diagnostic dialogic

Diagnostic and dialogic approaches for transformational change: what is the
potential for health and healthcare?
A quick paper for commissioning nurse leaders by Helen Bevan
Amongst leading practitioners in the world of organisational and system change, a
watershed is taking place in terms of how to think about transformational leadership [1].
The most significant shift is described as a move from diagnostic to dialogic approaches to
change [2].
Diagnostic change
The typical way that system leaders in the NHS go about change is to use a diagnostic
change approach. The way that leaders go about changing the system involves: [3]:
Diagnosing the problems or issues of the system or organisation through a
systematic process
Managing the change process from the top
“Objective” data collection, diagnosis and reflection
Often the use of a management consultancy partner who is skilled in diagnosis
Mapping the current state of the organisation or system (the “as is” state) and the
desired future state (the “to be”state)
Planning a series of workstreams/programmes/ interventions to improve pathways
and processes
The diagnostic approach allows us as system leaders to plan out complex change
interventions in a way that makes them feasible and allows us to align different aspects of
change. However, NHS experience suggests that these methods also have limitations. They
are based on the principle that there is an external “thing” out there called the system or
organisation that can be diagnosed and treated in the same way that a biological system
can. This diagnostic approach doesn’t regard the system as a complex set of interpersonal
relationships amongst people with diverse needs, perspectives and priorities. The diagnostic
approach to change is typically based on a model of replication; we take the principles of
what has worked well in one setting and try to replicate them in another setting. However,
history suggests that if organisation B (operating with the same structure in the same
environment) tries to copy a successful innovation from organisation A, it almost never has
the same result. In fact, attempts to transfer transformational changes between
departments or localities of the same organisation rarely succeed. In addition, diagnostic
change processes, carried out at a macro level, typically try to get people in frontline roles
to change what they do based on innovative thinking done by someone else higher up the
system. The problem is, if we haven’t co-created the change, we don’t feel that we own it
As health and care systems become more complex and diverse, the assumption that there is
some social reality “out there” to be studied, diagnosed and understood becomes
questionable. It is worth considering whether, in a world of persistent continuous change,
the episodic change processes inherent in a diagnosis-treatment model are less effective, or
that they take too long to get to a prescription, and the system might have already changed
too much for it to be valid by the time we get round to implementing the changes. It may be
that, given the current challenges of the health and care system, we have reached a point in
time when system leaders need more than incremental, controlled change processes.
Dialogic change
From a dialogic perspective, change results from transformational conversations; it is about
“changing the discussions” that shape everyday thinking and behaviour by:
 involving more and different people in the change discussions
 altering how and which people engage with each other
 by stimulating different perspectives to shape how people think about things
Therefore instead of (or as well as) change driven by diagnosing how to objectively align or
re-align different elements of the organisation or system (strategies, structures, people
practices, etc.), the dialogic perspective invites us to consider how to induce new ways of
thinking by altering the ongoing organisational conversations that continuously create, recreate, and frame understanding and action.
In dialogical approaches, the focus is on encouraging new thinking in the people who are the
targets of change themselves —new thinking that is not prescribed by some expert or
management consultant partner, but that emerges individually and collectively from going
through the change process. The creation of new perspectives, images, stories, texts,
narratives, and other socially constructed realities will impact on how people think and
make sense of things — and that, in turn, will impact how they act.
From the dialogic point of view, the reason an innovation works differently in organisations
A and B is that people make different meanings of the innovation in those different
organisations. As a result of exposure to dialogic ideas, an increasing number of system
leaders with transformational aspirations are turning away from a dependence on
diagnostic methods that treat organisations as if they were biological systems in their
change methods, even if they still talk like they are. These leaders assume that organisations
are socially co-constructed realities and, because of this, that there is nothing inherently
“real” about how we organise for health and care, no ultimate truth about organisations to
be discovered, and no model of the right way to organise independent of the people who
make up the specific organisation or system.
There are a range of dialogical approaches. Peggy Holman[3] suggests three aspects:
1. Create the conditions for transformational conversations by asking questions that
are focussed on future possibilities, by inviting diversity into the system, and by
being welcoming
2. Create opportunities for everyone to express their views, spot opportunities and
build on each other’s ideas
3. Create ways for people to reflect together to find meaning, understanding and
shared purpose in the change
The two approaches are contrasted below:
The organisation as a “thing” that exists
in its own right and that can be
diagnosed and changed
Convergent & reflective
People in the act of organising for
change (making meaning and
coordinating action)
Divergent & projective
Leader imparts wisdom, sets direction
and reinforces messages
Univocal (fixing on a clear problem)
Leader generates opportunities for
transformational conversations and
ensures everyone’s voice is heard
Resistance as an inevitable consequence
of a complex change process (based on
diversity) that should be embraced and
worked with
Working in and with the everyday
communicative actions and
conversations that constitute
the way people organise themselves.
Plurivocal (embracing multiple solutions)
Concrete (knowable and tangible)
Abstract (uncertain and intangible)
Resistance as a problem to be solved
Discrete “one off” change initiatives and
Expert with an answer
Solving problems
Identifying the best solutions
Mandate from the top
Source: based on sources 1-5 below
Difference that makes a difference
Exposing paradox
Collective sensemaking
Influence from everywhere
The use of dialogic principles is at an early stage in the NHS. We believe that the potential is
significant and that commissioning nurse leaders can be the pioneers in testing and using
these principles in their everyday practice as transformational leaders. Of course, the future
scenario won’t be an “either/or” with regard to diagnostic and dialogic approaches. Neither
do we wish to create the impression that diagnostic is “bad and dialogic is “good”. Both
have their role in future systems leadership and both are underpinned by a leadership focus
 strong NHS values and our desire to provide better outcomes for patients and the
 wanting to encourage and facilitate awareness of the system (albeit through very
different methods)
 building capability for change and developing the system[5]
Diagnostic approaches will continue to dominate but if we can create leadership capability
in dialogic approaches, we can foster the conditions for positive outcomes from our
transformation efforts
1. Katherine Farquhar NTL’s “Conference on the New OD”: Turning Thought into Action
2. Gervase R. Bushe Dialogic OD Turning Away from Diagnosis http://bit.ly/1cpBk8S
3. Keith W. Ray and Joan Goppelt Dialogic OD in Day to Day Complexity
4. Peggy Holman, A Call to Engage: Realizing the Potential of Dialogic Organization
Development http://bit.ly/IfwdP7
5. Gervase R. Bushe, Robert J. Marshak (2013) Revisioning Organization Development
Diagnostic and Dialogic Premises and Patterns of Practice http://bit.ly/1b28xUJ
Also see: Peggy Holman, Change Your Story, Change Your Organization