Risk and Leadership

Leadership is often lacking, and management is all too often to the fore where considerations of risk are concerned in health and social care agencies. In this scenario fear and back-covering hold the attention, while good practice is presented as an unconvincing façade. Managers strangely play down any questions about excessive bureaucracy while still demanding all the paperwork is completed as the primary target. If something goes wrong it is the paperwork that gets sole attention, and real practice considerations are relegated to a place somewhere to the right of obscurity.

'Good paperwork is a sign of good practice' becomes the convenient smokescreen. This would be true if there was less management and more supportive leadership, as the need for paperwork would be put into perspective: as the essential minimum to support good practice not to hinder it. Good tools are a range of checklists and formats that have been shaped by good practice, and thus they are able to guide and prompt firstly, and capture good practice as a secondary function.

The Risk Decision-Making publication is the update of 17 years of working with individual practitioners and teams across countless organisations, both from within the Sainsbury Centre for Mental Health initially and through the Practice Based Evidence consultancy since 2001. The tools and guidance are informed by what we know from the national and international research, but more significantly through the practice based evidence of hundreds of practitioners across all disciplines and service sectors. Most importantly, this publication refocuses the attention on risk as everyone’s business; so it is structured throughout to address issues from the perspective of individual’s, teams and the leadership & management of organisations. Whatever systems your leaders have bought or put into place there is still a role for guidance on best practice, so look no further.

Risk Decision-Making

How many times have you been asked 'where is the risk assessment?' knowing that the quality of the work is of secondary value at best. A new manual has been produced in 2013 to focus the attention of people at all levels of organisations involved in health and social care services. We all make risk decisions, but we occasionally need guidance to support our confidence in doing so. This manual is focused on reducing bureaucracy, promoting quality, and responding to what we should really mean when we talk of being person-centred in our work.

Risk Decision-Making is available from Pavilion Publishing.

Practice Based Evidence for Risk

Surrey and Borders Partnership NHS Foundation Trust recently engaged the Practice Based Evidence consultancy to undertake an organisation-wide programme of Working with Risk training. By identifying a large cohort of senior clinical staff in ‘Leadership’ roles the Trust is establishing a positive commitment to working as constructively as possible within all teams. My role was to devise a training workshop that would reflect the principles and practice issues identified in the initial Leadership workshops. In addition to adopting their locally agreed set of principles and edited filming of Leadership discussions, I used my own materials on ‘Positive Risk-Taking’ and ‘Risk Decision-Making’ to facilitate reflective practice discussions as a main focus of the workshops. With the help of colleagues in ARW Training the cumulative evaluations across 50+ workshops were overwhelmingly positive. See the following two summaries for the numerical ratings of the workshops (the narrative comments cover too many pages to include, but broadly reflect the ratings).

Cumulative summary of workshop responses

Cumulative responses of additional workshops

The summaries represent 1252 and 72 responses respectively. The main lessons to be learned are that practitioners respond best to relevant and practical content that enables them to reflect on and develop their practice. Successful training workshops start with close attention to design and detail.

Does the whole picture fit together?

This question captures the meaning of ‘care coordination’. Are all the elements coming together in a coordinated sequence or pattern? It is a question that we apply to many aspects of our daily lives. We ask it, for example, about the colour schemes and fittings of interior design; the layout of an exhibition or gallery; the clothing we wear in particular situations. Simplicity and straight lines in a map or set of instructions often seem to help us to understand what we are doing, where we are going and how we can get there more easily. Complex pictures and plans might please people who enjoy the challenge of working out puzzles rather than having the solution given to them but, depending on how much time you have and what kind of person you are, high levels of complexity may serve only to frustrate you and turn you off.
 
The degree of creativity experienced in the smallest to the most complex of mental health tasks will largely be influenced by the attitudes, feelings and personal values that are in play at the time. For example, the simple task of arranging an appointment, and then attending it, might just be part of what a particular person does, and they might do it methodically, with little or no thought. But even a simple task like this can be subject to enormous influences, such as the availability of rooms, effective computer systems, clarity of communication, motivation to attend and transport on the day. Failure to meet the appointment, for whatever reason, has the potential to cause frustrations, fuelling deeper tensions and attributions of blame. But the successful completion of a simple task like this rarely generates the positive feelings that perhaps it deserves. Not all appointments and methods of support are creative, passionate and artful events; but the message is that we need to be more reflective about the smaller details if we are to derive more pleasure from our work routines. This message applies to all practitioners involved in care and support, as the care coordinator occupies a role of supervising the whole picture, not painting the whole picture alone!
 
Successfully coordinated care and support can be a great source of satisfaction and pleasure for providers and receivers alike. See the ‘Art of Coordinating Care’ manual for a detailed approach to capturing the creativity in the role.

Missing the real target

Nothing drains passion more effectively than constant demands for information to meet apparent targets, asked without consultation or explanation, and with no meaningful returns in the form of useful feedback. Auditing everything has become an industry – but to satisfy what? The function of co-ordinating care, specifically CPA, has become a focus for quantitative returns that seemingly have little to do with the quality of the working relationships and everything to do with numbers and signatures. As many service users, carers and practitioners will testify, presence at a meeting and signing a form does not necessarily reflect influence, involvement or even truthful agreement with the documented outcomes. Yet, the bureaucratic process keeps requiring the numbers with no apparent reciprocal benefits for practitioners and teams.
 
I wouldn’t argue against the need for auditing practice; but it does appear from conversations with many practitioners that there are widely differing perceptions about priorities between the management of services and the deliverers of services. Anecdotal sources suggest that most practitioners feel they only receive feedback from audit sources when things go wrong, and that good practice is not confirmed or highlighted when it happens. If practitioners, service users and carers were asked to define the parameters of what needs to be audited, there would be some disagreements between them but the priorities would probably look a lot different from what currently occurs. Most people in the real world are concerned about relationship-building in order to support people to be more self-reliant through identifying and working with their own strengths. Audit needs to be of practice and for practice, with a focus on sustaining current good practice. But that would only put an awful lot of middle management and auditors out of a job, for their focus is 'change' for its own sake; as long as the merry-go-round keeps moving they will have a purpose.

See 'The Art of Coordinating Care' publication for a detailed framework on delivering a service user-focused, strengths-based, bureaucracy-busting approach to real practice. It has been developed as a reflection of what good practice looks like, but will challenge all practitioners to step up to the mark to deliver values-based personalised services based on working with people's strengths. Failure to do this leads to the alternative... the more usual current situation of an over-regulated system driven by the need to satisfy the politicians and public that if anything goes wrong 'it will never happen again'. What the current system can ensure will never happen again is the enjoyment and creativity fuelled by the passion of people who want to make a positive contribution to service users lives.