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Elevating quality improvement by telling patients how much the hospital harmed them: A Q&A with David Dalton, chief executive of England's Northern Care Alliance

May 24, 2018

    Andrew Rosen, former Advisory Board International executive director, sat down recently for a wide-ranging discussion with David Dalton, chief executive of England's Northern Care Alliance (Salford Royal NHS Foundation Trust and Pennine Acute Hospitals Trust). In this interview, David shares about his career in health care, sustaining quality improvements over time, and connecting with staff in meaningful ways.

    David Dalton
    David Dalton, CEO, Northern Care Alliance

    On career beginnings

    Andrew Rosen: Let's start out at the beginning. Tell me how you first got interested in health care?

    David Dalton: It began back when I was a teenager. I was due to go to university, but didn't. I got involved in a summer job at the age of 18 to audit fire extinguishers for the health service in Lincolnshire. I experienced the 'buzz' of the hospitals I visited and thought that this was the sort of place I would like to work in. I found out that there was an administrative training scheme available at that time, and they were taking a few non-graduates. I inquired about it, was interviewed, and got offered a couple of positions—I took one in London. That was my first foray into the NHS, some 38 years ago.

    Q: From there you went on to serve as a deputy hospital administrator in a small hospital in London—what was the biggest thing you learned from that job experience?

    Dalton: I was given a lot of responsibility at an early age and worked for a boss who was really supportive. At that stage, I just wanted to immerse myself and understand this organisation called a 'hospital'. I seemed to be good at bringing people together to discuss problems and try to find solutions to those problems together. It was fun, and I found that I really enjoyed doing that. I loved working with people. Thus, at an impressionable stage of my life and career, it reinforced for me that the hospital was a great place to be and to work.

    Q: And how did your career progress between then and coming to Salford?

    Dalton: A bit later I went on to be the equivalent of the deputy chief executive of the Radcliffe Infirmary at Oxford. I was keen to look at new ways of doing things—not maintain the status quo, but to look beyond to see what was possible. Afterwards I worked in a district general hospital in London, experiencing the challenges and fun of significant responsibility, without the infrastructure of support I take for granted today. It was also the place where I met my wife.

    After that I went to be—again—the equivalent of the deputy chief executive of St Bartholomew's in London. I stayed at Bart's for five-and-a-half years, then in my early 30s I took my first chief executive post in a small, specialist trust in Liverpool—The Walton Centre for Neurosciences. I loved growing that organisation, and developing a hub-and-spoke service. We were trying to figure out how to serve a population of three million people by distributing service delivery across a very wide geography, and building a referral flow back into the hub. I think we take for granted this model now, but when I arrived in the early 1990s, that wasn't how things were done anywhere. Everybody funneled into the specialist center, and had to travel many miles to get there.

    My time at the Walton Centre was characterised by my relationships with the staff. Some of the relationships I had with the senior clinical and other staff there still exist now. It's refreshing that those personal friendships have endured through the NHS for so long.

    On quality

    Q: I'd like to pivot a bit. We've studied a lot of organisations who have sustained high quality over time, and the stories are eerily similar. In almost every case, someone at the leadership level, or a group at the leadership level, has an experience that becomes a catalyst for embarking upon a very ambitious quality goal. Have you had this moment? And if so, how important was it?

    Dalton: Oh, incredibly important. The one I'm thinking of was shared by the leadership team. We had this idea of being the 'safest organisation' in the NHS and being really open about it by first telling people how much harm they experience from Salford. We put banners in our entrance area that said 'Salford Royal harms 850 patients per month, 10,000 per year'. The staff was really concerned about what we were doing, telling everyone we harmed 10,000 patients a year. But from there we shifted and told the story of what we were going to do about that harm. The focus was on the solution, not the problem. It elevated quality more than we ever had before. This really changed how we thought about care on a day-to-day basis—everything was about quality. We really involved staff by getting them to contribute their ideas and testing and measuring if they led to an improvement. This is the hallmark of our approach to our improvement methodology. 

    Q: One more on quality—the Institute for Healthcare Improvement (IHI) has taught their methodology on quality, as have plenty of others, so much so that it's available to virtually everyone. And yet there aren't many other organisations that are at the level of quality that your organisation is. Why do you think other organisations may be struggling, given that the knowledge exists and is open to everyone?

    Dalton: It's probably linked back to longevity of the leadership and sticking with it for years and years. I think things like quality improvement become fashionable and people get enthusiastic, but then that excitement wanes over time. I know for a fact that we have ebbed and flowed in our enthusiasm on it at Salford. So, you have to re-energise the organisation to continue with it as a theme. We've been at this now for almost nine years, and it's difficult—particularly with external conditions like funding being out of our control—for us to remain as focused as we were six, seven, or eight years ago. It's still thriving because the people who began this work are still here and have the memory of the time we implemented the change. So they remain stewards of what it was that we wanted to put in place and can now see it in place.

    Now we are progressing as part of a hospital group because we know that if we can do things well in Salford and there are approaches and methods that are in fact best practice, that it's possible to codify and replicate them at other organisations. We see this new model as a way of helping to stabilise other organisations, developing their standard operating model. And in the years to come, hopefully seeing some growth in the development of the group.

    Q: You're overseeing other hospitals now in a combined system in Manchester. What are the first steps in bringing this quality model into those systems?

    Dalton: First, it helps to bring clarity to the organisations involved by ensuring that their leadership and governance frameworks are fit-for-purpose. Early on there was no distributed local leadership, so I decided to break the Trust up into its component parts—called Care Organisations—in each of the localities. Then we appointed local leadership teams with the chief officer and the medical director, nurse director, and the finance director. Getting this strong, distributed local leadership structure implemented has been really important.

    Second, there are aspects of Salford's standard operating model which need to be deployed into the Care Organisations. We're still early days, proving that we can replicate its standards of service. But so far, so good. We know we have deficits and financial difficulties to attend to, but we know we will fix these in time.

    On people

    Q: Earlier you mentioned your relationships at the Walton Centre. Not all executives have great relationships with the consultant staff. What's your secret?

    Dalton: Across my career I've tried to embed a distributed leadership arrangement to enable relationship building. This gets people—particularly the medical staff—very much involved in leadership and gives them a real sense of ownership of the organisation. It lets them become part of its development.

    I also take the time to listen. When staff want to see me because they're concerned about something, I will find the time to do it. If I'm busy when they want to see me, I will call them in the evening. I like to get to know people, to look through their lens and get a sense for what it is that they're dealing with.

    I’m thankful that their view of me is that I'm someone who listens and will be straightforward with them. I always try to work with them to devise a way in which we can either overcome a problem or see some improvements together. It's about creating a shared agenda with the people who often commit their whole career to an institution and want to be involved in making it better.

    And now I've been at Salford for 17 years, and I realise that I'm one of a handful in the UK who has this longevity of a relationship with their organisation. All the issues, all the problems, all the successes here—I've been part of them and people know that I've committed myself to the organisation. People have an opinion about me because they've got a relationship with me.

    Q: I read that sometimes you ask consultants whether they work for the organisation or at the organisation. Can you expand on that a bit?

    Dalton: I'm really interested in the accountability that clinical staff have to their employer. I use that just to illustrate the fact that when I hear people talk about their work, they'll usually say 'I work at Salford Royal'. Very rarely do clinical staff say they work for Salford Royal. The mindset around accountability is important to think about if you want it to engage people in a different way.

    This is a conversation that we must continue to have in our organisation since all of the time that we spend devising our plans and policies is meaningless if we don't have an organisational arrangement which ensures that what's done at the board is connected to what the people do in their day-to-day work. We must ensure that every individual and team contribution is aligned to the goals and values of the organisation.

    Q: One more adage—a similar vein, I also read that you said 'we in health care are in the bird business, not the stone business.' What does that mean?

    Dalton: That isn't my own saying, but it's something I heard a long time ago and have really believed in ever since. This is tied to my naiveté in my younger years when I thought management was quite clear—you said what you wanted, planned things out over time, and achieved your goals over time without a hitch. But that isn't accurate at all. Some managers think that if they throw the stone, they can look at the velocity, the distance, the speed, and know where it's going to land. They think they have it all down to a science.

    There's a bit of that in management, but the more accurate analogy of complex, adaptive systems like ours is that you throw a bird, and it can take flight on its own and go in whatever direction it chooses. You just have to help guide the bird to where you want it to go.

    So you need to understand the type of organisation you're running. Your ability to direct things—speed, distance, velocity and so on—is nowhere near the reality of leading a health care organisation with professional staff, thousands of people, microsystems, etc. I use the stone-bird analogy to describe the mere fact that planning in this environment is really, really hard.

    Q: You mentioned how large your organisation is—tens of thousands of staff. How do you connect with all of these people? Because I note that you don't seem to use social media?

    Dalton: Yeah I never got into social media. In my mind, if I want to communicate effectively, I try to be present and have visibility. In January I took responsibility for all the operational management issues across our five hospitals and community services. And that means that I have to be out in the areas where we don't have reliability in our systems. I visit the EDs; I meet and talk with staff; I show up to the acute assessment units; I stop in on the weekends to hear what our middle managers have to say.

    It's this personal visibility and contact, knowing that people are seeing me, that I think is key. I'm not so naive to think that by visiting the emergency department in one of the hospitals one day a month means that all 17,000 staff will see me—of course they won't. So I write a good amount, and I do video blogs that are made available to everyone. And I keep it frequent, so they have a sense that I'm attaching importance to communication.

    Looking forward

    Q: Your success across the last 10 years has led to NHS requests for you to take on bigger roles at bigger organisations. How have you approached those decisions?

    Dalton: You're right, I have been approached about some interesting positions in and out of this country. But in the end, I always come back to a sense of duty I have here to something I feel deeply connected to. I want to be part of ours new group's development—developing a standard operating model, getting the best practice put into practice, reliably, across multiple care organisations. Plus I enjoy it, and I see it as the natural progression for me. At some point I'll have to exit the stage, but by then there will be many people who will be part of all of this work to take it forward.

    The other equally important consideration is my personal and family life. I discuss opportunities with my wife, and we're content where we are, where we live, with our circle of friends, and our roots in our local community. And that's important to me. Of course there's a part of me that finds these new roles appealing, but when I put it in context of what I'm doing here and what I want to continue doing, and the stability of where we are, I don't want to leave.

    Q: In closing, you've got to write the press release for the Northern Health Alliance for one year from today. What does it say? 

    Dalton: I would hopefully be able to say that the Northern Health Alliance has been able to do what it set out to do, which is to improve the quality of the services in our localities. That there is now a higher level of reliability and that staff are proud of their contribution. It would be a story about affecting some positive change, showing that the sun is starting to come out from behind the clouds and it feels warmer. Within a year, it's unlikely we’ll be able to say the sun shines every day, but I think that those warm rays will be felt even in the 'hard to reach' areas.

    If I could add a footnote to that story—I hope in a year's time that the group has grown and has associated itself with other organisations, then that would be great. It would show that our family is growing and that it has been worthwhile. 

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