Why compassion isn't just nice, it's essential
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Hello and welcome to this BMJ podcast on quality of care. I'm Rachel Hinton, an editor at the BMJ.

Today we're focusing on one aspect of healthcare leadership, compassion, and how it's not just a nice way to lead, but a foundational element of successful quality improvement with solid evidence and support. This podcast is part of our Quality of Care Collection in partnership with the World Health Organization and the World Bank.

The link to the collection is also available in our episode notes. We'll hear speakers from Kenya, Colombia and Ghana, countries where one might imagine resource constraints could force compassionate care down the list of priorities. Firstly, Dr Lydia Okutoi explains how compassionate leadership became the key to improving care in Nairobi's Kenyatta Hospital.

Then we'll hear from Pedro Delgado from the Institute for Healthcare Improvement. He'll outline the evidence for compassionate care and how this is a skill to be honed, not just a way of being. Finally, Dr. Alexander Ansamenu, a professor of epidemiology who splits his time between London and Ghana, talks about how building compassion into workplaces is surprisingly cost-effective. All that and more coming up.

Firstly, we're joined by Dr. Lydia Okutoi. Lydia worked for some years in obstetrics and gynecology before specializing with a master's degree in healthcare quality. For the last eight years, she's been the director of healthcare quality at Kenyatta National Hospital in Nairobi.

A lot of our conversation was about how Lydia developed her leadership style over time. And that's where we begin. So you have to be open. And what does open mean? It means I go there curiously listening and then also making that uncomfortable that I am on their side. I've not come there with a stick. And so for the last 20 years in health care,

and the last more recent years, seven or eight in healthcare quality, I have had to reflect and see again and again

that there is a system around what happens. Things are interconnected, that whenever we see something working well or something going amiss, there is a system, there is a context behind it. And so whenever as a leader I'm called to a scene or whenever something comes to my attention working well or not well, it is likely that it is not just what I'm seeing.

The aspect of there is a system around it and people form a big part of that system. The staff and the patient. And so as a leader, I need to care for my people, for them to care for their patients. And so kindness and compassion becomes very important. And so compassion requires that we go there wanting to connect, but to connect on the value that what is the right thing? What is the good thing?

If the leaders are able to show that to their team, to give them safety, safe spaces to say, I'm Esther, or to say we can do better, or to have the moral audacity to be able to confront status quo on matters of patient care. So it requires kindness to be on the front line among the people who see the patients. For them to have the boldness to raise up, we are not doing well here. And so one of the ways is being patient.

humble and knowing that you do not interact with that patient, the staff on the ground do. And so they understand that more. And how do we empower them to be able to voice it? And so compassion means the leader will both be present to listen, to seek to understand, and empathize, come out with what are these that we can do, listen,

And that will enable innovation. It will enable ideas. And those ideas will not move far if leadership does not support, whether financially or giving the space that it is okay to innovate or saying we can fail forward, we can try it and see because we need a solution for all of us to own that direction. And so it is both individual and organizational.

So Lydia, it sounds like you've managed to make space for compassion in your hospital. I'm wondering Al, what happens when these pressures ramp up? I'm thinking about, you know, staff turnover or limited capacity. Is it hard to keep compassion in place?

The staff healthcare workers in Kenya, we have about 2,000 leaving the country every year, or that is even the lower side. And our hospital being a tertiary institution, we have very well-trained nurses and doctors. And so we've been losing nurses in good numbers. And so those challenges of, so how do we share work as we wait for recruitment? And how do we address burnout? And so whenever there is an issue,

One of the ways of showing compassion is by going there to listen, to listen and understand. So that means I go with an appreciative inquiry. I don't have the facts. I don't say it happened yesterday. And so it is the same. Why? Because there are times we have different causes of the same things.

Not everyone works in that way, you know, and how does one make it from you to others in the organization to be this kind of waterfall effect that you mentioned, this cascading effect? I like somebody who defined leadership as a developing self for others in that it starts from you. So the value-based leadership cannot be imposed on you.

You have to be convinced because you will need to be vulnerable because you are not just directing and controlling. You are not just fixing and it will take time. And it also requires intentionality. So by your actions, by how consistent you are, that at the end of the day, for example, if there is a disagreement,

or an outcome that wasn't so good, your team members will be very sure what your motive was because you have shared at the level of value. In the recent, two months ago, something quite touched me.

We were having a challenge with our staff and one of the team members of the leaders mentioned, "I have gone through that. That challenge is familiar. Can you call that young man to come and see me?" And I was so excited. One time I came and they had a conversation. It means they are connecting. The senior was becoming vulnerable, sharing their own challenges.

And so in value-based leadership, there's authenticity. And authenticity is freedom. It means you even make friends. They connect with you. Because I'm sure from that day, that younger doctor has connected to the senior. And this will be an ally. For example, if he has a crisis, this is somebody who can talk to his life. Why? Because they have connected. So it is not that we are not looking at

the performance and the outcomes in the institution because remember these patients are our main interests they're the ones who made we are here for. Speaking with Lydia we've heard how one person came to understand how kindness was key to her leadership.

But was Lydia one person who was particularly empathetic or are there principles here that can be universalized? My next guest, Pedro Delgado, absolutely thinks that's the case. He'll tell us why compassion is something that can and should be practiced and how that practice can have a strong foundation in evidence. Pedro was a vice president at the global non-for-profit Institute for Healthcare Improvement, which many of you may know as IHI.

Over the last 20 years, he's worked in quality improvement, patient safety, population health improvement and equity and now directs IHI's work in Europe.

Pedro, welcome. Thank you, Rachel. And it's so good to be here. So Pedro, your organization has grown to really embrace kindness and joy at work. It's guiding principles for quality of care. Can you tell us a bit more about what contributed to this shift in thinking? So I'll give you some of my own perspective, obviously, because none of this has been linear. Over time, there's a growing sense of

that the biggest asset and the irreplaceable asset in healthcare is a human being. The person that's delivering the care and the partnership between the person delivering the care and the people organizing the care and the recipient of care.

and everyone being active in that dance. So I think those are some of the drivers for what's happening and the shift that we're seeing, which I absolutely love.

But there's a concept here, Rachel, before I move on to some of the IHI decisions over the years, which is ambidexterity, which is also applicable to sports. So when you play football, if you're right footed and you can only use your right foot, you're kind of 50% capable. And that's the bottom line, because you can't turn the same way because you don't see the full width of the pitch because you're...

So ambidexterity. And I mean that because we do have to be technical. We do have to focus on outcomes. We do have to understand our processes. But with the other hand, we need to be human and we need to understand behavior to proactively design for it and to proactively nurture a sense of trust and psychological safety and all the concepts that are now coming into play.

the lexicon of quality. So that is very important. Pedro, it sounds like IHI have really seized on this point about nurturing compassion. But how does this thinking scale for teams that might want to try it so that it's not just top-down but becomes bottom-up as well?

I suppose, like, what's the systems approach here? Yeah, and I'll go to the image first and then to the layers and the possibilities probably. And the image is stalactites and stalagmites. One's come from the top and the other one's from the bottom. So I think organizationally,

The move from a hierarchical way of leading to a distributed way of leading is a conscious, intentional decision that needs to be nurtured and trained because, again, historically we've grown up in a system that points fingers, not just in healthcare, but in education. So there is something about breaking the gravitational force

pool of normative behavior in terms of hierarchical ways of being and doing and a more distributed way of leading. And actually, I'll give you one very pragmatic tool that we developed with the members of our IHI Health Improvement Alliance Europe. And they came up in conversation with

with five simple rules for curiosity in leadership. And they're quite simple, actually. One is ask rather than tell. Listen to understand rather than to respond is the second one. Hear every voice rather than only those CCS to hear. So that's about including people that historically and traditionally haven't been, whether they're from a different profession or more junior in their rankings, or their patience and inclusion. Fourth, prioritize problem framing.

So how we interpret problems rather than problem solving. Obviously we want to solve, but there's a space there for framing. And the fifth one, which is probably the trickiest one, which is treating vulnerability as a strength rather than a weakness. There's something around narrative. So for leaders, the job is largely to create the conditions when you're not actually doing the work, but actually overseeing and leading the work.

And the way we tell the story of our organization, the way we ask questions around performance, the way we praise people or not, is part of that narrative that you need to build in order to create an environment that seeks to perform for sure. Right. I hope people are taking notes on these useful points.

You know, healthcare is stressful. It throws a lot at people. How can you, you know, stay kind when these pressures are at their worst? For all of you people who work in the caring professions, and that includes, of course, families and patients who care for each other and for themselves, there is a platform that we build from, which is our inherent goodness and our inherent kindness.

And on top of that, there is the possibility to pursue a kinder environment in health and healthcare that performs very highly, that reduces suffering, that improves quality. And we cannot kid ourselves with the fact that this is hard work and it's intentional work.

but also that we're building from an excellent platform, which is our inherent capacity to be kind and to love and to care. So as you move forward, continue the hard work. We'll be here alongside you and with you to learn together and to improve together.

You know, it's really nice to think that kind and compassionate leadership can help to deal with burnout and improve quality. After my conversations with Lydia and Pedro, I still wonder how it works in practice. Like, how can those leadership ambitions trickle down to the teams actually providing healthcare? My last guest has studied how teams operate in challenging, resource-constrained situations.

So I am Professor Alexander Ansameinu. I am a professor of epidemiology at the London School of Hygiene and Tropical Medicine, epidemiology of maternal newborn and child health. And I'm also an associate professor at the University of Ghana School of Public Health. I am a medic by background, but my interest, as you can see, has been in supporting and building resilient health systems.

and the pathway is through quality, that if we can improve quality of care health systems, we'll be resilient. But not only quality for a few people in a country, but quality that is equitable and accessible to all. Well, Alexander, you bring up improvements for quality of care, so let's talk about that a bit more. How have you seen the dynamic change in Ghana?

That is really interesting. And it's been a big challenge in the public health space, especially around quality of care and leadership. There is always this dilemma for a leader in quality now because we want to see the results. And sometimes it is normally unpopular because as a leader, you have political pressures that are coming to you, right? This is outside of health sometimes, right?

but we also have health politics. But generally, the political pressure comes that a government or the leadership in government wants to find results. Even funders are interested in seeing a 40% reduction in mortality, a 40% reduction in this, rather than anything else. So as a leader, you have that dilemma.

Then there are some times, especially in the settings where I work, you can have frequent personal changes. So today this person is opposed, tomorrow another person is coming. How do we even have continuity? You're also having these budget casts all the time. So every little money you have, you want to make sure that it is going towards outcomes, that you can demonstrate an impact, and I'm making it in quotes,

so that you can have additional funding to continue that stream of work. Now, we have done that. And I can give an example of Ghana, where I have lived and done a lot of my work, that at some point, we were driving towards the Millennium Development Goals. And we were sure that Ghana was not going to meet the Millennium Development Goals. So we started doing things to see the impact, drop the mortality to the level that we want for MDGs. What happened? We had an accelerated drop

at the time, but it's not sustainable because we are introducing measures that are not values-based. People are not doing the work out of compassion. People are not rendering services out of empathy. It has not been institutionalized. What they are doing is robotic. Let's get the numbers down. But gradually,

The world is saying that if we use this values-based approach, one, it appeals to our culture of empathy and compassion.

Because if you see your neighbor suffering, and there is a proverb in Ghana that says that if you see your neighbor's beard on fire, you must fetch water and put it beside you because yours could be the next to catch the fire. Right? So it means that what people are saying is that if we want these changes to be sustained, then it must be culturally aligned to what we believe in. And this is what is driving change.

the thinking and leadership around quality now. It's sort of, these might be seen as soft or, you know, leaders who focus on these things, it's sort of soft leadership or it's compromising outcomes or whatever. It's not obviously necessarily the case. No. No? No.