Leadership Counts

15 September 2007

Hospital cleaning and quality of patient care are rarely out of the headlines, but recent
research reveals why some hospitals perform better and achieve high higher standards
than others. Dr Rachel MacDonald and Prof If Price explain what they have found

IN RESPONSE TO THE FINDINGS OF PUBLIC CONSULTATION and the subsequent publication of the NHS Plan (2000), The Department of Health launched the Hospitals Clean Up and Better Hospital Food initiatives. They created a system - known as Patient Environment Action Teams (PEAT) - to inspect hospitals against a set of criteria that included the built environment and its maintenance, food, linen, catering etc. The results of the inspections were linked to a Trust’s overall performance and, consequently, to its ability to apply for Foundation Trust status. The link to the Trust’s performance rating put the quality of FM services firmly in the spotlight after years of market testing, competitive tendering and cost cutting.

Yet after three rounds of annual PEAT inspections only 15 non-specialist acute Trusts had delivered consistently high standards at all their hospital sites. Establishing what, if anything, they had in common became the research objective for a recently completed Doctorate in Business Administration (DBA) at Sheffield Hallam University FMGC. We could not find common external influences that might have given particular Trusts an advantage nor could we find common organisational factors. Some had Facilities Directorates, some did not. Some contracted out soft FM; others did not. Some were in inner cities; others were rural, and so the list went on. If there was to be a common explanation we concluded it must be internal. Were the responsible managers leading, differently?

Not all the trusts wanted to participate. Rachel Macdonald talked to, and observed 22 FM manager (directors, senior and operational) at six of the 15 Trusts. The results were analysed using a Grounded Methodology. Ten common themes of leadership appeared:

1. Pride and commitment – these individuals were proud of the services delivered by their teams, proud of their teams and their hospitals and proud of the contribution made by FM to those accessing services within the hospital. However, they themselves were quite humble and talked down their contribution and accredited success to their teams. They were very committed to their local community and the need for the hospital to retain the trust and faith of those that used it.

2. External perspective – the FM Managers were very focused on their local community, and were keen to integrate with that community. This called for different approaches to recruitment, for understanding of the community’s needs and recognition of the skills and attributes that the community had. They spent time and effort on building good solid services and teams adopting those initiatives that helped them do this, and they were less interested in the national scene.

3. Personal style – everyone was keen to emphasise the importance of their personal style. They wanted to project an image of fairness, openness and honesty. Many spoke about being accessible and having an open door. Most of all, they were concerned with using the most appropriate style for the situation and spoke of adapting their style to ensure a fit with the people or the occasion.

4. Luck and other contributory factors – most spoke of their lucky situation; lucky because they had one site/had many sites; lucky at being in the town/country; lucky because they had a new site/an old site they could develop and so on. We knew from our initial research that this claimed ‘luck’ was not actually shared. Many contributory factors were mentioned, for example, a committed CEO, an understanding Finance Director, shared objectives at Executive level, and funding for development projects. None was common across the group. We concluded that the thing they had in common was either modesty and/or positive thinking.

5. Opportunity for personal development – people were very keen to develop their skills and those of all their team members. Their own personal development included taking on work outside the traditional FM arena in order to grow new skills and understanding and using coaches and mentors to improve their understanding of clinical issues. Networks were also seen as a useful way to learn and keep up to date, either within the NHS or as CPD through professional bodies. Learning organisations were encouraged to allow staff to develop and to be rewarded for their interest and commitment to their roles. Basic skill training was seen as a must with NVQ’s being used widely and valued as a development tool.

6. Maximising the contribution from FM staff – the contribution of staff at all levels was valued, and respected motivating staff and thus enhancing their contribution. Both formal and informal processes encouraged staff to engage with service planning and improvement. We observed FM Managers talking and interacting with staff and respect from both parties was plain to see. Reward systems and recognition events were seen as key at many of the Trusts, underpinned by more informal feedback and praise on an everyday basis.

7. Maximising the contribution from the contractor’s team – where contractors were used, the FMs' approach did not change. Quality monitoring systems were identical and one Trust had training criteria as part of their contract and performance monitoring system. Every effort was made to ensure that the contractors’ staff felt part of the hospital and the hospital staff were encouraged to behave in the same way.

8. Stability, Experience and Change – those we spoke to took an interesting approach to this topic. They valued stability and thought that the experience of their team members enabled them to provide a better service. Yet they were excited and motivated by change, constantly seeking to find improvements in their services and the value for money that offered. One described change as “the cherry on the cake”. These eight themes of leadership can be found in the general literature on leadership (which is heavily biased towards Chief Executives or equivalent). However, it was notable that this group of FM managers were not only ‘leading but also ‘managing’ in the sense of paying attention to detail and ensuring systems and processes worked. They enacted both the role of the leader and that of the manager rather than the either / or distinction which popular business literature and much academic writing likes to emphasise. The research also evidenced two additional behaviours that are less commonly noted in existing literature

9. Integration with Clinical Teams, and

10. Integration with the corporate agenda and the ‘Top Team’. The leaders networked across the clinical and Top Teams in order to maximise the integration of their services. They worked consistently at this integration, being prepared to put much time and effort into it, recognising that they would be the ones who contributed the most. Relationship building takes time and is a slow process. Working at it allowed the FMs to ensure that FM issues remained on the agenda, and indeed became part of other people’s agendas.

These managers were deliberately choosing to manage across boundaries and investing their time building the social networks that underlie integration. They were concerned with the creation of such networks rather than with creating formal structures within the organisation. Although individual members were responsible for particular objectives the networks had little accountability as a group and little or no formal recognition by the organisation: yet they were the means to development of a common purpose. We heard about the PEAT inspection teams which contained people from many disciplines; for example non executive directors, nursing staff, infection control nurses with the FM Manager holding the patient environment target as their objective. The only shared accountability is that eventually all reporting ends with the Chair of the Trust.

The FM Managers’ were not only concerned with how they built and maintained their relationships with others, they also strove for these relationships to be mirrored throughout their area of responsibility. For example, they spoke of domestic staff coming under the supervision of ward managers. Some were prepared to give up day-to-day control of their workforce, accepting all the challenges this would bring, and some built non-formal structures such as zones or created joint FM/nursing cleaning schedules. In their various ways they brought about a physical manifestation (or symbol) of their belief in an integration that facilitated lateral solutions to problems. Such behaviour underlines the reciprocity that is required in order for networks to flourish. FM Managers were interested in and supportive of the clinical teams’ agendas,
eliciting collaboration in turn from those clinical teams. Trust was built through reciprocity.

Such a focus on integration could be seen simply as having a vision and ensuring that followers are recruited to help deliver this vision. However, that is not easily achieved in the complex arena of the NHS with its multiple stakeholders and agendas. We propose that this ability to be an effective strategic broker is where the FM Leaders are using to best advantage their leadership characteristics and attributes as identified in our leadership themes. The language in which these networks were described was not of driving people towards an organisational vision that has been developed from the top. Instead, the FM Managers’ conversations hinted of organisations that have loosened hierarchical control in order to allow networks to flourish, accepting that the organisations’ power to mandate would be weakened.

The networks that the FM Managers created are spun with a web of quiet, consistent conversations, reinforced with the tantalising glitter of symbols, decorations, stories and legends, and take place between leaders and between leaders and followers. The FM Managers spoke of time and effort being spent capturing the hearts and minds of others both laterally and vertically across the organisation. They spun those visionary webs in advantageous places (with clinical teams) at advantageous times (reward events for FM staff, or in meetings to discuss others agendas) to catch the juiciest of flies (members of the Top Team who had the most power and influence). When they were sure of having created this advantage they moved into practical implementation. Mutual adaptation improved the services offered and increasing the interdependence, and thus the bonds, of the network members.

Strategic broker
This research has shown that a leader with all the recognised skills, characteristics and attributes, can make a real impact on the Patient Environment if s/he has the skills, and is either given or earns the right, to take up the role of networker and strategic broker. There are, however, a number of questions that would benefit from further research, of which the key question concerns organisational context. The research, the researchers’ experiences and peer reviews held during the research period suggest leaders such as these may need to work within an organisation that accepted their languages and behaviours. Indeed it suggests that an organisation may attract many managers who share these identified leadership languages and behaviours, keen to run their organisation in a nonhierarchical, networked manner. Alternatively do leaders create their own context? Is the claimed need for a fit between a would be leader and their organisational context only a social defence put forward by those who consider themselves leaders, but have failed to reach the role of the strategic broker?

In 2002, Sheffield Hallam University launched a major research-based qualification designed to create a unique offering of information for the FM industry. Five years later, Rachel Macdonald is one of the first FM professionals to complete the new Doctorate of Business Administration (DBA) in Facilities and Properties Management.

Rachel’s DBA is a significant milestone, achieved after four years of intensive research and with the vital help of sponsorship from FSI, developers of the Concept range of CAFM software. When Director of Facilities Management for the Northern Lincolnshire and Goole Hospitals NHS Trust, she was awarded the first FSI Concept Scholarship - worth £15,000 - to provide the tuition funding for her investigation into why the NHS was not making better use of FM data to improve business performance.

“I did a Masters degree about eight years ago, and I’ve always been interested in researching the ‘hows’ and ‘whys’ of FM, particularly in relation to performance,” she says. “The DBA is a very new qualification as far as FM is concerned. It’s the same level as a PhD, although the research is focused on delivering information to industry rather than academia. I am part of an NHS forum which Sheffield Hallam runs for FMs and I was very excited when they started talking about the DBA and the possibility of a scholarship. Obviously it is an expensive qualification and the NHS is not in a position to spend large amounts of money on an individual in that way. So it was wonderful to hear that FSI was interested in sponsoring someone. I had to prepare a research brief and present my ideas to a panel.”

Rachel’s brief was based around her interest in performance. “I wanted to look at why some acute NHS trusts perform better with their patients’ environment in FM terms, when we all have the same basic resources,” she explains. “I wanted to examine the systems of measurement that might be used. I already had a strong idea that if people had the best possible measurement system, they would be better informed and therefore able to make more informed decisions to improve the way the business operates.”

Her findings will resonate with all FM professionals beyond the healthcare sector, throughout business and industry. “It was all about using the experiences of people I spoke to, and the fruits of my desk and book research, to look at how I, as a leader of facilities, observed what went on and how I could use that to improve my leadership capabilities,” she continues. “The DBA gave me time and access to these teams of leaders working in groups, and seeing how all their personalities fitted together, rather than just tapping into the views of an individual, top, charismatic chief executive. The impact for me as an FM leader has been huge – perhaps even greater than I understood during my research. It actually led to a change of career!”

Rachel decided that in order to give her research the attention it demanded, she would have to reduce her workload, so she moved from her position as Director of FM with an acute trust to take up a part-time position in primary care. Here, she was able to apply her FM skills to clinical service delivery – a neat parallel with the subject of her doctorate. Since completing her DBA, she has returned to a full time role and is now Director of Change Programmes at North East Lincolnshire Primary Care Trust.

“My DBA research let me explore the idea of FM becoming more involved with clinical services, and adding extra value. As a FM, you then become a strategic broker, helping the organisation to deliver the corporate agenda, working with people to design new services and contributing to an environment that is all about encouraging the modernisation of clinical service delivery.”

Rachel says the DBA was extremely hard work, but the vision she has gained as a result of her research has convinced her that FM is rightly moving to the heart of the business, giving FM professionals an exciting opportunity to stake their claim to a place at the top table.

Rachel is grateful for the unique opportunity provided by the FSI Concept Scholarship. She says that even before she embarked on her doctorate, CAFM had featured strongly in her thinking: FM managers need information management systems so that they can report to the board in the board’s language. “I look forward to offering FSI help and support with the information that I have acquired through my research, just as they made such a great opportunity available to me through the scholarship,” she says. “It is good to know that they will benefit from my DBA as well.”

● Professor Price leads research at Sheffield Hallam University's Facilities Management Graduate Centre (FMGC). Dr Macdonald is the former Facilities Director of Northern Lincolnshire and Goole NHS Trust and now works as an independent project manager and visiting research fellow at FMGC. Dr MacDonald’s studies were supported by FSI.