for the future and the investment in our teams to move well together, especially at times of pressure.

 

3) Purpose – My coach, Nick Robinson, asked me a great question the other day. I have been really struggling with the idea of ambition. For me, ambition is a word that is tied up in negative ideas like selfishness and arrogance (that isn’t true for everyone – just carries those connotations for me!). So, we explored what a better word might be to help me think about the future. The word we agreed on was purpose. So then he asked me, “So, what is your purpose? Who are you here to serve? And where in the world does that need to be manifest?” At one of the lowest points in their history, after crashing out of the World Cup in the Quater Finals – a match they really should have won, a group of the All Blacks shut themselves in a room to rediscover their purpose. One of the coaches spoke 6 words and it began to change everything. “Better people make better All Blacks.” This is true in every context. Better people make better doctors. Better people make better nurses. Better people make better managers. Better people make better receptionists. Better people make better leaders. We spend an inordinate amount of time developing the skills of our teams, making sure they can ‘deliver the goods’, but we invest precious little time, space or energy in ensuring that we develop better people. Do we help people confront their own ego issues? Do we enable people to get to grips with their shadows, their struggles, their root issues? It really matters who people are, far more than what they can do. Perhaps our development days should focus far more on tools like the enneagram and strengths finder than on some of the “mandatory training” we always make the priority.

 

4) Responsibility – this forms so much of the ‘culture of joy’ I have blogged about before. People need to know they are trusted to do the work they have to do. We have to create a culture of ownership, accountability (not micromanagement) and trust. The All Blacks talk about a collaborative culture in which individual talents can rise and flourish. Are we crushing the creativity of our teams by not allowing people to really come into their own?

 

 

5) Learn – for people to be at the top of their game, they need space and time to develop their skills. In a global landscape, we need to look beyond our own boundaries, discover new approaches, learn best practices and push the boundaries. It’s not OK to just settle for something a bit rubbish – learning allows us to strive for excellence in our work. There is wisdom in this Maori saying: “The first stage of learning is silence. The second is listening.”

 

6)Whanau – Rudyard Kipling wrote: “For the strength of the Pack is in the Wolf, and the strength of the Wolf is in the Pack.” The being of team comes from within. In the All Blacks, there isn’t space for “dickheads”. Team is everything and those who want the glory for themselves will not find a place within it. The All Blacks build on this principle. It is better to be punched in the stomach than stabbed in the back, or as the Arab proverb says: “It is better to have a thousand enemies outside your tent, than one inside.” We need to create a healthy culture of being able to challenge damaging attitudes and behaviour so that when we move, we move as one in adaptable formation, like the spearhead formation of birds as they fly.

 

7) Expectations – There is a saying the All Blacks use: “Aim for the highest cloud, so that if you miss it, you will hit a lofty mountain.” Why aim for something a bit rubbish? If we benchmark ourselves against the best practices, we will strive to be the best we can be. It’s OK to fail – that’s what a learning culture is about. But it’s also ok to not set your standards low and expect failure. Let’s expect the best from our teams so that we create a culture of excellence in the way we work.

 

8) Practice Under Pressure – I think this is especially important in a geography, like ours, in which we may not see some things very commonly. Simulation labs are vital and exposure to other working environments, so that we learn how to deal with serious situations with a calm head. When the heat is turned up, as it so often is in our working environments, we need cool heads and steady hands. Ensuring our training is as robust and pressured as possible, makes us ready for the times our skills are needed most. For this reason, we must not mollycoddle our medical, nursing and therapy students too much. We must expose them and our junior staff and help them be prepared for our times of greatest pressure.

 

In the next blog, I will focus on the other 7 principles of building a team culture. Plenty to think about above though, eh?!

 

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Continuously Learning Health Systems


Learning requires humility. It requires us to accept that we don’t know everything, that we get it wrong sometimes, make mistakes and need to own up to them so that we don’t do the same thing again. Learning is a vital part of all we do in health and social care, if we are to create truly safe, sustainable, compassionate and excellent services. But humility, although vital, is not enough on its own. There are things we need to put in place to ensure our organisations are continually learning, and not only so but that we actually implement our learning and incorporating it into new ways of working so that we change as a result.

The IHI and Allan Frankel have come up with a really helpful and pretty straight forward framework which enables us to do this. It requires 3 basic ingredients:

 

1) Leadership commitment

2) Individual responsibility

3) A shared learning culture for quality and safety

 

Leadership is absolutely vital in setting the right structures and support in place for learning to take place. It requires:

 

-transparency with the public, patients and staff

-vulnerability about weaknesses

-openness about what is being learned and what is changing as a result

-ensuring we are learning with and from our patients not just within our clinically teams. (Some of the most powerful learning we have done in Morecambe Bay has been from women using our maternity services. Our attitudes, communication skills and expertise have all improved dramatically as a result).

-commitment to the psychological safety of staff in developing a culture in which no question is too stupid and no concern is dismissed

-genuine care for each member of staff, creating a culture in which every person can be mentored, coached and encouraged

-time given and protected in which learning can be fostered

 

Personal Responsibility

Who are you?

In my role as a coach/mentor or trainer I have found that we have become far too obsessed with ensuring that people have the right skills but not necessarily paying too much attention to who people are, what their character is like, what their strengths and weaknesses are and how they are developing as a human being. Our medical/nursing and other clinical schools are filled with people eager to learn but who often have no idea about who they are and who, not what they would like to become. Knowing who you are as a person, hugely affects your clinical practice and we do not give it any way near enough attention. I am personally a huge fan of the Enneagram. For me it has been transformational to understand as a type 7, not only what my root need is (to avoid pain) what my root struggle is (gluttony) how I do under stress (become a falsely happy control freak) but also, what my invitation is (towards sober joy and deeper understanding), how to become a more healthy version of me and therefore a better gift to my family, my team and all the people I’m trying to serve. It has helped me to recognise when I’m doing well and when I’m not and to understand how to bring my core strengths to the fore whilst also recognising where I need discipline and boundaries to function from a more healed place. We each have a responsibility not just to be good at stuff, but to be good at being us. And  being us is more than just knowing how we function (e.g. ENFP in Myers-Briggs) but to get below the surface to the core of what makes us tick, that makes us human. Knowing who we truly are enables us to be better, kinder, more humble, genuine, compassionate people, who put aside the need to beat others down and learn to appreciate them so much more. When you really know the team you are working with, they become your friends, you understand the little idiosyncratic things about them with a whole lot more patience and you can also challenge them when they are not behaving in a way that is conducive to good care and you can also receive that challenge back when you are out of line. I wish that we were more interested in caring about who we are rather than only in what we can do. This has got to be a part of the culture of joy I have blogged about previously.

How are you?

Personal responsibility beckons us to be more honest with ourselves and others about how we’re doing emotionally/physically/mentally. It has been a transformational practice in our team to simply check-in with each other and talk about where we’re at. In this way, we can carry each other when needed and treat each other with kindness and compassion. But our individual agency, must also cause us to recognise when we are at a wall/ceiling/limit personally or professionally. We must simply own up when we don’t know something or are out of our depth or need help. We cannot pretend to be able to have a competency that we don’t have. We need to be self-aware and humble enough to accept when we don’t know something or have become unwell and ensure that we take it upon ourselves to find out or get the help we need. This is learning to have an internal, rather than an external locus of control. An external locus, always looks elsewhere for the answer. An internal locus takes responsibility to find out and keep learning. We need to develop a core value, that learning is really really important and we will prioritise ensuring that we keep making time to do so, through whatever form that takes, especially reflective practice. Yes there is some dependency on supportive structures and time being given, but there is also that sense of motivation that comes from within that we take ourselves and our roles seriously. It’s one of the reasons why I’m such a fan of a combination of problem-based learning and a solutions-focussed approach. If we do this ourselves and foster it in our teams, the care we provide will be beyond stellar!

Why are you Here?

We talk about the law of two feet in our team. You are responsible to know why you are here, or if you need to be somewhere else. That might even mean a job change, but more often than not it means having some good boundaries, knowing whether or not you really need to be at a certain meeting or somewhere else, if you should be doing what you are or if you need to ensure other things get the right focus. And what about yourself? Have you taken time to eat well, stay well hydrated, exercise, sleep well, maintain health in your relationships? In teams that care for each other we need to help each other to know why we are there and why we are important.

 

A Shared Learning Culture

 

It’s amazing to me that so many of our learning environments are still so teacher-based. Adult education is so much more empowering than this and it’s high time our clinical learning environments (both preclinical and in every day life) reflect this. They should also be more inclusive and we should be learning with and from our patients far more than we do. Although the above graphic applies to classroom settings, it contains many lessons for us.

 

With leadership and personal agency holding true, a culture then develops in which continuous learning is the norm. Learning environments, fuelled by kenotic power create a space in which an organisation can begin to truly flourish. It creates a net of accountability, teamwork, improvement and measurement, making the entire system more reliable. It is vital that we create this as one of the core principles upon which we build our future health and social care systems.

 

 

 

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