Integrating Work and Quality Learning without Geographical Constraints

1. Integrating Work and Quality Learning without Geographical Constraints

2. Leadership for Learning and Cultural Change: Reflections on the Berwick Report and other evidence NHS Scotland Annual Conference 2014Jean HartleyProfessor of Public Leadership, Open University

3. My Background • Organizational psychologist • Monitoring and evaluation of innovation and improvement in English local government over 10 years • Research on leadership with political astuteness among public leaders in UK, Australia and New Zealand • Research on clinical leadership in England • OU Policing Research Consortium with 12 police organizations to create evidence-based policing improvements • Member of Berwick National Group on Patient Safety

4. Don Berwick

5. The Berwick Advisory Group • Don Berwick invited by the Prime Minister to chair the 17-person group to make recommendations about improving patient safety for NHS England. • Group set up in the wake of the Francis Reports into problems at Mid Staffs NHS Trust • National Advisory Group on the Safety of Patients in England • Produced the report A Promise to Learn – A Commitment to Act in July 2013

7. The “Looming Implosion of the Health Service” Analyses show: • Demographic changes (especially ageing of the population) • Technological changes and new treatments • Financial pressures “The NHS is at a defining moment” – Simon Stephens (May, 2014). There are major policy and financial choices ahead. This is also an ideological debate – about the contribution of the public, private and voluntary sectors

8. Changes in Culture, Not Just Structure Politicians and some managers tend to get preoccupied by structural change but the Berwick approach emphasises changes in culture and creating change through people as much as policy and finance.

9. The Power of Learning “The NHS in England can become the safest health care system in the world. That will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning”. Berwick report, 2013. p. 6

10. Berwick report’s 4 guiding principles • Place the quality and safety of patient care above all other aims for the NHS. • Engage, empower, and hear patients and carers throughout the entire system, and at all times. • Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work. • Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.

11. Stepping Away FromA Culture of Fear and Blame Fear in organizations is toxic to improvement and to innovation: • Distortion of goals to feed targets (Targets and terror, Bevan and Hood, 2006) • If service is not better, it is made to appear better (Gaming, Hood, 2006) • Misallocation of resources (Hartley et al, 2013) • Anxiety about processes and procedures (MenziesLyth, 1970; Hoggett, 2010) • Reduces initiative and sense of responsibility (Bazerman, 2008 – ethical fading) • Blame culture leads to cover-up of mistakes • Lack of attention to warning signals of problems • A vicious circle of more pressure, more rules – and more fear

13. Shifting to a Culture of Curiosity, Evidence and Initiative • High quality services and a culture of improvement cannot be mandated from the top – it requires engagement and skill from the workforce • Improvement is dynamic – so needs observation, discussion, building the evidence base, sharing and comparing across contexts and across time • Innovation often comes from the front-line, where problems and opportunities are first experienced (Hartley, 2014) • Errors need to be distinguished from wilful neglect • Leadership is crucial in creating a climate of learning leading to improvement and to innovation

14. Leadership Beyond Boundaries Across the whole system and at all levels Front-line to politicians, patients and carers, media….. • Leadership in mobilising the attention, resources and practices of others towards particular goals, values and/or outcomes. • Leadership may be part of the formal responsibility of a particular job or role (e.g. ward manager, medical director) but it is also exercised by many others through informal channels and networks (e.g. opinion leaders, voluntary groups).

15. Whole Systems Thinking and Action The NHS is an open not a closed system (a complex adaptive system not a machine): • Interconnected and multiple influences • Non-linear effects • Can’t always predict consequences This requires careful observation and reflection; adapting action to changes. Leadership requires reading and interpreting the context.

16. Recognising and interpretingthe context - VUCA • Volatility – nature, speed, volume, magnitude and dynamics of change • Uncertainty - lack of predictability of issues and events • Complexity - the inter-connectedness of processes – whole systems dynamics with unpredictable outcomes. • Ambiguity – variety of interpretations about what is going on/what things mean (US Army, 1997) These create white water conditions for leadership. We are all at sea.

17. Leadership in a Context of VUCA • Ability to read the changing context – What kind of context is this? How fast is it changing? How might it be different from the way I assume? Who else might help interpret this context? What is coming over the horizon? • Leadership on the move – judgement is dynamic not final • Good antennae and networks for intelligence about a changing world

18. Clarity of Purpose is Key in a VUCA Context • The environment is dynamic and not totally controllable, if at all • It is possible to have a sense of where you want to get to • How you get there may depend on the conditions, but knowing where you want to get to is key • It helps to keep the workforce engaged, and clear about their purpose • Looking outwards not just upwards One useful way to define purpose is to discern and create public value (Benington and Moore, 2011).

19. The Loose-Tight Leadership Question Loose-tight leadership and management has been debated for some time (McGregor, 1960; Sagieet al, 2002) • When to adhere to clear rules, and procedures – the use of bureaucracy and hierarchy • When to decentralise and foster innovation and experimentation

20. Traditional bureaucracy often necessary to achieve large-scale improvement(eg roads, health, water, education)

21. Innovation is Not the Same as Improvement

22. Leadership Requires Political Astuteness political ‘nous’ Political awareness Political antennae savvy political acuity ‘Metis’ political intelligence Dealing with big p and small p politics

23. Leadership With Political Astuteness • The ability to work with diverse and sometimes competing interests, values, goals and priorities of a range of collaborators/competitors/stakeholders (Hartley and Fletcher, 2008; Hartley et al, 2013) • ‘Big P’ and ‘small p’ politics • Political astuteness can be used to achieve social and organizational outcomes – can be constructive (or destructive) • 5 key interlocking skills

24. Skills Framework(Hartley and Fletcher, 2008) Building Alignment and Alliances Reading People and Situations Strategic Direction and Scanning Interpersonal Skills Personal Skills

25. The Key Resource is NotFinance but Human Energy • Austerity often focuses on financial resources (budget cuts, ‘doing more with less’) • But creating a positive organizational culture helps the creation and development of new ideas and active problem-solving (and problem-spotting) • High performance organizations pay attention to staff, mobilising their motivation and engagement (Lawler, 1995; Huselid,1995; Purcell et al, 2009; and Gould-Williams 2004 on public sector) • Lessons from neuroscience about energy systems

26. Electrical energy in neurones continually creates and recreates new patterns of interaction between synapses and develops new neural networks.

27. Mobilising Energy “Your first and foremost job as a leader is to take charge of your own energy and then help to orchestrate the energy of those around you.” attributed to Peter Drucker

28. Organizational Energy • NHS (Land, 2013). 5 types of energy for organizational change: social, spiritual, psychological, physical, and intellectual • Public sector staff facing UK austerity budget cuts: attitudes to work, colleagues and services were more positive about organizational reductions involving innovation than about salami-slicing cutbacks (NB: researcher categories) (Kiefer, Hartley, Conway and Briner, 2013): • Manager and staff energy is critical in organizational change and innovation.

29. The Value of Thinking About Leadership Constellations • Constellation (Denis et al, 2001) – the interlinked roles to achieve complex change where power is diffuse • The need to think simultaneously about the project and the networks of support that can be engaged. • The value of leadership across networks • Leadership at different levels in the organization too – the role of front-line supervisors in shaping appetite for change among police officers/staff (Hartley and Kiefer, current work) • Connecting vertically and laterally, inside and outside the organization

30. Fostering a Learning Approach • Learning from mistakes • Continually seeking out learning opportunities • Embedding learning in processes and procedures. • Monitoring and evaluation as a fundamental stance about both innovation and improvement • Embed continuous professional development throughout the organization • Create collaboratives and other inter-organizational learning networks

31. The OU Contribution Patient safety and patient care central to the Mary Seacole Programme for the NHS Leadership Academy in England. • OU, with Hay Group, has created and is running an on-line and workshop based Postgraduate Certificate in Health Leadership – the Mary Seacole Programme. • It is for first line leadership across health and social care in England. First intake with 1500 participants studying over a year. • A hub and a catalyst for research, development and teaching on public leadership, innovation and improvement – through the leadership of learning.

32. Further information and papers: Jean Hartley Professor of Public LeadershipCentre for Public Leadership & Social EnterpriseOpen University Business SchoolOpen UniversityWalton HallMilton KeynesMK7 6AAjean.hartley@open.ac.uk www.open.ac.uk

34. Integrating Work and Quality Learning without Geographical Constraints