Surfing the waves

What a week! Seriously, I’m sitting in the garden reflecting not only on the unusually good weather, but the most amazing week of learning and connecting about improvement research and practice.

This time last week, I arrived in Montreal for the international conference in organisational behaviour in healthcare (OBHC), (thank you, as always, Health Foundation for funding my PhD and its dissemination). It’s a super conference covering many aspects of improvement, and strategic and organisational theory. The event started for me as last time by (losing my luggage and) meeting many early career researchers and PhDs. In what can only be described as a shouting frenzy, we enthusiastically participated in a round of speed networking, fantastically facilitated by Prof. Cathy Pope, where amongst other things we were asked to discuss our superpowers and our best teacher. The best part about this is that we all made many new friends, learnt about each other’s research and we were not at risk of being lonely at the conference.

Image: Joy Furnival

After a hike up Mont Royal, the following day the conference opened with a plenary about crossing paradigmatic boundaries. This included reflecting on the current state of the field including the need for pragmatic and real world trials, and the need for much more ethnography to develop insights to explain and influence organisational behaviour in healthcare. After this was a torrent of breakout sessions, for me the strength of this conference, with such a diversity of topics. I heard sessions about organisational change capability in Wales, knowledge mobilisation using boundary objects (I didn’t know what they were to begin with), leadership for quality improvement development programmes, the negative impact of leadership churn on quality improvement, the role of middle management in improvement, improvement sustainability, second victims in patient safety and so on. I was also delighted to present my theorisation of improvement capability.

I especially loved hearing from A.Prof Liz Wiggins and colleagues about their work to understand and develop the leadership of improvement via the GenerationQ programme (I am a former participant). This work (in press) describes leading improvement as ‘surfing the waves’ between perspectives, relationships and world’s; taking a complexity perspective to influence learning and practice in healthcare, one conversation at a time through leadership gestures and responses.

Two main highlights were a keynote from Prof. Henry Mintzburg speaking on managing the myths of healthcare; and the work from Prof. Stephen Shortell at CLEAR and colleagues to evaluate lean programmes in North America. I find this work very exciting. First, was research to evaluate the audacious lean programme in Saskatchewan province in Canada followed by a national lean survey in the USA. Shortell et al’s survey and analysis begins to demonstrate much needed research evidence of the positive [self reported] impact of lean (and other robust improvement) programmes especially after they begin to mature (warning for those looking to lean for a fast fix, this study shows impact really only starting after about 8 years of implementation). Whereas, the Satskatchewan story is rather depressing to hear, but nevertheless, there is much learning from the programme for other national and large scale lean programmes, to learn from. Not least ensuring early engagement of physicians, not being too fast/aggressive, being careful with jargon, the need for continuity and commitments from leaders particularly CEOs and being thoughtful about the personal and political risk leaders take. Thinking about our research which demonstrates a tendency of national orgs to focus on the ‘doing’, i.e. improvement tools, governance and data, the Saskatchewan story perhaps also a re-emphasises a cautionary tale, that lean programmes, particularly large national ones, must listen to stakeholders and patients from the beginning and pay as much, if not more attention to culture and leadership, and the political risks of such an endeavour.

Which brings me neatly to the end of the week, where I crossed back over the Atlantic boundary and joined the NHS Improvement (where I work) lean conference, (as far as I know, this was the first ever NHS led national lean conference). It was brilliant to reconnect with so many friends and colleagues from lean work, from the Virginia Mason partnership with 5 trusts, the NHS Improvement seven trusts embarking on the Vital Signs lean programme, and colleagues from NETS, CLIC, and from the Bolton Improving Care System (BICS). I was so proud to be there and I loved it. It was exciting, inspiring, energetic, and connected to research and practice, and so in a way for me, it felt like home.

Dr John Toussaint, from Catalysis and former CEO of Thedacare, from where Bolton learnt so many lean lessons, opened with a keynote discussing his personal lean leadership journey and shared 5 leadership lessons from organisations that he and colleagues have worked with. His keynote echoed the research lessons about the significance of culture and leadership, especially that of the CEO, from earlier in the week at OBHC. ‘Surfing’ between research and practice, he also shared Shortell et al. work and commented on the implications for practitioners and healthcare policy makers.

So after ‘surfing’ between improvement theory and practice this week – between two different world’s, associated paradigms, with seemingly different aims and remits, different communities and identities and many epistemic boundaries, there seems much to share and learn from both.

It is reported in an article by Prof. Jeffrey Braithwaite, that: only 50-60% of healthcare meets level 1 guidelines; healthcare expenditure seems to be 30% wasted; and adverse events remain stubbornly at a rate of approximately 1/10. In addition, much healthcare improvement continues to be challenged by a lack of scaling, magic bullets and a lack of evidence (Dixon-Woods and Martin, 2016). Following the OBHC research theme, more boundary crossing is going to be needed by researchers and practitioners alike to help ensure ‘we’ know how to improve healthcare. It does seem that ‘we’, improvers and researchers, might have to change and become more sophisticated, not only in how we think and learn about healthcare improvement, but also how we practice it. To me it seems much more ‘surfing’, and many more ‘surfers’, will be required to cross professional, organisational/geographical and paradigmic boundaries.

When will we be opening the surf school?

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