Cathy Balding Presentation (Strategy & Governance Symposium S2)

To be here today to talk to you about three critical steps for leading quality consumer care and experiences. So why three critical steps? Well, of course there's lots of critical steps, but I thought I would just try today to distill the things that I see perhaps not happening enough. We all want great experiences with our consumers and great care where we're providing care and care based services. But what are the things that really make a difference? And in my three decades of working with this and doing lots of research into it as well, these are the things that I think are just so important, but I don't see enough of, and I'm really talking today about leadership and the things that you can do, the tangible things you can do to lead your organisation to great care and great experiences with consumers. So number one is to define the quality experience you want to achieve for and with consumers. Number two is to equip staff to provide the quality experience. And number three is to support staff to create the quality experience. Now you might be saying, well, this is all very obvious, Cathy, and yes, it may be, but you know, common sense isn't always common practice and sometimes we think we're doing these things, but we're not. So I'm going to give you my top tips and a little bit of the research and hopefully some good guidance within each of these so that you can go away and apply it. So number one, define. So why define the quality experience you want to create? Isn't it sort of obvious? Doesn't everyone sort of know what good care is? Well, turns out, no, it's really important to define it both aspirationally and then in a really concrete way. And this is to take a quality system and a clinical governance system that can be quite operational and turn it into something more aspirational. You still have to have operations, of course, but you want to be going somewhere for all of that work and all of that effort and a lot of people are not. So what do I mean? So when I'm talking about strategic, I'm talking about long term or overall aims, interests and how you achieve them, how you get there, something that's designed or planned to serve a particular purpose. And so if we want our quality and clinical governance systems to be more than just doing the same things and hoping we'll get something good at point of care as a result, we need to turn them into an engine to propel us some somewhere that we really want to go. And another way of thinking about it is that a lot of quality and clinical governance work to Me, looks like you're running on a treadmill. You are getting some benefits. You know, you'll be doing some good things for some people some of the time. But the smart money is on turning your quality and clinical governance system into something more like running outside. You're getting more benefits and you're actually going somewhere. And there's good research that sits around this. It's not just me thinking this. You know, some people who do really very, very high level, very, very good, valid research in this area, such as Mary Dixon woods and Chris Hamm and Don Berwick, they all say that a positive relationship exists between strategic goal setting and organisational performance. And having those organisational and individual goals for quality consumer care are found in higher performing health services and high performing human services. And this was a great systematic review that pulled together a whole lot of evidence from many, many studies. And their conclusion was the evidence was clear that a consumer centered approach delivers results far beyond the bottom line. Better outcomes, improved risk management and happier staff, which we definitely need. We want happy consumers can all be driven by a strategic approach that puts the user at the center of an organization. And you might be thinking, well, the user is at the center of our organization, Kathy. Well, if they are, if they truly are, and it's not just something that everyone says, because I see and hear a lot of that as well, great. You know, perhaps some of these tips will help you to take it even to the next level. But often we think that's what our organisation is doing, but they're not really doing that in reality. And what we're striving for really is consistently good care. Anyone can do care that's kind of great today, not so great tomorrow. That's kind of our default state, really. But to provide something consistently good, you have to decide that's what you're going to do and plant your flag, essentially. And you know, Russ Akoff, who was a contemporary of Deming's and last century, he really understood this very, very deeply. And he'd say, you know, finding deficiencies and getting rid of them is not the way to improve system performance. An improvement program should be directed at what you want, not what you don't want. Then design the system to get what you want. So it's not to say that we shouldn't be looking at the things that go wrong. Of course they're a very important component, but you may just make incremental improvement by doing that. If you really want to go somewhere that's better for your whole organization and all of your Consumers, you need to design your system to do that. Every system is perfectly designed to get the results that it gets. So just having those jigsaw pieces is not enough, I think. You know, often we get rewarded, you know, through accreditation, particularly by having the jigsaw pieces. But if your organization isn't pulling those jigsaw pieces, those clinical governance systems, into an integrated approach to achieving something specific, you can get a tick for your systems and still not have great experiences at point of care. Excuse me. And we've seen that in many organisations where people have had a full accreditation and at the same time an inquiry into their organisation because of their poor care. So there's more to it than just having all the pieces. And I often think that we make quality all about the directions for staff. You know, we're constantly telling them, do this, do that, go here, go there. And, you know, it's like asking busy people to take a mystery trip. You know, they really would like to know where they're going to get on board and the journey will be a lot more pleasant if they all want to go there. And, you know, when I'm talking, you know, like this, are you thinking about your own service? And really sort of brutally honestly and thinking, wow, we do do a lot of stu. Is it really taking us somewhere? And have we defined where that somewhere is? You know, you're doing all of this work. Is it specifically focused, designed and implemented to support staff to achieve greatness of point of care? Or are all of these things just ends in themselves? We're constantly looking, yes, we're doing this, we're doing that, isn't that great? But it's not really taking us anywhere. We're on the treadmill. A destination is incredibly important in a complex system. And any human service is a complex adaptive system, just like the road system is, because there are so many things going on, there's so many moving parts and complex systems have a number of characteristics. You know, there's a whole lot of things we can control, there's a whole lot of things we can't control, but we have to manage anyway. You know, one of the characteristics of human services, isn't it, you know, we don't have control over everything we'd like to, so we have to manage. Makes it very challenging. Lots of unexpected events, such as pandemics, lots of human nature, lots of interactions between all of these things every single day. So one day is never identical to the next and lots of pressure. And if you think of the road system, if the people who run the road system weren't crystal clear about their ultimate aims. And really what they're trying to do is to provide a safe, efficient journey. If they weren't crystal clear about that as their flag on the hill, as their destination, they could very easily just end up doing and doing, doing, you know, planning and fixing and setting more road rules and trying to police them and trying to manage traffic flow, trying to plan for the future, trying to maintain the present. There'd be so much going on that you could very easily lose sight of why you're trying to do what you do and end up really with not a very good road system at all, just a whole lot of moving parts that don't quite fit together. And that can easily happen in any human service. Another way to think about this is that, you know, we do our best. We put all the things in to the mix that we know that we need to do. You know, policies and standards and training and governance and leadership planning and good implementation or hopefully good implementation. And that meets all the characteristics of complex systems or actually collides with them. You know, the risk, the stress, the interactions, the unwritten rules, the human nature, the natural erosion that happens in human services. If you don't keep moving forward, you actually don't stay static, you start going backwards. It's like the road system. If you don't maintain it, you very quickly start to get erosion, don't you? It doesn't just stay magically as it is. And all of these things are then impacted by massive external forces that we have to deal with, you know, such as funding and policy and compliance and all the external pressures and forces that we have to deal with. I call this the maze of complexity that we're working in. And the thing about the maze of complexity is that it naturally slopes down to the swamp of inconsistency. If you just have all these things happening with no clear idea of why or where you're trying to go. By doing all these things, if you're on the treadmill and not running outside, you will end up in the swamp of inconsistency. And that's where a lot of organizations are and where they stay, because they don't know that there's anything different or anything better that they could do. But the swamp of inconsistency is what consumers hate. They hate inconsistency. And so the only way to get out of the swamp of inconsistency is not to have the hope method or we'll do a whole lot of things and hope we get better but to absolutely plant your flag on the hill and say, this is our destination, this is our quality, care and experience destination, this is how good we want to be, so we can all gather together and move out of the swamp of inconsistency and up the hill towards the flag of a great consumer experience. So to do that, you've got to define that great consumer experience and there's all sorts of ways you can do this, and I'll just touch briefly on a couple today. But, you know, one way, a really simple way of thinking about it, is what would you like your consumers to be thinking as they're waiting to receive your services? So whether it's home care or resi care, where people are waiting, you know, they're waiting for someone to knock on the door, they're waiting for someone to come and get them up in the morning, they're waiting to be taken to an activity, whatever it is. What would you really like your consumers to be thinking as they're waiting? You know, if you think about that for a minute, what do you wish was in their head when they're anticipating their next interaction with one of your staff? Another way of thinking about it is you can imagine someone you love receiving aged care in a service on the other side of the world. What do you hope is happening on the other side of the world in that aged care service that the person you love is experiencing? What do you hope is not happening? And what will happen from either scenario is you'll get a whole lot of brainstorming kind of ideas. But if you to steal them and group them up, you always get the same fundamental foundations of what people want for someone they love or for the consumers they serve. Treat them like a respected human being, don't harm them or make them worse. Please let everyone be on the same page about what's happening and also where we're going. Don't let them fall through the cracks and do the right thing for them with the best possible result. And so if you think about your own consumers, I would say that you would really love them to be thinking as they're anticipating an interaction with you, with your staff or your service. I hope I'm going to be treated with respect, or now I know I am, because this organisation always treats me with respect and dignity and I'm a partner in my care to the extent I want to be. I know they won't harm me, they'll keep me safe. I know I'll be super clear about what's going on and the messages will Be consistent. And if I've got appointments or if I've got, you know, ongoing care planning and things to happen that we're all on the same page about that. So I feel really confident that we all know what's going on and that they're going to do the right thing by me and they're going to get the best possible result that we can, whether that's a quality of care outcome or a quality of life outcome or quality of experience outcome. That's what we're trying to get now. That's what your consumers are hoping that's what they want. So the thing is, you've got to be really brutally honest and say, wow, is that what every consumer gets every time? Are we still in the swamp of inconsistency where they get some of it some of the time, or perhaps all of it some of the time? Or are we really, very precisely and specifically focused on moving towards all the people all the time, which is really difficult in a complex system. Consistency is one of the hardest things to achieve in a complex system. Otherwise we'd already be doing it just like the road system. It's really hard to get it right all the time for all of the reasons that I've touched on and you can think of. But if we don't have a really clear idea of what consistently good is, we can never achieve it. And so you can frame that up into what I call quality goals or great consumer experience goals. Whatever works for you. But generally speaking, it will be a goal to treat them as a respected individual, to provide care and experience that are safe, to provide care and experiences that are connected or integrated, and to provide care and experiences that are effective. They're the fundamental foundations of what people want from a human service. And these are consistent with other definitions, such as the Pictor Principles and the Institute of Medicine Dimensions of Quality, which both of which were researched and have been in practice for many, many years. So these four goals incorporate all of that. I just like to have four, because people can keep them in their heads. You know, you might say, oh, but there's actually. I think there's, you know, I can count nine, Kathy, that we should be looking at. So I roll up things into four, because people cannot really keep more than four things in their head. And we want people to be walking around doing their work with these things in their head every day, not some nine principles on a wall, on a poster that no one can understand or relate to. These are things we want people to be coming to work to do. Every single day. So you're going to lead that now by equipping your staff to do it. There's lots of work done across the world looking at staff engagement in their organisations, you know, beyond their own job. And one of the polls that was done a few years ago in organisations, all sorts from all sectors right across the world looked at this, you know, staff engagement in contributing to organisational goals and the percentage of staff that really were going a little bit beyond their own job to try to contribute more to the organisation. Well, you know, you have a look, I've given you a little multi choice there, so you can, you can have a think about what you think it was worldwide, what percentage of staff, and you might think about what it might be in your organisation too. But the result of this particular poll was 15%, so that's not a lot, is it? And so we really then therefore have to specifically, as leaders, be realistic and work with what motivates people to engage. And I can assure you that compliance with standards is not it. We often act as if it is. And certainly when I was a Quality Director, I behaved as if people came to work to comply with standards because that's what I needed them to do. But, you know, clearly that's not why they come to work and it's never going to be the thing that engages them in really thinking about their role and thinking about what. What are the little things that I could do to make it more individual for consumers, more safe, more effective, more connected. So I always say trust before tactics for years and years. And as you know, I said before, I was as guilty of this as anybody. I took all the things I had to achieve as a Quality Director in terms of compliance and tried to shoehorn staff into it. And I can assure you people, it does not work. But I still see it happening all around and, you know, it really is putting the cart before the horse, because people create the experience. People are your greatest asset, your most useful tool in creating a great consumer experience and great care. But we often treat them as sort of the secondary thing. You know, the standards are the first thing, or your quality and clinical governance framework is the first thing. But no, you know, your people are the first thing. So a really important thing to think about as a leader and something that I can see around the world is gaining quite a lot of traction. There's a bit of research coming out about it. I can see that this is perhaps going to be a next wave of care improvement. I hope it is, because it will make a big difference if it is making staff satisfaction a key part of pursuing that great consumer experience. So what do I mean by that? So how could we make pursuing those quality and great experience goals really meaningful for staff in their daily work? Because people are looking for meaning to have job satisfaction. How could we help staff show off, develop and show off their skills and knowledge as they pursue the goals? That is, show off their mastery of what they're good at in the pursuit of those four quality goals? How can we make sure people get acknowledgement and are seen for trying to pursue those four goals in their interactions with consumers? How can we let them have a little bit of decision making? Doesn't have to be much, but a little bit of autonomy makes a big difference to how people feel about their jobs. Bringing their own experience to creating that great experience and that great care. And how can we foster more camaraderie and teamwork and that sense of shared purpose that. That people really long for and create that connection for them in pursuing the goals, make it a team effort. So there's all sorts of things you can do to make staff feel better about their job while they're pursuing the four quality goals. And to me, that is where we need to go if we want to get out of that swamp of inconsistency and up the hill towards the flag. So people support a world they help to create. I can't stress enough work with staff to design how to create the great consumer experience. Don't decide how to do it and then just tell them that's just more directions. Right. They need to be part of the map towards the great care destination, towards the flag on the hill. People support a world they help to create. Never a truer word was spoken. So a way of thinking about that is, if this is your staff in the middle here, are we really consciously or unconsciously telling them that the important thing is compliance with all this stuff? That's really why they come to work. You know, often staff will tell me that's when they do quality on Tuesdays. And I know straight away that this is the situation in that organisation. This is what staff think is important. Well, that actually isn't quality. Quality is what they create at point of care and service with consumers. A quality experience, quality care as we've defined it, clearly defined, with a shared understanding, a shared meaning. We want them to create a quality experience. That's where we want them to focus and that's going to help with their job satisfaction, because that's what most. I know not everybody, but most people come to work wanting to do a good job and to feel that they've made a difference. So what if we took the things we had to do and use them to support and equip staff to do what they want to do, which is to create a great experience with people. And, you know, Rockefeller said the secret to success is to do the common things uncommonly well. We're not talking about extra work here, we're talking about getting the basics right consistently, the things we know that people want and that we want to deliver. So start thinking about the difference between the dependency, between the quality and clinical governance system, which is not the point, and the quality experience, which is the point. Now, you've already got all the things you need to create that experience. You don't need anything new. You already have to do a bunch of things for clinical governance. And here's my take. I like symmetry. So I have four goals for great experience and then four clinical governance pillars to support it. And that works for my brain. So, you know, there's many ways to slice and dice. You will have seen four pillars and five pillars and six pillars of clinical governance, but essentially, essentially, this is the same cake, clinical governance cake, just differently sliced. So you already know what you have to do. We've got those things. It's how you implement them that counts. And the sorts of things I've been talking about today are already there as part of the things you should be doing for good clinical governance. Defining the experience, leading it. Making sure that consumer and staff wellbeing are the cornerstone of that experience. Making sure that there's clear roles and responsibilities and that they're supported. Making sure that staff are clear about their role, making sure managers are equipped and supported to guide the creation of that great experience with their staff. Making sure that training and professional development are giving people the skills that they need. All of these things are already what you should be doing for clinical governance. So it's not anything extra, it's all in the how you apply them and the clear intent and the destination you're trying to achieve. That's what's important. So briefly, just to finish off on support, the way that the point of care and the point of the great consumer experience is created is not through your quality team. That's been a myth for as long as I can remember, and I can remember a very long time. What is created at point of care, between staff and consumer, and that is where quality experience and care is created or not. That is the only place that is created. So we've Got to clearly define what we want so the staff know what that is. That's created through line management. It's leaders and managers that have the greatest impact on what happens at point of Care. So the board and the executive has to make sure that their clinical governance systems are implemented to support senior leaders, to support managers, to support their frontline staff to create that experience. It's as simple and as challenging as that. And then your committees and your support services and your quality team, they provide technical support and monitoring, but it's line management that will get you up that hill, to the flag, or not. And so, you know, it's a really important thing. If that's not how your organisation is thinking at the moment, that's how it needs to think. And that support has to be very specifically implemented to make sure that it is working through line management to get that result at Point of Care. A couple of important questions just before we wrap up. You know, always when you're thinking about leading for great care and great experiences, you know, are we doing the right things now? We're getting the right results. This is the sort of thing your board should be asking regularly. This is the sort of thing your executive should be asking regularly. And are we doing the right things? Of course, that's. That is your effective clinical governance systems. Do we have the right systems in place to support staff and are we implementing them with that intent, or are we just sort of having them basically exist in a policy somewhere and hoping that it makes a difference? And are we getting the right results? And when we talk about getting the right results, I like to ask really key questions related to the results we're trying to get. I know, amazing, right? But I see a lot of people looking at a lot of stuff that doesn't really tell them very much at all. So specificity is so important here. So if we have a goal for safe care, our data should tell us, do consumers feel physically and psychologically safe? And are they? We should have subjective and objective data to know whether or not we're providing safe care and safe experiences. Same for individual. Do consumers feel that staff understand and respect their perspective and situation and do that? Do consumers feel that care is planned and well coordinated? And is it? Do consumers feel that care and services achieve what they're designed to? And do they so that subjective and objective data for each goal? And then, very importantly, but something I don't see enough of, although, as I said, I am seeing it increasingly, which is really fantastic. And if you're out there doing that already, Great, keep going. Do staff feel supported to create and maintain high quality care and experiences? And are they? So do they feel that they are? And are we, are we putting the right things in place? What's the evidence that we are doing the right things, getting those right things in place? But if you're not also asking your staff, are these things working for you to help you provide safe, individual, connected and effective care, if you're not really clear about whether or not you're providing useful systems, not just any old systems, it doesn't matter how beautiful your clinical governance framework looks, it's all a bit of a waste of time. So it's as simple and as complex as this. In summary, a great consumer experience is created by great people, supported by great systems. And that means you have to have a clear purpose for your quality and clinical governance system. You need to focus first on your people because they are your absolute key, critical tool for creating that great experience, for getting up the hill towards your destination, quality flag. And then your pillars of governance have to be implemented with the absolute intent to support the people, to create the experience. And really, you know, if you can keep that sort of map in your head, it makes it a lot clearer when you're trying to work out which, which part you're in at any given time. And to keep in mind the interdependencies between all this and the importance of having that clear intent, that clear destination. Otherwise you can just get lost in all the stuff and never get out of the swamp of inconsistency. So I shall finish there. That was a bit of a whirlwind tour through Leading for Great Care, but I hope that it gave you a few tips. If you are already on that road, fantastic. I hope that it helps you to keep going and if you haven't been thinking like that, I really hope that it gave you a few ideas for perhaps where you can get started. You know, plant your flag, say this is the year, this is the year that we are out of the swamp of inconsistency and up the hill between towards that great care destination. So thank you very much and I'm very sorry I won't be around for Q and A. Just wasn't able to be organized. So I do apologise for that, but I'm very happy to be contacted and also I'm very happy to provide a free ebook which explains all of this in more detail. If anyone's interested, if you contact me through my website, kathybalding.com, i'll be more than pleased to respond to you and send you an ebook to help you on your great care and experience journey. Bye for now.