Paper: Implementing culture change in healthcare; theory & practice

This excellent paper on implementing culture change in healthcare; theory and practice was published 10 years ago. It's still relevant and there is no need to start another cohort of research on the theory now that "culture" is a big theme for the NHS.

Readers of this blog will know my aversity to the continuous stream of repetitive research - with insufficient action to put it into practice.  Culture is a difficult topic. The word defies easy definition  yet it's bandied around as both a devil and panacea - a cause of and a solution to the problems facing the NHS.

This paper is available free of charge and is worthy of a read and discussion with your colleagues.

Consistency of leadership matters

No matter what "evidence" you seek, leadership is always in the top ten of factors necessary for change and transformation of systems of care - or any system for that matter. There are books, papers and reviews all trying to qualify the type of leadership that works well.

I've been asking myself whether length of time in a leadership role makes a difference. When I look about me at the organisations who are held up as role models for good organisational processes, good collaborative working and good results - most often the leadership team has been in place for many years. Not just one leader, but at least 2 or 3 of the team.

Perhaps it important just to be there to hold the history and to maintain some form of continuity. Doing this while everything changes around you means the good leaders are naturally those who learn to adapt themselves  and their organisation, to the changing context.  I suspect they don't have great charismatic abilities, not do they espouse clever theories - they just get on with the job - year by year.

I applaud that level of commitment.

Reframing patient empowerment

It's good to talk - and following a chat with friend and colleague Bill Russell. I've been thinking about why it is "patient empowerment" doesn't seem to work in practice.

Firstly, it is an irony (check here for a definition and more info on what irony is). There is a dissonance between its implied meaning and what it literally means. Just thinking of the term assumes that someone other than the patient has power - and by creating a program or concept called "patient empowerment" comes across as them with the power trying to give them without the power, some of their power - ultimately the ones with the power are still power-full.  Hence the irony.

Secondly, who thought you in healthcare had the power anyway?  As a patient I am the only person who has power of my health  I may need help from health professionals, the gym instructor, my mother, advice from the bookclub ladies, thoughts from the parish priest etc.  The issue is that I may be seeking a way that health providers do not take away the power I have when I access them.

Thirdly, maybe thinking it is all about power is the problem.  Power itself has no use unless it is applied, employed, or used. This process is called influencing. Some people, with little obvious power can get a lot done through effective influencing - and vice versa. So I wonder what would be different if we thought about the relationship/s and the influencing flows between patients and healthcare providers?

Please add a comment if you have any reframing propositions for "patient empowerment"

Book Review: You can't order change: Lessons from Jim McNerney's Turnaround at Boeing - Peter Cohan

I was attracted to this book because the title said what I have always thought yet doesn't seem to be what I get involved with doing! I spend a lot of time on Boeings so I felt I had an interest in knowing what they doing and how they are doing it.

A while back Boeing was in a mess - stockprice was down, staff were complaining, revenue was not as anticipated, key people were leaving, lawsuits abounded and generally everything was on a downward trend.  Enter CEO Jim McNerney who gained a reputation of requiring results to speak for themselves rather than putting himself on a pedestal.

This book takes you through the CEO perspective and actions in turning around a self-destructing monolith. The view I got form the book was the importance of people stuff, relationships and leadership in times of trouble. Sounds obvious but in my experience I see organisations go down the route of more rules, process redesign and the like when the crunch hits.

Cohan interprets McNerney's approach as expressing what is required from leaders in the organisation, working with people so they jointly own these leadership attributes and encouraging communication at all levels. He also got rid of the people who didn't make the grade while investing in those who were growing into leadership roles with the right skills and capabilities. After people, the big message is the importance of the person who manages the finances. Then there is also the piece about customer involvement.

Written in summary here all this looks like the standard stuff of management and leadership texts. However, Cohan does explain all these actions in the context of Boeing. Still - to me, much of the diagnosis ended up a bit samey. Maybe that is more a reflection of my expectations - was I looking for something unique? Maybe the answer to large scale change in large organisations really is simple - the difficulty is in applying the tactics.

Overall - nothing new in here and maybe that is what is new.

Readiness for Spread. Whose readiness - the adopter or the "pusher"?

One of the most frequently asked questions I get is how program managers can assess whether organisations and teams are ready for spread. For me, the answer is a lot more than a quickie checklist or diagnostic tool - I've tried many, including developing my own, but they have their limitations. The first question to think through is "whose readiness"?

1. ADOPTERS: Mostly I have program managers wanting to know whether organisations and teams they want to adopt something are ready. This is a useful question to ask, and indeed much of the literature focuses on these potential adopters. So yes, it's good to consider their readiness and there are a multitude of tools and techniques for doing this - any good change management assessment will work.
2. "PUSHERS": What most people forget is to assess the readiness of the "pushing" organisation to go through the spread process. For example, a regional organisation may want all physician practices to adopt the use of new diabetes guidelines which includes an information monitoring system. It may sound obvious, but the "pushing" organisation does need to make sure they are ready and geared up for others to adopt the process.They need to have the support and systems in place. Often, great practices and ideas can be adopted so quickly that the "pushing" organisation panics and then becomes part of the "slow-adoption" problem as they put limits on the process.
3. CONTEXT: Finally, the context is crucial. When it comes to large scaling up activities, it's vital to assess the readiness of the context that organisations and teams find themselves in. For example, the context where a pilot program achieved great results may have changed in the year or so since they completed their work: a change of government, the financial crisis, new technology etc.

So, when you are next assessing the readiness for your spread / scaling up program, do take the time to think through the three different angles.

Patient Experience; report to help Boards build patient and public experience into quality fo care

If you are steeped in the healthcare quality improvement methods you will know how important it is to understand the patient experience. Scaling up project results to a wider audience does not mean the patient's views are no longer important. While the theory is obvious the practice is not. It can be difficult to engage non-executives and Board members with the patient experience and a new report on the Patient Experience  issued by Dr Foster in the UK covers the following:


Foreword 
Key messages 
The scope of this report 
What is patient experience? 
Good intelligence guide: The basics 
Good intelligence guide: Measuring what matters 
Good intelligence guide: Building an intelligent report 
Good intelligence guide: Advice from the sharp end
Board briefing: Intelligence types and uses 
Board briefing: 2010 policy directions 
Board briefing: Glossary 
Board briefing: The current state of play 
References 
Acknowledgements 

It provides advice on how Boards can produce a meaningful intelligence report on the patient experience. I particularly like the checklists and the brevity with which it is written.  They have nicely avoided the temptation to burst into theoretical concepts.

I found this report via Jocelyn Cornwall's blog at the Kings Fund - another good source of information.

Online Clustered Networks Spread Behavior Change Faster

Online communities have different dynamics to face-to-face communities of practice. New research suggests that for online communities, behaviour spreads more quickly when the community is grouped into networks with overlapping connections than when left to develop more random and distant links.

If you are managing online communities then the research is worth a closer look as it may provide hints on how to design and support it so behaviour and influence can spread amongst the participants.

For communities of practice not online this clustering effect is not new. Research has been around since the 1970's which show the importance of bringing groups together geographically, thematically and/or by profession or person type. As humans we like to be with people similar to ourselves and are most influenced by those the same as us - if Joe can make the change then I will probably be able to as well.

There is a lot of buzz about social movements, mobilising and organising for change in healthcare. One of the success criteria for this work will be the depth to which those doing the organising as well as those participating understand network dynamics, and design accordingly.  Random networks are less influential.

Transformation versus Metamorphosis in Systems & Organisations

Gone are the days where the method of reducing variation and improving quality was focused on the incremental spread of good practice, using mostly communication methodology from the 1960's. The current mantra is "transformation". I am proposing an alternative, "metamorphosis", which may be a more relevant meaning-making metaphor in some circumstances.

We recognise when an organisation has transformed because we perceive a difference. This difference is usually one to stay. Slipping backwards to the old way is not an option. Transformation is something we recognise after the event. Thousands of books and papers have been published describing the experience of others and their own summary, meaning making and production of frameworks and models. However, underlying all the noise of methodology lies the premise that all transformation requires a behavioural change of significance. In addition, to transform usually requires a high degree of emotional commitment, trauma, distress and joy. Transformation is touted by "those at the top" as a process and outcome that is positive. However, for some it is necessarily an unpleasant process.

An alternative concept is "metamorphosis". This focuses on the striking change in appearance, in form and function, of an organisation or system. Individual may transform their behaviour, organisations and structures may morph into new, innovative and maybe even shocking forms. Morphing can happen slowly, the result of an incremental drip by drip process. Then we look back and see it now looks totally different. The changes around Mental Health Care in England from the 1970's to date are an example. Experience a deep depression in the 1970's and you would find yourself in an open ward of a Victorian building, treated (in a rough sense of the word) as a curious, complex and perhaps untreatable patient. Nowadays, you'd be cared for in the home by multi-disciplinary teams who recognise you as an individual with a family and personal set of circumstances. While drugs may be used, talking therapies also abound.

So what is it you are wanting from your quality improvement work? Are you requiring the sorcery of personal transformation or the magic of metamorphosis? Is the aim a behavioural one or a structural version? Of course both overlap and are dependent on each other, though a focus on form is different to a focus on individual behaviour. The resulting process and consequential outcomes will also differ.

One way to use these concepts is to think of transformation as a bottom up behavioural approach and metamorphosis as a top down structural and form based strategy. The two are related, differently.