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James Mountford is Director of Quality at the Royal Free London NHS Foundation Trust, which has a multiyear programme focused on embedding quality and value improvement into routine practice, reducing unwarranted variation in care delivery and ensuring improvement efforts address what matters to staff as well as patients, families and populations.
James worked initially as an NHS doctor, then in consulting. From 2005 to 2007, he was a Commonwealth Fund/Health Foundation Harkness Fellow based at Massachusetts General Hospital, and at the Institute for Healthcare Improvement (IHI), both in Boston, USA. Before moving to the Royal Free, James was Director of Quality at UCLPartners, an academic health sciences partnership serving a population of 3 million, in and around London.
He is the editor-in-chief of the journal BMJLeader and sits on the board of AQuA, the improvement partnership based in north-west England. In March 2020 he was seconded to work as the Chief of Quality and Learning at the NHS Nightingale Hospital London, opened in response to the COVID-19 pandemic.
First and foremost, are there any key leadership messages you want to get out to our readership?
When a crisis like this happens, it changes the style of leadership that is called for. We need command and control leadership mixed with extreme clarity, kindness and compassion.
It’s also really critical to make sure the right hand knows what the left hand is doing. The temptation is to rush into action, but it’s important to pause first, to define the problem better, to figure out who might have a better solution for it—or may already be solving it—and to communicate the plan well, while appreciating that no plan survives contact with reality.
So this is not the time for ‘heroic’ leaders. At NHS Nightingale London, where I have been seconded to lead the Quality and Learning function, we are developing a philosophy of ‘peloton leadership’, meaning that we all need to take turns leading at the front, while other leaders get a chance to catch their breath and get ready for their next push. We feel really strongly that leadership from the whole team is essential, and that ‘heroic leadership’ would lead to burnout and possibly worse.
Tell us a little about your leadership role and how it is changing as a result of the pandemic?
Until Nightingale, as Director of Quality at the Royal Free London, my role focused on building a system of continuous improvement and learning into daily work—clinical and non-clinical. On the one hand the COVID-19 pandemic has stopped that kind of programme—our workshops, formal teaching, and many improvement projects have all had to stop. On the other hand, what lies at the heart of what we are trying to achieve through this work is helping people—to define what matters, to shape how they perceive things, and to learn best from experience. This way of thinking and working is exactly what we need in order to respond to the pandemic.
At Royal Free London, the improvement team has responded to COVID-19 in a range of ways. Clinically trained people have gone back to clinical duties, while other team members have set up an incident response centre, the role of which has evolved rapidly—supporting both staff and the public. Our first priority was to provide a single point of contact initially that staff could turn to for support, but we then developed a single point of contact for the public too, as the hospital has been contacted by lots of people wanting to donate food, their time, or other resources to the Trust. Our second priority has been to do more about staff welfare. We had been running a collaborative across 15 teams to improve ‘Joy in Work’. Of course, the title seems off-base now, but the core of the work, which is about caring for colleagues, understanding what matters most to them, and whenever possible doing more of that, is more important than ever.
On 25 March I was seconded to the London Nightingale Hospital to lead on embedding continuous learning into the way the hospital works. Most people will know this has involved turning a massive conference centre into a hospital with up to 4000 beds. It opened to patients 2 weeks after initial planning. Achieving that required leaders to show extraordinary consistency, visibility and focus—to an extent that I’d never experienced before. As a leader it has been astonishing to witness and to be part of. Much of the success so far is due to the collaboration with the military, whose leadership approach to clarity of task, clarity of mission, delegation of responsibility, execution and compassion is impressive to see. There is much learning I will bring to my future work from what I’ve seen the military do here.
My team’s role has been to define a model of continuous learning that will sit in the heart of Nightingale’s operational model, alongside more traditional reporting and incident management. Learning from what staff see and experience during their shifts will be rapidly worked into our protocols. We have two mantras; first, to get the best information possible to caregivers while doing nothing to make their lives harder; second, to really look after staff, so they can look after the patients. For example: ensuring that at induction staff learn about the challenges of communicating while wearing PPE; that staff have a range of options (from an informal ‘chat’ to much deeper psychological support) available to them to bolster their well-being; that staff know the feedback and ideas they give are heard and where possible enacted.
We will make errors and false starts of course, but our ethos and mechanisms for learning will help us quickly find and embed solutions that work.
What events in your past experience are most informing your leadership in this pandemic?
I have been really lucky to have had a number of chapters in my career which all feel relevant to what I’m now doing: clinical trainee, management consultant, roles at UCLPartners and the Royal Free as well as a Health Foundation Harkness fellowship at the IHI and Mass General Hospital in Boston. I’ve seen outstanding clinical and system leaders in action, who have taught me things like the importance of taking time—especially in a crisis—to clarify the exact nature of the problem and the goal, what the solutions could be and who holds the key to those solutions.
The different phases of my career have all given me experiences and relationships which are incredibly useful to draw on in gathering expertise, building a team, and connecting with other hospital and health system leaders in the USA and other parts of the UK. Drawing on these pre-existing relationships of trust, and rapidly forming new ones, is crucial to me now. I have found there is no more valuable time than now to sit and have a cup of tea with a colleague and hear about what brought them to Nightingale, what they are excited by (and scared of) and where they see themselves fitting into the overall picture.
And to add: it’s actually also helpful to be the husband of a working surgeon and a father of two children. That anchors me, and puts a boundary around the Nightingale work which allows me to recharge. Without something to force boundaries, something like Nightingale could become all-consuming.
What are you finding the biggest challenges?
They are legion. Treating a new disease where there is great uncertainty about its course and how to treat it would be the first—it feels as if almost every day we know more than we did a couple of weeks earlier about the natural history and treatment responsiveness of COVID-19. Next, staff are at risk of becoming sick themselves and needing to isolate, so we need to flex to people being unable to work on site, or at all. Beyond those two, which are ‘COVID-specific’, I’d highlight the challenges from plans needing constant revision; the effort of coordination; and the work inherent in trying to find simplicity in great complexity. And in all this knowing we have been racing against time to open to serve London and understanding the trade-offs that working at such pace necessarily entailed—none of us feel comfortable with these, but we know these trade-offs needed to be made. As a team, we have made sure we take the time to think clearly about what our key tasks are for each day, doing them, then reflecting and learning. These are the right things to do but are still challenging. Our daily clinical/operations forum, and the fact that all the clinical and ops teams now sit—appropriately socially distanced—in the same very large room provides a solution/defence against this.
Any particular surprises?
How quickly everyone at Nightingale has ‘teamed’ around this model—of building learning and improvement into the operating model. This does not feel normal compared to life in the NHS I knew. We are truly ‘one team’. The pace we can move at is linked to the context and nature of the task and the people—and also the ‘greenfield’ context at Nightingale, with no existing practices to ‘unlearn’ or ‘displace’. We test, learn, measure and retest on a daily basis as a central feature of the operating model, in a highly inclusive way. In some ways we are relieving the burden of developing ideas and cycles of change from the caregivers by building a model which takes their insights and tests them as routine. We constantly say: ‘What we know is that we don’t have it right; our goal is to make tomorrow better than today.’
Are you seeing any behaviours from colleagues that encourage or inspire you?
All the time! Every day, there are so many people giving their energy, attention, and help when asked. No one says ‘we can’t do that’; people are responding. Colleagues from the military, construction teams, St John Ambulance, security, clinicians, the wider NHS—everyone has been getting stuck in as ‘one team’.
How are you maintaining kindness and compassion ACROSS YOUR TEAM?
Nightingale’s executive leadership is relentless about the need to look after oneself and build an ethos of ‘one team’ across Nightingale as a whole. So, for my team, this is, primarily, my responsibility. And I can’t do it if I’m not looking after myself or role modelling that. At each daily team meeting, team welfare is the one thing I never fail to emphasise. For each and every one of us, looking after ourselves and each other is not ‘selfish’ or a ‘nice to have’. It is mission-critical for Nightingale. Especially in the pressured environment in which we are working, we must build a system which protects people from burnout—and transmission of a highly contagious disease. We cannot put the ‘blame’ for burnout on individuals.
For me personally this means two things, principally: I work from home two days a week as a main child-carer; and I trust and enable my deputies. I ‘advertise’ that every decision they make and everything they say has my support. This requires, of course, that I trust them absolutely and that we are tightly aligned on purpose and priorities—and check in very frequently. (WhatsApp is a wonder, but a 10 min phone call morning and evening even better.)
Are there any ideas or readings that you find helpful for inspiration and support that you would recommend to others?
I’d encourage people to consider a recent blog by Suzie Bailey and Michael West at the King’s Fund1: it beautifully encapsulates why compassionate leadership matters even more in a crisis. It describes how autonomy and control, a sense of purpose and belonging, and ‘competence’ are essential for success. By the latter they mean it is the organisation’s responsibility to ensure staff refresh and reflect, to be able to work effectively—‘a saturated sponge is unable to take on more water’.1 They also look ahead to what might be usefully taken from our crisis response when the system resets to a new, and better ‘normal’.
What are you looking for from your leaders?
Nothing beyond the above—though not to underestimate it. They need to have clarity of purpose, to look after themselves and to become kinder to others (and themselves) as the temperature and pressure rise. They need to be clear about the important uncertainties (what they don’t know), and to enable others to reduce this uncertainty.
Twitter @mountfordjames, @tony_berendt
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement No data are available.