Summer Newsletter 2017 - Flipbook - Page 2
Continued from page one.
7. Think about the risk association - if you have identified an action that needs addressing then
this by implication means that you have identified a deficit. At the point of developing the action
cycle make sure that you consider where a risk may be prevalent. Using action plans and risk
registers in a coterminous way towards the same end helps to drive sustainable solutions.
8. Make sure there is ongoing smart monitoring of causal factors - and where the same deficits
occur (particularly in the post implementation phase) ensure that this triggers a review of where
the implementation has failed and where learning has not been sustained.
9. Establish the correct governance - ensure that the committee and meeting structure engaged
in oversight around the action has sufficient upwards and downwards reach and also has
sufficient decision making authority.
10. Continuously work on a culture of quality improvement and ensure that there is reward and
recognition when a concerted effort has resulted in a sustainable change.
The leadership post-mortem
Themes identified when things go wrong, Kate Jury
Introduction
Our team have undertaken hundreds of high-profile investigations, serious case reviews and governance support
projects over the last few years. Recently, we have undertaken some primary thematic research into serious and
catastrophic healthcare incidents; this short piece gives you an overview of our findings around some of the
characteristic leadership traits which are in evidence when things go wrong. We also describe some of the elements
needed to ensure the scene is set for a positive care culture.
Thinking around leadership
It is crucial when things go wrong, to understand the
role that leadership plays in relation to ensuring a
positive care culture, right up to the role of the Board.
There is much helpful guidance and conjecture around
modelling the right leadership behaviours but less
insight into the leadership factors which are often
prevalent when catastrophic failures in care and
governance occur. One could easily ‘reverse correlate’
some of the positive leadership attributes and assume,
that the absence of these traits may automatically give
rise to poor leadership. For example, leaders should
show compassion but if they don’t, does that by default
make them an uncaring leader? Or, leaders are told
they should be inspirational, but if they aren’t, does
that mean that they can’t take people with them?
It is true that leaders can inspire in many different
ways and good leaders come in all shapes and sizes.
Great leaders can be strategic and visionary but they
can also be methodological and process driven.
Great leaders can be enigmatic and extraverted but
some can also tend towards insularity and
contemplation; what really counts is that your team
develop faith in you, what you do and how you do it.
Part of this is absolutely about demonstrating the value
of what you are doing, respecting other people and not
acting unilaterally in your decision-making.
We reflect that some of the best leaders that we have
worked with don’t fit some of the classically described
leadership profiles. Conversely, some of the senior
leaders who have presided over some serious
organisational failures may think that they demonstrate
‘classic’ leadership traits but they may lack the one
that really counts; self-awareness.
It’s not all about textbook leadership
Through our investigations and reviews we have
worked with hundreds of Executives, Non-Executive
Directors and Senior Leaders.
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