Archives July 2013

Rocking the boat and staying in it: how to succeed as a radical in healthcare

Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England.

Anyone who chooses to be a change agent or improvement leader in healthcare doesn’t choose an easy life. There are so many forces opposing the changes we want to see; a system that rewards people for “keeping the trains running” rather than radical change, those with the power and/or a vested interest in keeping the status quo, colleagues and leaders who are sceptical, apathetic or scared of change.  Many times in my career in improvement, I have felt isolated, vulnerable and misunderstood. People have treated me like some kind of oddball when I have craved to be taken seriously and appreciated for my efforts as a leader of change. Yet big change only happens in healthcare organisations because of heretics and radicals; the courageous, passionate people who are willing to take responsibility for change, who support their organisation in its mission but also challenge the status quo.

As Martin Luther King described it: ‘‘The saving of our world . . . will come, not through the complacent adjustment of the conforming majority, but through the creative maladjustment of a nonconforming minority’’.

The hope of healthcare rests with the non-conformists, the radicals, the heretics and mavericks in our midst.

So who are the radicals in healthcare organisations? Research by Debra Meyerson  shows that the most effective radicals are those who have learnt to oppose and conform at the same time. Or, as she puts it, “they are able to rock the boat and yet stay in it”. These are change leaders who stand up to challenge the status quo when they see there could be a better way. They develop the ability to walk the fine line between difference and fit, inside and outside. These leaders are driven by their own convictions and values which makes them credible and authentic to others in their organisations. Most importantly of all, they take action as individuals that ignite broader collective action that leads to big change. These leaders already exist in every healthcare organisation, in many different roles and multiple levels. They aren’t typically the Chief Executives or senior clinical leaders yet the impact of their change activities are often just as significant. We saw so many examples of this on NHS Change Day 2013. Many organisation-wide change efforts that led to tangible improvements for large numbers of patients were initiated by grass roots front line leaders.

Lois Kelly has developed some fantastic resources for “rebels at work” and I would recommend a trip round her website to all healthcare radicals. Helpfully, she makes the distinction between a “rebel” and a “troublemaker” and I have adapted her table below.  As rebels, we continuously seek innovative new ways of delivering care. We are committed to the patient-centred mission and values of our organisation. We are driven by our passion for better care for patients. We are optimistic about the future, the potential for change and see many possibilities for doing things in different ways. We generate energy for change which attracts others to unite with us for a common cause

“Troublemakers” also challenge the status quo but in a way that is very different to “rebels”. Troublemakers complain about the current state of affairs but their focus tends to be around their own personal position rather than achieving the goals of the organisation.

Source: Adapted from Lois Kelly  www.foghound.com

They are angry about how things are and don’t have much confident that things will get better in the future. They alienate other people because if others link with them, troublemakers will sap their energy. This just confirms what troublemakers probably know already– they don’t belong.

There are a couple of points I wanted to make about rebels and troublemakers. Firstly, many organisational leaders view ANYONE who challenges the status quo as a troublemaker, Therefore, rebels get unfairly labelled as troublemakers. It has happened to me on more than one occasion. It feels SO unjust but we are to be effective change agents, we have to anticipate that it might happen and learn to deal with it. Secondly, lots of change leaders  in healthcare start out as rebels but their voice doesn’t get heard, they begin to stridently question the status quo in a manner which is radical and self-defeating and they cross the line from rebel to troublemaker. As rebels, we have a responsibility to look out for this and try to prevent  it happening by building relationships and forming alliances with others who challenge the status quo.

So what are the tactics to survive and thrive as a radical/rebel/heretic/maverick in healthcare? I would like to suggest four:

1. Start by improving myself
2. Build alliances for change
3. Work out what might help others to change
4. Don’t be a martyr

I will discuss each of these issues in turn in my next four blogs. If you would like a preview on these topics, you can watch this short film

Corporate Rebels United is a global movement of “corporate rebels” across multiple industries and sectors. Many healthcare rebels/radicals are part of this. This is the manifesto of Corporate Rebels United which perfectly captures the mission of organisational radicals in healthcare to deliver the new truth of healthcare transformation

We are architects and scouts into the future, and we want to guide our organisations in navigating a safe path from now to then:

Relentlessly

Challenging the status quo

Changing the rules

Saying the unsaid

Spreading the innovation virus

Seeding tribal energy

With no fear

With a cause to do good

Leading by being from our true selves

Going after the un-named quality

Relentlessly

Calls to action for this week

1. Make time to reflect on your own role as a healthcare rebel/radical; what are the implications for the ways you operate as an agent or leader of change?
2. Seek out other rebels/radicals and discuss tactics for rocking the boat and staying in it
3. Identify and support others who are at risk of crossing the line from “rebel” to “troublemaker”

Helen Bevan (@HelenBevan on Twitter) works with NHS Improving Quality, the national improvement team for the NHS in England.  

I will be writing a regular blog for the BMJ Quality Blog. So this is  my introductory blog about my work passions which give some hints about what I might write about in future blogs. I should also tell you a little bit about my background, as I don’t think you can separate the blog from the person.

I’ve worked in quality improvement in the English National Health Service for more than two decades. I’ve learnt so much first-hand about delivering change, mostly because large scale change rarely ever goes to plan. I also had a “pre-NHS” career, although it feels a long time ago now. My first degree was in social science. I am a very good advertisement for the benefits and relevance of a social science education; I still use many of the ideas and principles about large scale change that I learnt as a teenage undergraduate. In my 20s, I worked in organisational and leadership roles in local government and education. My roles were always about leading change, helping people think differently and building new skills; I worked on one of the earliest “Total Quality Management” projects in the education sector in the late 1980s. I joined the NHS in 1991 as part of a scheme to bring senior leaders from other industries into the health sector. My change management skills were identified very quickly by the NHS and since then, my entire NHS career has been about enabling big change to happen. I’ve undertaken all my subsequent education, up to doctoral level, part time whilst leading major change programmes. It isn’t something I’d recommend to the fainthearted.

I spent much of the 1990s leading The Leicester Royal Infirmary “re-engineering programme”; a massive effort to transform an NHS hospital on a scale never attempted before. Not everything we tried worked but much did and that experience was seminal for me as a leader of change. It taught me greatly about the importance of big ambition for service change and for patients. Terry McNulty and Ewan Ferlie wrote a book about it which remains one of the most informative texts on healthcare improvement ever written. If, as a country, we had followed McNulty and Ferlie’s advice on how to go about change in a clinical environment, we would be significantly more advanced in our change efforts today.

In 1998, I was given my first NHS-wide job in improvement, working with policy makers, clinicians and hospital managers from across England to eliminate waiting times for patients. And in 2013, I’m still working at a national level in the NHS, supporting quality improvement. I’d say that my biggest achievement has been helping to make improvement mainstream in the NHS, hopefully in a way that had an impact on a lot of front line clinical teams and patients. When I first started life as a healthcare improver it was a lonely occupation, undertaken by only a few enthusiasts and visionaries. Now, the systematic application of quality improvement methods happens in most NHS organisations to some degree. I think that I have helped along the way through very practical but effective strategies such as the Ten High Impact Changes for Service Improvement and Delivery, The Productive series including The Productive Ward and Productive General Practice, the use of social movement principles in healthcare improvement and more recently, the NHS Change Model. These initiatives have spread to healthcare systems around the world. I have stuck with my role at a national level in the NHS for many years and I believe the continuity has helped.

It’s obvious to me that the current era offers the best potential ever for large scale change in healthcare. The challenges that the NHS and other healthcare systems face now mean that many of the previous incremental ways of undertaking change aren’t fast enough or broad enough for the future. We need to build on the strengths that we have as an NHS system but bring in fresh perspectives.  We have to design change strategies with a “second order” mindset (possibilities, connections and innovative solutions at scale) rather than “first order” thinking (limits losses and fears, doing more of what is done already, on a bigger scale). But more of this in coming weeks.

Over the years, I have trained in many different methodologies and philosophies for quality improvement and organisational development; from Lean and Six Sigma to the Model for Improvement to Polarity Management and large group engagement to McKinsey’s five frames for organisational health and transformation to community organising and social movement thinking. I have huge respect and appreciation of all these approaches and utilise them all but I’m not a purist about any one approach. I think that the skilled improvement leader has a toolkit of approaches that can be utilised to any given situation.

And no, I’m not a direct descendent of Aneurin Bevan, although I’m proud that I share my surname with the founder of the NHS. My paternal ancestors (“the Bevans”) were seafarers and sailmakers from Bristol. At some point, centuries ago, they crossed the Bristol Channel from South Wales. My greatest NHS inspiration is my mother, Beryl Bevan who worked as an NHS domestic assistant for nearly 30 years. My mum lived out her NHS values in her job, through her hard work, her kindness and positive attitude. She epitomises thousands of NHS workers in the extent to which she was willing to help others and do far more than she was employed to do. I aspire to be like her every day in the way that I do my NHS role.

I hope this has whetted your appetite for my blog and look forward to many great comments and conversations in coming weeks.

Helen Bevan (@helenbevan on Twitter) is part of the delivery team for NHS Improving Quality, the national improvement team of the NHS in England. 

I live in a world of healthcare improvement, quality and safety. I spend my hours working with others to build action for change and transformation and seeking to solve the eternal challenge of how to help change spread from one place to another.

Increasingly in my world, people are talking about “hack days” and “hackathons”. A number of the young NHS leaders and trainee doctors that I interact with take part in “NHS Hack Days”; the Management Innovation eXchange, is running global virtual hackathons to reinvent the way that organisational leaders lead change and across the world, governments are using hack day methods to create more transparent, accessible services for citizens. A hack day is essentially an event of one or more days where people involved in software development (known as “developers” or “devs”), subject matter experts and others get together to invent creative solutions or new insights to tricky problems. I can see from my world that leaders of change are starting to apply methods that originated in the software industry (and were about technical data-driven solutions) to solving big strategic issues such as strategic planning, community building, system redesign, and transformational leadership development.

Team SGULIT hard at work at #BMJhack

So I thought I had better experience a hack day. When BMJ offered me the chance to be a judge at their hack on 6^th and 7^th July, I jumped at the opportunity to take part, observe and learn. The event started at 10am on Saturday morning and ended at 7pm on Sunday night. There were about 50 people taking part in the hack day, about two thirds of which were “devs”, many of whom had no or little health background. There were also medical students, academics and clinicians. They could choose from one of four challenges to work on. The first was around “digital medical students”, building innovative applications to help create future doctors. The second challenge was about creating a “zero harm NHS”. The third challenge was about contextualising knowledge content, such as BMJ Best Practice, to local settings around the world and the final challenge was about how to revolutionise the scholarly publication process, to enable greater collaboration and access.

So after the initial briefing, the participants started to share ideas, identify potential areas to work on, define their hacks and build teams. Some people had bought topics that they had already been working on for months, others offered their services as specialist contributors to teams. They were given access to BMJ data to work with. Over the next 24 hours, I observed the teams diagnosing problems, generating ideas, experimenting and prototyping their solutions. At first, I was surprised that some of the teams didn’t spend longer finding out about the context of the problems they were seeking to solve, by talking to the people who were present at the hack day who could give them a lot of information. Many of them dived straight into the data. What I realised after a while is that they used the data to understand the problem and the context. I was astonished at what they could do with data!

All of the developers were volunteers. They gave up their weekend to take part in the challenge. Many of them slept overnight at the venue and worked well into the night creating their solutions. There was a fantastic spirit and enthusiasm for the topics. At 4pm on Sunday, each of the 13 teams took part in a “show and tell” to present their solutions to the judges. There was a wide range of hacks, ranging from on-line calendars for clinical students in hospitals to a motion tracker to prevent patient falls and pressure ulcers to medical decision trees using basic mobile phones in locations where availability of technology is limited. In nearly every case, the presenter of the idea had actually built a computer application that they were physically able to demonstrate. They had done this in a period of a little over 24 hours. They challenged my pre-conceptions about what can be achieved in a short timescale.

Participants start to show and tell their contributions at #BMJhack

You can read about the winners in the next copy of BMJ. There is also a blog from a member of the winning team. The winning entries tended to be those where developers and clinicians had formed teams together, combining specialist developer expertise with subject-matter expertise to tackle big problems in a context-specific way.

I benefitted so much from this experience. These are some of the learning points I took away:

• We need to engage lots of different change agents to tackle the challenges of health and care and get fresh eyes on the issues. This weekend I learnt a lot about change from 15 and 17 year old developers
• Open innovation (innovating in partnership with those outside of your organisation or usual collaborators) is a very powerful way to get new ideas and perspectives and we need to do more of it
• People will volunteer and give of themselves greatly if we set the challenges in an exciting way, engage with their values, support them to work with others for a shared purpose and value their contributions
• There is massive potential to build communities of learning and action, based on hack methods, to tackle some of our biggest challenges
• The best solutions come when we combine effective data analysis with creativity and imagination and human values and intuition

Thanks BMJ for inviting me to my first hack day. I hope it is the first of many.