Culture and values are central to delivering good patient outcomes at Royal United Hospitals NHS Foundation Trust (RUH), where employee values are co-developed across all organisation levels, and championed by senior leadership. By using ThanksBox recognition and engagement technology, the RUH has driven the uptake of cultural values across the trust.

This case study explores the application of recognition technology within a complex organisational environment, and offers insights from senior HR leadership as to how to best implement technology to drive up engagement.


Organisational culture is highly complex. Given that at their heart organisations are bound by relationships and social connections, the often ambiguous concept of culture and values can appear to be too intricate to accurately measure, let alone manage. Nowhere is this more apparent than in knowledge-based organisations, such as the NHS, where high degrees of knowledge, skills and capabilities are harnessed to drive performance, in the form of high-quality care for patients. In these highly social environments, in which resources are often restricted, the relationships people have with one another can impact not just the health of workers and their colleagues, but also the patients they’re caring for.

The Royal United Hospitals Bath NHS Foundation Trust (RUH) employs a workforce of 5,000 in a broad spectrum of roles, and cares for a catchment population of around 500,000 people across Bath and North East Somerset, Wiltshire, Somerset and South Gloucestershire. The RUH provides 736 beds and a range of clinical care, which includes acute services including medicine and surgery, specialist services, services for women and children, emergency services, and diagnostic and clinical support services through an employee skills base that includes highly trained medical specialists and their support staff, as well as technical, administrative and estate roles. 

Transforming culture to further improve patient care

To deliver these services and to ensure the RUH offers the best-quality care to patients and their families, the trust has gone through an extensive engagement programme to co-create clear values and behaviours which provide an ambition for how staff, patients, carers, and families said they want individuals to behave now and in the future. They represent the RUH at its best. Following the acquisition of maternity services in 2014 and the Royal National Hospital for Rheumatic Diseases (RNHRD) in 2015, there has been a considerable push to build a shared culture that is centred on patient care, focused on well-being, and delivering value through efficient use of resources. As Angela Hayday, Associate Director of Organisational and People Development, describes, this is a journey which must include the entire workforce:

‘In September 2015 we launched our values programme, which was a way to bring together staff, patients and carers representing a wide range of health services, to co-create shared values and behaviours. This was important culturally because of the integration of staff from maternity services and the RNHRD. It was hugely important – our values work was seen as a way of creating a shared future.’

To inform the development of the values, an extensive amount of time was spent talking with and consulting various parts of the organisation. In an iterative development process, the senior leadership was engaged to listen to all parts of the organisation to build a set of values that align to the idea of one culture across the organisation. In doing so, a dialogue was created across the organisation about its purpose, and opportunities to improve, as well as highlighting areas of risk that needed to be explored and appreciated in greater detail. It was particularly important for the organisation that the final values described were not changed by the board; instead, the board would adoptand act with the  values described by the workforce, patients and carers:

‘We spent a thousand hours listening to 800 staff and around 70 patients, carers and their families … about their experience of working and being cared for at the RUH … to help us co-create a set of values and behaviours based on the best of what we are. I think what was unique about the way we approached it was that the board agreed right from the beginning that they wouldn’t change the values and behaviours when they were presented to them at the end of the process. They went to the board simply to be ratified: they weren’t changed at all. That in itself was quite an important part of the engagement process.’ Angela Hayday, Associate, Director of Organisational and People Development, RUH

To get to this point it was important that senior leaders in the trust owned the programme of work. The chief executive and directors were instrumental in opening events in which employees could share stories of good and bad experiences at work. In addition to individual staff experiences, patients and carers were heard by staff. The approach included a range of perspectives from staff to service users to ensure that, in the debate around values and behaviours, staff and patient voice was strong. As a result, the organisation defined its values from the bottom–up, landing on three core values and a set of linked behaviours (see Table 1).

Table 1: RUH values and behaviours 



Everyone matters

Understanding individual needs – see the person, understand their needs, respect their views, choices and dignity

Caring – be attentive and considerate, notice the little things

Valuing others – make everyone feel important, recognise people’s contributions, say thank you

Being friendly and polite – smile, introduce yourself, welcome everyone and build relationships

Being kind and caring – put yourself in others’ shoes, show empathy and compassion

Being calm and reassuring – put people at ease, create cheerful and welcoming environments

Working together

Communicate – clearly, openly, honestly, sensitively and in a timely manner

Actively listen – make time to listen, hear people and respond

Share information – be transparent, keep people informed, explain clearly, invite people to ask questions, check people understand

Involve and empower others – share learning, welcome people’s ideas and give choices

Be helpful – be aware of others, ask people if they need help, follow things through

Support each other – co-operate to provide the best possible service

Making a difference

Be proactive – prepare, take responsibility, influence whenever you can, focus on solutions, be open to change

Speak up – encourage everyone to have a voice and help people to be heard

Take pride – in ourselves, what we do and where we work, celebrate achievements and choose a positive attitude

Contribute – share ideas, be curious, challenge yourself and others to continuously improve the way we work

Be willing to learn – develop yourself and others’ skills, knowledge, confidence and ability, be prepared to learn from others, give and receive feedback

Be responsive and efficient – take the time to do things effectively and be respectful of other people’s time


A continuing dialogue: sharing stories through ThanksBox

Involvement and engagement in the development of the values was a key principle for RUH and was held as a core part of the programme of work as it developed. Engaging workers to share their stories not only allowed the team to develop and build the values and behaviours, but also itself acted as a way to foster positive relationships between colleagues. Communicating through testimonials and individual stories was seen to be an effective mechanism that brought people together across the trust and engaged them in something they all felt they had ownership over:

‘There’s something about hearing staff and patient stories that seemed to resonate with our staff. The chief executive presented alongside staff, a patient and a carer at the launch, and staff said they felt that their engagement was genuinely wanted – but they had concerns over how the values would be embedded so they weren’t just empty words in pamphlets and posters. One of the things that came out very strongly in the listening events was how important it was to feel appreciated….

For us, this was really a key behaviour. Appreciation is core to our “everyone matters” value, and it was critical to bring this to life. We needed to be able to bring that behaviour alive.’ Angela Hayday

Tapping into the inclusive ideas of engagement and appreciation was deemed to be crucial if the values were to be fully embedded across the trust. It was at this point that the trust looked to partner with a best-in-class technology provider to support this initiative, and discovered ThanksBox, a system designed to foster positive relationships across organisations by providing an easy-to-implement recognition and engagement tool.

ThanksBox provide a suite of digital tools for employees to share ideas, offer feedback, complete surveys and recognise each other. ThanksBox utilises the data created through these interactions to provide real-time insights into employee behaviours, relationships and levels of engagement. 

The RUH cultural framework was aligned to the ThanksBox recognition tool, attributing a value behaviour to each thank you message sent through the system. This information is then aggregated and visualised for users via a monthly update email using the data analytics.

RUH can then understand which people, teams, departments or demographic groups had been recognised, how frequently and which behaviours and values these messages align to.

The challenge to understand how people behave at scale is often tough, as the mechanism to capture behavioural data is observation – the nature of today’s work makes this difficult to rely solely on managers. ThanksBox utilises the very essence of recognition, observing a behaviour and positively reinforcing it, to capture this data and provide insight.

It should be noted that organisations are required to go one level deeper than thanking relating to only the organisational value. It is felt by ThanksBox that values can sometimes feel abstract to the employee, and behaviours are often far easier for an employee to identify and recognise. ThanksBox then provides the charting between the behaviours and the values in their analytics dashboard. 

Visibility of who messages are sent from and to, which behaviours are recognised and how these relate to the values all allow RUH to easily identify where inteventions are required to continue to develop the cutlure and amongst which groups of employees.

ThanksBox is helping to drive engagement and recognition throughout the trust. Participation in the tools is available at all levels, with the chief executive sending messages on a regular basis to thank the winner of the Chief Executive Customer Care Award. The use of the tool by directors and very senior managers has been successful in engaging all parts of the clinical and non- clinical staff in utilising the tool. Staff find out about ThanksBox when they receive a message of appreciation from a manager: 

‘Our chief operating officer thanked a colleague for coming in to work on their day off, which is fantastic recognition for a big commitment from someone. The workforce tells us that sometimes it feels as if people in very senior positions don’t know what happens on the ground … this gives employees the opportunity to see how managers appreciate the work they do.’ Angela Hayday 

A social movement for change

To transform RUH, the senior team took a strategic approach to building a social movement, aimed at delivering long-term sustainable behaviour changes. This was reflected in the launch of ThanksBox, whereby the ThanksBox technology was only launched to 350 managers and leaders; it was only when they thanked someone that the recipient of the message would then be added to the system and be able to recognise their colleagues. It was important to ensure that managers led by example, which is fundamental to the transformation RUH wanted to see: 

‘We have deliberately taken a very organic approach; we wanted to see what would happen. We’re now using ThanksBox to help analyse how the social movement is doing, and to help us understand which of our values and behaviours are most and least recognised. One of our HR graduates has used the ThanksBox analytics to identify and work out what action we will take next to encourage more managers to use ThanksBox, with the aim of using the system to encourage a climate in which staff feel appreciated by managers and ultimately each other.’ Angela Hayday

 ‘As the social movement takes shape, the idea is to encourage trust managers to adopt the practice of regularly appreciating and recognising the contribution of individuals within the workforce. To the trust, the strength of ThanksBox is that it encourages communication and recognition on a real-time basis. Staff tell us it means a lot to them when managers take time to acknowledge their contribution sing ThanksBox and that it is much more powerful than a cursory “thank you” as part of a conversation in passing.’  Angela Hayday

Uncovering behaviours: using technology to go deeper into culture

Technologies such as ThanksBox allow organisations to look closer at how employees view aspects of the business that were until recently hidden from view. As people professionals look to understand more about cultures and behaviours, there is a need to interrogate data through a different mindset, and build linkages between data which has historically been out of reach. With ThanksBox, the team at RUH has been able to locate values that are being enacted more often than others, as well as highlight those which may need further intervention – invaluable for a team trying to drive engagement:

 ‘One of the things that we’ve learned is that the values are being recognised to different degrees according to ThanksBox. For example, we found that making a difference represents 45% of messages, and being responsible and efficient is the dominant behaviour for which the workforce is thanked. Under the “working together” value, it’s supporting and helping and then for the “everyone matters” value, you can see that caring is number one. We’ve looked at what behaviours managers are recognising, and what behaviours were being recognised between colleagues.’ Angela Hayday

Looking more closely at this evidence is allowing Angela to lead her team to make more effective decisions about how to drive cultural change in a sustained manner across the trust. This means ensuring that, when evidence is being used in the organisation, there is a clear understanding of the quality of evidence being evaluated. For an organisation driven by evidence and data, such as an NHS trust, this is crucial:

‘We now need to encourage more managers to use ThanksBox. The more people use it, the more clarity it will provide, and the more influential it will be for encouraging leaders to create a climate of appreciation. We want to focus on making using the tool a regular habit for our managers – by understanding and sharing with managers the positive impact it has on those who receive ThanksBox messages.’ Angela Hayday 

A clear recommendation for implementing technology of this type is to drive uptake through engagement. Choosing the right technology is important: if the technology is easy to use, employees are likely to continue to build it into their working life. As the implementation of ThanksBox suggests, giving employees the ability to explore the data themselves is key to integrating technology into practice.

Continuing cultural transformation: embedding the change

As the transformation programme grows, and more colleagues are engaged in the conversation, technology such as ThanksBox can help to facilitate debate in a manageable and transparent way. To embed change, an important task is determining which areas of the organisation are on the journey, and which require further investment, perhaps through complementary interventions that help to embed specific behaviours and values:

‘Looking at function by function, or team by team, is a great way to focus investment in specific interventions. Similarly, you can evaluate by managers/non-managers or demographic data, allowing you to answer questions such as: are men or women more appreciated in our organisation? Which behaviours do our managers regularly recognise in our people? How does it compare with the reasons employees recognise each other?’ Luke Fisher, CEO and Founder, ThanksBox

Drilling down to the team level is something that can help understanding of how cultures and values operate on a micro-dynamic level, as opposed to organisation-wide. This information is seen to be critical for the team if they’re to understand how to effect change on an individual level: 

‘We know from the engagement work that we’ve done that people feel very aligned to their teams, and by teams, I mean the people they’re with every day. They don’t necessarily feel as close across the organisation. This is important because often patient flows go across teams, not within teams, so this could have an impact on patient experience. ThanksBox can help us work out where we may wish to encourage cross-department appreciation to improve relationships for the benefit of patient care.’  Angela Hayday

While the impact is still coming to light, initial findings from evaluations such as the NHS Employee Staff Survey illustrate that changes are occurring for the trust. While difficult to describe causally, there has been an uplift in the mean responses of employees when asked whether they feel recognised and valued by their management, with a 6% increase from 2015 to 2016. ThanksBox was implemented between the 2015 and 2016 survey and RUH feel the improvement in results is largely owing to the RUH values work and the effective implementation of their recognition approach with ThanksBox.

As these findings demonstrate, the progress towards effective workplace cultures requires investment in strategy, operations and evaluation. As the partnership with RUH shows, technology implementation is an effective way by which organisations can use data to improve recognition and engagement, and ultimately create more effective cultures in which people work every day.

The full series

your talent

Find out how other businesses are using people measures to improve their organisations through these case studies

Callout Image

More on this topic

Employee turnover and retention

Learn how to measure turnover and retention, and understand why people leave organisations

For Members
A woman working from home with her back to camera
Health and wellbeing roles

Creating a holistic offering to help improve workforce wellbeing