Creating the conditions for transformational change:
An analysis of the initial stages of the Pursuing Perfection
Programme from the perspective of complexity
Durie RH
Wyatt KM
Fox M
Sweeney KG
1.
Executive summary
Pursuing Perfection is an international healthcare improvement initiative led by the
Institute for Healthcare Improvement (IHI), based in Boston, Massachusetts.
Healthcare communities and organisations participating in Pursuing Perfection seek
to dramatically improve outcomes for patients in all their major care processes, by
means of undergoing radical, whole system, transformational change.
Since, in the UK, the aim of the programme is to secure whole system
transformational change within health and social care communities, it is clear that it
will take a period of time significantly longer than that covered by the research upon
which this current paper is based to determine whether such change has indeed been
successfully attained. The period of the programme covered by the research upon
which this paper is founded represents the initial stage during which the conditions for
whole system change were being created or developed within the health and social
care communities participating in the programme. It was striking that, in a meeting
with one of the IHI leaders, representative leaders from all of the participating sites in
the programme should independently identify the creation of such conditions as
constituting the most successful outcomes of the first 18 months of their participation
in the programme. The purpose of this paper is therefore to identify in what the nature
of these conditions consists in 2 of the 4 sites participating in the programme, upon
which we have chosen to focus. Then, utilising the principles of complexity theory,
we shall, in the final section of the paper, seek to explain why it is that these particular
conditions do indeed constitute a ‘receptive context’ for whole system
transformational change within health and social care communities.
This paper presents the results of a detailed case study of the evolution of the
Pursuing Perfection programme at two sites in the UK NHS. The researchers
conducted 37 semi-structured in depth interviews with key informants, observed 23
leadership and implementation meetings and spent approximately 25 hours holding
informal conversations with participants, on the sites and also with the Modernisation
Agency.
From this data set, and the initial ‘1st level’ qualitative analysis to which the data was
subjected, eight themes were identified, which, we submit, constitute a set of
conditions for a receptive context. We use the term receptive context here to describe
organisations which are configured for change, and thus able to adopt innovative
concepts and practices in order to meet the challenges they experience and the
aspirations they share (Pettigrew, 1992). The assumption lying behind this claim is
that whole system, transformational, change is not something which can be ‘done to’
an organisation or community, but is, rather, something like an ‘epi-phenomenon’1 of
the system, an emergent property which is manifested in the behaviour of the whole
system, when it comes to be configured in certain ways. These configurations are
determined by a set of conditions, which are shown in Table 1.
By using the term ‘epi-phenomenon’, we wish to suggest that transformational change is a property
expressed by the whole system, which depends on changes that are occurring within the system, but
which cannot simply be reduced to these smaller scale changes; nor can a direct causal relation be
established between these small scale changes and the property of whole system change, even though
whole system change could not occur in the absence of the small scale changes.
1
2
Table 1
Principle conditions constituting receptive context
for whole system transformational change
Recognising that things are not working well enough, or could be done differently,
with better outcomes for patients [page 11]
Leadership, demonstrating genuine commitment to aspirational goals, visible
behaviour change, genuine commitment to the programme and to projects, and
flexibility and comfort with ambiguity and emergence [page 12]
Behaviour change and the reconfiguration of relations/creation of new relations [page
15]
Culture of experimentation and supported risk taking [page 17]
Accepting the possibility that different ways of working and thinking will be better
for patients [page 18]
Genuine and meaningful patient involvement [page 19]
Language (including the challenge of professional language) and communication
(between and within organisations) [page 20]
Pursuing Perfection as a ‘way of working’ [page 22]
There is, effectively, a two-stage process involved in the creation of a receptive
context for the transformational changes noted at these sites2. First, there needs to be a
recognition that the current way in which the organisation or health care community is
working is not functioning as effectively as it could in order to deliver the best
possible care to patients – in other words, that things could, or indeed should, be done
differently, and done better. In the second stage, following on from this, one discerns
the development of genuine and visible leadership commitment to the principles of
the transformational change programme, and to the various projects undertaken as
part of the programme. This commitment is expressed, in part, through the visible
evidence of a change in the behaviour of the senior leaders.
After this, the evidence accumulated for this case study suggests four further features
necessary for the continuing receptivity of the organisational context. These are:
1. A change of behaviour spreading through the community, particularly
manifesting itself in the creation of new relations, or the reconfiguration of
existing relations, both within and between elements of the community.
2. The creation of a culture of supported experimentation and risk-taking, where
a project which didn’t work is not punished but seen as an opportunity for
learning.
3. Visible evidence of things being done differently, and of the outcomes which
occur as a result of these new ways of working.
4. A genuine, and meaningful, patient involvement, to the extent that patients
become the drivers of change.
The methodology of Pursuing Perfection, in accordance with the general methodology
adopted by the Modernisation Agency, stresses the importance of PDSA cycles.
2
This document assumes familiarity with the nature and extent of the transformational changes which
have been set in place in these two sites, which is documented elsewhere as part of the Pursuing
Perfection programme itself.
3
Without the formality of the PDSA structure, doubt might remain as to whether
effective learning could or had taken place as a result of the local experiment. PDSAs
appear to help to create an atmosphere in which staff can undertake small scale
experiments, experiments which are small enough that their failure will not destabilise
the organisation, while well enough documented that significant learning pertaining to
the outcomes of the cycles can be integrated into the behaviour or practices of the
whole system.
One of the conditions which yielded data which was most difficult to interpret in
straightforward manner pertained to patient involvement. All participants agreed that
genuine patient involvement constituted a key condition for whole system change, but
there was significant disagreement concerning the extent to which patient
involvement was being undertaken successfully, or indeed as to just how difficult
patient involvement really is. One apparent source for this difficulty lies in the
willingness that, in particular, clinicians display towards having their ‘comfort zone’
challenged by engaging with patients. We use this theme in our concluding discussion
to indicate how and why genuine engagement with patients might provide a sufficient
condition for maintaining the process of radical whole system change.
The evidence yielded by the initial qualitative analyses, and the interpretative analyses
contained in this paper, suggest that the culture of experimentation created through
participation in the Pursuing Perfection programme, may contribute to the
development of an organisation which is successful in achieving patient centredness
in the re-design of their services. If it is to do so, however, the conclusion to be drawn
from the interpretative analyses is that such a development will be a consequence of
what is, in effect, an evolutionary process. This process also involves the recognition
by leaders, distributed throughout the health and social care community, that their
services need to be re-designed, because they are not providing the outcomes, from
the perspective of patient care, that they could, or should, be doing; and a resultant
change in leadership style, which must be genuinely visible throughout the health and
social care community. If we are correct in stressing such an evolutionary process,
this would further suggest that patient-centeredness is not an outcome which can be
achieved ‘in isolation’ by health and social care organisations or communities, that is,
it is not simply a goal which could be achieved through the implementation of a
discrete process or project. Patient-centeredness should rather be seen as an effect of
the other changes which are being undertaken by the health and social care
community, an effect, that is, of the development of a receptive context for whole
system change, and that, in turn, it is an effect which can lead to whole system,
transformational, change occurring in a way that is genuinely centred around the
needs of patients.3
3
We anticipate that the next part of our interpretative research will focus on the question of the
transferability of successful change programmes, where these have occurred in the Pursuing Perfection
sites, both throughout the health and social care communities that constitute the ‘whole systems’, but
also beyond these communities to other health and social care organisations and communities in the
NHS.
4
2.
Introduction
A recent SDO publication, Managing Change in the NHS, highlighted the diverse
models and ways of implementing change in the NHS (Iles and Sutherland 2001). It
came to the conclusion that organisational level change is neither fixed, nor linear, but
rather emergent, and that there is a need for the:
understanding that organisational change is a process that can be facilitated
by perceptive and insightful planning and analysis and well crafted, sensitive
implementation phases, while acknowledging that it can never be fully isolated
from the effects of serendipity, uncertainty and chance. (Dawson, 1996)
Thus the outcomes of change are essentially unpredictable and, according to
Ackerman, need to be understood in the context of their extent and scope (Ackerman
1997). Ackerman identifies three types of change: developmental, transitional and
transformational. This paper is concerned with the necessary requirements for
transformational patient-centred change in the context of two sites participating in the
Pursuing Perfection programme.
Transformational change has a number of important characteristics.

It is necessarily radical, requiring a change in the underlying assumptions held
by those involved.

The outcome of transformational change will be an organisation that is
significantly different in terms of structure, process, culture and strategy from
its pre-metamorphic state.

If the transformation is successful the emergent organisation will be one which
exhibits continuous leaning, adaptation and improvement (Iles and Sutherland
2001).
Whether or not single health or social care organisations are ready for radical change,
it is clear that in order for communities of health and social care providers to
undertake ‘whole system’,4 transformational, change, it is necessary that such
communities should develop a ‘receptive context’ for change. This paper presents
evidence from a detailed case study of the initial stages of a transformational change
4
There is much debate within the literature about the appropriateness of employing systems based
thinking to understand organisations in general, and health and social care communities in particular.
Within complexity theory, Stacey et al. (2000) has been particularly critical of the systems approach.
The problem, according to Stacey, is that a system based approach suggests that human interactions,
when understood from a systems perspective, become things which can be influenced or controlled by
someone standing outside the system. The source of novelty or change in the system is then displaced
to the exterior of the system. Without entering into this debate, we would wish to claim, first, that by
emphasising whole systems, we would concur that there is no position of transcendence with regard to
health and social care communities regarded as whole systems; and second, following Bergson’s
(1907) argument, a system is whole to the extent that it is dynamically open, and as a consequence,
interacts with its environment. It is significant that Stacey’s emphasis is on what he calls
‘transformative teleology’, and it is thus possible that to talk of transformational whole system change
may indicate a potential line of reconciliation with his position.
5
programme in two health and social care communities – both of which participated in
the Modernisation Agency’s Pursuing Perfection Programme – in their attempts to
create receptive contexts for service re-design leading to whole system patient-centred
care.
Pursuing Perfection
Pursuing Perfection is a major international programme of transformational change in
health care service provision, initially developed by the Institute for Healthcare
Improvement in the United States. In the United Kingdom, the programme has been
led, in collaboration with IHI, by the National Health Service Modernisation Agency,
in partnership with the Department of Health’s Directorates of Health and Social
Care. The overarching aim of the Programme is to develop the most appropriate
system to meet the needs of all patients and users, thereby ensuring that the right care
is provided, at the right time and in the right place. Implicit within the Programme is
the need to instil an ambition to constantly strive to ensure that patients and service
users receive the very best standards of care and services available. The emphasis is
on a community-wide approach to transformational improvement where transparent
and ambitious targets for improvement developed in partnership with patients and
service users. Furthermore the Modernisation Agency states that ‘this is a radical
approach in which patients and users are partners and decision makers in their own
care.’ [http://www.modern.nhs.uk/scripts/default.asp?site_id=40]
In May 2002 the Modernisation Agency funded four pilot sites for the two year
programme. These pilot sites were selected as ‘health and social care communities
which have a strong record in partnership working and modernising services for
patients and service users’ [‘Pursuing Perfection – Raising the Bar in Healthcare’
http://www.modern.nhs.uk/documents/Pursuing_Perfection.pdf]. Subsequently, a
further five sites have become affiliated, on a non-funded basis, with the programme.
The initial expectation of Pursuing Perfection was that each health and social care
community would choose two pilot projects to test the feasibility of whole system
change and use these projects to identify the transformational change across the whole
community. These projects would be structured according to a set of ‘promises’
which were explicitly made to patients, in the expectation that this would remove
organisationally constrained thinking, while also providing a format within which to
begin the process of genuine patient engagement, such that the involvement of
patients would explicitly drive the change process. The improvements would be
clinically led and supported by managers, with service users/carers as full participant
members of the project teams and the leaders were expected to use the projects as
vehicles for whole system learning.
The expectation from the Modernisation Agency was that the Chief Executives of
local Trusts and the Directors of Social Services would meet monthly to lead system
wide improvement. The improvement work was expected to be aligned with strategic
goals and that the goals set for perfect care would be across a multi-dimensional
framework.
What is most distinctive about the Pursuing Perfection programme is its overarching
aim of achieving ‘whole system change’ to deliver ‘perfect patient care’.1 In order to
facilitate the accomplishment of this aim, a necessary condition has been the
6
development of a ‘receptive context’ for such whole system change. The term
receptive context describes the degree to which an organisation or group naturally
adopts change and new ideas. Organisations with a ‘high’ receptive context are seen
as ripe for change; they quickly adopt innovative concepts in order to meet the
challenges they experience (Pettigrew, 1992).
The need for the receptive context to be developed is represented most strikingly by
the fact that the Pursuing Perfection UK sites comprise primary and secondary care
trusts as well as mental health trusts, ambulance services and social services. This
paper will explore the conditions which constituted the formation of receptive
contexts for whole system health and social care change in two of the pilot sites.
7
3.
Methods
The Health Complexity Group has devised and implemented a unique methodology
for evaluating change processes. The approach which we advocate in all of our
evaluations confronts the conventional notion of evidence in an attempt to secure and
describe the principle characteristics of transferability in the context of organisational
change in health care. The conventional view – of organisations as machines – is no
longer appropriate for understanding change in health care systems. The machinic
metaphors which form part of this approach, such as negative feedback and self
regulation, need to be replaced by an emphasis on relationships and partnerships, by
an exploration of context, and by a firm grasp of how each element in the programmes
of change co-evolves in a continuing process of change. It is for these reasons that our
programme of evaluation will be informed by the principles of complexity.
The approach, termed a ‘constructive enquiry’, is structured on three levels. First, a
standard in depth qualitative case study is undertaken. Data will be collected by
means of one-to-one semi-structured interviewed, focus groups, from participant
observation of relevant meetings and informal field notes. The analysis at this level
consists in coding of the ‘phenomena’ as described in the raw data, subsequent
collation into higher order categories and themes, the latter representing major
coherent concepts brought together from the participants’ accounts. At this stage, the
researchers wherever possible ‘bracket’ any pre-conceived notions in order to classify
the emerging themes in as neutral a way as possible. Data collected from interviews
and focus groups will be triangulated with the field note observations from meetings
and appropriate written documents corresponding to the services.
This will be followed by a secondary analysis of this description using the evidentiary
framework of complexity. Our ongoing research supports our proposal that processes
of change can most clearly be understood from the perspective of complexity theory.
Following this a radically fresh third level of enquiry will entail a rigorous
philosophical interrogation of the themes and analyses of the preceding two steps. It is
this three level analysis which will permit the main themes of change to be
systematically described; will substantiate the extent to which the process of
organisational change thus described is illustrative of complex adaptive systems; and
will rigorously consider the assumptions underlying the findings, and their
implications for health care policy.
A key element in the research methodology consists in the formative process of
iterative negotiated feedback, whereby initial findings will be discussed with
participants, and their responses fed back into the data. Therefore, at regular intervals
the qualitative analysis will be fed back to the participants, patients and the wider
community which will enable the health community to actively learn from the
ongoing research, discuss its implications and formulate a refreshed process of
enquiry in conjunction with the researchers. In addition, the negotiated feedback will
ensure the accuracy and relevance of the proposed research findings.
In summary, the three levels of the evaluation are:
8

Analytical: a standard qualitative case study at each site, collating data from a
purposive sample of key informants, extended until data has been saturated,
and analysed using a systematic grounded approach.

Interpretative: an examination of these themes from the perspective of
complexity.

Philosophical: a rigorous philosophical analysis of the change process, whose
purpose will be to distil the characteristics of the change process, examine any
assumptions underlying these findings as well as the implications of our
conclusions for policy.
Participants and Settings
Between September 2002 and November 2003 the Health Complexity Group
undertook a qualitative case study, using data derived from a variety of qualitative
sources to gain an understanding of how the four pilot communities were striving to
address the concepts of Pursuing Perfection. With the help of the leadership groups
and the Modernisation Agency, we identified key informants from the four pilot
communities, at strategic (leadership) and implementation (Programme leads, project
leads and clinical leads) level as well as from the wider ‘environmental’ level, IHI and
Modernisation Agency (Figure 1) and asked them if we could record interviews with
them, attend relevant meetings and gain access to appropriate study documentation.
We obtained ethical approval and followed stringent procedures to ensure the
anonymity of participants. This paper reports on the data collected from two of these
sites.
Figure 1
Environment (IHI, Modernisation Agency)
Organisation (Strategic leads)
Clinical team
(Implementation team)
Patient and
community
Data collected
We conducted 37 semi-structured in depth interviews with key informants, observed
23 leadership and implementation meetings and spent approximately 25 hours holding
informal conversations with participants, on both sites and also with the
Modernisation Agency. All authors conducted at least some of the interviews and
observed some of the meetings. The interviews were all held either on the
9
organisational site or after a meeting in another locality, whichever was most
convenient for the respondent. We used a semi-structured interview guide for the
interviews. Key themes for questioning included identification of the promises, with
in the projects, their role in Pursuing Perfection, how the Programme was proceeding,
the involvement of patients and their vision for Pursuing Perfection. In all interviews
and informal conversations, respondents were encouraged to tell stories to illustrate
points that they were making. Each interview lasted between 45 and 90 minutes and
was audiotaped and transcribed in full.
Data analysis
Formal data for the analysis presented in this paper were the transcribed interviews,
focus groups and notes taken during informal conversations. Observation of meetings
was used to support and strengthen our interpretation of the formal data. Our analysis
of the data was guided by the broad precepts of constant comparative analysis.
Transcripts were subjected to a process of open coding in which descriptive codes
were attached to fragments of data, usually a few lines of text. Data fragments were
compared and grouped into conceptual categories. A proportion of the transcripts
were read by at least one other researcher to ensure sufficient congruence in analysis.
(Miles and Hubermann, 1994).
Following this, a second level of analysis was carried out from the perspective of
complexity theory; transcripts were re-read to focus on the participant’s narratives and
these, in conjunction with the major identified themes, were analysed using
complexity to understand the nature and the context of the organisational changes
occurring within Pursuing Perfection. It is this second level analysis which yielded
that results which are discussed in the next section. The concluding discussion in this
paper makes explicit the means by which this data can be theoretically explained from
the perspective of complexity theory.
10
4.
Results
Eight principle themes were identified from the data from the two sites, which
delineate the conditions of possibility for transformational change in health and social
care communities in the pursuing perfection programme. The themes are shown in
Table 1, and are described in turn in this section.
Table 1
Principle conditions constituting receptive context
for whole system transformational change
1 Recognising that things are not working well enough, or could be done differently,
with better outcomes for patients.
2 Leadership, demonstrating genuine commitment to aspirational goals, visible
behaviour change, genuine commitment to the programme and to projects, and
flexibility and comfort with ambiguity and emergence
3 Behaviour Change and the Reconfiguration of Relations/Creation of new Relations.
4 Culture of experimentation and supported risk taking.
5 Accepting the possibility that different ways of working and thinking will be better
for patients.
6 Genuine and meaningful patient involvement.
7 Language (including the challenge of professional language) and communication
(between and within organisations).
8 Pursuing Perfection as a ‘Way of Working’.
4.1
Recognising that things are not working well enough, or could be done
differently, with better outcomes for patients
The evidence indicates that a first necessary condition for transformational change is
the recognition by significant members within the health and social community that
there is something wrong with the current way of working, or that this way of
working is not functioning as well as it could do (for instance, with respect to
delivering shared care aspirations), or indeed that there are different ways of working
which could deliver desirable health-care outcomes more effectively. Thus, one
participant emphasised that change in behaviour would not begin “if you don’t
acknowledge that something is wrong and that you want to make a difference.”
Similarly, in order to get clinicians to change their practice, and thus for
transformational change to take root at a clinical level, it might be necessary for them
“to say Oh God, I actually know my service is not as good as it could be – I want to
make a difference, help me do it.”
That this is indeed a necessary condition for transformational change is indicated by
the counter-evidence provided by one of the participating sites in the Pursuing
Perfection programme, which also helps to clarify further this theme. Since a
necessary condition for participating in Pursuing Perfection was the attainment of a ‘3
star’ rating by the acute trust in the applicant site, there was a tendency among
participants to think of the sites as being success stories, a success which the award of
Pursuing Perfection status confirmed – indeed, the perception at one site was that it
had been selected because of “the supposed maturity of the organisations and the
11
collaborative work that’s going on.” As a consequence, there does not appear to have
been any sense, at this site, of an initial realisation of the need for change, and this is
confirmed by the rationale cited for the choice of one of the initial Programme
projects. The evidence indicates that this project area was selected because it was
perceived to be an “easy option”, since the acute trust had a well-recognised service
already in place. Another participant confirmed that the “reason we chose [this
project] was because we thought it would be easy.” The project was thus perceived to
be already underway – “it already had an order” – that it had gained national status,
and as a consequence, the leadership group was of the belief that if the project
continued along its pre-existing pathway, it would be successful. Pursuing Perfection
represented nothing so much as an aid to “help us deliver the agenda we’ve already
got.” In fact, this turned out not to be the case – as one participant exclaimed, “we’re
a year down the line, but nothing’s happened.” Another participant reflected that the
“challenge was to make them [i.e. the participants in this project] think differently,
because they were all already experts.” Ultimately, the principles, promises and terms
of reference of the project were revisited in response to a series of challenges put
forward at meetings with service users and carers. Reflecting on this process, a senior
executive observed that “the mistake we made was that we thought we had a group
but then didn’t progress the learning and development in the same way” as in the
other project. (In fact, the dominant criterion for the selection of this other project had
been that it comprised a “key issue within the local health community, and that it
presented problems that had to be solved.”) The view that Pursuing Perfection had not
led to any significant change in the way participants in this project were working or
behaving was confirmed by a representative from social services, who argued that the
recognition that change needed to occur at a fundamental level was lacking in this
project: “We can’t have these projects that are… having a gesture towards doing
these things, and not saying what are the serious things that have got to be changed
and tackled.”
The other site also selected for one of its initial projects an area of work which was
already underway, but in contrast to the selection criteria of the first site, what was
significant about this programme of work in the other site was that, although the
project “had actually begun already, so it was a project that was migrated from some
existing work”, the essence of that project had already been “about trying to think
completely differently.” Thus, where in the former site, sticking with a project which
already had an established order meant that there was no ‘different thinking’, and
hence that no progress was made in the project, the project in this latter site was
informed by the principle of ‘thinking differently’. Finally, as another participant
reflected, this particular project was significant because it “crossed organisational
boundaries.”
4.2. Leadership
Pursuing Perfection offers an ideal opportunity for assessing the role which leadership
can play in creating the conditions for whole system transformational change. Our
evidence indicates that there are three interrelated aspects of senior leadership in the
Pursuing Perfection programme which are of significance for the creation of a
receptive context for whole system transformational change:
12
(i)
(ii)
(iii)
visibly genuine commitment to the aspirational goals underpinning
transformational change – a visibility which in part consists in
demonstrably different behaviour;
visibly genuine commitment to the transformational change
programme generally, but also to the specific projects undertaken
within the programme;
flexible leadership style that reflects a comfort with ambiguity and
emergence.
The data relating to each of these aspects will be discussed in turn.
4.2.1
Commitment to aspirational goals and visible behaviour change
The initial stages of Pursuing Perfection were important in securing senior executive
support for the principles of the programme. The Modernisation Agency sought to
have unequivocal commitment at a local (as well as a national) level, from senior
leadership teams: “Initially they [the Modernisation Agency] wanted a chief exec from
the acute trust.” Senior Executives from participating organisations were invited to
attend an introductory workshop in London at the beginning of the programme,
organised by IHI; and a number of senior executives also attended the initial IHI
conference in Boston, along with participants from the other European and US sites.
This visit was clearly successful in conveying to participants generally, and senior
executives in particular, the potential power of Pursuing Perfection. Direct exposure
to the founders of Pursuing Perfection had something akin to an evangelical effect,
which is borne out by numerous testimonies from the data-set. One participant
observed that the “verbal and non-verbal” behaviour of some of the senior executives
at the outset had suggested that they were only paying the programme “lip service”,
and that “they were not engaged in it, which was quite frustrating”, but that after
“these two days in London they have been brilliant…the penny’s dropped”; while
another participant agreed that the effect of these meetings was that the senior
executives “saw for themselves.” This sense of ‘being converted’ following the direct
exposure to IHI constituted a first example of a significant change in the behaviour of
senior leaders in the programme.
The data from one of the sites suggests that it was not sufficient simply to have chief
executive ‘sign-up’ to the programme in order to create a genuine context for
transformational change to occur within the health and social care community –
people needed, in addition, to see a change in behaviour from the leadership group:
“what we need is unusual behaviour from the Chief Executives.” Another participant
from this site observed that “you need people, I think, at a senior level to sort of
almost co-ordinate that into permission for changes to happen within different
Directorates, different organisations.” Nevertheless, at the same site it was felt that
this was not initially reflected in the behaviour of a Senior Executive, who said that
“in terms of working through with [project leads], that’s a task they need to deliver. I
shouldn’t need to get involved in that detail.” Over the period of the first phase of
Pursuing Perfection at this site, however, many participants were of the opinion that
this change in behaviour was beginning to occur. The senior management style has
changed and was described by the same Senior Executive, in relation to one of the
projects, as being “much more focussed now …. I’m interested in a much more
detailed way.” At the level of implementation, changes in style of leading were
13
identified too: one participant described the ease with which they could engage senior
professionals in either planned or impromptu meetings, which previously they would
have been less confident about doing. At the same level a participant felt empowered
to “knock on doors of directors”, without seeking permission for this behaviour from
the strategic level. One senior manager was described as chairing meetings in a
different way, “of wanting to see change happen more quickly.” Overall, the effect of
this change of behaviour was that “a member of staff feels that they can be
empowered… so that they don’t keep going back to the hierarchy.”
4.2.2
Genuine Leader Commitment to the Programme and Projects
There was widespread agreement that Pursuing Perfection benefits from senior
executive ‘buy-in’, with one representative participant recognising that “the people
leading it are very senior.” The recognition of the seniority of the people leading the
programme is important, since, as one participant observed, “you need to have very
experienced Chief Execs…people with credibility and clout,” while another
concurred, arguing that “there are certain components that you need to run a good
transformational initiative – you need strong directorial input.”
In fact, this involvement of the chief executives was perceived by some as what made
Pursuing Perfection different to other modernisation initiatives: “This programme is
led by the Chief Executive… That’s what seemed to be new about the project… I
thought it was going to be radical. Yes, the radical bit was that the Chief Executive
would take daily personal responsibility.” One of the sites had been involved with a
previous modernisation initiative which was perceived to have had limited success,
because of the lack of ownership from the chief executives: “We’d been through the
[name of other modernisation programme] process and that had a very mixed review
within the community, and the reason I think it had a mixed review was there wasn’t
sufficient Chief Exec engagement.” This feeling was echoed in the other site, who
spoke of modernisation programmes as: “It was done to them (the organisation), they
were told, here comes the modernising health care team for a year or whatever.”
Equally significant is that these leaders be genuinely committed to the programme.
Such commitment can have a considerable effect in ensuring that members of staff
buy in to the programme – one person was said to have become signed up to the
Pursuing Perfection programme when “she suddenly realised that there was a genuine
commitment” from the leaders. For those that are signed up to the programme, the
effect of the visible commitment of the senior leaders is to instil a culture in which
people feel able to experiment. A senior executive talked about “identifying the
problem but shifting the burden of guilt”, and a series of comments confirmed that
“people feel safe or safer.” The principle of senior leadership commitment was
summed up by one participant in the following way: “The top has to sign up, the top
has to agree to the principle. It gives us the freedom then to use that” [i.e. the
Pursuing Perfection methodology].
4.2.3
Flexibility of Leaders, and Comfort with Ambiguity and Emergence
Alongside the importance accorded to the commitment of senior leaders to the
programme, the dataset indicates that flexibility of leadership is a crucial component
in enabling the principles of Pursuing Perfection to take root: “It is ok to be flexible. X
14
[a Chief Executive] is fine leading with all this ambiguity…So to actually have the
leadership group comfortable with this approach gives it strength.” Another
participant confirmed that the management style “doesn’t feel top-heavy”, while
another argued that “in order to make things happen you need to be flexible and
responsive.” This flexible leadership style is important, since it was felt that the
Pursuing Perfection programme was “emerging all the time.” Moreover, it was felt
that “the programme has been very organic – we have built the structure of the
programme around what has arisen out of the projects…We have a structure that
supports the projects as they grow.” Speaking about the nature of leadership which is
required for the role of change facilitator, a participant said that “it’s more about
facilitating, supporting, keeping the project on track, as well as directing where it
goes, but more of an enabling role, rather than sort of coping, managerial role.”
A further aspect of this flexibility consists in a commitment to ensuring that
embedded practices of professional hegemonies do not act as barriers to change from
the outset. For instance, in relation to the conviction that, in order for modernisation
to begin it is necessary to “acknowledge that something is wrong”, a Senior Executive
spoke of trying to “loosen up the status quo”, indeed, of trying to “detonate the status
quo as much as possible, but not in ways that people find terrifying.” What this
consists in, as this participant went on to make clear, was “making sure that people
aren’t satisfied with things they shouldn’t be satisfied with.”
Our evidence suggests that the fundamental impact of committed, flexible, leadership
is manifested by the creation of a culture in which staff feel empowered to
experiment, a necessary condition for radical change to take place. One leader
observed that “it’s almost like we are saying that it is ok to make mistakes”, while
another senior executive captured the leadership style after which they were striving
as “trying not to control things but to give the organisation a kind of infection” which
has the consequence that people begin to “do things themselves”. There was
agreement that leaders were striving to enable staff to feel that they were “able to
reinvent things locally.” Another participant summed this up, saying that “the
leadership group are quite clear that they are saying that you have got to try; they are
giving people permission [to] give it a go. Just giving people permission to do
something different is important.”
4.3
Behaviour Change and the Reconfiguration of Relations/Creation of
new Relations
In order for transformational change to occur within a health and social care
community, our evidence confirms that it is necessary for a widespread change in
behaviour and working practices to occur throughout the system. Such a change in
behaviour can be seen as an effective patterning of the change in behaviour
demonstrated by senior leaders, discussed in the previous section.
Participants often characterised their own perception of behaviour change in quasireligious terms, suggesting a type of ‘conversion’, reiterating the theme to which
attention was drawn in § 4.2.1. Thus, one way of behaving differently identified by
participants consisted in “taking a leap of faith.” Such a leap of faith can manifest
itself in stark behavioural changes – commenting about a colleague on one of the
projects, a participant said “if you had spoken to x [before, they would have] told you
15
that [they were] deeply suspicious about the whole thing and saw it as another
burden – and now [they are] wildly enthusiastic. So now the penny has dropped.”
This is suggestive of the fact that, in Pursuing Perfection, behaviour change does not
consist so much in a change in degree of behaviour as a change in kind, a point to
which we shall return in the concluding Discussion section below.
For example, one participant who talked of the importance of “changing the way we
work at the moment,” suggested, as examples of such changes in working practices,
“being much more involved in the community, being prepared to do things
differently… reconciling excellence internationally with being a local first class
provider.” From the dataset, it appears that one way in which Pursuing Perfection has
enabled such behaviour change is simply the space it has created within organisations
for thinking and reflection: “I think that what has been useful, particularly for the
notion of changing professional behaviour [has been] that time out to think
differently.”
The data suggests that a key condition for enabling behavioural change consisted in
providing staff with the opportunity to work outside the strict parameters defined by
their professional roles. As one Pursuing Perfection leader described, “I’m trying to
encourage people to think other than in ways which are constrained by their
professional boundaries, or the ways of getting the job done within the limits of their
relationships”, and it was in this context that this leader went on to say that it was a
matter of “loosening up the status quo.”
The notion of professional boundaries parallels that of the boundaries between the
component organisations of health care communities, and, in turn, the notion of
behaving in a way that is no longer constrained by professional boundaries parallels
that of a change in the behaviour of organisations, specifically, in the way in which
they relate with one another. Thus, once again utilising the quasi-religious language
which we have already underscored, one participant talked of the need to start trusting
a partner organisation: “We talked in this meeting about lack of trust between health
and social services”, and on the basis of this, agreed to try to do something “that is
going to be different, that is going to show a leap of faith”. On the other hand, an
already cited view expressed from the perspective of social services in one participant
community was that change at a really fundamental level was lacking: “We can’t have
these projects that are… having a gesture towards doing these things, and not saying
what are the serious things that have got to be changed and tackled.” Even the way in
which meetings were scheduled was indicative of the lack of recognition of what it
really meant to work together differently. For example, at the early stages of the
Pursuing Perfection project at this site, meetings which involved social services
strategically were scheduled at times they could not attend – “so that at CEO level we
were excluded de facto. What is happening now is that Pursuing Perfection items are
put into a time slot we can get there to.” At the other site, a senior leader remarked
that “the relations between organisations were based on [financial transactions] at, if
you like, a corporate level. On an operational level there was very little connection
between people working in primary care and people working in secondary care.” This
participant went on to explain that Pursuing Perfection was being used as an
opportunity to try to “converge the commissioning process with the change process”,
and on this basis, that the community was progressing with “linking partners, turning
16
that into a firm relationship, getting real trust in there, and just having confidence in
exchanging ways of doing things.”
Another participant reflected on this aspect of transformational change in the Pursuing
Perfection programme: “I think that there have been huge hidden benefits that haven’t
been measured, and perhaps can’t be measured, so if you were to ask me what the
biggest benefit of pursuing perfection has been, I would say it’s got the organisations
talking to each other, organisations working together. To me, that is the biggest
benefit and biggest change and will have the biggest impact on patient services.” That
this is a fundamental element of the sites’ experience of participating in the Pursuing
Perfection programme is confirmed by the fact that many of the participants drew
attention to the fundamental significance of relation forming within the programme:
“It is about making connections as much as doing discrete pieces of project work.”
Another stressed that they thought that it was “personal relationships that were
important”. Moreover, what was significant was that such relations were not forced
on people, but rather, that “people are making the connections themselves.” And
summing up the impact of the initial stage of Pursuing Perfection, another participant
concluded: “You say ‘Has it been worthwhile?’ and I am saying ‘Absolutely it has’ –
but mainly about the relationship building, and building the capacity and capability
for the whole system to change, to change itself.”5
4.4
Culture of Experimentation and Supported Risk Taking
The culture of experimentation, and the suggestion that there was a need for a change
in the way that the leadership team at one site behaved, constitute two aspects of a
more general phenomenon that participants identified as being necessary for initiating
the programme of radical, whole-system change within Pursuing Perfection, namely
the need to behave differently. We have referred to the way in which leadership style
changed in one of the sites, the better to accommodate the Pursuing Perfection ethos.
In addition, the opportunity to behave differently was afforded by the emphasis on
small-scale local change, through Plan Do Study Act (PDSA) cycles, allowing a
culture of experimentation to flourish. The scale of the changes realised through these
cycles was, on the one hand, small enough not to destabilise an organisation if they
proved ineffective, while, on the other hand, easy enough to adopt more widely if
successful. For some participants, the advantage of these PDSA cycles was that “it’s
about being able to reinvent things locally, invent things here, as opposed to not
invent things here, give people the chance to understand they might have a
contribution to make.” The data shows that using PDSA cycles allowed people to
“feel safe or safer” initiating such controlled changes. “If you do something quite
radical, you would much rather try it on one or two, when you feel it is a much more
controlled environment”. The opposite also seemed true: if large-scale change were
adopted, “and somebody came to harm, I would revert back to my old way of
working.” The enthusiasm for the PDSA technique was summed up thus: “The
traditional ways are that (you should) change everything and it’s just impossible and
it never happens and this is just, let’s change something for one person and that is
5
In a further confirmation of the importance of this theme to the Pursuing Perfection participants in the
UK, during a meeting of leaders from each of the participating sites with a senior executive from IHI,
in an exercise focused on identifying the key successes of the programme to date, each of the outcomes
highlighted consisted in a ‘cultural success’, and it is precisely as cultural outcomes that this theme of
behavioural change and relation forming can be understood.
17
possible… it’s how much it enables people, it’s just a process of – they learn through
doing the test.” There are several examples from the interviews of successful adoption
of small-scale change. In one community hospital, the senior nurses in charge of the
medical wards began to experiment with new approaches to delays in discharge,
planning these events from the moment a patient was admitted, as they had seen their
colleagues in the local acute trust do successfully. Similarly, the cardiology staff, in
one of the acute trusts, successfully reduced the waiting times for angiography by
using their own PDSA cycles to test ideas out initially.6
For one site, it appears that less emphasis was placed on the precise process of the
PDSA cycles, preferring to encourage a culture of experimentation, through allowing
swift testing of small-scale changes and their subsequent rapid evaluation: “you don’t
want to kill the enthusiasm and say ‘you can only do it if you plot this on a graph’,
because some of it is so obvious, they just needed a catalyst to do it.” The formal
structure of PDSA cycles created a tension in adopting the culture of experimentation
at one of the sites. Thus, one participant reported a desire to support local rapid
processes of creative change, to be undertaken by front line staff. However, it was felt
that to compel such staff to go through the formal structures of PDSA, might
jeopardise that front line creativity. “If I went back and said actually we need a run
chart, we would stop some of that [culture of change].” In this context, there is ample
data to suggest that the tendency at the sites is to work according to the principles, but
not the letter, of the PDSA cycle.7
4.5
Accepting the possibility that different ways of working and
thinking will be better for patients
A vital element in enabling staff to change their behaviour is witnessing the effects of
change initiatives undertaken as part of the Pursuing Perfection programme, as is
clear from the testimony of one participant who began to change their behaviour when
they “saw results coming through”. Another participant argued that “when staff can
see”, then they are motivated to experiment with “different ways of thinking.”
With respect to the preceding discussion of behaviour change, our evidence confirms
that it will not always be enough simply to give people the opportunity to change the
way they behave, or to think differently – a decisive contribution motivating the
actual occurrence of such changes is enabling people to experience at first hand how
others in similar positions conduct their business. Thus, one participant identified the
importance of “getting people out”, getting them “to visit other places” in order to
“get people to understand there are different ways of doing it.” Another participant
reflected on going on a visit “with someone from here who works in the PCT, and it
was good to get away and see different things.” What is important to remember with
respect to this, however, is that the best practice in one organisation may not
6
Interestingly, neither of these departments had been involved in the formal Pursuing Perfection
programme. This may suggest that, as a ‘culture’, rather than a specific technique, the PDSA way of
working has the capacity to spread within an organisation more or less of its own accord.
7
The potential problem identified in relation to this way of working was that, by not observing the
letter of the PDSA technique, certain key aspects which are constitutive of the technique may be
ignored, such as specific reflection on data collected – with the consequence that effective learning
based on the utilisation of the PDSA technique might not take place. As will be highlighted in the
concluding discussion, such learning is a key element of whole system transformational change.
18
necessarily constitute the best practice in another organisation, or in another part of
the same organisation. It is not, therefore, a case of forcing people to “move to this
best practice” so much as giving them the sense that “you can pick and mix with
this.” Bearing this in mind, it may be that a basic opportunity afforded by visiting
different working environments is the creation of a space within which people can
begin to think differently. Thus, one participant talked of “sending people away to do
some different ways of thinking” which can lead to staff “try[ing] little bits”, such as a
“particular nurse working differently, you know, to speed up the process, to stop some
of the bottlenecks, to improve communication”.
Evidence of different ways of working and the outcomes to which they lead can also
help people to attain an intuitive sense of the principles of Pursuing Perfection: “With
regards to my involvement, it started to gel more this year…when I saw results
coming through, and when I had a better understanding of some of the principles
underlying it.” In turn, gaining such an intuitive understanding can help in spreading
the Pursuing Perfection principles: “When you are trying to persuade staff, the fact
that you have been persuaded helps. I would find it very difficult to do that if I hadn’t
been.”
4.6
Genuine and Meaningful Patient Involvement
Central to the whole Pursuing Perfection programme was its commitment to
reconfigure services around patients, and in this way go beyond the rhetoric of
patient-centeredness towards genuine and meaningful patient involvement in service
re-design. The data from these two sites reveals that, while both saw it as a central
aspiration, many participants struggled with the concept and approached it in different
ways. Firstly, the data from senior participants depicts a commitment to, and
enthusiasm for, active and meaningful patient involvement. Secondly, while the
general impression from participants in both sites was that being truly patient focused
was difficult “the patient centredness appeals to me…but I think it’s the one everyone
has been struggling with,” this view was challenged by some senior individuals. In
particular, participants from a social services background in one site did not feel that
the health care community had taken this notion fully on board: “No, I don’t see
that…we haven’t got that, that patient centred stuff. I don’t see Pursuing Perfection
challenging the current comfort zones of the bureaucratic structures…..we have to
change the way we work to give a more patient centred service, and I don’t see any
signs of that what so ever.” At the other site, one senior manager challenged the more
widely held view that involving patients was difficult. “I think it’s easier than people
think it is. If you did that [design services around patients] you would find it easier
than people think it is…but people get into a defensive position about it… that’s how I
tend to approach all the work I do is I try to think what would I like.”
Implicit in the discussion in the interviews about the difficulty of involving patients
was the challenge professionals experienced in altering their behaviour when talking
to patients about the design of services. The data suggests that doctors find it difficult
to change their behaviour – that is to listen, talk and behave in a different way – in
front of patients, which is what they nevertheless recognise as a prerequisite of true
patient centredness. “This is something that we are learning a lot about, and pretty
fast,” commented one programme lead. However, in the same interview, the
participant observed that, once the two groups came together around a focused area,
19
“what was amazing was, bar language, what doctors wanted and what patients
wanted was so close.” At the other site one of the project initiation documents had
proved very difficult to write because of the desire to have meaningful patient
involvement in the nature and language of the promises: “…they [the promises] were
not in patient language and they weren’t really promises to patients, they were quite
medically orientated.. I went from that situation where it was all in patient language
but it didn’t mean a thing I couldn’t measure any of it.”
A number of participants focused on this tension by suggesting that one way to
achieve meaningful patient centeredness was to have patients in the same room as
doctors and managers. While doctors and managers behaved “defensively” when
faced with each other in a discussion about service delivery, some thought that the
presence of patients in a meeting changed the nature of the discussion – “God, do you
think differently!” This appears a strong and consistent theme within this data set: the
potential of patients, if consulted in a substantive sense, and on ‘equal’ terms, to
confer a strong influence on the way services might be configured. To achieve this,
one clinician manager thought, “My colleagues (should) spend more time talking to
their patients about the experience of being one of their patients, I suspect they would
change…” In some ways, the nature of the process of making project promises
allowed some blue sky thinking to develop in groups where doctors and patients came
together. One participant discussed how valuable it was to consult patients on their
direct lived experience of receiving a service, “actually asking them what their
experience of having a procedure done this way as opposed to another way”, in order
to “really look at different ways” of delivering services. Another manager described
the perspective he aspired to this way: “Please base your service around my life, not
base my life around your service.” In another interview, this elegant distinction was
expressed by distinguishing between services which were “patient focused”, and
services which were “patient driven”. The context in which this distinction was made
indicates that the former, although worthy, remained a paternalistic notion, whereas a
willingness to accept patient driven transformation confirmed a commitment to
fundamental change.
The data reveals several perspectives which the doctor-patient relationship could
express within the Pursuing Perfection programme, and how the way that the two
groups related to each other had shifted over time. “I personally believe it has been
like a pendulum swing. So, to begin with it used to be clinicians who told patients
what to do, and then we were all told, no you’ve got to listen to patients, then you’ve
got patients telling us what to do. And I have felt for some time that I wanted to be in
the middle, a partnership.”
4.7
Language and Communication
Language in this data set appears to have a dual importance. First, there is data to
suggest that clinicians’ and managers’ language could be a barrier to developing a
shared understanding of Pursuing Perfection. Second, there is clear evidence that
participants recognised the importance of articulating a shared vision for how the
projects should succeed through the medium of a common language.
Non-clinical participants expressed concerns about clinicians’ language during the
group meetings where patients and clinicians came together. One manager
20
commented, “you know, you don’t know what the clinicians were talking about”.
Responding to this, some clinicians began to reflect on their own use of language in
front of patients. Managers did too, but in the context of helping meetings become
more “conciliatory.” The challenge of ensuring that clinicians and patients did
actually share a common understanding led to Programme Directors on one of the
sites being referred to as “translators”. This indicates two inter-related points. On the
one hand, it is evident that all participants recognise that different groups within
health and social care communities have, and speak, different languages. On the other
hand, the data suggests that there is a widening recognition of the need to develop a
shared, or common, language.
In the interviews from the two sites, it does appear that there is a difference in the
extent to which they initially recognised the need for a shared language as the basis
for ensuring a common vision for the Pursuing Perfection promises. On the one hand,
the participants from one site asserted that clinicians’ use of language could constitute
a barrier to effective collaboration, agreeing that, “bar language, what patients and
clinicians wanted were so close.” Adjusting the language professionals used seemed
an important component of developing iterative discussions with patients, either
individually or in groups, to ensure consensus about the details of the shared vision.
Thus, when patients proposals were made about a particular project, professionals
drew them up in what they called a “visual paper”: importantly, they took that back to
the patient groups asking “is that what we have understood that you have said?” On
the other hand, at the other site, while the need to involve patients and therefore
ensure the ‘sharedness’ of language was accepted, the matter appears to have been
delayed until the managing group itself felt it had securely understood the complexity
of the challenge in each promise. Thus, here patients did not form part of the think
tank meetings, arranged to determine the strategy and direction of the Pursuing
Perfection programme, as it was felt by the managers that “things might be said that
the leadership people would rather weren’t heard by service users.”
The importance of disseminating and communicating the message of Pursuing
Perfection was highlighted at the Steering Group meetings in one of the sites, one
senior leader emphasising that “I need very effective communication”. The data set
suggests that the Chief Executives at this site receive their news about the progress of
Pursuing Perfection either from the Programme Leads – “they report to us in terms of
progress” – or via the Chief Executive group – “…everything comes back to the chief
execs group”. Although this may seem an orthodox mechanism for senior managers to
learn about the activities of their organisations, there is data which suggests that in the
context of Pursuing Perfection, such a conventional route seemed to some participants
to be lacking in direct involvement – it was “not at the coal face”. One interviewee
then went on to observe that this lack of direct involvement might mean that it is not
so easy to “go in and implement the changes that we wish to make”. A senior IHI
representative did comment on this route of communication at a meeting in London,
where he challenged the chief executives as to what feedback they received from the
Steering Group meetings “You nominated a director to attend your steering group,
have they ever fed back to you?”
The importance of communication in terms of keeping everyone engaged was further
commented upon: “…you only need someone from [names site] not to turn up at one
steering group and you’ve lost it...” However it was also noted that “what we haven’t
21
done is worked with them to be the communicators down”. There is a need for
communication about the programme to get to the frontline staff, but the data showed
that initially it was unclear whose responsibility this was. When one of the
interviewees was asked whether they considered the front-line staff to be engaged,
they commented that “I would love you [researchers] to feed that back to me.”
Another interviewee spoke of the message going back up to the chief executives as
not being their responsibility “I hope that some of the learning will be taken back
higher.” This evidence suggests that there is an awareness of the necessity of
communication for enabling health and social care communities to learn about their
own activities, and of the changes that are taking place – a necessary condition for the
learning from such changes being integrated into the system as a whole – but that this
awareness does not translate into an active taking of responsibility to ensure that such
communication does indeed occur.
4.8
Pursuing Perfection as a ‘Way of Working’
In one site a review of the interviews shows that the initial momentum within
Pursuing Perfection was configured around the promises associated with the two
projects identified in Boston. A strong theme in the early interviews centres on the
way the promises were identified, the cross-health and social care community
relationships needed to enable them, and the management structure required to deliver
them. However, a shift in focus can be discerned as the two sets of interviews
progressed, which is characterised by a move away from thinking about projects in
isolation, towards news ways of working generally. A number of influences seem to
come together to promote this change.
The first of these is the conspicuous change in style of senior leadership at this site
which we have described above. In summary, the change in style permitted a greater
dispersal of leadership power, and also became more focused about the details of how
the Pursuing Perfection programmes were developing. Coupled with this was the
early success in one of the projects, which was welcomed, indeed needed, by the front
line staff to sustain their interest. While, in some early interviews, participants
regarded the Pursuing Perfection programme as “yet another flipping initiative”, it is
clear that these participants were prepared to change that view if they could genuinely
see that Pursuing Perfection could indeed deliver better care. “We need”, one
participant said, “a quick win…something that’s very visible, that people can see, that
they know what their part is to play in this project.”
Two other influences appear to come together to create a consensus that Pursuing
Perfection is not just about projects, but entails the potential to be a new way of
working. These were the spread of news about the programme through the health and
social care community at one site, sustained in part by the culture of risk-taking which
was empowered as part of the PDSA approach to change. In one site, the metaphors
used to describe the spread of Pursuing Perfection were vividly commercial, one
manager, for example, speaking of “selling it to staff and other managers, trying to
keep people who have gone through a lot of change interested.” Another manager at
this site firmly identifies communication as fundamental to the working of the
organisation by drawing “on my favourite definition of communication…the means by
which an organisation exists.”
22
There is clear evidence at this site that the programme spread to areas not initially
earmarked for project status. Thus, nurses in two community hospitals heard about the
one of the projects, acquired the basic change measurement skills, and started to apply
them to their own wards. Field notes of informal conversations at this site describe a
similar example in another unit within the acute trust. Exploring why these change
experiments were allowed, and indeed encouraged, to take place, the conclusion
reached was that it was related to the culture in the acute trust which enabled small
scale changes to take place spontaneously – a move in itself related to the change in
leadership style. This approach was summed up in one interview thus: “Well, come on
guys, if you want a different type of healthcare, you’ve got to help us take risks,
because you know, sometimes things get worse before they get better.”
The interviews from the other site support and develop this interpretation, where it
was acknowledged, in the words of one participant, that in encouraging change, “I’m
kind of detonating the status quo, as much as possible, but not in a way that terrifies
people.” This benefit for the spread of the programme arising out of positive early
experience is found also in interviews at this site where, for example, a primary care
manager says “With regards to my own involvement, it started to gel more this year
when I saw results coming through.” The first round of interviews at this site contains,
as was emphasised in previous sections, a large amount of data about “doing things
differently” and “thinking differently”. As was noted, one participant described
“sending people away to do some different ways of thinking…that particular nurse
working differently, you know…to speed up the process, improve communication
dialogue across that using the Pursuing Perfection principles…and so I think that
when staff can see…they can try little bits, and keep(ing) motivated in that.”
The data suggests that the emphasis on Pursuing Perfection as a culture, as a way of
working, rather than a series of more or less discrete projects, may be related to the
apparently slow initial progress of Pursuing Perfection in these sites. One SHA
participant argued that “change takes longer than people think…because there is a
huge amount of preparatory work to be done”. The initial stages thus consist in
“doing preparatory work and getting people engaged, getting them on board, getting
the team together – getting people a really good understanding of what they are
doing”. It was also argued by another participant that “if you were to measure the
output through each of the pieces of work that [the] change programme did, you
would never say that this has made a radical difference to this organisation, but it
clearly had made a radical difference…It’s all the soft stuff that is never captured…I
would strongly assert that…it wasn’t the individual projects, it was the way the
change was done that changed the culture of the organisation, made people feel
empowered.”
One important consequence of changing behaviour implied in the move to see
Pursuing Perfection as a different way of working is described in the data in terms of
the realisation that sustainability should not be a matter of “sustaining what we have
done” which can be interpreted, in fact, as avoiding change. Rather, practices should
be directed towards “engendering health care improvement as an ongoing, iterative,
never-ending process”, and as a consequence of this, what might subsequently be
sustained is, in the words of one participant, “people’s thirst to learn, and change, and
move all the time in a way that is manageable.”
23
Summing this theme up, one senior leader observed that “Pursuing Perfection was
already there, but I was quite keen, and still am, to migrate into people’s everyday
thinking. It’s not different from the work, it’s not a project – it is the work”. Another
participating leader argued that “the project part of this is all very important, but the
biggest thing in all of Pursuing Perfection is behaviours, cultures, and people talking
to each other face to face”.
24
5.
Discussion
The preceding discussion of the conditions which, the data suggests, are constitutive
of a receptive context for whole system transformational change, provokes a series of
difficult questions. Is there a reason why it is these specific conditions which are
constitutive of such a context? Are they necessary, or sufficient, conditions? To what
extent are these conditions context specific – either to the specific location of the
individual health and social care communities in the programme, or indeed to the
Pursuing Perfection programme itself – or are they transferable? Can we be sure, at
this stage in the programme, that a receptive context for whole system
transformational change has been created, and if so, that such change will indeed take
place? And finally, if such a transformational change does take place, will it result in
the achievement of the outcomes identified for the Pursuing Perfection programme,
specifically those concerning genuinely patient centred care?
It should be possible to begin to frame answers to these latter questions based on the
subsequent research to be undertaken on the programme. For the purposes of this
discussion, therefore, we propose to focus on the issue of how and why the conditions
that have emerged from the data should be constitutive of a receptive context for
whole system transformational change. In order to address this issue, it is necessary to
develop a theoretical framework within which to interpret the conditions which have
been identified from within the qualitative data-set. Without such a theoretical
framework, any interpretation would be at best ad hoc and piecemeal, and therefore
unlikely to provide a coherent understanding of the data. The theoretical framework
informing our work is complexity theory. Complexity is a rigorous, scientific,
theoretical paradigm, which has the benefit of being able to interpret whole, or open,
dynamical systems (standard scientific theories are constrained to deal with closed
systems),8 and hence of being able to deal with system based change. In the following
discussion, therefore, we will be considering receptive contexts precisely as contexts
for change.
The first point that must be borne in mind is why whole system transformational
change is being sought in the Pursuing Perfection programme. The programme is
informed by the thinking of the IHI, and particularly its Director, Don Berwick.
Berwick’s well-known aspirational vision is for health care systems in which there are
no needless deaths or disease, no needless suffering, no needless delays, no needless
waste, no feelings of helplessness, and no inequalities.9 These aspirations function,
effectively, as quality markers of a perfect health and social care system. The
fundamental insights informing the Pursuing Perfection programme are that, on the
one hand, these quality markers represent properties which pertain to the whole
system, and, on the other hand, that gradual, incremental, changes in existing practices
will neither alter the properties of the whole system nor lead towards the attainment of
these aspirations. The intuition is, therefore, that where there are changes in practice,
these will have to be, in effect, ‘changes in kind’ rather than ‘changes in degree’ – that
changes in thinking or behaviour will have to consist, literally, in doing or thinking
differently, rather than carrying on thinking or behaving in the same way, but ‘doing it
better’.
8
9
See Rosen, R, Life Itself, New York, Columbia.
As cited at http://www.modern.nhs.uk/scripts/default.asp?site_id=40
25
But this way of thinking yields a fundamental problem: it appears as if change, in the
context of the Pursuing Perfection programme, has two fundamental dimensions, and,
moreover, that there is no apparent necessary connection between these dimensions.
The two dimensions of change consist in local changes in behaviour – ‘doing things
differently’, as captured in the technique of PDSA cycles – and whole system
transformational changes. Can there be a causal relation between local changes and
whole system transformational changes? Is it simply the case that an arithmetical
accumulation of local changes will inevitably result in whole system change? Of
course, anecdotal evidence would suggest not – but why should this be so?
Complexity theory indicates that it is because, to the extent that health and social care
organisations are open dynamic systems, they respond adaptively to internal changes,
and also to changes in the environment within which they are situated. [Wheatley
(2000)] Open systems are susceptible to feedback loops. According to a quasihomeostatic principle, systems will tend, for the most part, to seek to maintain their
current configuration, to maintain, that is, their dynamic equilibrium. An alternative
scenario would be when too great a local change leads to catastrophic consequences
for the whole system. Is there then an alternative, from a whole system perspective, to
the systemic responses of catastrophe or maintenance of equilibrium?
It is in response to this question that the true significance of the conditions of a
‘receptive context’ for whole system transformational change begins to emerge. For
the key, from a systems perspective, clearly consists in how the system is configured,
such that local changes can in fact be integrated into the behaviour of the whole
system in such a way that a positive, rather than negative, feedback loop is created
(where the latter would underpin the system’s homeostatic capacity to maintain
equilibrium). In seeking to detail how this might happen, we can begin to frame an
answer to the question posed of why the conditions identified in the previous section
do indeed constitute a receptive context for whole system transformational change.
The evidence from which the set of conditions identified in the previous section were
derived suggests that there is, effectively, a two-stage process involved in the creation
of a receptive context for whole-system, patient-centred, transformational change. The
initial stage consists in the recognition that the current way in which the organisation
or health care community is working is not functioning as effectively as it could in
order to deliver the best possible care to patients – in other words, that things could, or
indeed should, be done differently, and done better. In the second stage, following on
from this, one discerns the development of genuine and visible leadership
commitment to the principles of the transformational change programme, and to the
various projects undertaken as part of the programme. This commitment is expressed,
in part, in visible evidence of a change in the behaviour of the senior leaders.
If we consider the initial stage first, then we can characterise the realisation that the
system’s current way of functioning, or working, is not as effective as it should be, as
being akin to the system’s being forced into a state of disequilibrium. What is then
crucial is whether, having entered into such a state of disequilibrium, the system is
‘successful’ in returning itself to its prior state of equilibrium, or whether this state
becomes the initial phase for a process of radical change that the system will undergo.
What is striking about this initial phase is the source for the realisation that things
need to be done differently. The system moves to a state of disequilibrium as a
26
consequence of an encounter with what lies outside of the system – in this case, the
IHI, but also, as is beginning to be suggested, via a genuine encounter with patients.10
Clearly, in order for such an encounter between the system and its outside to occur, it
is necessary for the system to be both open and dynamic.
In order that this encounter with the system’s outside, and the tendency towards
disequilibrium which it provokes in the system, generate a process of transformational
change, a further stage in the creation of a receptive context needs to occur. 11 The
evidence indicates that this second stage consists, within the sphere of the leadership
of the system, in the setting of, and genuine commitment to, aspirational goals
founded on the realisation that things have to be done differently, characteristic of the
system’s being in a state of disequilibrium. However, in and of themselves, these
goals are not sufficient for the generation of a momentum for change. This is because,
for the most part, such goals lack the degree of specificity that would make them
meaningful for the lived experience of workers within health and social care
organisations. This is where we encounter our second dimension of change, namely
local change. With respect to local change, it is of the utmost importance, as the
evidence confirms, that leaders respond flexibly and positively to local change
initiatives, if these are to flourish and generate whole system change. Such flexibility
may in fact represent a change in the standard behaviour of leaders – but the visibility
of such behaviour change in itself may offer a behavioural change that can be
patterned throughout the organisation. For, as the evidence makes clear, a
fundamental necessary condition for whole system transformational change is local
changes in behaviour of people working within health and social care organisations.
How should these local changes be understood? From the perspective of complexity
theory, they can be interpreted as constituting ‘explorations of adjacent possibles’12.
With respect to this notion, we believe that the theme explored in § 4.5, namely of
witnessing at first hand how others in similar conditions conduct their business,
10
The evidence suggests that a further source for this realisation can be clearly and effectively
represented quantitative data. Now, it could be argued that data presented in this way is also effectively
an encounter with the outside of the system, since the data constitutes an ‘objective’ representation of
the system’s working practices. But if we were to argue in this way, we would need to respond to the
counter-argument that the data collected in order to demonstrate the meeting of centrally set
Government ‘targets’ has not had the effect of pushing organisations into disequilibrium, as a first
phase of beginning processes of radical change. The response to this argument which the evidence
suggests is that, in the case of data collected in response to government targets, the measurements are
not ‘owned’ by the people in the organisation, and therefore are not meaningful to them in the way that
data which is generated as a consequence of decisions and choices made from within the system is. In
other words, there is a fundamental difference between self-generated processes of measurement and
measurements which are externally imposed. What would finally need to be underscored would be the
fact that, just because a process of measurement is self-generated, this does not mean that the results of
the process do not thus represent an ‘objective’ and hence ‘external’ perspective on the system.
11
In making this point, we are not claiming that this further stage needs to occur temporally after the
previous stage – indeed, there is evidence to suggest that in the participating sites, it can occur at the
same time as the initial stage; nevertheless, we are arguing that this ‘second’ stage cannot occur if the
‘first’ stage does not occur – and to this extent, the ‘first’ stage represents a condition of the ‘second’
stage.
12
An adjacent possible could be defined as the phase space which would be generated by change to one
variable determining a work practice or process. In other words, ‘what would happen if, in this care
pathway, we tried doing x instead of y?’ The key point is that a minimal difference can, within a nonlinear system, result in a maximal change being expressed by the whole system. Furthermore, this nonlinearity entails that such outcomes cannot be predicted in advance. See Kauffman S (2000).
27
constitutes a first step in the exploration of an adjacent possible. Indeed, the process
of actually visiting another organisation or community, to witness at first hand their
working practice, could be construed as literally representing such an exploration.
Equally, as discussed in § 4.6, genuine engagement with patients frequently provokes
people to think differently, a difference in thinking which parallels that provoked by
witnessing at first hand how others work. In both cases, the stimulation for the
different ways of thinking consists in an encounter with the ‘outside’ of the system,
whether embodied by patients or workers in another system (just as the initial
recognition that the system was not functioning as effectively as it could required an
encounter with the outside of the system). It might thus be claimed that these visits, or
the meaningful engagement with patients, as encounters with the system’s outside,
actually consist in the creation of an adjacent possible – where possible would here
entail the potentiality contained in a new way of thinking or working – which can then
be explored.
But as this last observation indicates, these are only first steps, since the incorporation
of a significant change, on the basis of either first hand experiences, or of engaging
directly and meaningfully with patients, is also necessary if change is to occur within,
and ultimately to, the whole system. In other words, it is not enough to create the
adjacent possible – it has also to be actively explored. PDSA cycles represent a
striking means by which adjacent possibles can actually be explored, to the extent that
they enable small scale experiments which support the testing of outcomes that might
transpire from such changes in kind. Crucially, the scale of PDSA cycles means that,
should they fail, the effect will not be catastrophic for the system. This is precisely the
rationale informing the exploration of adjacent possibles. Two further principles of
complexity are significant here: on the one hand, because complex processes are nonlinear, rather than linear, the outcome, or effect, may not be commensurate with the
input, or cause – a small change may lead to a large difference, or vice versa; on the
other hand, and as a consequence, the outcomes of such changes will be
unpredictable. Furthermore, the key point, as we have stressed, is that these changes
should not be understood, or indeed undertaken, as changes of degree, that is, doing
the same as before, but trying to do it better. Rather, these changes should be genuine
‘changes in kind’. This is why leaders – at all levels within the community – must be
prepared to be flexible, and engender a culture in which such experimentation is
supported (rather than failure being censured). Moreover, they must work to help the
system respond adaptively to the outcomes of these explorations of adjacent possibles.
This leads us to the final point of difficulty we identified, namely, of the connection
between local changes, what we have characterised as the exploration of adjacent
possibles, and whole system transformational change. The issue is that of how local
changes can become part of an iterative, positive, feedback loop which enables the
system as a whole to change, and thus to begin to manifest new emergent properties.
It is here that the most profound dimension of the receptive context becomes evident.
It is noteworthy that a significant proportion of the data-set pertaining to behavioural
change should characterise such change in terms of the reconfiguration of relations, or
the creation of new relations. It is quite evident from a series of testimonies that,
whatever else involvement in the Pursuing Perfection programme entailed, a
fundamental outcome has been the building of relations within organisations, or the
reconfiguration of relations between organisations. On the one hand, new or
reconfigured relations are necessary conditions for change because old, or well-
28
established, relations will tend to reinforce old, and well-established, modes of
working – they will function as networks of corroboration. Once again, the
importance of relations for whole systems finds its theoretical explanation in
complexity theory, in which it is demonstrated that, with regard to the creation of
novelty, and the evolution of organisms or organisations, it is not the parts of the
system which are of importance in and of themselves, but rather the relations which
subsist between the parts.13
In addition, and just as importantly, if the whole system is to learn about itself, and
from the ongoing programmes of small-scale, local, change, it is crucial that networks
of relations exist such that local learning can circulate around the system. An
atomised system cannot, of necessity, learn about itself, and cannot, in consequence,
integrate the outcomes from ongoing change processes. Such networks of relations
form, effectively, ‘infrastructures of communicability’, and these infrastructures
constitute, we believe, necessary conditions for the integration of the learning from
local change initiatives. In turn, without these infrastructures, whole system change
could not follow, as an emergent outcome, from local changes. In light of this claim,
it becomes clear how important the theme of language and communication is, and in
particular, the necessity that within the system, as was discussed in § 4.7, that
language functions as an aid, rather than a barrier (which latter can occur due to the
fact that different groups within communities speak different languages), to
communication.
Taken together, these themes of relations and communication, understood as the
context which enables a connection to be formed between the two change dimensions,
that is, local, small-scale, change processes and whole system, transformational,
change, further underscore the significance of the evidence which demonstrates that,
for the participants, Pursuing Perfection consists in a way of working – an holistic
notion – rather than in a set of discrete projects. For it will be the case that, when the
whole system manifests the ‘Pursuing Perfection way of working’, it will be
expressing the properties of whole system change.
The further point to be made about the formation of such networks of relations is that,
if they are to function effectively as supporters of whole system change, then they
must themselves be fluid, or dynamic, and in all likelihood, transient. There is a
tendency amongst policy makers in the contemporary climate to view relations, or
‘partnerships’, as ends in themselves. Complexity theory indicates, however, that such
relations, or networks, will be ‘self-organising’, and responsive to local conditions.
They cannot, once again, be predicted, or imposed, either from the centre, or from
outside, the system. Thus, the role of leaders within a system which is seeking to
undergo transformational change, is to work towards creating a context which
supports and enables the formation of self-organised networks of relations (for
instance, by removing organisational barriers to the formation of novel relations).
In conclusion, we
discussion of the
underlying concept
distinction between
13
wish to make two further points. Throughout the preceding
receptive context for local, and whole-system, change, the
has been that of difference – as attested by, for instance, our
difference in kind and difference in degree. We would argue, in
See Goodwin B (1995); Durie R (2000).
29
relation to this concept, that much literature concerning organisational change, which
stresses the significance of ‘shared beliefs and solidarity’,14 or which places undue, or
exclusive, emphasis on the role of whole system aspirational goals (or mission
statements) is misguided. What appears to be fundamental for enabling whole system,
transformational, change to occur is not shared beliefs but rather a flourishing of
difference, different ideas, relations, behaviours, concepts, intuitions, hunches, etc.
We would argue that organisations that manifest a receptive context for whole system
transformational change are, in fact, organisations which seek to maximise qualitative
difference, and in which difference flourishes rather than being sacrificed for unifying
principles or shared beliefs. Of course, this is not to deny the potential worth of whole
system aspirational goals, but rather, to underscore once again the fundamental
importance of understanding the nature of the relation between such whole system
goals, with their ‘unifying’ tendency, and the ‘differential multiplicity’15 of local,
small-scale, change initiatives. It needs to be further stressed, with respect to the
capacity of a system to learn about itself, and thereby adapt and change on the basis of
changes occurring either within or outwith the whole system, that the system must
also express the capacity to integrate the change initiatives constituting such a
differential multiplicity. Indeed, there is a sense in which it could be argued that for a
health and social care community to manifest a receptive context for whole system
transformational change would be for that community to demonstrate the ongoing
capacity to integrate the differential multiplicity of local, small-scale, change
initiatives, whether what is integrated is the learning from successful outcomes, or the
learning that accrues from initiatives that have not led to successful outcomes.
The second point we wish to make concerns the potential ‘sustainability’ of change
processes begun in consequence of the creation of a receptive context. Again, we
would wish to question the applicability of ‘sustainability’ as a concept which pertains
to whole system, transformational, change. By definition, sustainability suggests
protecting what has been achieved, and hence interrupting a change process. If whole
system change processes are to be truly dynamic, then the concept which is genuinely
applicable is that of maintaining the change process itself. What might this entail?
We believe that it is possible to provide an answer to this question by returning to the
initial stage in the formation of a receptive context for whole-system change, namely,
the realisation that things need to be done differently, that the current way of
functioning of the system is not as effective as it might be. In order to maintain the
momentum of change, to maintain the change process as such, it is necessary that this
realisation is perpetually reinforced, that is, to ensure the system does not fall back
into a state of equilibrium. We believe that it is in this context that the role of patient
involvement takes on its true significance – for, through an ongoing, genuine and
meaningful engagement with patients, health and social care organisations have an
ideal resource for accessing an ‘external’ perspective on their service provision. It is
through the ongoing process of actively listening to the stories that patients have to
tell about their experience of, precisely, the whole system – for it is, uniquely, patients
who, in their journey of care, pass through, and hence experience, the system as a
whole – that the system can learn where it needs to change, to explore adjacent
possibles of care provision. It is in such exploration that the themes of recognising
14
15
See, for instance, Della Porta D & Diani M (1999)
Durie, R (2000)
30
that things are not working well enough; committed and flexible leadership;
behaviour change; the configuration of new relations; the culture of experimentation;
working and thinking differently; genuine patient involvement; language and
communication; and, ultimately, Pursuing Perfection as a culture, a way of working;
will together function as conditions for the ongoing creation of receptive contexts for
whole system, transformational, patient-centred change.
31
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