Culture, Creativity and Innovation:
Basic Premise for Effective
Change and Improvement
Paul Plsek
Consultant in Complex Systems
& Innovation
Atlanta, US
paulplsek@DirectedCreativity.com
“I believe that public servants are working
flat out, but in a system that shrieks out
for fundamental change…If we don’t get
the systems and structures right we will
never get to the roots of the problem only
prune its visible branches.
The key to reform is redesigning the
system round the user.”
Tony Blair
UK Prime Minister
“The challenge is to bring the full
potential benefit of effective health
care to all… this challenge
demands a readiness to think in
radically new ways about how to
deliver health care services.”
US Institute of Medicine
“Crossing the Quality Chasm”
Culture, Creativity and Innovation
• Comments on the Norwegian strategy
• Caution: The Door Into Summer
• Innovative thinking for making things
better
• Change in complex systems
• Patterns in organizational culture that
can hinder or aid transformation
• Signs of transformation
Norway’s National Strategy for
Quality Improvement In Health
and Social Care
Opening the door to
“…and it’s going to
get better”?
Each leg of a
three-legged
stool is vital…
Norway’s
Quality
Strategy
Quality
Improvement
Evidence
Based
Practice
Research
It must all work together…
Norway’s
Quality
Strategy
Quality
Improvement
Evidence
Based
Practice
Research
Goal of any health and
social care system:
Deliver evidence-based
care in a timely, effective
and caring manner
Research feeds evidence
based practice
Quality improvement helps
to implement evidence
based practice and
measure performance
Strategy for Quality Improvement
Quality services:
are effective
are safe and reliable
involve users and allow them to have influence
are coordinated and integrated
utilize resources appropriately
are available and equally distributed
Strategies and Action Plans
Strengthen
the
user
Strengthen
the
provider
Improve
leadership
and
organization
Strengthen the
role of
improvement
knowledge in
education
Monitor
and
evaluate
services
Strategy for Quality Improvement
• Three legs can build on each other
• Aims are excellent
• Deeply understand the inward-looking
strategies…
– Strengthen the provider
– Improvement leadership and organization
– Strengthen the role of improvement
knowledge in education
• Transformation drivers…
– Truly strengthen the user
– Transparently monitor and evaluate services
Norway’s National Strategy for
Quality Improvement In Health
and Social Care
Opening the door to
“…and it’s going to
get better”?
Or… will it be like
The Door Into
Summer
(Robert Heinlein, 1956)
The Road to the Future?
Source: Gareth Morgan
We are certainly committed to
continuous quality improvement…
…we solve the same problems
over and over again!
QI Director
for a major US
healthcare system
Odds of transformation
increase when we…
Avoid simply repeating old patterns…
…when we exhibit the courage to take
the “path less trodden”…
…when we innovate!
Altering Patterns of
Thinking and Performance
Let’s begin at the beginning
with Creativity 101
What is innovation
and creativity”?
Why are creative ideas
relatively rare?
How does one generate a
creative idea?
Innovation…
The purposeful production of
creative ideas in a given topic
area, followed up by
deliberate efforts to implement
some of those ideas.
Creativity...
The connecting and rearranging of
knowledge — in the minds of
people who will allow themselves to
think flexibly — to generate new,
often surprising ideas that others
judge to be useful.
Creativity...
The connecting and rearranging of
knowledge — in the minds of
people who will allow themselves to
think flexibly — to generate new,
often surprising ideas that others
judge to be useful.
“Hey, I can hear the traffic!”
“To hear the ocean, press 5…
for sea gulls press 6… for…”
Creativity...
The connecting and rearranging of
knowledge — in the minds of
people who will allow themselves to
think flexibly — to generate new,
often surprising ideas that others
judge to be useful.
Edward deBono’s Mental Valleys
Model for Thinking
Streams of thinking
Valleys
“Creative thinking involves breaking out of
established patterns (valleys) in order to look
at things in a different way.” de Bono
Purposeful channel
Random jump
Odds of transformation
increase when we…
• Come up with non-traditional ideas
and approaches to the delivery of
health and social care
• Make novel connections among
what we know
• Think creatively!
Why don’t creative ideas come more
naturally?
Because our mind is not optimized
for creative thought…
But, we can do something about that!
Connect all nine dots, with just 4
straight lines, without lifting your
pencil once you start.
3
2
4
1
Connect all nine dots, with just 4
straight lines, without lifting your
pencil once you start.
Boxes, Rules, and
Mental Models
• Our mental models become natural
way of seeing and explaining things
• Difficult to see (“like water to a fish”)
• Hard to imagine any other way
• Filters our perception of reality
How you see things all depends on
your point of view…
The Other Coast
Boxes, Rules, and
Mental Models
• Our mental models become natural
way of seeing and explaining things
• Difficult to see (“like water to a fish”)
• Hard to imagine any other way
• Filters our perception of reality
Three Deliberate Mental Processes
Attention
Escape
Movement
Attention! Escape!
Yes… and…
Patient and client safety
is a personal
responsibility of
professionals. When a
safety issue occurs,
someone is at fault.
Patient and client
safety is a property
of the system that
professionals work
within. When a safety
issue occurs, it is
often traceable to
failures in the
system.
Attention! Escape!
The cost and quality
issues in social care,
primary care, and hospital
or specialist care must be
resolved by and within
social care, primary care,
and hospital or specialist
care (“silo mentality”)
New efforts and
investments
(spending some
money) in one part
of the system
might better
address the cost
and quality issues
in another part of
the system
Attention! Escape!
We need more
resources!
We may need
different processes
and systems that
utilize our resources
better. (“process
improvement thinking”)
We may have
enough resources;
let’s look at how we
might be wasting
them. (“lean thinking”)
Attention! Escape!
Measure and
reward activity and
budget
performance
Measure and
reward what is
of real value to
patients and
the public
(“value compass”)
Attention! Escape!
Demand for services
is unpredictable and
often exceeds
capacity; restrict
access to services
and use waiting
states
Demand is largely
predictable and
most often does
not exceed
capacity. Work to
understand and
match capacity to
demand. (“flow”,
“SPC”, and “process
engineering”)
Odds of transformation
increase when we…
• Identify and challenge the “rules”,
traditions, and “boxes” that have
been handed down to us about
health and social care delivery
Attention! Escape!
Professionals are
the experts and
patients come to
us to find out what
they should do.
Many patients are
actually the
experts in their
unique version of
a disease. How
can we engage
them in dialogue
and use their
insights to better
work with them?
Attention! Escape!
Some patients are
non-compliant
with the treatment.
All people are
simply living
their lives as
they do. How
can we help
them integrate
our professional
advice into their
lives and
situations?
Attention! Escape!
Patients and carers
would make
unreasonable
demands if we really
let them drive the
system.
Let’s take the
risk of at least
asking them—
not neglecting
our duty to
educate them—
and see how it
turns out
Seeing the System
Through a Different Lens
• What does it look like to patients and carers?
– Beyond surveys, focus groups, and superficial
involvement
– What would you do if the patient was your loved one?
– Use of video walkthroughs
– Real patient/carer involvement
in system redesign
• Beyond product and solution
innovation to innovation in
“experience space” (Prahalad and
Ramaswamy. Sloan Mgmt Review, 2003)
Seeing the System
Through a Different Lens
• What does it look like to patients and carers?
– Beyond surveys, focus groups, and superficial
involvement
– What would you do if the patient was your loved one?
– Use of video walkthroughs
– Real patient/carer involvement
in system redesign
• Beyond product and solution
innovation to innovation in
“experience space” (Prahalad and
Ramaswamy. Sloan Mgmt Review, 2003)
Odds of transformation
increase when we…
• Learn to look at the system through
other “lens” beyond those of the
traditional health or social care
professional or manager
Six Characteristics of Highly
Innovative Organizations
•
•
•
•
•
•
Broadly define the business they are in
Passionately customer-driven
Never-satisfied curiosity
Appreciatively relentless
Incubators for staff
Deliberate attention to internal culture
and process (especially willingness to take
prudent risks and try new things)
To what does this refer?
“That it will ever come into general use, not
withstanding its value, is extremely doubtful
because its beneficial application requires much
time and gives a good bit of trouble; both to the
patient and practitioner. Its hue and character
are foreign and opposed to all our habits and
associations.”
To what does this refer?
“That it will ever come into general use, not
withstanding its value, is extremely doubtful
because its beneficial application requires much
time and gives a good bit of trouble; both to the
patient and practitioner. Its hue and character
are foreign and opposed to all our habits and
associations.”
The Times of London
1834
The Stethoscope!
“That it will ever come into general use, not
withstanding its value, is extremely doubtful
because its beneficial application requires much
time and gives a good bit of trouble; both to the
patient and practitioner. Its hue and character
are foreign and opposed to all our habits and
associations.”
The Times of London
1834
In order to innovate, we
must overcome
our worst fears…
…and that
requires courage.
Odds of transformation
increase when we…
• Actively lead in ways that enhance
the culture for innovation and
willingness to try new ways;
system-wide, organization-wide
and in day-to-day work
Norway’s National Strategy for
Quality Improvement In Health
and Social Care
Opening the door to
“…and it’s going to
get better”?
Odds of transformation
increase when we…
Avoid simply repeating old patterns…
…when we exhibit the courage to take
the “path less trodden”…
…when we innovate!
And that demands attention, escape,
and movement
The Road to the Future?
Source: Gareth Morgan
Complex Systems
• Metaphor: Raising a child
– Contrast with complicated system where the
metaphor is sending a rocket to the moon
• Complex systems involve structures,
processes, and patterns (SPP)
• We often rely on structures and processes,
and fail to acknowledge patterns
Key Point: Successful large-scale
Key
Point
transformation requires integration and
change in structures, processes, and patterns
Successful large-scale
transformation requires
integration and change in
structures, processes,
and patterns
Odds of transformation
increase when we…
• Work simultaneously to change
structures, processes, and
patterns in an integrated and
self-reinforcing way
Frederick Winslow Taylor
(1856-1915)
• Metaphor: Organization
as a machine
• Hierarchical and
functional organizations
• Separation of planning
from doing
• Search for “the one best
way”
Mary Parker Follett (1868-1933)
“The Prophet of Management… the brightest star
in the management firmament…” Peter Drucker
• Colleague of Taylor, known for
innovative social programs in
working-class Boston, who became
interested in organizations
• Lectured widely in US and England
• Metaphor: Organization as a social
system
• Emphasis on patterns of interaction
in organizations
Five Key Patterns in
Organizational Culture
Key patterns that need rethinking in
health care organizations include:
•
•
•
•
•
the nature of relationships
how decisions are made
how power is defined, acquired, and used
how conflict is handled
how learning is supported
Our Hypothesis…
The inability of a system to innovate,
transform or reach its aspirations,
despite good traditional
improvement work, is due to poorly
understood and poorly managed
tensions within a complex system.
What is Pattern Mapping?
An approach which helps groups of
stakeholders recognize and describe
patterns of culture & behavior within
a given system and to work jointly on
ways to influence these to support
improvement
What is Pattern Mapping?
Concepts, models and tools to enable
deep and honest conversation about
“things below the surface”
Provocation:
Power
Do individuals and groups acquire
and exercise power in positive,
constructive ways toward a
collective purpose, or is power
coveted and used mainly for selfinterest and self-preservation?
Provocation:
Conflict
Are conflicts and differences of
opinion embraced as opportunities
to discover new ways of working, or
are these seen as negative and
destructive?
Provocation:
Learning
Is the system naturally curious and
eager to learn more about itself and
about what might be better, or is
new thinking viewed mainly as
potentially risky and threatening to
the status quo?
Provocation:
Relationships
Do the interactions among the
various parts of the system generate
energy and innovative ideas for
change, or do they drain the
organization?
Describing Patterns
Descri
be
• Groups of 6-10 people
• Facilitated discussion
• Dialogue about current
and desired patterns
within the system for a
given dimension
Ground Rules
• Openness and honesty
• Respect for views of others
• Sensitive about what goes
outside the room
• Curiosity!
Ground Rules
• Openness and honesty
• Respect for views of others
• Sensitive about what goes
outside the room
• Curiosity!
Examples of Patterns
• The only times we ever talk is when there is a
problem or issue; we don’t really take much time
out for relationship building.
• In our organization, decisions are made pretty
quickly, with lots of opportunity for everyone to input.
• While power is generally exercised in a wonderful,
open, inclusive and constructive manner, there is
sometimes frustration about all the talking and how
much time it takes to make even simple decisions.
Examples of Patterns
• We tend to avoid conflict. We say “Let’s
take the heat out of this,” but that also
takes the energy out of things and we go
nowhere.
• We learn well from outside experts; we are
keen to try out new ideas and approaches.
What we do less well is learning from our
own people who often have very good
ideas and lots to contribute
Describing Patterns
Descri
be
• Summarise patterns for
each dimension and map
current to desired
• Share maps across
groups to generate further
discussion and insight
• Identify key themes
Influencing Patterns
Influen
ce
• Synthesise information on
structures, processes &
patterns
• Identify changes needed to
shift from current to desired
patterns
• Take action to support aims
• Identify role of leaders
Flow of a Pattern Mapping
Intervention
• What do we want to achieve?
• What are the current patterns of behavior
that may be blocking or supporting this?
• What are the ideal patterns that would help
us achieve our aims?
• What Structures and Processes do we need
to change to support our desired Patterns?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
April 2003 - August 2004
au
g
ju
l
ju
n
m
ar
ap
r
m
ay
fe
b
ja
n
de
c
no
v
oc
t
au
g
se
p
ju
l
ju
n
pattern
mapping
event
ap
r
m
ay
Admissions from WL
Percentage of patients treated in less than 6 months
New Patterns of Behavior
From…
To…
Difficulty getting staff to work
as a team
Staff calling in on their day off
to offer help to achieve the
department’s target
Staff bringing problems and
complaints to managers to
resolve
Senior leaders thinking
clinicians were only interested
in lining their own pockets
“This was the problem and this
is what we’ve done about it”
Clinicians delivering on their
promises to patients
“If what happened that day hadn’t
happened then, what has been
achieved since wouldn’t have
been because all that baggage
would have got in the way”
Senior Clinician
Multi-Organization or
Whole-Community Efforts
East Lancashire Health & Social Care system:
• North West England - hills & valleys!
• Urban & rural; high deprivation
• 7 organizations collaborating - Pursuing Perfection
(P2) site
• Leadership Group - CEOs and Directors of
Improvement
• Patterns of leadership impacting on planning &
delivery of complex services, e.g. mental health
Sustaining Patterns in Times
of Leadership Change
“I have got to say that the work on pattern mapping
has become embedded in the system. Over the last
3 years only 3 of the 7 chief execs have been in
post more than 2 years—there’s been lots of
change. But by being explicit about our patterns,
the system influences the new individual. We are
more explicit about saying, ‘We don’t do things that
way around here’… or ‘OK, you got away with that
one this time, but better think about it next time.’”
Chief Executive
Multi-Organization or
Whole-Community Field Tests
East & Mid Devon Health & Social Care system:
• South West England - seaside!
• Predominantly rural; older population
• 8 organizations collaborating - Pursuing Perfection
(P2) Sites
• Patterns impacting implementation of Single
Assessment Process (SAP) across the system
• SAP Implementation Team
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Community Aspirations
Pursuing Perfection
• No needless deaths
• No needless pain
• No needless helplessness
• No needless
delays
• No needless
waste
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
The health and social
care community
Social
Services
 Local
Authorities
Acute
Trusts:
RD E
and NDDH
Voluntary
Organisations

Users/Carers
Distinct sectors fusing
into one whole
Patient
Population
North Devon:
Mid Devon:
Exeter:
East Devon:
Total:
154,415
104,254
129,871
114,928
503,468
PCTs:
Exeter
East Devon
Mid Devon
North Devon
Ambulance
Trust
Partnership
Trust
Pursuing Perfection
Raising the Bar in health and social services
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Single Assessment Process
Our vision . . .
• Patients will give personal
information only once
• Professionals work
together in the best
interests of the patient
“Don’t you
people talk to
each other?”
• The older persons views
are central to the
assessment process
• Assessment builds a
rounded picture of their
problems and circumstances
• Carers’ views are
considered
Acute Care
Housing
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Cross Cutting Themes Identified
Phase 3 - Synthesis
1 Disconnect between strategic and frontline levels
2 Participation of frontline
3 Participation from service users
4 Collaboration across boundaries
5 Engagement of all partners
6 Practical challenges for SAP implementation
Example Theme:
Participation of Front-Line
• Current patterns:
– Can be excluded from ‘higher’ decisions that affect way
team works. (DM)
– Lack of consultation input in relation to SAP paperwork and
others decisions… Feeling powerless… Lack of feedback
to SAP board… Don’t believe we can change the system
ourselves… No opportunity to influence decisions. (P)
– Tend to avoid conflict – not sure who to challenge or
question regarding SAP… Signed up to common goal and
aim, but because feeling of being undervalued, lose sight
and lack motivation to achieve goal. (C)
Intervention
• Patterns have to be influenced within the
system
• Facilitators not external consultants
• Work alongside key stakeholders to help
develop thinking and action plans
• Move system from ‘current’ to ‘desired’
patterns in order to achieve aims.
Phase 4 - Intervention
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Outcomes . . . Feedback
What has changed/improved since the Pattern Mapping event?
“ Pattern mapping allowed comparisons
to be made and progress identified
through discussion which helped in
identifying what the RD&E (hospital)
needed to achieve.”
Charlie Mason
“ The pattern
mapping process
reassured us that we
were heading in the
right direction ”
Older Persons’ Nurse, RD&E
“ Relationships have
“ Different perspectives
and priorities are
understood ”
been strengthened
leading to
improvements in
communication
structures ”
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Outcomes . . . Feedback
How did you feel during/following the Pattern Mapping event?
“… the pattern mapping event was fantastic …
it helped us focus on the process rather than the
paperwork, emphasised the need to keep patients
at the centre and not to lose sight of why there
needs to be change. It was also about the need
for a professional/discipline change in culture
which meant professionals not being precious
about their own assessments.”
Angie Lindop
Discharge Services Coordinator,
Access Team
“ It was clear there
needed to be
executive sign-up
”
“The best bit was that
members of the group
agreed a set of actions.
The event gave us all
the impetus to work
co-operatively and so
much has moved on
since the event.”
“
The new work is so
encouraging for us all as we
know it will benefit patients.
”
Exeter, Mid and East Devon Health and Social Care Community, United Kingdom
Key insights
Our Results
26 clear actions
Developed relationships across
the key system
‘Ripple’ effect
Transferability
Pattern Mapping is the
‘missing link’ which has
the power to embed
improvement and support
the spread of good
improvement ideas
“ Pattern mapping is
like an onion, you
have to peel away the
layers to get to the
heart of the
matter ”
Culture, Creativity and Innovation
• Comments on the Norwegian strategy
• Caution: The Door Into Summer
• Innovative thinking for making things
better
• Change in complex systems
• Patterns in organizational culture that
can hinder or aid transformation
• Signs of transformation
How will we begin to
know if we are
opening the door into
transformation through
our national strategy?
Signs of the Door Into
Transformation
• Many concrete examples of:
–Integration of research, evidence
based practice, and quality
improvement
–Improvements covering all the
aims of the strategy
Signs of the Door Into
Transformation
• Many concrete examples of:
–Strengthening and involving
users in non-traditional ways that
make providers uncomfortable
–Enthusiastic use of measurement
at all levels, with open
sharing that feeds real
curiosity
Signs of the Door Into
Transformation
• Many concrete examples of:
–Deep understanding of
improvement thinking that
provides a new lens and new
questions throughout the system
Signs of the Door Into
Transformation
• Many concrete examples of:
–Providers, leaders and educators
being aware of their “boxes” and
willing to think outside them
–Active movement of resources and
effort among social,
primary, hospital, and
specialist care
Signs of the Door Into
Transformation
• Many concrete examples of:
–Difficult, but rewarding dialogue
about patterns of relationships,
decision-making, power, conflict
and learning (especially among
leaders, but not limited
to them alone)
Culture, Creativity and Innovation:
Basic Premise for Effective
Change and Improvement
Paul Plsek
Consultant in Complex Systems
& Innovation
Atlanta, US
paulplsek@DirectedCreativity.com
“Dream
Believe
Dare
Do”
Walt Disney
Culture, Creativity and Innovation:
Basic Premise for Effective
Change and Improvement
Paul Plsek
Consultant in Complex Systems
& Innovation
Atlanta, US
paulplsek@DirectedCreativity.com