For many improvement practitioners and researchers, leadership is the essential element of building sustainable improvement cultures, capability and systems. Nevertheless, it is clear from the evidence that despite leadership for improvement being a ‘well known’ factor, understanding and practicing enduring improvement leadership seems to be perpetually ‘just’ out of reach for many in health and care. And yet what else are leaders leading for, if not leading for improvement? Leading to get worse or stand-still doesn’t quite have the same ring to it.
To tackle this enactment gap, over the last few years, one of the more persistent metaphors for leading improvement is that of growing a garden or being a farmer. The seeds, the farming tools and the farm-hand time and skills are essential. In addition, the environmental weather conditions and the soil really matter, created metaphorically by leaders both within and external to organisations. Regardless of the farming skills and abilities, it can be difficult to grow plants and crops in droughts or floods or with poor soil or without sunshine or rainfall. It is a nice and helpful metaphor, illustrating the importance of context when leading and growing improvement cultures and capability.
Yet, despite the benefits of this nurturing growth metaphor in helping us make sense of why improvement doesn’t always succeed, I have always found it a difficult metaphor to completely relate to. I reflect that this might be because I find the metaphorical comparison to the weather, soil and environmental conditions rather passive.
I was struck this week by an alternative metaphor from the statistician and author Davis Balestracci, who instead used a metaphor of pregnancy. He suggested in this blog that ‘many leaders just want their organisations to just be a little bit pregnant with improvement‘ (paraphrasing). Whilst there may be a risk of exacerbating a ‘parent-child’ image of leadership in this metaphor; I still like this metaphor because of the word ‘pregnancy‘. Overloaded with hope of what is to come, the idea of new life and birth, of opportunity and potential. Imagine an organisation pregnant with ideas, brimming and bursting with pride. Ready to give birth to it’s new improvement culture and system, building improvement capability and delivering better care and health for patients, service users and the population.
Thinking back to my pregnancies, that early phase, that ‘little bit pregant’ era during the first trimester is so exciting*. The discovery, the surprise, the nervousness, the sharing the news with close family, the first scan image, the cot buying and the gorgeous baby clothes. Loads of new things, lots of learning from that ever growing pile of baby books, lots of awwes, congratulations, lots of ‘glowing’ comments and interest from friends and acquaintances and strangers.
This early stage reminds me of the early stages of organisations finding their way towards practicing improvement. A feeling of newness, excitement, difference, a little bit of anxiety, some new opportunities with bit of training and learning about improvement practice. Maybe even a little bit of centre of attention for the future parents.
Maybe that early phase is a little bit tougher on the future mother with morning sickness and all that health advice to change your habits for a healthy baby: don’t eat blue cheese, don’t drink alcohol and don’t eat raw seafood. But for most involved*, fairly easy, and exciting. Everyone else can still celebrate the impending baby with prosecco. No need for everyone involved to change their habits too. Everyone else arguably being the observers and bystanders of the metaphorical organisational pregnancy. The ‘pregnant improvement team‘ can do the hard habit changing stuff. Can’t they?
Sadly, for some pregnancy can become more difficult and sometimes end from miscarriage. No longer only ‘a little bit pregnant’. In my case, my context changed when I was diagnosed with gestational diabetes. This diagnosis increased the frequency and duration of my check up appointments, required further diet changes and included ten mins of being shown how to take a blood sugar reading but little explanation of what to do if the score was higher than recommended. Ten minutes, not much by the way of advice, training in a new sugar reading tool and reassurance. Work the rest out myself, for my context, for my abnormal conditions. Lots of new things that I didn’t know about before I became pregnant to worry about. I remember that oversized babies and their potentially large heads were my number 1 concern, especially because of the gestational diabetes. Really not that much fun being a lot pregnant, rather than a bit pregnant, for me.
Often not much fun for a new improvement team just after that ‘little bit pregnant’ point either, imho. Carry on using all the new improvement tools and interventions you have barely just learnt, just ‘adapt’ them intelligently to your context and work it out for yourself. And then the realisations. The ‘Oh no, this is becoming a bit more difficult than expected‘. What happened to the early pregnancy fun stuff? When is the baby shower? Can we not just have that nice looking data chart for a external presentation now? What do you mean ‘it’s‘ not fully gestated yet, the graph needs a few more dots to be certain it’s a statistical improvement? We are still learning? Really? But it’s been 6 months now?
Then the birth. For many, hopefully a healthy baby**. A great improvement project with some fabulous, and measurable patient, staff or organisational benefits. The improvement equivalent to 10 fingers and thumbs, 10 toes, a healthy weight and a no/low risk Agpar score. Maybe even twins or triplets. A cause for celebration, wetting the baby’s head, and maybe even a HSJ award.
After my first baby, after an exhausting 20 hours of labour with some anxiety inducing complications, my Auntie sent me a text saying ‘Congratulations, the hard work starts now!‘ Not exactly the text I wanted to read at that moment. I just done all that labouring hard work, thank you very much. At that point I mostly wanted to sleep, dreaming of the blue cheese, smoked salmon and prosecco that I hadn’t consumed for 9 months waiting for me on discharge. Old habits, die hard.
For many improvement teams I have worked with, I recognise this moment. Maybe you do too? The elation and exhaustion of having gotten ‘a result‘, an improvement story. Finally able to share the story with leaders, pacing the corridors, anxiously waiting for results to share themselves with their boards and stakeholders. Then usually in rapid succession, a quick well done then leaders asking for more, one successful improvement story is not enough.
For me, this is the last thing an improvement team wants just then, at least in my experience. Teams are often exhausted just wanting to take a breather, relax some of the harder processes and newer habits, just for a moment, and recognise their achievements and take care of themselves by sharing and reflecting on their learning. And whilst doing so, hoping for a different ‘family member’, just to take over for a moment, distributing the responsibility. Somebody else to have the next pregnancy. Somebody else to share the improvement leadership with them.
To really raise this ‘improvement baby well‘ so many extra hands and help are needed than during that ‘little bit pregnant‘ phase. So much more to do, so much more to get wrong, the occasional ugly baby to learn from, never enough time to practice improvement never mind learn daily, and as my Auntie would say, so much harder work, but so worth it, to develop an improvement culture and system.
I know that I couldn’t raise my kids on my own and I need more than a warm house to help me to raise them^. (Thanks to all those that help me). The warm house and other environmental conditions help, but they are not sufficient: feedback, advice, reassurance, expertise, love and patience are also needed. So too, with improvement cultures and systems. Leaders all have a role in building those supportive environmental conditions in which improvement can thrive, but whilst they are necessary they are insufficient. Leading improvement, for me, also requires leaders to be active in raising the metaphorical improvement children, not just celebrating the early pregnancies and buying the cot. Playing an active role in each further stage of development, learning and practicing hands on improvement for themselves.
To stretch this metaphor further, this means helping with the nappy changing, the night feeds, the weaning, the toilet training, the parents evenings, school plays and illnesses and so on. The metaphorical equivalent of leaders doing an improvement project themselves; practicing Toyota Kata and/or Gemba walking (or other similar improvement habits); following through on suggestions from staff quickly; ensuring clarity of priorities and ensuring or even enforcing the self-discipline to stick with those priorities overtime; and saying ‘I’ve got your back’ when the improvement causes unforeseen problems. Finally, as with all parents being patient and taking a direct, an personal interest in what is happening and how the improvement children are developing and behaving on a daily basis.
They say it takes a village to raise a child; so too, an improvement culture and system. Not just the CEO or the board, also the senior clinicians, the middle/senior leaders and crucially the first line managers, leading improvement together. Leading improvement is so much more than ‘knowing‘ what improvement is or knowing 1 or 2 or even 200 improvement or measurement tools, and then repeatedly articulating and advocating the creation of the conditions for improvement.
Leading improvement, rather like parenthood, is so much harder, so much more hands-on and so much more ambiguous and complex, than wanting an organisation to be a ‘little bit pregnant‘ and buying the cot and providing the warm house. But, as any parent will tell you, in the end it is worth it.
* this blog assumes the parent(s) wanted to be pregnant and was relatively straight forward and easy to become pregnant and be pregnant.
**Sadly, for some new parents, this may not be the case.
^Respect all those single parents and foster parents, and my heart goes out to those that want for housing and heating.
NB this blog is based on my experiences and observations working across many organisations on the last 23 years; but it is not based on any one organisation.