Anyone trying to improve the way public bodies deliver their services is likely to be working across organisational boundaries, involving multi-professionals in teams within multiple systems. Traditional ways of gathering data and information for change management are increasingly found to be wanting in delivering significant shifts in complex contexts. There is a real need for exploring different ways of engaging with the workforce and using data to facilitate improvement.

Lewis Walker, GP, author and Clinical Lead for the Moray region of NHS Grampian and I recently had a conversation about the need for real-time, descriptive data to enable change in complex environments. We discussed what is not working, what is causing frustration and barriers to change as well as the tools we think do help us make real progress in these situations. 

Here are 8 learning points from our conversation:

  1. Leaders, even those who regularly walk the floor, often don’t have access to what is really happening on the ground, which limits their ability to look at things as complex realities. Coal-face interaction is easily “gamed” (on both sides) and rarely provides information for sustainable change.
  2. Increasing leadership awareness is imperative, so that leaders get a sense of what is really happening where the “rubber hits the road”. Developing anticipatory awareness for weak signal detection and paying attention to descriptive rather than just evaluative feedback are two key skills.
  3. In most organisations “on-the-ground” information passes through a number of hierarchical evaluative reporting levels before being presented to the “Top Team”. In the process the meaning of such information can change out of all recognition to the original.
  4. These intermediate levels of reporting tend to be not only slow in the feedback they provide but tend to focus on what is assumed to be important to measure – from the viewpoint of the “Top”.
  5. A Solutions Orientation approach using target destination, outcome-focussed, end-state tools is then often utilised even though it may be a poor fit for a Complex issue.
  6. Quality Improvement tools that rely on a problem being predefined by one particular viewpoint (e.g. driver diagrams) can be useful where there is a “Best Practice” solution but are usually unhelpful in complex environments.
  7. Instead we need access to distributed cognition – where work-force voices and narratives give personal, uncontaminated, real-time, descriptive feedback which can be rapidly analysed to provide “adjacent possibles and nudge points”. The here-and-now disposition and direction of travel of the system can be mapped in such a way to give entry points for multiple, small, safe-to-fail experiments.
  8. Rapid, iterative PDSA cycles, multiple small safe to fail experiments together with facilitation tools that promote open space conversations and avoid premature decision making closure, are required to access “liminal space”. This is a place where a system can convene together to explore the adjacent possibles and hold off on full implementation until the new shift can be seen to be moving in a useful direction, able to be both amplified and codified.

This blog was co-authored with Lewis Walker, who can be contacted at lewis.walker1@nhs.net

Horizons uses SenseMaker® to gather and analyse stories of real-time, day-to-day experiences to facilitate improvement in complex environments.

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