Mary Jane Kornacki, MS, interviews Navina Evans, MBBS, DCH, MRCPsych, Chief Executive for the East London NHS Foundation Trust, recorded live during the 2017 IHI National Forum.
Mary Jane Kornacki: We’re at the IHI National Forum on Quality Improvement in Health Care, and I’m with Navina Evans, who is the Chief Executive of the East London NHS Foundation Trust, a mental health hospital in East London that has been providing a lot of wraparound services in the community to support health in general.
Navina, could you tell us a little bit about your leadership journey and something that you learned along the way that you think is critical to how you lead and that could be helpful to others?
Navina Evans: Sure. I’m a clinician. I’m a doctor. I trained as a doctor. I never actually thought, when I started my career as a doctor, that I would end up being a chief executive of a provider organization, but along the way I was very interested in service development, changing things, making things better for my colleagues and for patients. It was more than seeing a patient and doing my job, and so I took on more and more tasks, management tasks, or leadership tasks as I went along.
In the organization that I worked in at the time, which is the one I now lead, there was a real drive to have clinical leaders responsible for delivery of care. In the English NHS [National Health Service], at the time when I was working there, there was a kind of separation between what clinicians did and what management did. There was a management and clinician divide, and it was getting to the point where our leadership felt that we needed to bring that closer together. We pay clinicians an awful lot of money and we should get our money’s worth from them. Also, they had a lot of solutions for problems that we faced and they often would stand on the sidelines commenting or giving an analysis, but then sit back and expect managers to solve problems.
In our organization, our previous chief executive made a policy decision to have clinical accountability and leadership for delivery of our outcomes, and that included things like finances, performance indicators, quality indicators, managing risk, and all of those things. It was through that process that I gradually found myself in a leadership management type role. It just sort of played to my strengths.
Kornacki: He was really trying to bring together those two seemingly disparate parts of the care delivery system, the management and the clinicians, and pull them closer together, giving clinicians a greater voice in how things were run.
Evans: That’s right.
Kornacki: It appealed to you and you stepped in.
Evans: That’s right, and greater accountability as well. So that’s how it happened, and it progressed through that. I enjoyed it, I found it interesting, I found it rewarding. The other important thing is that I had, at various stages of my career, you might call them mentors, or sponsors, or supervisors — it was interchangeable, really — all along the way. They said, “I’m going to push you towards this. Why don’t you think about this, why don’t you do that?” It wasn’t a formal program as such; it happened in an informal way and I was curious and happy to be guided. That’s how I got to this place, in the end.
Kornacki: Great. Top of the organization.
Kornacki: When you think back to some of the lessons or advice that were shared with you, does anything come to mind that sticks with you that continues to be the way you lead?
Evans: There are three things that come to mind. One is to listen hard, and I try hard to listen to people and at places that I wouldn’t normally go — not wanting to hear the stuff that makes me feel okay, but the stuff that might make me feel uncomfortable. That was good advice, so I would seek out those, what we call in England whingers, but actually the whingers have got something quite helpful to say. If 50 people are whinging about the same thing there’s something going on there. So that’s really important, the listening aspect of it.
The second thing, for me, is grabbing opportunities to have a go, as we say. So not thinking, “This is unusual. I haven’t got a great deal of experience here.” But, “I will try and I will make sure I’ve got the right support around me” — a kind of experiential or learning on the job as opposed to going away and sitting in a classroom, and reading lots of papers, and writing a thesis. I found that really helpful and really useful.
The third thing, for me, was once I started to develop a partnership and conversations with patients. I did that myself, talking to patients about what works, what doesn’t work, what they want, what we should be doing differently, and talking to patients about when we get things wrong and being transparent and open about it. “This was a mess, sorry. Can you help me? How could we have done this differently?” Most of the time there was going to be one occasion where a patient just was so angry they wanted punishment, they wanted —
Evans: Revenge. But really, the rest of the time it was all about, “Okay, this is what was terrible, terrible, terrible. This is how you could’ve done things differently.” Those were the key points for me.
As an example of the listening and learning, listening to something quite difficult, we have a system where the doctors, [if] there’d be serious incidents they’d have to be investigated. It’s important that we learn from those lessons. And we try hard to be a no-blame organization, because it is my belief that the reasons things go wrong is usually a process or a system issue, not an individual [issue]. Very rarely is it incompetence or negligence.
I take pride in the fact that that is how I run my organization. I went to a meeting where my fantastic senior doctors wanted me to sit there and listen to how they didn’t feel that. They felt blamed. One of them said [the organization] didn’t defend our honor, and I was shocked to hear that. It made me think, well, how can you say defend your honor? Against whom? And defend their honor against patients? But these were people who cared deeply about patients. I know they would advocate for patients, yet in that situation they felt that the patient was “the enemy.” That was terribly painful and difficult for me to hear, especially when I have worked so hard to engage with my senior doctors.
I didn’t say anything. I went away. I spent a lot of time thinking about it. I have an advisor, a facilitator, who’s outside of the organization, and he said, “They want you to hear how hard they’re working. That’s one thing, and sit with it. [I said,] “Yes, I can do that. “But also,” [he said,] “you need to listen. Is there something in the system that you need to go back and look at, and review?” And one of [the doctors] said, “When you write the report, you write a letter back to a patient who made a complaint and you say, ‘Thank you so much for raising this issue. It’s been so helpful.’” And they said it in this sarcastic voice, and that starting the letter with that made them feel that we were already admitting that they had done something wrong, which was interesting because I also see it from the patient’s point of view.
I have thought long and hard about that, and I have a little group of senior doctors now, who are my advisors. I sat with them and said, “How would you write this letter back to the patient, and how would you like to be supported during an investigation?” One of the things we do is that when an incident happens, I always phone the senior clinician. “This is awful. Are you okay?” They’re always very happy and grateful and appreciative of that, and then I say to them, “If you need anything, give me a call, or give the chief medical officer a call, and we’ll make sure that you’re properly supported.” They never do.
And I realized, why would they? Because it’s an admission of weakness, admission of something. So I spoke to a couple of them, and I said, “From now on, I’m not going to say, ‘Call me or call the chief medical officer.’ I’m going to say, ‘Three sessions of support with so-and-so is compulsory. We don’t have many things that are compulsory in our organization, but it’s going to be there for you to just have three sessions to talk to someone about how you feel about that incident.’”
So there’s an example for you.
Kornacki: It’s brilliant, because I think it’s listening hard, it’s reflecting on your own contribution, and it’s going back and working with a small group of people to help reshape the process. Also recognizing that it’s very, very hard for clinicians, especially more senior clinicians, to ask for help and taking that off the table, saying something like, “Here is something that is provided for you. You don’t need to ask for help.” So you take that away.
Evans: Yes. That’s right.
Kornacki: That’s a great story. I think people will get some good learning out of that.
You mentioned that there was a time that you weren’t your best self, perhaps, or that you really learned an important lesson by something that didn’t happen. Can you talk about that?
Evans: Sure. As an executive chief operating officer, we had a situation where we had mixed-sex wards, mixed gender, and we were going to single-sex accommodation. In mental health, as a woman, I feel that’s really important; I feel strongly about women being looked after in single-sex accommodation. We’d done it in most places, but there was one particular part of our organization where, the consultants, who were all very good — mostly men, in fact virtually all of them men — this would’ve been too difficult to organize, the layout of the wards, the configuration, their time tables, their ward rounds, their clinics. It would’ve meant a great deal of inconvenience, so they were very resistant to this happening. And my boss, my chief executive — a very wise man who I admire greatly, who took very wise decisions —felt that now is not the time to tackle this head on with these guys.
We’ll leave it, because they’re doing well. The bed occupancy is low, all their outputs are good, we’ve got goodwill, we’ve got them on site, let’s just leave it. And I felt very upset and uncomfortable about it. But he’s the boss, so we left it and we carried on elsewhere. That went on for about a year and a half, and then there was an incident, and we had potentially a care quality commission looking into it, and then he was able to go back to this group of senior clinicians, talk to them, and they changed things.
For a year and a half, I allowed for many women to be cared for in that environment, and there was one incident. It wasn’t hugely serious, but it was still an incident, and as a woman I questioned why I let that happen and why I didn’t speak up and make it happen, because I got on very well with [my boss], and he would’ve listened to me, I think, in the end, if I had had the courage to sit down and appeal to that side of him, which I know is there. I would have liked to have done that differently.
Kornacki: So the key advice is, don’t give up when you feel strongly.
Evans: Don’t give up when you feel strongly. Also, I think if I’d gone and had a big row with him, or accused him of being sexist, or whatever, that wouldn’t’ve helped, so to find a way of understanding what his concerns were — he was very worried that we would lose something in pushing this too far — and maybe finding a way of talking to him about how we could still get it done and preserve the goodwill that we had.
Kornacki: Right. Courage is key for leadership.
Evans: Absolutely. Absolutely.
Kornacki: Great. I want to thank you very much.
Evans: Thank you.
This story was recorded live at the Institute for Healthcare Improvement’s 29th Annual National Forum in Orlando, Florida, on December 10–13, 2017, by Mary Jane Kornacki on behalf of NEJM Catalyst. We wish to thank IHI for support of this project, especially Madge Kaplan for her technical advice and guidance. Click here for more Lessons in Leadership stories.