SERIOUS UNTOWARD INCIDENTS AND THE IMPORTANCE OF COMMUNICATION

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SERIOUS UNTOWARD INCIDENTSANDTHE IMPORTANCE OF
COMMUNICATION

• Jan Filochowski
• NHS Turnaround Specialist
• Senior Associate, Judge Business School,
  Cambridge

Presentation to NSC Clinical Governance Leads 4th
April 2006, Fulbourn, Cambridge
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SUIs are failures so

• Lets look at organisational failure for clues

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Why and how does failure occur?
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Trajectory of failing organisationsThe Six Phases
Performance
_______ Performance ----------- Perception
c
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Trajectory of failing organisationsThe Six Phases
Performance
_______ Performance ------------ Perception
Perception
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Trajectory of failing organisationsThe Six Phases
Performance
______ Performance ---------- Perception
Perception
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Trajectory of failing organisationsThe Six Phases
Performance
______ Performance ---------- Perception
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Trajectory of failing organisationsThe Six Phases
Performance
______ Performance -----------
Perception
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Trajectory of failing organisationsThe Six Phases
Performance
______ Performance ----------
Perception
Perception
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Trajectory of failing organisationsThe Six Phases
Performance
_______ Performance -----------
Perception
Perception
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The tipping point is the point of denial
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The tell-tale sign(if you could see it)
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When reality and perception diverge
or
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to put it another way
Communication breaks down
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• The key symptom is
• COMMUNICATION
• FAILURE

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• What happens
• and
• Why is it key?

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Trajectory of Failing OrganisationsThe
Communication Story

--------------- Performance


--------------- Perception
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Trajectory of Failing OrganisationsThe
Communication Story ---------------
Performance
--------------- Perception
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Trajectory of Failing OrganisationsThe
Communication Story

--------------- Performance


--------------- Perception
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Trajectory of Failing OrganisationsThe
Communication Story
---------------
Performance

--------------- Perception
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Trajectory of Failing OrganisationsThe
Communication Story
--------------- Performance

---------------
Perception
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Trajectory of Failing OrganisationsThe
Communication Story

--------------- Performance


--------------- Perception
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Trajectory of Failing OrganisationsThe
Communication Story
Performance
Perception
Important information gives way to spin. Bad
performance explained away. No news is seen as
the best news Dont tell
Transparency. Internal communication rebuilt and
evidence of improvement offered externally.
Evidence not consistently picked up.
Reassuring message problems not highlighted
Non-stop bad news. No messenger. No story being
told
Success recognised and celebrated internally and
externally
Bad news continues. Morale awful. Explanations
and a new story begin. Acknowledging failure and
promising better future
Performance
minimum acceptable performance level
Point of Acknowledgement
Point of Denial
Point of Exposure
DANGER ZONE 1
DANGER ZONE 2
Dead cat bounce
Time
Point of Fresh Start
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The Unbreakable Triangle
Behaviours
Beliefs
CULTURE
Communication
Communication
Communication
SYSTEMS
GOVERNANCE
Actions
Standards
Competences
Organisational Structure

• Break any of these links and you are in trouble

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How do you put it together generally?
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- Communicate honestly and transparently from
day one and keep it up
- Dig till you are sure you have found out the
root cause(s) of the failure

• - Tackle and be seen to tackle problems,
  especially visible and immediate ones

- Create a team to deliver confirm or remove
staff. Recruit. Clearly state your confidence
in the new team
- Get the structures working again and
re-organise so they are geared to deliver
- Make process change drive the organisation
- Consolidate your success and develop it into a
confident culture of innovation
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Lets be specific about governance
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The Importance of Governance

• In my experience
• Organisational failure is accompanied by
  governance failure
• Good governance can prevent organisational
  failure
• Clinical and corporate governance are Siamese
  twins if one is good or bad, the other will be

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The case of Bristol (1)

• Clinical failure was not caused by management
  failure
• BUT
• Its continuance highlights (to us) management
  failure

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The case of Bristol (2)
Management should have identified and stopped
clinical failure Competent governance systems,
fed by proper information would have detected the
problem and made management answerable for action
or inaction
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• A Board needs to ask
• What it needs to know to assure itself that the
  organisation is doing all it can
• A Board needs to endorse
• The behavioural culture of the organisation
• A Board needs to declare
• In public what it thinks, to say and to show what
  it is doing to monitor

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Governance is of key importance in identifying

• Basic duties unfulfilled or side-stepped
• Conflicting duties or demands which are
  unresolved or unresolvable
• Actions that cannot be avoided

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Some suggestions for governance (1)

• Wish to know
• Ask to know
• Keep asking until you know
• Ask for action till you get it
• A relentless algorithm

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Some suggestions for governance (2)

• Openness, honesty and admission of weakness
• Confession, tolerance and forgiveness
• Encourage, applaud and reward

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Some suggestions for governance (3)

• Defend people if they do the above
• Take responsibility if the problem is insoluble
  in your own area
• Help to get it redefined

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Some suggestions for governance (4)

• Use the specific expertise of Non-Executives as a
  reality check
• Use monitors that are already there auditors,
  inspectors
• Bring in other independent third parties if you
  remain unclear

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Some suggestions for governance (5)

• Trust your judgement
• Follow it up
• Nothing is too obvious it will often be the
  truth

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Some suggestions for governance (6)

• If in doubt, ask
• You may be wrong, but so what?
• But if you were right and you didnt ask

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Understanding your Organisation
Think organism not mechanism and remember
the wisdom of crowds
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And also
Dont panic
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Some key observations
- Attentiveness
- Honesty
- Go for detail be painstaking

• Watch out for the obvious
• often the answer thats easily missed

- Understand and follow up
- Looking for answers the wisdom of crowds
- Be specific and then generalise
- Understand and practise fault tolerance
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• tolerant of the fact that faults will occur with
  honest endeavours

• and structured to tolerate those
• inevitable faults without damaging delivery

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• A CULTURE OF
• FORGIVENESS
• NOT
• PERMISSION

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• This will foster
• creativity and high performance
• - QUALITY in short

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Some positive thoughts

• All the evidence suggests that deep and radical
  innovation is disruptive and is less likely in
  smoothly functioning, succeeding organisations

• The recovery phase from failure unleashes a
  huge potential for staff to innovate.

• If carefully utilised, this can catapult the
  recovering organisation into a leading
  organisation.

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• When I said dont panic

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At some point you should
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• Many people dream of success.
• To me success can only be achieved through
  repeated failure and introspection.
• In fact, success represents the 1- percent of
  your work which results only from the 99 percent
  that is called failure
• by Soichiro Honda