Challenging culture in the HSE?

The HSE’s Values in Action initiative is tasked with delivering
widespread ‘culture change’ within the organisation, but the project
has both its supporters and its sceptics. Catherine Reilly reports

To energising orchestral music, The Chalfont Project’s promotional video for ‘Viral Change’ promises of “grass roots, peer-to-peer, fast behavioural change” and not another “top-down corporate programme”.

“Viral Change provides solutions for any situation which depends on stabilising new behaviours or new ways of ‘doing’ and which requires the changes to be sustainable and multiplied at a rate and scale,” according to the website of the UK-based management consultancy firm.

“The formula is, behaviours x peer -to-peer influence, x informal networks, plus stories and backstage leadership = RESULT.”

The HSE has bought into this concept — literally. In 2017, it paid almost €300,000 to The Chalfont Project in support of a culture change project called Values in Action, which aims to build “a culture in the health service that reflects our values”.

Following a research exercise, the Executive identified nine behaviours relevant to working lives and relating to oneself, colleagues and patients/service-users, such as ‘am I putting myself in other people’s shoes?’; ‘ask your colleagues how you can help them’; and ‘do an extra, kind, thing’.

These behaviours are promoted by nominated champions who attend a ‘boot camp’ to learn more about the process.

“Champions will also recruit others to the Values in Action way so that over time, there will be a critical mass of people engaged and the behaviours will flow naturally throughout our organisation,” according to HSE literature.

<h3><strong>Brainchild</strong></h3>

Values in Action is the brainchild of Ms Kirsten Connolly, the HSE’s former Deputy Director of Communications. She was recently appointed to the new role of Director for Organisational Culture within the Executive. The eight members of Values in Action’s core project team, or “social movement leaders”, have been subsumed into a ‘culture unit’ which, as with Values in Action, sits within the Office of the Director General (DG).

Ms Connolly says the idea for Values in Action fermented during her MBA studies between 2013 and 2015, with her thesis focusing on organisational culture. Around this time, the HSE was examining ways to improve internal communications as part of a new communications strategy, while the broader issue of retention and recruitment was also on the agenda.

<strong>Ms Kirsten Connolly</strong>

“We would have had a lot of discussions at senior management level… conversations we hadn’t had previously in the health service, which was really about looking at the impact of the last decade on staff,” she says. “I think it was acknowledged at a Leadership Team level around that time — this is 2015, coming into 2016 — that the culture in the health service was not good and we had all the data to support that.”

Ms Connolly says she “came across” the approach to culture change devised by Dr Leandro Herrero, CEO of The Chalfont Project and “organisational architect”.

The Chalfont Project was engaged to assist in developing Values in Action, which began as a pilot in the mid-west in 2016. It has since extended to the HSE National Divisions, Community Healthcare Organisation (CHO) 9 (Dublin North City and County), and to doctors (<strong>see panel</strong>).

<h3><strong>Pilot </strong></h3>

Viral change is a “particular methodology to developing a culture within an organisation”, according to Ms Connolly.

Asked how viral change differentiates from other methods, Ms Connolly says she is “very conscious it is a methodology — it sits beneath what we do”. She says Dr Herrero developed the method and “it is his to explain, in terms of, he is the man behind it”.

However, she says there a number of key aspects that may differentiate it.

For example, it is “very much grass roots-led, so we involve staff from very, very early on”. This includes staff from across clinical and non-clinical roles.

<strong>Dr Leandro Herrero</strong>

It is also “behaviour-based” because values are “generally concepts and tend to be a little abstract”.

“We have taken the [HSE’s] conceptual values, if you will, of ‘care, compassion, trust and learning’ and translated them into behaviours. That is quite unique actually — not a lot of organisations have done that.”

Currently, there are over 1,100 ‘champions’ of Values in Action. Their role is to “engage with colleagues, on a peer-to-peer basis. This will happen both in conversations and actions to help spread the behaviours to affect a cultural change in the health service,” according to HSE literature.

There are 100 ‘mobilisers’ —champions who take on roles as local organisers.

Ms Connolly says that “by the end of the second year, as we are currently seeing in the mid-west, the behaviours begin to embed and become internalised, ie, they start to become ‘the norm’… ”

She says only half of staff were routinely introducing themselves in 2016; now 99 per cent are doing so (behaviour: ‘Use my name and your name’).

Staff also say they feel more valued and appreciated for the work that they do, up 30 per cent since Values in Action began, according to Ms Connolly.

Asked if Dr Herrero has published evidence about his methods in peer-reviewed publications, Ms Connolly says the viral change approach “very much comes from a commercial background”.

“As far as we are aware, this is the first time any health service anywhere in the world has attempted to use this particular approach to changing culture; it has been used in lots of other industries but not applied to healthcare settings,” she says.

The HSE has been invited to present on Values in Action at the International Forum on Quality and Safety in Healthcare in Glasgow next spring, she adds.

In 2016, The Irish Times reported that the HSE was paying €70,000 to Dr Herrero “for about 15 days’ work on a project described as a pioneering system of ‘viral change’ to help it improve its communications and image”. The same newspaper also reported that the HSE paid €129,147 to The Chalfont Project in 2016.

In 2017, The Chalfont Project won a three-year contract “to provide behaviour-based culture change implementation support following a competitive tender process”, according to the HSE.

The value of the three-year contract is to a maximum of €250,000 per annum, with an option to extend for one year. Ms Connolly says the intent of the HSE is to build internal capacity around culture change.

According to figures released to <strong>MI</strong> under Freedom of Information legislation, The Chalfont Project was paid €292,509 in 2017 and €113,935 from 1 January to 1 June 2018.

Other costs accrued by the HSE in respect of Values in Action, over the course of 2017/2018, include digital supports (€5,043 in 2017 and €48,685 to June 2018), printed materials (€28,260 in 2017 and €21,067 to June 2018), events and meetings (€72,567 in 2017 and €14,993 to June 2018), videos (€13,443 in 2017 and €8,883 to June 2018) and rent/IT/stationary/misc (€14,018 in 2017 and €23,876 to June 2018).

Despite this level of investment, Values in Action is not the only culture-change initiative active within the HSE. The Executive has also been rolling-out the Caring Behaviours Assurance System — Ireland (CBAS-I), which “creates a culture for all healthcare professionals that promotes a positive care experience”, according to an information booklet. It sits within the Office of the Nursing and Midwifery Services Director (ONMSD) and was adapted for Ireland by a company called Choice Dynamic International. It involves teams of ‘quality champions’ chosen to train and implement CBAS-I.

A tender document published by the HSE in October 2017 invited applications to evaluate the programme’s roll-out at Saolta University Health Care Group and Dublin Midlands Hospital Group.

There is also the “National Programme to Enable Cultures of Person-centredness”, which involves developing work-based facilitators “to lead culture change that supports person-centred practice within their own services”.

According to the HSE website, it is delivered by members of the HSE’s Quality Improvement Division and ONMSD, in partnership with Queen Margaret University, Edinburgh, UK.

Mr Andrew Magee of the HSE’s Human Resources (HR) Directorate is leading roll-out of the HR aspect of the National Programme to Enable Cultures of Person-Centeredness. He sees it as complementing Values in Action.

“The person-centred culture programme is about changing people’s cultural attitudes in the service on a very fundamental level, and so, it is about encouraging people to be more engaging in the values that the Values in Action programme espouses,” he reasons. “But it is a far more intense programme and it takes much longer to deliver.”

Mr Magee is also curator of the Twitter account @PeopleofHSE, which is an initiative of HSE HR to “highlight the positive things that happen every day in the HSE”, with the hashtag #PrideinHse. It was established earlier this year and its messaging can be similar to that of the Values in Action Twitter account, @HSEValues, #weareourvalues.

Mr Magee says @PeopleofHSE is not “glossing over what is not working in the HSE”, but rather emphasising there “is a lot of good happening and the response to it has been very warm,” he says. “There has been some scepticism, naturally.”

Ms Connolly laughs when asked if there’s a ‘turf war’ within the HSE over culture change.

“No, I don’t think so,” she says. “I think it is easy to look at things like that and draw links or commonalities; certainly, there is some common intent behind them.”

She insists the aforementioned initiatives are “all quite different”.

The CBAS-I and person-centred culture programme are training programmes, which are required in any healthcare organisation, she says. Values in Action “is a social movement, so it is not a training programme”.

Nevertheless, correspondence seen by <strong>MI</strong> shows Dr Herrero has posited the idea of accrediting people as “viral change practitioners”.

According to Ms Connolly, this is not currently being pursued, but “accrediting people is something that we will certainly look at in the future”.

Much of the media publicity around Values in Action has surrounded the high consultancy costs.

There is also the sharp dichotomy between the values espoused by Values in Action, and what many would view as recurrent failings in openness and transparency within the HSE.

Last May, when Mr Tony O’Brien resigned as HSE DG amid the CervicalCheck controversy, which was marked by a lack of open disclosure, Ms Connolly specifically cited Mr O’Brien’s support for Values in Action in a ‘goodbye’ tweet which read: “Farewell Tony. Thanks for your leadership and support over the years. And for being our very first @HSEvalues champion! You taught us what it is to speak truth to power. #weareourvalues!”

This prompted many disapproving messages, with MEP Luke ‘Ming’ Flanagan wondering, “is the HSE a cult?”

<strong>MI</strong> asks Ms Connolly if the HSE was just too large an organisation for Mr O’Brien to ensure an acceptable level of transparency, in line with Values in Action.

Ms Connolly does not want to comment on Mr O’Brien in this specific context.

Speaking generally, she says the HSE is “huge and complex”, with “significant challenges” in terms of IT infrastructure and information flow.

“Sometimes — not all [the time] — the ability to provide information and to be transparent by providing that information, is encumbered by the lack of systems and infrastructure to enable that to happen.”

Ms Connolly (whom <strong>MI</strong> interviewed in late July) says she is “not at all” disappointed by the publicity surrounding Values in Action. She suggests the overall narrative around the health service has been too heavily weighted on the negative, thereby affecting staff morale, and Values in Action is part of redressing this.

<h3><strong>The champion’s view</strong></h3>

Ms Miriam McCarthy is among the over 1,100 Values in Action champions.

Having trained and worked as a physiotherapist, Ms McCarthy is now Manager of the Patient Advocacy Liaison Services (PALS) in UL Hospitals.

Ms McCarthy says her nomination by peers was “a real honour… these values would resonate very strongly with my own personal values”.

Following her nomination, she attended a two-day boot camp, which she describes as having been “totally different”.

“This was very much around acknowledging who we are, what we brought to the table and how do we actually spread [the behaviours] and do it differently. So, it was super — very, very different, very invigorating, very powerful, and again, I felt very strongly it is giving great credit to the softer skills… ”

<strong>Ms Miriam McCarthy</strong>

But is there some scepticism at the frontline, particularly around the terminology associated with Values in Action?

Ms McCarthy says there can be. However, she says she took “great confidence” from her nomination. She says her role as a champion ties-in strongly with her work engaging with staff and patients around compliments and complaints.

According to Ms McCarthy, being a champion does not take up a lot of her work time. This had been one of her concerns, but she was reassured at the boot camp that this was something she was doing already. Values in Action “gives credibility to the softer skills”, and if anything, “it has helped me in my role”.

However, an account sent to this newspaper shows the programme in a less favourable light.

During another boot camp, attendees were divided into smaller groups and encouraged to share examples of when they demonstrated the behaviours of a Values in Action champion.

One healthcare professional told how he purchased an item for a client, while another spoke about the thoughtful gesture of a colleague. These examples were shared within the larger group and praised by the speakers for being reflective of champion behaviours.

Considering there were a large number of relatively inexperienced staff, non-clinical staff and mental health staff present, it was “perhaps surprising that there was no clarification on how professional boundaries should be maintained in order to protect both clients and staff”, according to the account.

“There was confusion among some attendees afterwards as to exactly what was expected of them. Attendees were not provided with opportunities to provide feedback on their experience of the boot camp… Ways in which the change that the champions bring about within the health service could be measured were never identified.”

Ms Connolly says the stories told by healthcare professionals at boot camps illustrate the impact of the behaviours. Stories have also been shared on social media.

“One that stuck out for me was a nurse in the mid-west taking a resident who had recently been admitted for a procedure to see his cattle. He had been an emergency admission and had not gotten a chance to ‘check on’ the cattle before leaving the farm. He did not have family or other people to call on for support and was finding it difficult to settle in the hospital in advance of having the procedure. One of the nurses drove him out to the farm to help give him peace of mind, after which point he settled and was able to have his procedure and focus on his recovery.”

Ms Connolly says attendees at boot camps are nominated by their peers and are broadly representative of the staff population.

Values in Action does not focus on ‘professional boundaries’ “as that is not its purpose, and there are other programmes and training opportunities that deal with this”.

Ms Connolly says boot camp “is just the beginning of a champion’s journey” and it is normal for them to have questions afterwards. She says that is why Values in Action is about building a community of champions “who support each other over the long term to deal with the challenges and issues that will inevitably arise as part of a culture change movement”.

<div style=”background: #e8edf0; padding: 10px 15px; margin-bottom: 15px;”> <h3><strong>Engaging clinicians on Values in Action</strong></h3>

In recent months, the HSE has established a doctors’ Values in Action project team.

This followed an approach by NCHDs who were keen to improve their working lives, according to Ms Connolly. Dr Louise Hendrick, formerly National Lead NCHD, has been a co-sponsor of this development.

There is “no doubt” that NCHDs face “huge challenges” in the workplace, says Ms Connolly, referencing issues around pay, taxation and rotations.

She says Values in Action “is not going to solve those things” and there are “significant drives” within National Doctors Training and Planning (NDTP) and HR on these fronts.

“The reality is, there are a lot of things people can do to make their working environment better — that is not going to change things like pay, contract, training programmes and structures…but can significantly change the environment, relationship with your colleagues, what it feels like to go into your workplace… ”

Speaking to <strong><em>MI</em></strong>, Dr Hendrick says “we can all acknowledge that there are issues with HSE culture”. She ultimately feels it’s better to be engaged than not. But will there be wider NCHD buy-in?

Dr Hendrick says the NCHDs who have become involved in the doctors’ project team “are very keen to try to start to work on this”. Dr Hendrick “wouldn’t forgive” the problems relating to NCHD employment conditions, which she says must be addressed.

However, she senses a willingness to say “ ‘okay, we know we need to work on the other stuff as well, but actually there is a lot of merit in addressing this and starting to appreciate that how we talk to people, how we interact with people, how we behave and how other people behave towards us, is actually hugely influential’.”

Dr Gerry Burke, Clinical Director for Maternal and Child Health, UL Hospitals Group, believes doctors have bought into the initiative. He says many “typify the behaviours and attitudes in Values in Action”.

“But they are treated like Boxer, the loyal, hard-working old horse in Animal Farm. And they will end up like him,” he continues. “Overall, Values in Action is very commendable. Unfortunately, the top level of the HSE acute service seems to have a blind spot about junior doctors’ hours. In the case of UL Hospital Group, there just isn’t an adequate number of doctors, a deficiency of 130 compared with national rates… Cynicism, apathy, mistakes, mental health problems, physical illness, emigration are the inevitable consequences of relentless overwork.”

Dr Ellen Newman, an SHO, was not familiar with Values in Action. But when provided with information by <strong><em>MI</em></strong>, she felt it was “100 per cent papering over the cracks and to be quite honest, insulting”.

“‘Do an extra kind thing’? I think NCHDs are going far above and beyond anyway to try and compensate for an unsafe system on its knees… I think the vast majority of doctors are kind and pleasant people to work with, and I think anyone who’s done more than three months of intern year understands and appreciates that if anyone is unkind, etc, it is because they are under immense and inappropriate pressure, being stretched beyond capacity.”

A survey of champions in the mid-west in April 2017, which asked what further supports they needed to spread the Values in Action message, pointed to some frustration. “I have a very heavy workload — little time to spread the values or look or share on Twitter or Yammer. I have to attend [a Values in Action] café on day off — no time in diary during my working week.”

“Time,” wrote another.

“Needs to be evident that management structures are aware and supportive,” was another contribution. Others were pleased with the support to date. Asked about what they would change, one respondent wrote: “I love the concepts of Values in Action but the workload is enormous within my work and I already routinely take home work… ”

Acting Chairperson of the Midwives Association Ms Jeannine Webster told <strong><em>MI</em></strong> the Association welcomed any initiative that would improve patient/service user experience while improving staff morale. The Values in Action initiative “sets out to do just that” and much credit should be given to staff who have embraced the concept, she adds.

“However, this must be contextualised, considering recent reports and studies that have shown that all is not well at the heart of our midwifery services,” Ms Webster says. “A report by Mark Hilliard in The Irish Times in August 2018 pointed out the damage that bullying is doing to midwives and midwifery students in everyday interactions.

“Midwifery respondents to the recent Birth Project Group survey of 280 midwives and students (Untangling the Maternity Crisis, Routledge, 2018) showed that while respondents clearly understood that care must be given in a healthy, collaborative working environment, these reasonable ideals have proved to be unattainable within the clinical settings in which they worked. Issues outlined by both midwives and students were: Inadequate levels of staffing; poor managerial behaviour; poor oversight and governance; a workload so great as to bring about physical and mental ill-health, and lack of resources.”

Ms Webster says it is important to acknowledge the value of colleagues, challenge unacceptable behaviours, and “recognise that the ‘blame culture’ does not belong in progressive healthcare”.

“However, there needs to be an honesty in how difficult it is to embrace such aspirations with enthusiasm unless they are matched with strategic developments which tackle the overwhelming issues, such as staffing levels, workload and poor management practices.”

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