The Power of Feedback

Time can pass you by if you're not watching. As a nurse, revalidation is a triennial expedition through mountains of files and rivers of paper. Scrambling through the scraps of paper, one can get lost in the depths of despair trying to find that golden piece of feedback. And yet as we go through life we receive feedback almost constantly. From the person behind you tutting for taking too long at the self checkout, to the 'nice outfit' comment from a co-worker. Feedback is everywhere but how you use it is key.

Giving useful feedback to colleagues has never been something that we have been very good at in the NHS. Most feedback has been focused around critical reports, performance management or rag-rated tables with a big red mark through the middle. Such approaches to feedback mean that it makes it almost impossible for people to learn from these. Improvement is all about collaboration and learning to do things better for our patients. Unless we can learn to give open and honest feedback in a way that can engage people and also help them to grow, we will struggle to make sustainable improvements to services.

The key to good feedback is summarised in “Thanks for the Feedback” and is broken into three key components. The first is appreciation and is area that we need to get better at in the NHS. We are always told when something isn’t going right but are too infrequently told when things are good. But there are groups of people out there that are trying to make things better. Programmes such as “Learning from Excellence” and the “The Academy of Fabulous Stuff” are all about sharing the great work that people are doing on a regular basis. There are pockets of real outstanding and innovative services and it is key that this work is promoted and shared. If we are to maximise improvement capability within organisations, we must work to be kind and collaborative and celebrate this when we get it right.

The second is evaluation which is something that is systemic across the NHS. We have Service Regulators, Professional Regulators, Commissioning Groups and Advisory Groups. There are 126 organisations with regulatory influence over the NHS all pushing and pulling services in a variety of different ways. Through this cloud of performance and financial targets it can often be challenging for teams to clearly understand where to focus their energies. Whilst evaluation is important to ensure standards, we must be careful that this doesn't become the basis of all feedback within the NHS. We must continue to evaluate improvements in order to share learning effectively but we must not lose that appreciation for people trying and pushing to bring change in the NHS.

The final key component to effective feedback is the coaching element. If we want individuals and teams to grow we must provide them with the tools and support to improve. Coaching is about helping people to improve their performance and how to approach problems and come up with solutions. This form of feedback is about being supportive and listening, discussing ideas to enable individuals to grow and build improvement. The new offer of Hexitime is a modern community based innovation that looks to build this sharing collaborative approach within the NHS. It is a timebanking concept founded on the idea that you give an hour of your time in order to share tools and skills and in return you can claim an hour back to utilise another members strengths and experience. This is concept that reflects the coaching methodology by providing an opportunity for a community to share expertise in order for individuals to grow and develop.

Feedback is a powerful tool and we must work in healthcare to give more valuable feedback that is appreciative and constructive. Too often we have relied on the red pen and we need to get better at understanding and listening to why things aren’t working. Whilst challenging, we can start to build this, by working collaboratively across services, professional groups and trusts to share feedback on what really works in the NHS and what things needs fixing. We must understand what the data is telling us, learn to listen to our stakeholders and develop services together. Only by appreciating the difficult realities of the NHS can we begin to make meaningful change. So now it’s back to my pile of papers to dig out the smiley-faced sticker from my dentist as some good solid appreciative feedback.

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To learn more about feedback and how to use it, I recommend Douglas Stone & Shelia Heen on how to utilise feedback. It teaches the art of how to give constructive feedback but also how to receive it so that you can grow and develop:

Let Today be the Start of Something New

I have a very long and difficult relationship with the gym. When it good, it's good, but when it's bad it's almost like we never even knew each other. It's a relationship built on mutual understanding but one that has often resulted in us arguing over how often we see each other, hurting each other (mainly me and my back) or ultimately going our separate ways. I know that I should try harder and make myself go more often but the motivation is often lacking and the draw of the sofa is often too overwhelming. Motivation and how to use it is a complex science, motivating yourself is hard, motivating others is even harder. When trying to make improvements in the NHS we need to think carefully about how we motivate our staff to bring about change and improve patient outcomes.

The numbers visiting A&E have risen by over 40% in the past 13 years. NHS services are struggling and can't see how they could make improvements in an already overstretched and challenging environment. Financial pressures, workforce issues and increasing demand on healthcare services makes day to day working in the NHS increasingly challenging. As a nation we are passionate about the NHS, the opening ceremony at the London 2012 Olympics and the tribute to the NHS clearly shows us that. So how can we develop our staff in the NHS to bring about change and improvements in patient care?

A common misconception is that to get people involved in an activity we must reward them for their participation, whether that be a bonus or a promotion. However this isn't the case. A recent BBC article shows that the number parents hit by financial penalties for children not attending school regularly, rose 93%. In a further step, some schools have decided to penalise parents who bring their kids into school late, they implement a fine in an attempt to reduce the number of late attenders. But their plans may not have the desired effect. Rather than reducing the number of late attenders, the number will probably increase. The effect of money will change the mindsets of the parents from an intrinsic mindset of "I want to maintain a good relationship with my child's teacher" to a transaction extrinsic motivation, "I can buy more time".

Whilst we might feel like extra £££ in our bank account would be great, our engagement and passion for an activity diminishes. We give rewards thinking that it will increase a person's motivation and drive but it also has the effect of undermining someone's intrinsic motivation to under take that task. Look at the difference between blood donations around the world. In the UK and New Zealand, people give blood donations altruistically with no financial reward but rather leave with the knowledge that they have done something good. In the USA, Russia and China, giving blood earns you between $20-$50 and demand is currently far out running supply in these countries. The WHO have come out to say that blood donation should be voluntary as the safest blood donors are non-remunerated donors from low-risk populations. So how can we tap into this altruistic motivation within our NHS workforce?

Well the good news is that everyone I have ever met in the NHS is there because they care. Through their belief in the concept of free health service, their love of the NHS, or the dedication to give the best possible treatment for their patients; they all care. We want to deliver the best possible service that we can and we want to motivate ourselves to deliver it. Improvement is a tool that enables all staff to get involved and motivate us to make a change. The essence of improvement is about collaboration and working together to make things better. It builds, constructs and grows services and feeds on the intrinsic values of participants. It is much easier to go to the gym when you have a friend by your side to encourage you to go and motivate you to attend. There are ways and means to get involved in all kinds of improvement activities within the NHS, whether you are a staff member or a patient. The key to improvement is to be curious and to get involved, so check out improvement going on in your local area. Be curious, be proactive and get motivated!

Rage Against the Fax Machines

Technology is everywhere, from instant online grocery shopping to GP apps that use AI to triage you to the nearest hospital. It feels that soon we will be living in a technological utopia in which we will all be creatures of leisure, where work is a thing of the past. And yet, waiting for the arrival of driverless cars feels like waiting for a food delivery after your fridge has been ransacked from too many midnight raids. It doesn’t feel like it’s coming anytime soon. So when the chance came up to see how modern technology is used in manufacturing and how lessons can be learned in the NHS, it felt like it was an unmissable opportunity to have a glimpse into the future.

How many NHS improvers can you fit into a MINI?

MINI have around 1000 robots at their plant in Oxford and have produced over 3 million cars since the factory opened in 2001. The plant has an assembly line stretching 1.7 km and every single MINI is manufactured to order. The plant is on the cutting edge of productivity with an efficiency rate close to 95%, making it one of the most productive manufacturers in the UK. To achieve this they apply LEAN methodology to processes and use Kanbans and root cause analysis to analyse their daily activity and see where improvements can be made. Every station has an improvement board and the team regularly reflect and debrief in these areas to monitor their output. The factory is a LEAN consultants dream with every process monitored, counted and analysed to ensure that nothing is wasted within the system.

Increasingly NHS organisations are relying upon LEAN tools and consultancy models to look at inefficiencies within the service. Often we are told that we need to process map systems and reduce wastage from within healthcare. And whilst these tools are effective for looking at the way we run systems and analyse data, there is a real danger that when used in isolation we miss the complexities of the NHS and the unique values that exist in healthcare. MINI is a slick operation employing 500 staff members at their Oxford plant and achieving impressive results. In contrast the NHS in England alone employs 1.5 million people with 168 trusts spread across the country

The ideas of robots and AI feels like a science fiction movie to the majority of frontline staff who continue to face daily battles with fax machines, Windows 95 and reams of paper. Whilst robotics will play an increasing role in the operating theatre and other areas of the NHS, it is far from the sheer scale of technological achievement they have within manufacturing and other industries. Therefore when we talk of applying LEAN methodology principles, we must be careful to base it in the reality of the NHS. Making processes more efficient isn’t just about reducing waste, creating new policies and streamlining processes. The key to successful change is about building improvement capability within staff and working collaboratively to improve patient outcomes. The NHS does not have the luxury of robots to tweak or new machines to change processes. Instead the greatest asset of the NHS is its amazingly talented staff and its patients. Whenever we look to make any real lasting change in an extremely complex system such as the NHS, we must ensure that it is collaborative with all involved.

The question of whether technology will deliver its promise to healthcare is still up for debate. All of humankind may one day be replaced by robots in the future, but plumbers, electricians and nurses are projected to stay in employment the longest due to the nature of their roles. A Chinese factory in Dongguon City replaced 90% of its human workforce with machines and saw a 250% increase in productivity when they brought technology into their company. The reality of the NHS is very different. The size of the workforce and the variety of different treatments and care that the NHS provides is currently far too complex to solve without taking a collaborative approach. Looking at the NHS today, I think my fear of my job being replaced by a toaster is safe for now.

A big thank you to Alan Dodge and Andrew Pentecost at MINI plant Oxford for the visit and providing facts and figures for this article.