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The Issues at Mid Staffs NHS Governance Report

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Updated: Jun 27th, 2020

Introduction

Leadership can either make or break the success of an organisation. Priorities that leaders have towards the achievement of organisational goals influence both the followers and the organisation’s reputation. Companies have adopted various theories of leadership such as contingency hypothesis, transformational theory, situational theory, and path-goal theory. Working from a particular theory dictates the principles and values that the leadership upholds. This paper seeks to analyse the issues at Mid Staffs (Trust). The aim is to give an insight on principles and theories of leadership that the institution applies. The analysis further recommends the best practice theory and principles that can help the organisation out of the problem.

The History of Governance Crises at Mid Staffs

The history of the governance crises at Mid Staffs can be traced back to 2004 when the Trust lost the star rating (Duffin 2010). The commission for health Improvement (CHI) reported a drop in rating standards of the Trust. According to Carter (2013), the 2004 report indicated that the Trust had dropped from the three-star status to the zero status. Dean (2011a) points to the fact that the drop in rating was attributed to the Trust’s failure in meeting the set targets in elective surgery, waiting time for cancer, poor financial performance, and the time that patients took while waiting. Triggle (2014) observes that since the Staffordshire Health Authority (SHA) depended on the star rating in measuring its service quality, the Trust set up a plan to recover the star rating. However, officials in the plan were not concerned. They assumed that the drop in rating was attributed to bad record keeping. Officials then relied on a balanced scorecard foregoing the star rating. This ought to have raised an alarm. Secondly, Duffin (2010) observes that in 2005 and 2006 peer reviews highlighted several intriguing concerns that indicated that there was a problem with the ability of the Trust in service delivery.

The reviews also indicated that the management of the Trust was incompetent. Thirdly, Carter (2013) observes that HCC national review indicated that the Trust failed to meet patient and Trust expectations in 2006. In an effort to compromise this situation, the Trust claimed that inability to meet public and patients expectations was caused by non-submitted data. Fourthly, according to Dean (2014), auditor reports indicated major shortcomings in risk management by the Trust. The report indicated that the accuracy and dependability of Trust’s assurance were questionable. The implication of this situation was incompetence of the management. Fifthly, Iven (2010) affirms that surveys by Picker Institute in 2007 confirmed that the Trust was among the 20% worst performing category in the country. Sixthly, in 2007, a whistle blowing report by the staff nurses on leadership was made. However, the Trust management did not resolve the issue at hand. The Royal College of Nursing (RCN) failed to inform the management of the Trust officially. In addition, Dean (2014) reveals how a 2007 report by Royal College of Surgeons (RCS) termed the surgical department of the Trust as dysfunctional.

However, this claim did not awaken the action of regulators. Moreover, the Trust had started a staff cut. Authorities did not question the impact of such a move on service quality. Ignorance of actions that were being undertaken by the Trust resulted in escalation of the problem. Application for Foundation Trust (FT) by the Trust focused on financial status rather than quality. This plan formed another loophole for identification of the escalating quality standards in the Trust. The officials of SHA that was promoting the status of the Trust were aware of the problem of quality and poor management. However, they ignored the case. According to Iven (2010), the pursuit of the promotion of the Trust was therefore made based on finance but not on complete analysis of status. This observation meant that quality and leadership problems in the Trust would not be addressed. Finally, according to Bruce (2013), the background of the problem of Staffordshire Trust is also attributed to the HCC investigation report. This report was accused of being selective. It only addressed the most serious issues in the Trust. This caused laxity in other organs in the Trust that relaxed waiting for the investigator to point at issues that were more important relative to others and/or issues that warranted action. This move resulted in confusion and further escalation of the problems that the Trust was facing.

Kaufman and McCaughan (2013) assert that the impact of all actions was the development of negative culture in the Trust. Since the management did not act swiftly on the arising problems, employees developed laxity. They did not care reporting the problems or raising alarm. For example, according to Hamilton (2013), leaders of Stafford Trust did not appreciate the problems that the Trust was facing, thus resulting in more escalation. Professional disengagement also resulted from failure of the board and the leadership to pursue change. For example, clinicians in the Trust approached the problems they faced with little efforts. Gilam (2013) confirms that employees and management worked from different approaches, a move that attracted conflict and lack of teamwork. The Trust also began facing complaints from customers. Patients complained that leaders and clinicians did not listen to them. Gilam (2013) says that the Trust did not put mechanisms to resolve customer complaints.

Disconnection between the board and clinicians denied the management understanding of what was happening to patients. This scenario worsened the situation. Moreover, poor governance also resulted from the gap between the management and clinicians. According to Bassett (2012), the Trust board failed to account and/or govern the structure of the organisation during the founding years of the problem between 2004 and 2005. Dean (2011b) observes that the board and clinicians delayed in assessing and acting on major risks, for example in addressing the problem of inadequate skilled nurses. Finally, the outcome of shortcomings in the Trust also compromised the standards of nursing and performance of health workers. Poor recruitment, training, and equipping of nurses were evident in the Trust. The situation resulted in poor service delivery.

Analysis of Governance and Leadership Issues

Governance and leadership issues are at the heart of the failure of the Staffordshire Trust. One of the governance issues that come out clearly is development of a negative culture in the organisation. According to Triggle (2013a), the leadership of this Trust had access to various warning signs concerning failure of the Trust to meet quality standards and/or to meet patients’ complaints. However, the leadership department decided not to act on the problems or underrate their significance by concentrating on other issues such as finance. Kaufman and McCaughan (2013) affirm that leadership has a role in cultivating and developing the culture of an organisation. The leaders should have cultivated a culture of openness and sensitivity to issues of quality. The principle of quick response to issues would have ensured no piling up of problems to the extent of shocking the government and public.

Another leadership issue that comes out clearly in this report is the failure of the leaders and board to listen to patients’ issues. Dean (2009) asserts that it is evident that leaders of this Trust had a poor culture of ignoring the views and complaints of their clients. In fact, the management never established structures of dealing with patients’ complaints. Triggle (2014) confirms that several surveys were conducted on patients and employees of the Trust. The results showed that patients were dissatisfied with the management of the Trust. However, in spite of having access to such reports, the management did not act. Clients of any organisation make the organisation remain in business. Paying less attention to their views portrays a culture of ignorance and inverted priorities in the Trust. The Trust’s leadership ought to have had a strong customer affairs department or structures that would have addressed the issues. As a principle, leaders should listen to their followers and/or act on the problems with diligence.

The issue of leadership disconnection is also demonstrated by the poor way in which the board of management governed the Trust. As Bassett (2012) observes, the report indicates that the board was not accountable to actions that took place in the organisation between 2004 and 2005. For example, the leadership resisted clinical governance that was targeted at improving the Trust’s efficiency by 2009. This move resulted in fear and reluctance by clinicians to report problems to the management. As a result, the leadership did not have access to adequate information about the issues of concern in the organisation (Dean 2009). Leaders should cultivate a culture of openness that allows access to information. They should deploy a two-way communication policy that permeates the leadership structure, thus acting as an antenna to sense information. As a principle, a good leader should be an effective communicator.

Fariha (2013) observes that poor governance was evident in terms of lack of focus on the standards of service delivery in the organisation. The management of the Trust mainly focused on financial gains, thereby ignoring the quality of standards. Greed for monetary gains by the management resulted in poor sensitivity to risky issues of standards. Quality of service delivery appeals directly to the clients. Hence, the management should have prioritised it. In addition, Parish (2013) affirms that although the management concentrated its efforts on finances, the Trust was one of the worst financial performers in the country. This observation is an indication of the inability of the board to govern in the leadership. The board also imposed certain economies to the organisation that failed to flourish. The governance principle of foresight was evidently absent in the board.

According to Triggle (2013b), the management also failed to maintain good nursing standards and performance. Poor management of staff policies in the Trust resulted in poor nursing services in the wards. Triggle (2013b) reveals that nurses were inadequate to attend to patients. Besides, they were poorly trained on handling of patients. Therefore, they made the whole system seem to have failed. Leadership is in charge of recruiting the most qualified and equipped employees. It is also the responsibility of the management to ensure employee growth through training and workshops. However, the board of management at Staffordshire failed. Dean (2011b) observes that although nurses reported the problems they faced in the wards, the leadership did nothing to salvage the situation. This case resulted in unmotivated nurses as indicated by the findings of several surveys in the report. Finally, Dynil (2013) observes that the leadership completely failed in goal setting. Prioritising of issues seemed to defeat its competence. For example, the board prioritised financial stability and/or gaining of a foundation status whilst ignoring the most important issues such as quality of service and patients. This observation was a complete lack of foresight in the leadership. Gormley (2010) asserts that governance principles of charisma and involvement of followers were less observed by the management. Hence, the disconnection between them and the nurses resulted in failure of the whole system.

Theories of Leadership

Various leadership theories can be associated with the leadership in Staffordshire Trust. One of such theories is the contingency theory of leadership. According to the theory, there is no one best way to lead an organisation, to organise it, or even to make decisions since decisions are made according to the state of affairs (Tyssen, Wald, & Spieth 2013). In contingency leadership, actions that the leadership takes are fully dependent on the available internal and external environment (Wooton 1977). In the Staffordshire Trust, the board of management seems to be operating based on this theory. For example, Latham (2014) observes that the management appreciates the need for the Trust to acquire the foundation’s status. The appreciation makes the institution fully focused on factors that will enable it succeed at the expense of all other affairs of the organisation. The management department ensured that financial positions would enable it to get this position. It even took action to cut staff nurses, thus leaving inadequate staff members to attend to patients in the ward. The board of management also paid lip service to clients and employees that it would manage the situation but immediately focus attention on finances. According to Malik (2012), this contingent approach followed the wrong priorities. The management also failed to make decisions early enough concerning how to solve its problems. For example, it was not able to predict the consequences of failing to act on patients and employee complaints. According to a survey by McClesky (2014), it was indecisive in terms of acting as evidenced by the low employee morale.

This situation was attributed to the assumption in the contingent theory that no best way could be adopted to make decisions since such decisions had to be made according to the environment or issue at hand. Triggle (2013c) affirms that the management of the Trust handled decisions wrongs. Failure of the applicability of this theory in leadership could be attributed to the poor relationship that existed between the leaders and members (Malik 2012). For example, poor relations between the board of management and the clinicians resulted in poor information flow. Sprinks (2010) asserts that the relationship between the leaders and the nurses was also a cause of failure. Success of the contingency theory also depends on how well the task is structured. In this case, the work of the nurses and clinicians was well established. However, the leadership failed in facilitating them. As a result, the Trust suffered poor communication. Wooton (1977) also confirms another determinant of success in the contingency model of leadership, namely leaders’ position power. In this case, leaders of the Staffordshire Trust were well empowered by the Trust’s policies. However, their pursuit for finances and foundation status made them fail to lead the institution towards success.

Another leadership theory that is applicable in this situation is the path-goal theory that was developed by Robert House (1971). According to the theory, followers will only be satisfied with a leader when they feel that his or her behaviour will lead them to their contentment. In this theory, satisfaction of the subordinates is only achieved if they feel that their leader supports them in their efforts to achieve individual and organisational goals. According to Tyssen, Wald, and Spieth (2013), the path-goal theory further affirms that if goals are understandable, there will be less need for guidance from the leader. In the case of the Staffordshire Trust, the subordinate staff members were not satisfied with the behaviour of the leadership. For example, Gormley (2010) observes how clinicians complained about poor working conditions to the management. Besides, little was done to solve their complaints. In the same case, nurses reported their dissatisfaction with the management of the Trust in different survey reports, although the management did not act on their complaints. Dean (2010) mentions that although the goals of the nurses and that of clinicians may have been clearly set in their job structures, the leadership failed to enable their accomplishment. Sprinks (2010) reveals how the board of management did not support the subordinates in achieving their set goals. The behaviour of the board resulted in a culture of employee disengagement. Employees did not bother to report any incident to the leadership since they believed that they would not act. According to Parish (2013), the existence of a divide between leadership and employees resulted in patients’ complaints on service delivery.

Recommendations for the Development of Governance and Leadership in Mid Staffs

Caillier (2014) asserts that transformational leadership theory that was developed by James Macgregor Burns can be used to salvage the situation at Mid Staffs. According to this theory, followers’ morale and motivation can be enhanced in order to instil a sense of responsibility, teamwork, and organisational identity. The leadership acts as role model in the work setting. Followers are motivated through rewards and recognition. Their empowerment is done through allocation of more responsibilities and higher job involvement. Besides, tasks are aligned with their qualifications. Followers are also occasionally trained and refreshed to fit well in their jobs. McClesky (2014) affirms that leadership and governance in Mid Staff can be developed to achieve the goals of the Trust and/or meet employee and patients’ needs. Firstly, the various principles of leadership that the management failed to engage have to be revamped (Kendall 2010). For example, proper communication lines and structures need to be established in the Trust. Communication is at the heart of good governance.

Access to information through open door policy and proper listening ensures that communication between the leadership and employees is successful. The management should not impose its rules and policies on followers. Instead, it should seek their input and act on them. According to Kendall (2010), the problem of employee disengagement can be resolved through the establishment of functional communication in the organisation. The contingency theory that was applied by the management of the trust should therefore be abandoned. Communication between the management and patients also need to be reorganised. In several reports, clients complained of poor governance and services in the Trust. However, the board failed to act on complaints. Successful communication is a two-way process. Hence, feedback is important. Action-oriented leaders will identify themselves with the followers’ needs. The management of Mid Staff failed to connect with its employees and customers. Communication can solve this problem. Dean (2010) asserts that governance principle of valuing the customer should also be prioritised in the organisation. The management of Mid Staff failed to listen to customers, a situation that resulted in a wider cause of alarm in the country. Customers make an organisations remain in business.

The management should therefore be trained on the value of the customer and the importance of listening to them. According to Latham (2014), assessment of risk factors should also be done in advance to prevent loss of money and/or soiling of the institution’s reputation. For example, before staff reduction or enlargement, the board should engage experts on human resource issues. Well-trained and qualified nurses should also be hired to guarantee high standard services. Nurses and clinicians should also be occasionally trained and refreshed in workshops. The standards of service should not be compromised with pursuit of profit. In a health institution, standards are a priority that should be withheld. The Trust should therefore reorganise its priorities. For example, human life is more important than money and status. Transformational leadership will therefore be witnessed if the board of management in the Trust motivates nurses and clinicians. All stakeholders need to work together as a team. This work plan will result in better standards of service delivery and patient satisfaction.

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