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

Contents
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 seem ripeare 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, These which themes are shown in Table 1.

Table 1 Features of receptive context

Principle conditions constitutingthemes describing featuresof 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) [page20]
Pursuing Perfection as a ‘way of working’ [page22]

There is, effectively, a two-stage process involved in the creation of a receptive context for the transformational changes noted at these sites[2]. 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, in 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 failure a project which didn’t work is not punished but seen as an oportunityopportunity for learning.
  3. Visible evidence of things being done differently, and of the outcomes which occur as a result of these different 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. 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 without formally seeking strategic permission,;these experiments can which are be small enough so that their failure will not destabilise the organisation, while well enough documented so that they can be rolled out more widely.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.

What is it about patient centredness which creates the conditions for change? A strong theme, on the basis of the data, appears to be the extent to which healthcare professionals ( and the participants suggest this particularly for doctors) are abel able and willing to “challenge their comfort zone”, and try to think like patients might think in all they plan and do.

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 theP2Pursuing 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]

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 programme in two health and social care communities – both of which participated in theModernisation Agency’s Pursuing Perfection Programme – in their attempts to create receptive contexts for service re-design leading to whole system patient-centred care.Both the health communities were part of the Modernisation Agencies Pursuing Perfection Programme.

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,.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.’ [

In May 2002 the Modernisation Agency funded four pilot sites for the two year programme. These pilot sites,Bradford, Central Norfolk, Lambeth and Southwark and North and East Devon 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’ 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 the to use these projects to identify the transformational change across the whole community. These projects werewouldto be made structured according to a set of as ‘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 would be removed. The improvements wshould 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 wais that the Chief Executives of local Trusts and the Directors of Social Services will would meet monthly to lead system wide improvement. The improvement work wais expected to be aligned with strategic goals and that the goals set for perfect care are 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 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 way conditions in which constituted the formation of receptive contexts for whole system health and social care change was developed in two of the pilot sites. We will discuss: the significance of the concept of a receptive context; the way in which receptive contexts were developed in two of the participating Pursuing Perfection pilot sites; what distinguishes this process from processes undergone in traditional modernisation or organisational development initiatives; how the development of receptive contexts relates to the initial outcomes achieved in the Pursuing Perfection programme; the extent to which these key findings and principles are transferable to other change initiatives in the NHS.

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.