April 26, 2018 Nick Downham

Facilitator Tips

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Whether you are a leader, an improvement facilitator, an internal consultant or a coach, much of your success in not down to your technical knowledge – it is down to your skill in influencing and getting others to change.

Positioning these tips:

The first thing to say is these tips are not about an intervention, improvement methodology, idea or solution. They are about the facilitation skills regardless of the idea or change you trying to help along (more on this later). So this is not about QI, or Lean or a type of change such as triage etc. It is also not aimed at large group facilitation, which is a different set of skills.

This list of themes is aimed at the facilitation skills required when working with individuals (leaders or otherwise) or small groups.

1) Leading by asking questions. You can help people create less fragmented and more systematic / robust understanding of their work and organisation through careful questions. This can help shape views through asking questions rather than telling (offering solutions or answers). Very powerful stuff.

2) Being a skilled helper*: The skilled helper model from Egan is a core text for social workers (and many GPs are aware of it). The model essentially has three stages:

  1. A) Listening (establishing trust through exploration, empathy and shared experience).
  2. B) Suggesting alternative frames of reference (note, this is not solutions).
  3. C) Action and Implementation (encouragement).

This process takes many weeks and is counter to how many management consultants, leaders and managers work (they see their role as offering solutions in a lot of cases). The reason I do this is because no one ever responds well to being told what to do – especially in the short term. It is especially important if we are looking at system change (doing better things vs making things better). For system change those in power often need to let go of the existing shape of things – they won’t if they are just told – they will if they come to that conclusion themselves.

3) Plan a normative loop* On that subject of the ineffectiveness of just telling someone to do something, the second model is the three strategies to change by Chin and Benne. Essentially the three strategies are:

  1. A) Coercive: i.e. forcing someone to do something through the use of power, incentive etc. Given how educated our workforce in our system is, the independent ownership structure which some large parts of the system (GPs in primary care for example), and the fragmented structure of the wider system, then the limits of the commonly used strategy of Co-ercion are clear.
  2. B) Rational: i.e. traditional didactic training. I don’t view training on its own as particularly effective. Especially on skills and areas that are so contextual. On world class programmes I am involved in such as the Darzi fellowship programme and my own master classes we use a lot of simulation, coaching, reflection and observing to ensure learning is effective and context is considered.
  3. C) Normative (to make normal, or re-educational). This is all about reflection and personal experience. i.e people need t1o find out for themselves. This is why we use things like coaching, qualitative and quantitative data collection (by them) and lots of space for reflection. It is also why it is good to insist the senior people do it also, because they own the system which shapes the work.

4) Don’t undermine those responsible for the unit / system or change. It is really easy, through enthusiasm, to force a change through by doing it for someone / some department. i.e. we want to demonstrate impact and we are often resource light. But it is a false economy. It is not our system, so it cannot be our change. It will just revert to the old way as soon as the facilitator leaves.

5) Avoid going native. When you spend time with a team, you of course want to show empathy and understanding – but you also need to be objective and offer alternative frames of reference. It is really easy to get so close to the culture (become one of them) that this independent view is lost.

6) Process rather than solution. Linked to the first points around the fact that no one likes being told what to do, then offering an answer is ineffective. In fact, the ‘answer’ or solution is not effective because it was the context of the solution in the place it was first developed that was as important as the solution. This is the problem with many purchases of data systems and borrowing of ideas. It tends to happen after industrial tourism / healthcare tourism – going to see other providers and copying the things you can see – rather than the context that made that solution possible.

7) Humility. It goes a long way. Demonstrate humility and fallibility and people warm to you very quickly. It is often a life skill we develop as we get older – as we are more reflective on what we have tried previously.

8) Conversation starter. Assuming you may not know the people you are working with very well – have something in mind to start a conversation. Humans are social animals. Think about something funny that happened on the way to work, or read up on the local football team or whatever. But don’t go in straight with the work agenda. People trust people – so they need to get to know you.

9) Credibility – This is a little bit of a contentious one. An old boss of mine suggested to me that you had to be a GP to influence GPs, or a surgeon to influence a surgeon. I don’t believe this, as it has never stopped me in any setting (even as an engineer). I think that if you show listening skills, respect, contextual understanding and proven results then you will be fine.

10) Listening. You will probably not be surprised how rubbish listening skills are in the NHS. In many meetings people are not listening with an open mind, they are just waiting to put across their fixed view of the issue. So listening and replaying is powerful method. For you and the people you work with – it builds trust. If there is a chronic lack of listening skills (often the root cause in many disagreements), then there are methods that can be applied with meetings to ensure listening takes place.

11) Adjusting your dress – personal choice this, but I adapt what I wear to my audience. So I will wear jeans / shirt with collar for somewhere like a GP practice, but dress up for more formal settings. It is a fine balance – it should not matter, but people do judge on first appearances.

12) Being prepared – Nothing reduces trust like someone who looks like they are ill prepared and making things up on the spot. So read materials ahead of time. Something again that does not happen in the NHS in many meetings I go to. It is a real differentiator.

13) Being on time – Again, it is all about the tone it sets. Be on time or let people know if there are problems. Again, in many parts of the NHS, being serially late is the norm (and of course makes everyone else late).

14) Doing what you say you will do – it is amazing how surprised and pleased people are when they turn up and you have done the actions that were agreed of you. Again, it helps differentiate you and most importantly helps move things along.

15) Context – Deming states that an outcome = intervention + context. So much of a facilitator’s job is to build that context. There are some great papers on context from the Health Foundation that give you a framework on which to begin to understand the context within an organisation. Many of the previous tips are aimed at precisely that.

16) Honesty – This works on three levels:

  1. A) With a team or client, it is fine to say I don’t know the answer or way forward – so I need to go away and reflect on things. Better that than through in half baked thoughts.
  2. B) A facilitator should also ask for help from others. So for example I pull on my network of like minded independents when I want an alternative perspective on something.
  3. C) If you do something wrong, or want to revisit something, or something did not work as well as you planned, then say so.

I hope this list of facilitator tips was useful.

**Two and three on my list of tips are courtesy of improvement guru John Seddon. While this has always been my core approach, I would like to acknowledge him in helping me to formalise them by bringing them to my attention.

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