Where are you today? How much of your environment, the jargon and language you use,
the attitudes, do you take for granted? Do you sometimes find (for example at conferences, or dinner with non-work friends) that you have to explain something you thought ‘everyone knew’?

The biggest barrier is assumption
In professional circles, particularly where the training is lengthy and the regulations and license to practice onerous, one of the biggest barriers to communication is assumption. You hear a word and think you know what is meant – the other sees you nod and carries on, and 10 minutes later you realise just how far apart you really are.
What would it be like to be understood first time around? Not to win every argument, but at least to be heard, permitted to make your point? And what can you learn from your colleagues, if you take the time to recognise that they may be talking a different language (using the same words with different meanings, or different words to talk about the same thing)?
Think what you could accomplish!

Action
Next time you’re talking with people of a different professional background (eg health and care professionals to administrators, health professionals in different environments, the next MDT meeting especially if it includes enforcement staff), listen out. Not just for the words that help you build rapport, the pace and tone of speech and representational systems used, but for the line of reasoning, for the little red flags that suggest you might have missed the point although most of it sounds familiar.
When is the next interdepartmental meeting? What could you achieve by getting this right? What do you need to prepare to achieve this?
A lot of questions, but I’m sure you’ll agree (after the event) that it transforms what used to be frustrating wastes of time into really valuable and productive meetings.
If we’d known the start point, we wouldn’t have ended up here!

Why did you join the caring professions?
Everyone I speak to has a story to tell – a family connection, a loss, a deep desire to help / to heal / to cure. But so often this original spark, this burning desire, lies buried under the petty annoyances and humdrum activities of day to day service.
Doctors and nurses, AHPs and social care workers, managers and support staff talk about the high points in their career in terms of single instances – the child who felt strengthened at their lowest moment, the obscure diagnosis with a straightforward cure. Moments of inspiration that are few and far between. Most days a seemingly endless and uninspiring routine.
As you know, my work is to help people involved in service delivery and service change to remember why they are doing this, to understand what a difference they are making, and if it isn’t good enough, to change their approach THEMSELVES to make it better. I do this through helping people, teams, organisations and whole health economies to define the measures that mean something (reports that people can take home and tell the kids “I made a difference today”). To record things that they put a value on, to analyse and report because THEY WANT TO, and to feel good about the outcomes.
We align the measures for new and existing services to the objectives of the workstream, the organisation, and the health economy. You can see your individual contribution, how you fit in, the difference you are making. You have a place, a significance.
This has an interesting knock-on – public sector objectives move as fast as (or faster than) local demographic change, political whim, and new understandings/ new technologies. Which is pretty fast. When teams set their own measures, they tend to align the measures with strategic objectives meaning that as these change, so the individual team measures change. And as people do what is inspected not what is expected, as we change the measures we record and report, we change what we do. No longer the need to send someone from management in to redesign services and impose the changes on people, because we’re doing it ourselves.
This theme and others on the use of measurement and Benefits Frameworks for performance improvement, alignment to strategic objectives and Recruitment and Retention, are explored further on my web site www.minney.org and blog http://benefits.minney.org. Please call me to talk further

Two heads are better than one, especially when they look at a problem from different perspectives.
The saying goes that if you ask 2 doctors for an opinion, you’ll get 3 different opinions. And probably each will assume that everyone agrees with him/her. This could apply to any professional, and even more so between different professions – picture a question of additional hours: someone with a responsibility for finance argues completely logically for a very different outcome from someone concerned with staff development. They haven’t understood their differences, and none understands why the initiative hasn’t gone ahead exactly the way they assume it should.
This lack of understanding of each other affects many service transformations: nobody is exploring what the blocks to delivery are; clinicians are blaming management as the key block, and of course vica versa
Facilitated sessions have unblocked similar situations in the past. In particular elucidation of what each means by their understanding of the overall goal, where there are similarities and how they can be brokered together has fostered new understandings and a common desire to achieve a common goal (exactly where you thought you’d started).
Think of the time these professionals spend in meetings and not able to make any progress. Think of the frustrations, and the mood that puts people in to obstruct future “management initiatives”, the measurement and monitoring, and service transformation. I’ve facilitated a change in awareness and appreciation of difference that breaks down barriers and aligns people, both with each other and with strategic goals.
Call to Action
Invite facilitated workshops specifically arranged around bringing different professionals together.

"Sometimes I hate my work" – so said a nurse to my wife, whilst looking after a friend of ours.
How can someone been such a caring profession get to feel this way? Surely, seeing sick people is enough to bring those feelings of compassion that they felt 20 years before, when they made the decision to become a nurse?
 
So what should we do?
Philosophical arguments about it being the nurse's responsibility to manage their own state of mind, and putting a brave face on in front of the public, are pointless here. This is about culture. What would make this nurse, doing the same job, feel inspired and enthusiastic?

 
Measurement and reporting
How does she (and in this case, it was that she) know that she's doing a good job? Who pats her on the back?
Well in my experience, clinicians (and all health and care professionals) are number phobic. Nothing gets measured (how many people got better, how many people are unhappy) by these professionals, and nothing gets reported back to these professionals, no matter how many measurements of financial performance or activity the management take – to report UPWARDS.
 
Does this sound familiar?
I've been preparing ROI and business cases for NHS and social care for nearly 10 years, including the development of the Emergency Care Practitioner (ECP), frameworks to structure benefits management in front-line clinical change, courses for charity providers of services to mental health and care support. My experience is that staff rarely get to see WHY we are making a change, and almost never get told how well they're doing. And yet, they get really excited and inspired when they do find out. In contrast to the above opening remarks, one senior nurse I worked with said "now I remember why I joined the NHS. I spent the last 15 years turning up for work at eight, seeing a bunch of sick people all day, and then going home at four. You've shown me how to see how well I've done, so I can look back and feel good about it."
 
Why? What? And how?
Why should you, management, leaders and trustees of organisations delivering services for public good (public sector, charity, not-for-profit, independent) care? Because staff are the lifeblood, and staff hours the main way of delivering care.
Inspired staff deliver more for less. Knowing where we going, and what progress we are making, helps us all pull in the same direction – patient care. It isn't even difficult, it just takes a bit of imagination and a bit of experience to identify: what to measure, how to measure it with the minimum disruption to the day job, and how to report it to inspire us all.
I deliver common sense, reliable measures and reporting. It will mean something to your staff and your clients, to the public and the politicians, and of course we can make sure that we tick the civil service boxes along the way.
So transform your organisation and your staff. But the right measurement in place, so your staff can go home to their children every evening and say "I did a good job today/this week". Watch the culture change. And see the people who pay for services coming back to you for more, because good news, just like bad news, travels fast. Inspired staff result in inspired clients, and the feedback will reach the people who commission services.

 
Water cooler discussions; the smoking 'bus shelter'; where the real work gets done?
Do you sometimes feel left out?  Do you, as a manager, sometimes feel that an untrue or spiteful rumour is getting out of control, but you feel powerless to stop it?  What if the rumour is about downsizing, but your privileged position on a management board also imposes a duty of secrecy?
I know I have personally felt left out (I don't smoke), and powerless (I know the truth but can't say).
Gossip isn't always a negative thing, as an article in Professional Manager (March 2010 - vol 19 Issue 2 pp34-36) points out.  We (humans) may be programmed to need gossip in the same way that most primates spend hours grooming each other - you're fighting a losing battle to try to stop it!
My own feelings of powerlessness when I was starting out got me interested: gossip is a part of networking, a kind-of "this is the sound of my voice.  How does your voice sound today?  Do I want to help you?" or even a Social Glue.  It can be destructive, but in the same way that social networking can be a distraction, or a force for good, if you manage and use it, it can be enormously beneficial.
Understand - before you try to use
Don't just leap straight in!  Begin with the end in mind - what are you trying to achieve.  Then put your ego on one side - what approach is most likely to get you there?  These are standard advice for any form of negotiation, and apply just as importantly with tackling the "thought leaders", if negative gossip mongers can be given such an elevated title.  
You know who started the rumour that is distracting everyone from their work, and has people threatening to go out on strike (or at least look for another job).  Will tackling them face to face achieve the right result?  You'll satisfy your own desire to look tough in the eyes of your fellow managers, but the person you talk to will deny it completely and call you every name under the sun for accusing them (those who are most guilty often protest most loudly).
You could try asking for help ... "rumours are flying around, I know you keep your ear to the ground, I wonder if you've heard, I'd like you to know the truth because I feel I can take you into my confidence".  Often gossip is about a power play - "I have information which I can share with those I favour, and obviously they have to give me something in return" is what the gossip monger is implicitly saying.  Well now you've shared information with them which obliges them to reciprocate, to do something for you, but more importantly, you've given them real information (as opposed to something they made up) which makes them even more important when they share it with everyone.
Gossip could actually become your team's greatest strength, rather than a destructive weakness!

The Integrated Service Improvement Programme (ISIP) (2005 - 2008) was a process which enabled whole health and care communities to plan together, and deliver services that met the needs of the community whilst making best use of resources. In project management terms, PRINCE managed a single project, MSP supported management across a work stream, and ISIP managed the interdependencies between workstreams for a whole region or health community. I focussed on the benefits side, and following development and delivery of the programme in South Yorkshire, repeated this nationally with “ISIP LHC Demonstrator Practical Guides” (specifically “Benefits Driven Change & the Benefits Approach to Service Transformation” Powerpoint 373k) (Connecting for Health, Oct 2007) along with a number of Local Health Community (LHC) Demonstrator Case Studies.  ISIP was sponsored by Connecting for Health.  It is now archived here: http://webarchive.nationalarchives.gov.uk/20100809114547/http://www.isip.nhs.uk/

The key to delivering benefits across a whole health community is to ensure that each project, each initiative is understood in context.
This is what is meant in World Class Commissioning terms by the whole stream of "assessing needs", "Review Current" and "Decide priorities" (WCC was presented in 2008).
All too often, projects and initiatives are sparked off in isolation. This is simply human nature - it is much more difficult to think about everything at once than to come up with an idea, create a business case, and then implement it.
Benefits Frameworks workshops consists of a series of three workshops which bring together all of the main stakeholders to
agree the priorities for a particular area of work (I'm thinking whole community priorities, such as caring for the elderly, long-term conditions, which may encompass a whole series of existing services and new ideas)
understand what benefits (what adds value) and outcomes (what the community will look like, and what service delivery will look like) need to be in place, and by when
identify gaps in the existing services, and prioritise ways to fill those gaps. Identify areas where resources could be redeployed
define the benefits in a way that all agree makes sense and means something
put the existing services and new initiatives/projects into context and define a way of measuring them
confirm a joint way forwards with agreed shared outcomes and benefits, and recognition of each individual organisation or team's benefits and outcomes
Although this is presented as a series of three workshops, it has been delivered in different formats for different numbers of people and with shorter timescales

I try to read junk mail - surprisingly, it often contains real gems of useful information.  Of course some get a quick glance and straight in the bin, but a recent report from IRIS got my attention; a carefully thought through paper explaining the concept of resource balancing (of course to sell their software), that agreed with processes we use in Minney.org.
IRIS describe 7 steps to optimising utilisation:

Set a realistic budget for the project.  Use historic information on similar projects if you can, and avoid overcommitting or under-resourcing.  We take this very seriously - in a year's time nobody remembers the price but everyone can see the quality, so although we are a relatively low cost provider in our specialist area, we would rather lose a bid than compromise quality by not allocating enough resource.
Review the demand of potentially successful bids against available resources.  To tell the truth, this is probably the most difficult thing for a small specialist consultancy.  We aren't going to win everything we bid for, so we have to overcommit during the bidding stage, but by using a network of associates there's only been one occasion when I've had to go back to the client and say "sorry, can't accept your contract".  We did tell them before anything was signed, and they went to the second bidder (who hadn't yet been told they'd lost) and contracted with them - it's good to be popular!
Allocate resources against the programme and the budget seems so obvious yet many consultancies find it too much of a chore.  Resourcing at even some of the largest consultancies is about 'Who shouts loudest' and I remember working for one where around 25% of my time was spent internally making sure I retained the consultants committed to my project and - dare I say it - pinching the best consultants from other clients' delivery to bolster my own. Luckily, Minney.org is small enough to be upfront and honest, and negotiate step ins and step outs which most suit each client project
Plan for non-project-related time such as holidays, training etc.  We put an enormous emphasis not just on training, but on creating new solutions, and on learning by talking.  This time is often scheduled well in advance (for example courses, conferences, panels) and we plan our contracts and services taking it into account.  We also put a high value on holidays - NOT a time to go and do something else but a valuable time to rest, recuperate and think. 
Update the programme regularly.  This is another of those VERY IMPORTANT actions we like to do in spades.  You (the client) need to know where we are at any one time, particularly because during a discovery phase it may seem like there's not a lot going on, and during a communication phase you may think that we've finished when we're just starting the second wave.  By the same token, if you take a long time making a decision or approving a stage, we have to advise you of the risks in terms of allocating resources elsewhere.  We both need to be honest with each other
Review the actual costs vs the plan with the team.  Everyone likes to do a good job.  Knowing where we've reached not just against timetable but also against budgeted resource use is a vital part of this.  We need to plan for unexpected and disruptive delays and changes in scope, and agree together how resources, and corresponding costs, should be allocated.  We'll take our costs honestly, and we expect where your actions or lack are causing problems, that you will act appropriately
Report regularly on overall workload to pre-empt quiet periods or shortfalls of resource.  Perhaps my time at Manpower Software (now Allocate Software) has stuck more than I thought it would - we're constantly scanning for periods of risk to project delivery, and are planning round them typically 3 months' and more ahead.  This means that if there's a bottleneck with the prospect of too much to do in too short an elapsed time, we're talking to clients about rescheduling or stepping in additional resource with plenty of time for them to recognise the changes they may need to make, and if it's a quiet period then we're using it appropriately for additional training or dare I say it, a holiday.

Junk mail takes a lot of effort to create, and it deserves a cursory glance.  Not always for the service it's promoting, but for the concepts and ideas.  Next time you're sweeping it into the bin, ask yourself "what could I learn?"

Half-way to implementation, we have to look at the unrecognisable mish-mash of a service that’s somehow evolved from the original idea, and seriously consider whether to cut our losses or whether it can be remodelled into something functional. There’s many a slip ‘twixt the cup and the lip. The right research, analysis and design puts forward the right solution, for example a new care pathway complete with new or adapted services and service delivery. But a service definition can only define so much, and you still need people to align with the reason WHY. It brings to mind my report on the pilot of Payment by Results. I interviewed medics, nurses, commissioners and managers in the South Yorkshire Laboratory after PbR had been running there for 12 months and was about to be rolled out in the rest of England. I asked them “how do you see this evolving?” (and to stop them committing suicide after I left, I concluded each interview with “what are you personally doing to put things right?”). The overall conclusion was that PbR is simply a system, and its success or failure, its ultimate benefit to the health of the population and best use of resources, depended almost entirely of the will and intent of the people who work within it. It’s possible, nay easy, to game the system. It’s also possible to provide an exemplary service and to receive due reward for quality. I like to think that the current HRG4 with reward for quality was in response to my little report.
So
What are you trying to implement, that you haven’t explained? Worse, what are you trying to implement where you haven’t involved people in designing, ensured everyone agrees the goals and strategic directions, that you haven’t put in place inspiring markers that let people know whether they are making progress (I call them “benefits”)? Social care and health care are staffed by inspired, highly intelligent, highly motivated super people. Without a system to report progress made, to tell each and all of us what progress we are making, many become demotivated. At least if you are following an accepted protocol you can assume that you’re having the effect that usually follows from following this protocol, but when change is asked for, naturally change meets resistance. If people understand the why and the evidence for the change, they are far more likely to engage.
How do you demonstrate improvement?
Do you have a reporting system (especially on service initiatives)? Is it designed to report on things that motivate people, such as proxies for quality outcomes (better health, better quality of life, better results, even better targeting of resources) – or does it just report a table of numbers or activity? What could you achieve by aligning all of these superpeople (supermen and superwomen)?

Many people who work in health and social care don’t like numbers.

Perhaps it is because they like people so much – computers seem far too simple?!

The result is that people spend hours on administration, fighting with their spreadsheet to try to make it do the budget; or endlessly retyping from one application to another to complete the mandatory reporting that both the Health Service and Social Care think is compulsory.  In the end, the very thing they hate the most comes to dominate their working day.

It doesn’t have to be like this – computers can sing and dance for you

Lots of people struggle to understand the mountains of data that, let's face it, you have to understand if you're going to plan ahead or to make things better.

I met a “data expert” the other day, who'd struggled for half a day putting a large data file into MS Access (the database), filtering for the bit of data he absolutely had to have, and then putting it into Excel to cross-reference (very slowly).  With the right tool for the job (in this case, MS Access for much more of the job) it took about 10 minutes which allowed him to get on with his life (helping cancer patients).  The next time he needed to do it, it took a couple of minutes.

In another Strategic Health Authority, they have been assessing their health commissioning and providing organisations against quality standards.  This means that each service (eg Vascular Care) in each organisation (eg an Acute Trust/ Hospital, or an Out of Hours service) fills in a form saying whether they are doing 'best practice', the things likely to lead to the best outcomes for patients.  Then the SHA has to collect the forms (by email, luckily), retype the data into a spreadsheet (because the form is in MS Word), cross reference some 500 or so specific local Quality Standards (which define exactly what needs to be done) against the 16 Care Quality Commission (CQC) essential standards (which are general so it's difficult to know what you need to do to improve), compile the reports by PCT cluster and send the results back out.  After they'd taken 10 days to do 1 service in 1 PCT cluster, they realised it was a hopeless job (hmm, 14 services X 15 health areas - that's 10 years of work per year and we haven't even started on the Mental Health standards) and asked me to look at automating.

Now they have a self-creating spreadsheet, where they fill in the data and press a button, and the computer does the tedious work, and doesn't make mistakes.  Managers and staff can get on with improving the quality of care for patients!  Two things really stand out

• Automation: it took me around 14 days to write the automation into the spreadsheet.  Now it will work with any set of local standards, any way of comparing local standards to CQC essential standards, any combination of Consortia, individual PCTs, clusters, any range of services.  It now produces all of their reports in a matter of minutes.  And the report shows not only how they are doing against the CQC standards, but also specifically what they need to change to improve things
• Self-Assessment:front-line staff can take control.  Instead of collecting numbers to "feed the beast", they are making decisions on the information they collect - right here, right now.  They can see how making a difference to the patient, also scores with CQC essential standards.  They don't wait for "management" to find out what is wrong and come and wave a big stick - they can change themselves.

Let the computer do the hard work.  That’s what it is there for.

Where did I learn to do this?

Over the years I've taken on some pretty tough assignments (I know I don't go out there and save lives, but I try to make sure the right decisions are made about numbers of people to train, facilities to build, etc).  For the Emergency Care Practitioner new ways of working project, I developed the economic models that said how many ECPs we'd need, and therefore how many paramedics, how many ambulance technicians, ambulances, cars; also how many A&E departments and appropriate staffing, and of course additional staff for the community services where people would be referred directly.  I've been given questions like "I need to know all the academic literature on Head and Neck cancer, compare it with our own survey data, and present options.  Oh by the way I need it in 4 weeks' time and I've only got money for 10 days' work" and the same for Domestic Violence and Obesity (and others!).   I've looked at "Why do we need to ask User Experience?  Is it just feel-good or is it worth doing?"

I couldn't do this without making my computers sing and dance.  I automate all the time to get the best result, accurately, within the time and budget available.  Now is the time to let you get access to all of this, without having to define your problem as a whole big project.  As one friend (who still comes back for more) says: “what I like about you is that you can understand what I want even when I can’t explain it very well”.

How can I help?

Maybe it can help you.  Do you want to spend your time on improving care, improving the quality of your services?  Do you wish that your paperwork would magically sort itself out? Do you want to see results rather than struggle to get there?

I’d be delighted to talk about your options.

Marc Woods, Paralympic medallist and motivational speaker, came to speak to health service staff in Easington today.
He is superb, and in between explaining how he changed from moderately successful (a county level teenage swimmer who was sufficiently good that he didn’t have to try, so he didn’t try), to realising how much he had lost when his leg was amputated below the knee, to deciding to make something of his life, Marc made a number of very important points.

If you don’t really REALLY want to win, then you won’t win. If you are trying to swim a world record time, then it might not be fast enough to beat the others who are also trying to swim a world record time. You need to WIN, to beat everyone else – self leadership
If anyone in your team doesn’t REALLY want to win, then your team won’t win. You are as strong as your weakest link (see the look of disappointment on the faces of two of the silver medallists, Marc included) – clarity on your goals
Everyone who has anything to do with your success is on your team, from the person who makes sure that the water is clean and the ropes laid out at the training park, to the coach and those who swim. Everyone needs to feel involved, and everyone has to be COMMITTED to winning gold. It’s up to the leader to get them there
Personal relationships count. When the chips are down, that’s what pulls you through. When you need to make changes, then do it on the basis of the strengths and weaknesses of each player, and with everyone’s agreement. Communication is all ways, communication doesn’t just “come out of the tip of my finger” as Marc said about his early days as British Swimming Team Leader. Marc said at this point “do you know someone who leads by talking AT you instead of with you? Don’t all look at him/her, that would give the game away”.

It’s a clear reminder of how easy it is to get complacent. We’re good enough, so we don’t try to be the very best. We sometimes can’t be bothered to get up and go to training, so arrange enough different reasons why you should that at least one will mean something to you when you are tired, aching all over, and hungry.
 
What will I do differently?
Give myself five reasons to be the best at benefits realisation:

It inspires people to enjoy their work, because they can see what a difference they will make
I enjoy understanding what a difference people are trying to make, and helping them make it
In health and care, the difference that frontline teams make is real and makes a real difference, improving the quality of people’s lives
I respect the people I work with and who mentor me
I love it when people say “thank-you” and “you did a good job”

Every day, live on purpose to be the best I can at whatever I’m doing. If it’s a relaxing day, then I’m going to be the best at relaxing, and so on
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