The challenges of providing safe and timely care, along with meaningful and rewarding work for staff at all levels, are more intense than ever. Board members and senior leaders feel this as deeply as anyone. Creating a culture of continuous improvement that enables quality, safety, morale and engagement to flourish requires radical change – starting with the way we lead.
Many healthcare leaders are governed by deep-set habits, behaviours and lessons learned over many years in an environment that was much less complex than today's. This creates barriers to success, perpetuating the challenges that we strive to overcome.
But before we can adopt new habits, behaviours and processes, we must first create new space in our brains. We have to "unlearn" the lessons of old – a concept supported by decades-long research. Unlearning occurs "when organisations proactively question long-held routines, assumptions and beliefs". A 2022 study shows organisational unlearning is crucial to maintaining organisational viability and competitiveness.
At Virginia Mason Institute, we've helped leaders of trusts and healthcare organisations around the world to unlearn what's no longer serving them, and we've seen firsthand how powerful it can be to achieve what we all want: lasting and continuous improvement.
Here's how to unlearn four obsolete lessons and move forward.
Lesson unlearned: It's a leader's job to adhere to regulators and corrective mandates
The relationship between trust leaders and regulators can become antagonistic. Regulators act at the top of the decision-making hierarchy and typically subject leaders to scrutiny and criticism. All too often, the leaders comply in fear of losing authority. They follow corrective mandates from regulators, even if these mandates are at the cost of long-term improvement and culture change initiatives.
Lesson reframed: It's a leader's job to partner with regulators while continuing to steward their organisation's priorities
Change the paradigm by inviting regulators to work together toward common goals. This starts by looking for common ways to say 'yes' and align regulators' mandates with your organisation's improvement efforts – but, in the same breath, also educating them on how your improvement system will achieve the outcomes that both parties want.
In other words: You can reframe the relationship by redefining how regulators can help your organisation stay accountable as you work toward the shared vision.
In 2021, the NHS concluded a five-year partnership with Virginia Mason Institute that focused on building a culture of continuous improvement at five hospital trusts. As explored in the recently published Warwick Business School evaluation report, supported by the Health Foundation in partnership with NHS England, a core part of their journey was the Transformation Guiding Board. The board brought together the five NHS hospital trust chief executives and select NHS regulators for monthly full-day meetings centred around collaboration, peer coaching and a collective commitment to improvement.
To establish this new way of working, the board created a compact – an explicit written agreement outlining the vision, behaviours and responsibilities shared by and expected of everyone in the group. The board mutually agreed upon the compact and referenced it regularly to reframe the relationship and make meaningful progress on safety, quality and access. The compact helped stakeholders navigate challenging conversations and stay focused on long-term improvement by respecting trusts' management systems and regulators' priorities. The board continues today.
"The compact has helped all stakeholders recognise that sustained change takes time – it doesn't happen overnight. When challenging performance conversations arise, we come back to our shared commitment to the compact. That enables conversations about respecting the UHCWi Management System and allowing staff to improve performance and services, while still focusing on regulators' priorities that align with our trust's values and strategic triangle."
— Andy Hardy, chief executive, University Hospitals Coventry and Warwickshire NHS Trust
Lesson unlearned: A leader responds to complexity by being absolute and controlling
Traditional leadership training instills the belief that strong leaders should respond to complexity and crises by being absolute. In situations that are highly uncertain, like the beginning of Covid-19, the tendency is to lean into this behaviour even more, embracing a command-and-control management approach. But this can have the opposite of the desired effect, by creating mistrust and confusion that leave staff disengaged and feeling undervalued.
Lesson reframed: A leader responds to complexity by being humble and flexible
Learning from failure fast and pivoting – while simultaneously empowering staff – are essential leadership skills to drive continuous improvement. This requires leaders to demonstrate humility and flexibility in the face of complexity and uncertainty. Instead of solving problems and giving absolute direction to staff, frame the problem and empower staff to create solutions. Commit to purposeful leader rounding, practise humble enquiry and actively listen to staff to identify problems and any barriers to solutions. In crises or highly uncertain situations, invest even more time listening to staff. The people doing the work know how to best improve it.
In March 2020, Leeds Teaching Hospitals NHS Trust set out to improve their turnaround time for Covid-19 test results. They were posting 65% of test results within 24 hours, and they aimed to increase to 95% to better serve patients, as noted in a July 2020 article in the Health Service Journal. Leaders framed the problem – lagging test results – and practiced humble enquiry with staff to understand the entire testing process. They asked staff about the problems from their perspective and their ideas on solutions.
Together, leaders and staff determined five areas of improvement. From there, frontline staff, including nurses and service managers, identified and tested improvement ideas, while leaders supported them and encouraged them to learn from failure fast. By implementing the team's ideas and empowering staff through the improvement process, the hospital reached their goal in less than two months.
"We get better ideas and higher engagement when leaders frame the problems and empower people to solve them." — Clare Smith, chief operating officer, Leeds Teaching Hospitals NHS Trust, featured in a July 2020 article in the Health Service Journal.
Lesson unlearned: The power to make decisions belongs as high in the organisation as possible
In the peak of the Covid-19 pandemic, hospitals around the world experienced the power of embracing streamlined decision making that's as close to the frontline as possible. Learning and action that previously took months, was moving at the pace at minutes. Today, many trusts are struggling to maintain that, with some reverting back to placing decision-making higher in the organisation. Why? Because these organisations lack trust and assurance in local leaders.
Lesson reframed: The power to make decisions belongs as close to the point of implementation as possible
To shift decision-making to local leaders, start by trusting that they're working in the organisation's best interests. Build assurance by empowering local leaders with the capabilities, tools and processes they need to execute on the shared vision. When you have trust and assurance, you eliminate the need to vet every decision.
At Surrey and Sussex Healthcare NHS Trust, a dedicated frontline team lead the transition from paper patient records to an electronic patient record (EPR) system, as featured in a case study by Virginia Mason Institute. The frontline team worked directly with the software vendor to build a customised EPR that helps staff to be efficient and engaged, and ultimately, better serve patients.
The first step was to assess the current state and plan the ideal EPR. The software vendor's standard process for this assessment was just one week. With support from leadership, the team pushed back and instead developed a six-week process, which included multiple workshops to get input from doctors, nurses, therapists and other frontline staff members.
Then, the team built out each workflow to fit the needs of the staff using it. By trusting the team and building assurance through processes, leadership empowered frontline staff to implement an EPR that would achieve their shared vision. The EPR implementation successfully launched in September 2022, marking one of the biggest changes for Surrey and Sussex Healthcare NHS Trust in a decade.
Lesson unlearned: Urgent needs require rushed processes
On the long-term journey to build sustainable improvement, it's inevitable to feel pressure to urgently address negative metrics. When this happens, it's common for leaders to try to increase the pace by taking shortcuts and eliminating steps in established processes.
But processes that are transforming an organisation in major ways – behaviours, relational patterns, values and priorities – take time and methodical action. Rushed processes don't address the underlying issues and end up being detrimental to long-term success.
Lesson reframed: Urgent needs require urgent attention and methodical processes
Following proven processes – without skipped steps – is essential for long-term sustainable improvement, but there is a way to do that while also addressing pressure on urgent needs. Build in quick wins that are aligned with the improvement work to demonstrate progress and earn additional buy-in from regulators, leaders and employees on the long-term journey. Be honest and clear on the timeline it takes to transform, and be patient and diligent through the process to get there. Embrace a "go slow to go fast" mentality.
"When leaders deviate from long-term improvement to focus on recovery and quick wins, it may appear there's a gain from those efforts – maybe those specific metrics improve. But that simply pushes the underlying problems to another part of the organisation, which will resurface in other metrics." — Melissa Lin, senior partner of transformation services at Virginia Mason Institute.
Healthcare transformation can't wait
In today's complex healthcare environment, you can't do some of these and still be successful; you have to do them all. Unlearning decades-old lessons to adopt new behaviours and processes is incredibly difficult. But it's also incredibly rewarding.
It empowers organisations with a new way of working – one that addresses the urgent needs of patient safety, quality care and a respectful workplace, and propels us to strive for better. Now's the time to reframe the lessons that will enable us to better fulfill our promise to the patients we serve, and each other.
Learn more about how to overcome the barriers to improvement in our key takeaways from the Warwick Business School NHS partnership evaluation.
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