Customer-Led Success Stories Beyond the Book: Introduction to the Series Charlie Dawson, Seán Meehan Summer 2021 2 Stories of Customer Pioneers Some companies are great for customers – not only do they care but they change whole markets to work better for the customers they serve. Think of Amazon, easyJet and Sky. They make things easier and improve what really matters – obvious, surely? They have also enjoyed huge business success, growing and making plenty of money. The Customer Copernicus answers the question that follows – if it’s obvious and attractive why is it so rare? And then it answers a second question, because Tesco, O2 and Wells Fargo were like this once. Why, having mastered it, would you ever stop? Because all three did, and two ended up in court. In The Customer Copernicus book we explain how to become and how to stay customer-led, making things better for customers by going first, into uncharted territory. We tell the stories of 18 different organisations who have each become what we call customer pioneers, a shorthand description of the kinds of customer-led successes at the heart of our work. 3 Customer-Led Success Stories – Glasgow Neonatal Unit Customer Copernican Examples Beyond the Book There are a great many stories about customer pioneers that we couldn’t fit into the book. This is a series through which we can share them, showing how the framework we developed in writing the book can be illustrated with a growing collection of shining, fresh and interesting examples. Of course not everyone reading these will have read the book. Even those who have won’t remember every detail. So this note is a foreword to the series, to each of the stories explaining the essential elements of the journey from conventional self-interest, seeing the world from the inside-out, to genuine customerled pioneering leadership, seeing and believing in a world that works from the outside-in. The Customer Copernicus Framework - How to be Customer-led We have learned that the crucial element explaining it all is belief – people’s shared beliefs about what matters inside an organisation, not a clever measurement technique or a magical structure. It is cultural but more precise than just‘a customer-led culture’. Building the relevant beliefs takes a particular kind of leadership, helping people across an organisation change deeply held shared-but-unspoken assumptions… • From a starting point that is natural but not customer-led based on looking from the insideout, prioritising the organisation’s success, targets and agenda over that of customer • To one that is not natural, where success is defined by making things better for customers having understood what matters most to them, one that presumes doing well for them will also work out well for the organisation. These beliefs are outside-in 4 The journey from inside-out to outside-in goes through four stages 1. Burningness. Organisations only start this journey when the people involved feel burningness – the current situation is on fire, conventional action untenable if they are to succeed. Burningness has three possible causes – pain, fear or ambition, and that is in descending order of effectiveness. Pain is most commonly good at creating these conditions because things are going wrong, visibly, viscerally, now. No one can argue that action must be taken that is bold. Fear is a step less convincing because things are fine now, it’s just that they are clearly going to get worse at some point in the future. Ambition is the least likely cause of burningness to work. This is not because it is weak – far from it. It’s because it has to come entirely from within. There is no crisis visible and instead the leader or the leading team has a burning desire to reach somewhere further on, somewhere seriously stretching. 2. A first Moment of Belief. Stories and the like don’t change people’s shared beliefs. Only seeing something real that works, clearly contradicting the prevailing assumptions, is strong enough to start the process. In this case it means seeing a customer-led initiative, obviously good for customers but clearly costly and risky for the organisation, actually work. Only the presence of burningness got them to try it in the first place. Seeing it not just benefit customers but also work for the organisation is convincing and shared-belief-challenging. We call this a Moment of Belief, like a moment of truth but with the effect of shifting at least some individuals’ unspoken assumptions. 3. A flow of Moments of Belief. Having seen something counterintuitive work once, confidence grows that something similar might work again. So a second initiative is tried with a little more confidence. When that works the third follows and so on, eventually broadening the scope of customer-led activity. People across the organisation see a pattern emerging –‘every time we do something great for customers it works for us too’. It becomes the way to impress others, get a pat on the back or promotion 4. Sustaining the Outside-In belief system. Once the organisation is a customer-led success the shared beliefs still need attention. It remains unnatural to have widely shared assumptions that customers really do come first, ahead of hitting the quarterly numbers. So the leaders need to pay attention to their belief system and its health, and ensure a continual flow of Moments of Belief to keep showing people‘this is the way we do things around here.’ 5 An analogy and some illustrations might help to bring this journey to life Imagine the business is a planet and customers are floating in space, free to make choices between alternative offers from different planets or businesses. The people who serve customers are on the surface of the planet, in touch with customers, but the leaders are buried right at the core. They literally look at the world from the inside outwards, with the customer view obscured by layers of people, departments, issues and the like. Then add the idea of gravity – the bigger the organisation gets the stronger gravity pulls leaders in, keeping them anchored to their internal perspectives. Escaping from the company’s pull, lifting off from the planet is hard. It needs rocket fuel and a multi-stage rocket – successive Moments of Belief – to get to escape velocity and up into an outside-in orbit. Having got there, staying there, maintaining orbit, is just as hard. The gravitational pull continues, relentlessly pulling the leaders down, and unless they actively resist – more rocket bursts, more Moments of Belief – then they will lose momentum… …start to fall from orbit and eventually crash back down to earth. They become inside-out again, often with a bump. This is the natural arc of a customer-led company. 6 The Customer Pioneer stories that follow The organisations described are diverse in sector and type, including a neonatal care unit, an asset manager, a public sector operator of a city’s transport system and businesses, both established and more naturally digital. All have achieved customer-led success, pioneering in their own sectors and worlds, confounding the established beliefs about how business should be done. We hope you enjoy reading about them as much as we’ve enjoyed hearing about them. And maybe ultimately your own organisation might join their ranks. We’d love to hear from you if so. The Foundation @TheFoundation The Foundation Growth Consultancy www.the-foundation.com +44 (0)20 7255 8720 info@the-foundation.com IMD Switzerland @IMD_Bschool IMD Business School www.imd.org CH +41 (0)21 618 0111 – SG +65 6715 9988 www.imd.org/why-imd/contact-imd Customer-Led Success Stories giffgaff Charlie Dawson, Seán Meehan Summer 2021 2 A story of Customer-led success giffgaff giffgaff takes being customer-led, pioneering innovatively on behalf of customers, to the extreme. For twelve years and counting giffgaff has grown and led in its sector with its outside-in thinking, trusting the community which the business serves and being steered by them to an extraordinary degree. First conceived in April 2009, it launched as an innovative new venture by O2 (by then owned by Telefonica) in the UK with the aim of seeing whether a mobile network inspired by social media and digital collaboration could create value in new and better ways for a segment of the market. CEO Ash Schofield sums the giffgaff ethos up with one word.“It’s about mutuality,”he says.We believe that giffgaff’s approach epitomises customer-led success. They have been prepared to lead, to believe that they will ultimately succeed if they make things better for their customers (or members as they call them) by listening, trusting and reflecting what matters most to them in the ways they operate. 3 The burning need to do something different Openness to learn from a variety of outside sources is vital to any business wanting to achieve customerled success. Two light bulb moments in exactly this spirit were the genesis of giffgaff. Gav Thompson, an O2 brand strategist, returned from a 2008 US web 2.0 conference about what can be achieved with digital communities, asking himself “Why can’t a mobile company work in a more joined up fashion with customers?” He had recently purchased his first motorbike and discovered he could get multiple highquality answers to technical bike issues, quickly, day or night, by posting his questions on online forums where there seemed to be expertise and goodwill on tap. Other elements of the 2008 landscape influenced the business’s thinking. Wikipedia was growing rapidly based on collaboration, with open, public, unpaidfor input creating a more complete encyclopaedia than ever achieved by experts on someone’s payroll. Another was the financial success of the Obama campaign funded by micropayments from the masses. These elements came together in the idea for what would, after nine months of design and development, become giffgaff: an Internet 2.0 mobile phone business that used social technology to allow customers not call centres to provide the customer service. Customers effectively look after each other saving them all money. People who helped were rewarded with a giffgaff currency called Payback Points where one point equalled one penny, with one hundred points for posting helpful answers to the forum community and withthedefinitionof‘helpful’ comingfromtheperson asking for the help, so the answers rewarded were the good ones. Marketing would also be member-driven with five hundred points for recruiting a new member. The points could be cashed in every six months and for helpful members, they added up. We talk about burningness being essential to this kind of bold, pioneering customer-led transformation. So where was it coming from with giffgaff? It was O2’s burning ambition to innovate and never allow themselves to stand still that influenced Thompson directly. That got the idea to land. But the business’s success is down to another more sharpedged form of burningness – the pain associated with the serious risk for those involved from here. O2’s backing of Thompson’s idea came with conditions attached. The branding could have nothing to do with O2. They had to build their platform themselves using only their start-up funding, with no input from the O2 IT teams. They had to work at another site and were not allowed to take all the good people. And the launch team at giffgaff had to commit wholly to making the new company work. There was no job to go back to at O2 if the idea failed. An outside-in approach The idea was developed and early in the process a group of ‘mobile-interested’ potential customers were recruited to input into the prototype. The idea appealed to technology enthusiasts who were used to this collaborative approach to problem solving and who didn’t identify with the existing big mobile brands. giffgaff made clear choices in deciding to appeal to these potential customers and not to everyone. The idea was based on creating a Mobile Virtual Network Operator (MVNO), a mobile business that used other companies’networks and in this case that of parent company O2. Many others did the same, but in this case customers helping each other, and as a result helping the whole community, meant that there was a highly unusual core idea of mutuality. This became the most important shared belief for the company and the inspiration for its name, giffgaff being a Scottish idiom meaning‘mutual assistance’or ‘fair exchange’. giffgaff’s beliefs are reflected in its language – the business has members not customers, and by respecting them and having an adult-to-adult relationship with them, it turns the classic masterservant mobile model on its head. The first Moment of Belief After nine months of development, giffgaff was launched at midnight on November 25th, 2009. By 5.00am three super-users had started answering questions. Schofield describes those early hours of initial feedback as “an incredible moment that validated the idea. Remember, we had launched the community before the network. People wanted to have the conversation with us and giffgaff hadn’t even sold them anything yet. This meant a huge amount to the team back then who had taken so much risk.” The service model was working and in February 2010 things really started to take off with the launch of SIM-only deals, called goodybags, that tapped into an unmet need and meant that members were now not only contributing to the community but spending money on the giffgaff proposition too. This was momentous because, as Schofield points out,“giffgaff was odd. No contracts, no call centre. Nowadays, we 4 have 3.6 million members and we’ve recently won Uswitch 2021 network of the year, topped the Which? best provider and Ofcom’s own provider satisfaction survey. (Uswitch is a UK-based price-comparison service, Which? a UK based not-for-profit consumer advice organisation and Ofcom the UK telecoms regulator). But these things make it easy to forget just how weird our position was twelve years ago.”Members could move freely between different goodybags from month to month depending on their usage, working in members’interests to keep their costs down and not the mobile phone company’s interests by tying people into an inflexible deal. Despite the initial validation of the idea, by month eleven the company was a long way behind its business plan and with questions being asked about its longterm viability, O2 considered shutting it down. The Chairman was supportive but torn. He and the team at giffgaff could see signs that something special was going on: the rates of advocacy were exceptional, and members were by now recommending giffgaff and distributing SIM cards in a way that also gave Mike Fairman (CEO 2009-2018) an unambiguous belief in the customer value they were creating and the mutuality that defined the business. Given the underlying metrics it looked like revenue would follow. So, the Chairman managed to be unavailable for Board meetings for a couple of crucial months, giving time for the revenue to catch up. The stay of execution meant that O2’s leaders saw enough in the results to change their mind, and with a modest price decrease after twelve months and some marketing to support it, growth accelerated. It is worth noting now, twelve successful years on, that if this moderate rate of growth had been in the initial plan it wouldn’t have been signed off. More bold Moments of Belief Having survived, giffgaff followed up with a flow of successful customer-led actions that reinforced the ethos of mutuality and cemented the bond between the company and its members. As the community grew, a natural desire by members to invite like-minded friends grew too, driven by the simple instinct to share something valuable that individuals cared about and felt some ownership of. giffgaff made the sharing easy, providing free SIM cards that took a moment to send on to someone who might be interested. This was valuable – it was continuing to keep down one of the biggest costs of a conventional mobile phone businesses, marketing and sales, protecting the low-cost part of the proposition. Belief within giffgaff was growing that this was a model that worked. 5 The next huge Moment of Belief for the business came with an Apple iPhone introduction. “When Apple launched the iPhone 4, we didn’t know that it came with a different-sized SIM card,” Fairman told TheTelegraph in 2015.“Our SIM didn’t fit into the new phone and it would have taken three months to get the new size. A few giffgaff members got hold of a hand-stamping machine online, which neatly cut the existing SIM cards down to size and set up a website called Microgaff to solve the problem. We forwarded requests for micro-SIMS to them, and they sent them out. It meant we were able to give members the new size three months earlier than we could have on our own.” A problem solved with customers’ help is quite unusual in the business world, and belief grew another notch. “It was the biggest vote of confidence yet in a way of operating that was far more trusting of customers” Moments of Belief weren’t always so straightforward. When giffgaff launched, people didn’t use vast amounts of data and the offer included tariffs with unlimited data for a fixed price. As the technology world evolved people’s behaviour evolved too and a small number started using a great deal of data for films or games. Even though customer numbers were low, the costs were too high for giffgaff to absorb. But the company knew they couldn’t just put the prices up because if customers felt upset they had at their disposal the membership forum giffgaff had created, the perfect platform for mass complaint and mass defection. So giffgaff realised they had to consult – to explain openly what was happening and to put forward their proposal for what to do about it. The giffgaff team was highly apprehensive about the response they were going to get. To their relief the response was, in the main, honest and open too. They received improvement suggestions on their proposal and support for the direction of travel. So, when they introduced the updated changes, although some members were unhappy, other members stepped in and argued for the changes as well as for giffgaff’s approach. It was the biggest vote of confidence yet in a way of operating that was far more trusting of customers and far more customer-led than the norm. This was the moment the team knew they had created something truly better. But their CEO, the person who had launched this new creation, decided to move on and while navigating the handover to incoming chief Schofield, the reputation-threatening revelation emerged that giffgaff had been inadvertently overcharging 2.6 million customers for most of its existence. Talking to The Drum (a marketing and advertising website and magazine) in 2020, Schofield said, “I knew that people would judge us on what happened next. By the time we’d told Ofcom, we had already started paying everybody back, including people who had already left giffgaff. We hired an agency to try and find them to give them the money back, even if it was only a pound.” This honesty worked, with giffgaff’s growth and customer satisfaction ratings seeing an increase. It also acted as a barometer of how the company was doing as an outside-in business under new leadership, a potentially risky time. Making it systematic Customer ideas to improve giffgaff are continually put forward and voted up and down by members. Those at the top are implemented fast with daily deployments, something at the heart of the credibility of this member-led approach. Monthly texts to members telling them how to save money with giffgaff were introduced and a major focus on sustainability has seen heavy investment in its refurbed phone division, which allows people to buy a second-hand phone whether they plan to use a giffgaff SIM card or not. “We’ve moved away from prescribing answers in the form of projects. Now we have a rolling twelve-month roadmap, brilliant quarterly sessions with the product teams when they report on what they’ve done, the value created, and ambitions for next quarter. It’s designed to save us from ever becoming a bunch of execs taking out-of-touch decisions.” In fact, members are joining the team.The membership includes a strong tech community and when giffgaff started developing apps they discovered that some had already been written by people in the community and were available on the Apple store. The company identified the best and took the people behind them on. The latest app platform was built from the ground up, launching initially to a small beta group of giffgaff members. Top-up voucher scanning and an App that makes member SIM card sharing easier are new features that have arisen directly from the ongoing flow of help requests, information sharing and app reviews in the members’community. Beyond human insight the company has invested in a data warehouse to spot things they might not have 6 otherwise discovered.“What we’re really excited about is data creating more intuitive experiences for our members.” The aim is to make giffgaff relevant on an individual level to every single member with features such as its personalised best plan advice, a unique offering that puts each individual member’s needs first, even when that means recommending them to spend less with giffgaff. Sustaining the outside-in belief system For the CEO, sustaining giffgaff ’s unusual beliefs means maintaining a sense of reinvention and making sure that it remains what he terms a “new-new company.” “I took over when giffgaff was nine years old and the tenth birthday felt big to me,” Schofield says. “The question I posed was, at ten years old are we old or new? Everyone said we’re new. I asked, are we an oldnew business or a new-new business? This started a rallying cry, that we have got to make decisions now that guarantee we’ll be around for the next ten years. The opportunity is there for more of a fusion between tech and marketing.We’ve got to stay‘new-new’.” giffgaff has dialled up its community work with the set-up of Community Pioneers which began with Schofield challenging his marketing team who in turn reached out to the forum asking if members would be interested in getting more involved by testing prototypes and functionality as Pioneers. Eleven thousand people signed up. Pioneers helped build the new community platform for the company when they grew out of the old third party one they had launched with. Members helped design the pages, functionality, look and feel and when it went live, they shared the story of why it was like it was and how it’s going to develop. “There’s this idea people talk about that you are the average of the five people you spend most time with. I find that interesting,” Schofield says, when talking about the company’s decision to invite other nonTelecom businesses in to talk about how they work. “In the case of Bulb and Monzo , these companies saw us as inspirational for their own journey and were really pleased to come in, but we saw it from the opposite view, that these are digital-first businesses and we want to be in that pack, learning from them.”This is textbook outside-in thinking, to get stimulus from everywhere and anywhere as a way of staying‘newnew’and sustaining the belief system. In giffgaff ’s case, the mantra is that people have the answer, so people are the basis of everything, and mutuality the key to opening it up. 7 Schofield sees his role as an internal protector of culture.“If colleagues leave, the culture can’t leave with them.The risk is that everyone becomes such a brand guardian that a level of conservatism creeps in by the back door, so we have to do stuff for a reason we believe in and we have to not become self-referential.”He has beendeterminedtomaintainthestart-up“habits” that would have been so easy to park at some point along the way.“When I joined, every Monday forty people got together to talk about what had happened in the past week and what was going to happen. We still do that today,”he says of the weekly ritual which sees all two hundred colleagues congregate in its Uxbridge auditorium to update on business priorities.“It’s really important to keep these things as you scale. Because you don’t want to lose that edge. I don’t want anyone to ever say ‘I don’t know why we do this’. You’ve got to challenge constantly what you do and how you do it.” about playing to your strengths. When you have high advocacy like us you just put those things together and better service is the result.” Outcome The initial proposition was simple but risky - respecting your customers by trusting and involving them. It sounds dangerous but giffgaff shows that it can work in a big way. From the outset, the team could demonstrate that customer positives lead to commercial success. A different set of beliefs about customers created a sense of ownership born out of mutuality. Members helping other members saves on the costs of service, then commitment to the company means members find new ones by word of mouth, saving yet more. Schofield commissioned The Little Book of giffgaff to remind people why ‘this is the way things are done around here’and in response to what he described as his “fear of screwing up the culture.”He started writing down core beliefs, “harnessing the power of people, challenging the established way and improving it”and it became a book that is now there as a reference point, keeping the company constantly challenging itself to do the right thing.“We cannot turn into a homage to our previous selves,”he says. But fine words, in the end, don’t matter – it’s action that people believe in. So, having identified the ineffectiveness of constantly retraining staff for the small (5%) element of third-party customer calls that are needed to handle payment issues, Schofield posted on the community forum to invite members to provide this support as proper employees. Thousands responded and work-fromhome agents were recruited using giffgaff’s Golden Questions to find people genuinely enthused and who understood mutuality. Two years after their launch, giffgaff outshone the rest of the sector in the UK Customer Satisfaction Index and scored on a par with the likes of Google, Apple, and First Direct. giffgaff’s Net Promoter Score ranks higher than O2, Apple and Google. The Community Health Index, a measure created by online forum community provider Lithium to measure positivity, speed of answering questions and level of engagement across 700 organisations’ forums, ranked giffgaff highest of all 700, with an average response time to a posted question of 45 seconds. Within five years, giffgaff was a major player in mobile telecoms without ever having run a call centre and having paid out £11m to members for their services. Revenue reached £490 million in 2019 after a decade in which the company was nominated as Which? recommended mobile network provider of the year seven times. Since 2016 giffgaff has won the Uswitch Network of the Year for 5 consecutive years. They also won three other Uswitch awards in 2019 for Best SIMOnly Network, Best Network for Data, and Best Pay As You Go Network. As a happy side-effect, the company didn’t miss a beat when lockdown came because giffgaff’s team was already set up to work from home.“This is not about a recruitment strategy,” Schofield maintains, “but In Scottish proverbs you’ll find the phrase, “giffgaff makes good fellowship.”It makes good business sense too. The Foundation @TheFoundation The Foundation Growth Consultancy www.the-foundation.com +44 (0)20 7255 8720 info@the-foundation.com IMD Switzerland @IMD_Bschool IMD Business School www.imd.org CH +41 (0)21 618 0111 – SG +65 6715 9988 www.imd.org/why-imd/contact-imd Customer-Led Success Stories The Glasgow Neonatal Unit Charlie Dawson, Seán Meehan Summer 2021 2 A story of Customer-led success The Glasgow Neonatal Unit This is a story about a policy change in the Neonatal Unit of The Royal Hospital for Children in Glasgow. That might sound like a technicality but it’s fundamental, a change in the shared beliefs that guided the way care was provided. It has seen parents (the customers in this situation, at least the customer group old enough to speak) controversially taking the lead in the treatment and nursing of their premature and sick babies. Despite the perceived risks, this has had a profound positive effect on the lives of the babies, the families and the culture of nursing and care in the unit. While some changes on the unit are the direct suggestions of parents, the new policy is not a matter of implementing a list of requests. It is a culture of listening to families and understanding what they really value and need from neonatal support, then taking the initiative in providing a radically different form of care by being innovative and by empowering colleagues. 3 The burning need to do something different and two first moments of belief The neonatal care system in the UK has, for many years, been associated with traumatic experiences. In cases where babies have ultimately had good outcomes, discharged in good health, the neonatal care experience has had long term adverse effects on the mental and physical health of both baby and parents, the latter sometimes suffering forms of PTSD. Traditionally, neonatal units in the UK have been about high tech and specialist expertise.“The approach had been to get patients well quickly and then bring the families in,”says Dr Neil Patel, Consultant Neonatologist at The Royal Hospital for Children in Glasgow. “Caring for sick babies tends to be highly technical, with a lot of procedure and equipment. Families get excluded unintentionally.” And at a time of such profound stress, in which some parents report feeling so emotionally bewildered that they are unable to ask even if they are allowed to touch their baby, a system that distances the parents is accidentally self-sustaining. With a baby’s life at stake, what neonatal specialist would suggest that untrained parents do the caring? And what parent would say their baby would do better if they were helping to run things? Despite the high standards of care, parents were expressing unhappiness. The feedback came through complaints and despite being taken very seriously, the organisation wasn’t set up to understand what lay behind them and so truly address the issues that were causing the upset. Meanwhile, the individual neonatal staff who did try to be more inclusive of parents in their baby’s care were seen as outliers, their actions seen as a voluntary addition to what mattered rather than being prioritised as a recognised component of care. But in some developing countries, neonatal units don’t have the luxury of the levels of staffing available in developed settings and greater parental involvement is needed. In his work training neonatal doctors and nurses in the Women’s and Children’s Hospital in Da Nang, Vietnam, Dr Patel saw first-hand the value of so-called Kangaroo Care rooms, where mothers, fathers and grandparents look after acutely premature babies around the clock, supervised by staff. But this only happens because there aren’t enough staff or incubators, something that would constitute a crisis in the UK. This was not a matter of mere passing interest. The work at Da Nang was generating data suggesting clear benefits for the babies cared for by their families – better weight gain, earlier discharge, increased success rates in breast milk feeding. This had a powerful effect on Dr Patel, one reinforced by a subsequent visit to the Mount Sinai Hospital Neonatal Unit in Toronto. The Canadian team members had been inspired by their own experiences working in another under-resourced unit in Tallinn, Estonia. What he witnessed in Toronto was what they had taken from their experience, something they called Family Integrated Care (FIC). This was a new neonatal approach that helps parents to be primary caregivers, working in partnership with the clinical team. “One hour there completely changed my perception of involving families, and I saw that, in contrast to the costly technical upgrades we habitually pursued, here was a potential improvement that bore little cost or risk.” Dr Patel was convinced that changes in neonatal care born out of crisis in lower-resourced settings were presenting an opportunity to address needs in our own system, needs that would eventually become critical if left unchallenged. An outside-in approach The established approach to neonatal care has historically been rooted in control based on unspoken fear. Consultants and senior nurses operate in a commandand-control mode, making time-critical decisions and directing operations using their many years of experience. The fear was of losing any measure of control and listening to babies’ parents might slow them down or expose them to dissenting points of view, creating conflict or raising problems they weren’t trained to solve. Dr Patel had seen a different way of doing things and he found himself increasingly determined to apply changes, originally made out of necessity in developing countries, to a unit at home that he simply wanted to be better. From burningness as pain to burningness as ambition. What he had not seen was that there was a hidden but equally burning desire in families (and colleagues as it turned out) to approach neonatal care with their babies in a more human way. Dr Patel invited his colleagues at the neonatal unit to a meeting he called the Family Communication Group, and then asked parents to join the meeting 4 in order to talk to staff about their communication needs. The meeting did not go to plan; instead of the parents talking about communications they described wanting to be taught how to care directly for their sick baby. They were asking for the FIC model of care without ever knowing it existed. This was a shock to the clinical staff, and it lit a touchpaper. Hearing the families directly express their wish to be carers inspired nurses and consultants to take control of their unit and to do things differently. This was despite a historically restrictive and hierarchal culture in the NHS. It felt risky. They weren’t diverging because of a directive from senior management, but because of a challenge from their ‘customers’, the families that wanted the unit to change; the team decided they didn’t need permission, they wanted to do it their way and were prepared to take responsibility for the changes they made. Bold new outside-in beliefs Still taken by the looks of horror on many faces when he’d told his colleagues he was inviting parents into their meeting, Dr Patel was surprised and relieved to afterwards receive feedback from a senior colleague that it had been one of the most inspirational meetings he’d ever attended. This was a crucial first moment of real belief for the team. “They gave us permission to be human on a Monday morning” The more they listened to babies’ parents, the more they realised that huge inside-out assumptions had been made about what families really wanted. They thought families wanting to be present on ward rounds would throw up impossible obstacles around privacy and confidentiality, but the families said they didn’t care about other parents overhearing clinical details and trusted the team not to say the wrong thing. They presumed parents expected them to know everything about their baby, and as a result would sometimes make excuses to take time to read up clinical notes, keeping parents waiting. But parents reassured the team that they would prefer to be asked about their baby in order to help clinical staff get up to speed.“They gave us permission to be human on a Monday morning,”notes Dr Patel. Another false belief was that parents didn’t need or want to know all the details.“We often find ourselves 5 using generalisations like she’s had a settled night, but in the conversations we have with parents they’ve told us they want specifics, she slept from 2-5am, then had a 40ml feed, then vomited twice… her next feed is due at… In retrospect it’s completely understandable, but we had a misplaced, slightly paternalistic view that if we didn’t go into detail it would be better for them.” In Glasgow, the parents now expected the unit to begin again with not just a blank sheet but a totally open mind. They needed staff to put aside assumptions and place their views front and centre. The team responded by drawing up a whole new policy towards neonatal care from the ground up, starting with the normalisation of Kangaroo Care, the practice of skin-to-skin contact between infant and parent. This saw improved cardiorespiratory and temperature stability, sleep organisation and duration, neurodevelopmental outcomes, breastfeeding and modulation of pain responses. Mothers began to show enhanced attachment behaviours and to describe an increased sense of their role as a mother. These successes led to a wave of more nuanced moments of belief which further shifted the emphasis of neonatal care at Glasgow from the inside-out expert tech approach to an outside-in trusting and supportive human practice: • Whiteboards were installed at the foot of each bed where staff and parents could leave messages for each other: words of thanks, support, as well as shared communication about care. Colleagues, especially on nightshifts, wrote updates and messages of encouragement, including translations for non-English speaking families. One parent left a message saying,“thank you for being a voice for my baby.” • A video messaging system was introduced at the suggestion of a father who asked if he could be sent short videos of his son when he could not be present in the unit. Staff could now create video messages, often during the night, and send these securely to parents, who feel reassured receiving them. The bond with staff was strengthened and mothers reported that receiving a video of their baby from the ward reduced their anxiety, aided their sleep and helped them express breast milk. • A biometric fingerprint entry system was brought in after families expressed the tension caused by having to wait to be let into the unit. They associated a long delay at the door with a crisis on the ward that their own baby might be the subject of. The unit benefitted from no longer having to have a member of staff stop work to open the door an estimated 150 times a day. The cumulative impact of these small customer-led changes established the unit’s principle of committing to FIC without the advance promise of the measurable results and control delivered by technical care. This philosophy of informed bravery based on customer benefit is at the heart of a new culture which has seen the normalisation of the idea that the unit meets the needs of the baby and the baby’s family, with positive clinical outcomes and other immeasurable gains the result. Sustaining the new belief system What made the new way of doing things at Glasgow move from experimental to systematic was listening to the families. Doing this is what keeps the team connected to parents coming into the unit. It ensures, in a tangible way, that the team pay continual attention to their new outside-in approach and keep it fresh and fit for purpose. It deepens the foundations of the new beliefs so that they are strongly held and fully shared. This is why the prevailing, unambiguous belief has become that this level of family-centric innovation is the way things are now done around here. As well as daily meetings, the unit now holds Helping Us Grow (HUG) group meetings every four to six weeks. These are always packed. New families come in with fresh ideas meaning that the work moves on. Dr Patel facilitates this by keeping the agenda of HUG meetings loose.“The conversation goes where it needs to go.”All colleagues are surveyed, without exception.“We talk with those who aren’t coming to meetings and get their opinion, so that this is not a new policy being enforced but something we do together by reaching a consensus view.” Staff and parents have formed subgroups to lead different strands of improvement in the unit, coordinating their work using WhatsApp to communicate rapidly. Each subgroup is encouraged to think differently to meet challenges and find improvements in FIC. A support group, Peer to Peer, runs family awareness sessions. There are joint teaching sessions for staff and families, and special days to promote staff education, like International Kangaroo Care Day. One group thinks creatively about the ward environment, resulting in improvements like the introduction of reclining chairs at each cot-side for parents to perform skin-to-skin care and breast milk feeding. In the early stages of FIC at Glasgow, the unit 6 assumed that all parents would want to be involved in their baby’s care. But they are learning, by listening to them, that each parent is different – that some want to be involved from day one whereas others need time and encouragement to feel confident. They also learned that things can change day-to-day. The key is supporting each family as and when they are ready and challenging their own commitment to family involvement so that they offer something far more bespoke and sensitive than a one-size-fits-all FIC policy, which could be potentially harmful. The unit continues to examine its own assumptions and ideas, with the ambition of maintaining a continual flow of moments of belief, actions that reinforce their customer-led approach. For example the decision was made recently not to follow the example of other hospitals where nursing staff have been appointed as paid FIC leads, because the aim at Glasgow is to have parent-led patient care supported by all staff doing what they can. Their own model is one in which parents and staff are committed to doing the extra work between them with no emphasis or burden placed on any one individual, and where the unit delivers this as part of its normal care, not as an add-on at extra cost. Their belief is that their outside-in ethos will be best served by not accepting funding for, or in any way formalising, FIC roles at Glasgow. They are being boldest by rejecting the opportunity to formalise their model. 7 Outcome Does it work? According to UNICEF, it does. UNICEF’s Baby Friendly Accreditation external assessors gave Glasgow’s Neonatal Unit their sought-after Level 3 accreditation in 2018, Glasgow becoming one of the first tertiary surgical referral centres to achieve this level of recognition in what UNICEF describes as, “excellence in the care of mothers and babies.” Results in the most important field of clinical benefit to the baby have been impressive. Increased breast milk feeding leads to associated benefits of improved immunity, improved neurodevelopment, reduced infection, reduced necrotising enterocolitis (a severe and potentially devastating gut-related complication of prematurity) and reduced lung disease in preterm infants. There have also been improvements in rates of weight gain, earlier discharges from hospital and in increased holding and Kangaroo Care (this FICare approach bringing benefits proven in Canadian studies). Parents of sick babies have benefitted from reduced stress, earlier discharge and improved confidence at discharge, and improved long-term psychological outcomes, including reduced PTSD symptoms. The benefits for the NHS are significant, with the potential for large numbers of earlier discharges and fewer re-admissions. The customer-led approach to neonatal care at Glasgow supports the NHS’ long-term social strategy for self-management and person-centred care and supports Scotland’s Realistic Medicine policy of a person-centred approach to improving quality and safety of care. There are fewer complaints and improved safety of care because parents speak up to prevent errors and because of the unit’s approach spreading to other paediatric and non-paediatric disciplines. The positive publicity and public engagement with FIC has led to Glasgow’s unit benefitting from increased charitable support. More than a quarter of a century ago, Kangaroo Care for low-birthweight infants was introduced in a neonatal unit in Bogota, Colombia, in direct response to a crisis of overcrowded nurseries, with too few incubators and high rates of neonatal infection and mortality. In the UK, not long ago, nurses who tried to bring Kangaroo Care into their personal practice were viewed with suspicion. Now, those nurses are seen not as outliers but as early trailblazers for what has become the norm. Dr Neil Patel wants it to soon be the case that families can’t believe how neonatal care used to be.“If I had one simple message from our work,”he says,“it would be to listen to the families and staff and help them lead the change.” The Foundation @TheFoundation The Foundation Growth Consultancy www.the-foundation.com +44 (0)20 7255 8720 info@the-foundation.com IMD Switzerland @IMD_Bschool IMD Business School www.imd.org CH +41 (0)21 618 0111 – SG +65 6715 9988 www.imd.org/why-imd/contact-imd
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