Management lessons from the NHS
I recently had cause to spend time in hospital, having been admitted as an emergency with likely gallstones. With too much time on my hands while lying on a bed waiting for swelling to recede, the antics of the doctors, nurses and auxiliaries got me drawing parallels between the NHS and industry. I did have a stint as Deputy HR Manager at Hinchingbrooke Hospital so I suppose I have something of an insider’s perspective. I was a rebel then and was forever wandering into wards and specialist areas on a quest to meet and learn about the managers I supported.
Now, we hear bad things about the NHS. We are led to believe that all staff are stressed to blazes and unable to function properly. But far from it. My conclusions from my brief period as voyeur are that these guys know how to make a system work. I think industry can learn a lot from the way that hospital staff interact.
Let’s just set the industry scene. Marketers set out what’s to be offered. Sales people interact with customers. Orders are placed. Orders morph to projects for action and delivery. Deliverables are assembled and delivered to site. And on-site technicians implement. And then project managers invoice. Most commercial activity is a variation on this theme – even morning coffee in a café.
In medicine, researchers develop diagnostics and corrective procedures. Patients suffer maladies and are triaged using those diagnostics. Some, like me, are escalated to a hospital like the Borders General. Repeated diagnostics lead to procedures and on to recovery and discharge.
If one were to plot the industry and health ‘customer journeys’, mapping the ‘projects’ from inception to satisfaction, there are remarkable parallels. It’s that which allows comparison and learning.
So, to the detail.
Unlike industry where everyone has their own day book, there is one ward ‘project book’ per patient. This is completed every time data and treatment information on a patient is received from off-ward sources. This includes x-rays, scans and Consultants notes.
Ward staff who administer a treatment, medication or blood pressure test complete the logbook traditionally held at the foot of a patients bed. Vital stats and other relevant information are noted. This book and the ward project book show the whole picture of each patient and this is shared with the whole team.
In industry we use Slack or the like as communications device and we use project trackers like MS Project, progress minutes and QA logs to show progress and actions – the patient record is the equivalent on the ward. It holds all relevant information about that patient, the diagnostics and the planned procedures to effect return to health (in effect, the ‘statement of work’).
A typical ward will be spilt into rooms: perhaps four rooms with six patients in each, plus some side rooms. That’s about 30 discreet projects running at any one time! Each project is of differing urgency and severity. Each has differing deliverables, differing timescales and differing outcomes or patient satisfactions. It’s a bit like busy café: each customer wants something different and each will spend different amounts and be more or less satisfied. It’s a café playing in patients wellbeing.
And that's one ward. Hospitals have many wards.
Whilst NHS staff have designated jobs, I noticed that they are happy to do any other jobs when necessary to ensure smooth running. Someone needs help with a bath, a urine pot needs collecting and weighing or someone needs their water jug filling – no problem. Whilst these jobs are generally the domain of support staff, nursing staff were very happy to step in if no-one else was available. Where junior nurses were unable to undertake a particular procedure (such as inserting a cannula) because they lacked the competence, they still maintained ownership of the problem until they could hand off to a colleague.
I observed that staff were very willing to help each other – their discretionary behaviours were high, indicating high empowerment and high motivation. Flexibility is not restricted to nurses and auxiliaries. It’s evident in consultants too, swapping operation schedules to ensure that patients have the most suitable surgeon for the required procedure. Sometimes in industry, staff are disinclined pass work to others like this. There, it is perhaps seen as a sign of weakness. To pass work on requires collective problem ownership. It requires high individual self-confidence and is in fact a sign of staff being aware of their own competence, while seeking the best outcomes for patients.
In industry, we so often pay bonuses and commission – can you imagine bonuses in the NHS! With nurses making a bloody pin-cushion of a patient as they botch inserting a canula, just because they are paid per canula and won’t hand off to a colleague, thereby foregoing ‘their’ money. They got the job first after all! I could go on about why bonuses don’t work – but we’ve written enough on that.
And I could continue all day detailing my observations. There are many examples of excellence.
The above examples show that above all, the NHS has great teamwork. Each member of staff is supportive of colleagues and will ensure that the best person for the job is tasked. There are many examples of high competence, with consultants showing great skill in communication, drawing diagrams to aid understanding. Consultant surgeons also show us how to manage delivery of bad news. They don’t send a nurse to say that a patient’s been bumped down the list because of a more urgent case. As problem owners, consultant surgeons deliver that information personally, ensuring that the patient fully understands what is happening and why.
So, a hospital team is a busy team – that can’t be denied. Staff stay until the work is done. But then that’s found too in industry with the right environment. If implementing project deliverables is taking a bit longer, staff in industry don’t down tools. OK, they might in a highly unionised environment factory or perhaps junior staff in a call centre might stop where a system controls their activity. But generally, staff work the hours needed by the job.
NHS staff support each other, they share information with patients, they spend time with patients to ensure that the correct level of care is given. Yes, there are some who are not as adaptable as others. And hopefully they are managed appropriately to ensure they improve. But it’s no different in industry.
My final observation is the use of probably the most important communication activity: at shift change all participate in a ‘stand up’ – common, of course, in some parts of industry. The staff get in a huddle and discuss aspects of care that must be understood by the incoming team. Handover is the single biggest cause of error in all enterprises and endeavours. As Frederick Brooks’ adage goes, ‘errors collect at boundaries’. Every manager, everywhere should mandate stand-ups: a time when everyone shares what they know and what needs to happen in the coming hours, days and weeks.
So, you know, despite huge apparent differences, industry and NHS are not too dissimilar. Don’t get me wrong, staff do suffer stress. Emergencies happen, ward rounds are delayed and several emergency buttons are pushed all at once. Managers in industry also suffer stress when project timelines slide, expected data is not available or people don’t deliver as promised. The key difference is that teams in industry tend to contribute to smaller numbers of discreet projects at any one time. At any one time the ward team are managing around 30 projects – all urgent and all with stakeholders keen for answers. Overall, industry can certainly learn from the NHS – and maybe from cafés too. And as a source of observable activity, no personal emergency is needed for your café visit, other than the desire for coffee.
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