Applying appreciative inquiry theory could help your trust and its staff innovate, interact and progress successfully, says Mark Hayes

Treasure chest

Berwick tells the senior leaders they are “the stewards of a globally important treasure”

A sense of balance was restored to the debate engulfing the NHS following the Berwick review. This report merits being read carefully and more than once.

Of particular interest are the three letters contained in annex B of the report, which Don Berwick, President Obama’s former health adviser, addressed to three groups:

  • senior government officials and senior executives in the NHS;
  • the people of England;
  • the clinicians, managers and all staff of the NHS.

‘If appreciative inquiry is deployed widely within the NHS, it could be the answer to the “how” that critics of Don Berwick will ask’

The messages

In his first letter Professor Berwick tells the senior leaders they are “the stewards of a globally important treasure” and that “faults are to be expected in any enterprise of such size and ambition”.

He encourages them to “invest even more than ever before in learning, growth, development, ambition and pride”. And through this we can “make the NHS a learning organisation in every sense of the term, and it can unleash momentum for improvement that no simple, top-down, control orientated, requirement-driven culture ever can”.

Although he has bowed to the throng in recognising the need to act on “rare and outlying behaviors and on exceptional cases of poor performance”, he is clear that this “will not create an overall far safer and better NHS; it cannot”.

In his second letter, to the people of England, Professor Berwick says the process now under way “will help the NHS to emerge over time as one of the safest health care systems in the world”.

But he reminds us that this will be harder if staff “experience a culture of fear, blame, recrimination and demoralisation”. Tellingly, he says, “I hope that you resist such general negativity”.

In the opening paragraph of his final letter, to NHS staff, he declares: “Your nation’s commitment to healthcare as a human right and to healing as a shared mission is second to none in the world. And all of that is possible through you; only through you.”

He goes on: “As you probably know, real, sustainable, active improvement depends far more on learning and growth than on rules and regulations.”

The reaction

So how will the various audiences receive this important report? Does it succeed in speaking to the wider audience or can it be dismissed as a salve of interest only to the demoralised workforce?

Fans and critics alike will recognise in the tone and content of the report messages that Professor Berwick has been expounding for many years. These messages, such as profound knowledge and “the joy of work”, have their roots in the teaching of W Edwards Deming, taking us back to the 1940s.

‘Appreciative inquiry is the difference between viewing an organisation or situation as a problem to be solved or a possibility to be realised’

There are many examples of systems that have adopted and developed the work of Deming to become successful in their fields. From Unipart and Toyota in industry to Jonkoping and Virginia Mason in healthcare, there are systems where this approach has taken root, flourished and resulted in dramatic success. And yet they remain isolated “examples”.

Why is this? Why is “share and spread” so difficult to achieve? Are there some techniques that are more likely to lead us to success?

Martin Seligman, professor of psychology at the University of Pennsylvania, has shown in his research that a key differentiator between high-performing and low-performing teams is “happiness”. And, before the cynics convulse in guffaws, this is not a “fluffy” definition of happiness; there are three distinct elements:

  • pleasure and joy – perhaps, surprisingly, the least impactful and least long-lasting element;
  • engagement – feeling you are using your strengths rather than overcoming your weaknesses, feeling valued and having accountable freedom; and
  • meaning – believing and experiencing that what you are doing has a higher purpose and you are part of a greater whole.

Problems or possibilities?

Appreciative inquiry is a strength-based approach to human beings and communities that focuses on developing capacity. Developed by David Cooperrider, Suresh Srivasta and Frank Barrett at Case Western Reserve University, at its simplest level it is the difference between viewing an organisation or situation as, on the one hand, a “problem to be solved” and on the other as a “possibility to be realised”.

Appreciative inquiry has the impact of creating energy, promoting innovation, being expansive and driving a proactive approach. It is more than a method – it is a philosophy that can lead to new ways of interacting and working together.

It is more than simply adopting an optimistic view of the world, it is a discipline defined by its “5D” cycle:

  • Definition
  • Discovery
  • Dream
  • Design
  • Destiny

If appreciative inquiry is deployed widely within the NHS, it could be the answer to the “how” that critics of Professor Berwick are bound to ask.

I would recommend to anyone interested in making Professor Berwick’s NHS a reality that they explore the literature on appreciative inquiry and consider how to apply it to their organisation.

For too long we have lived with a deficit view of the world but the time has come to shift to the appreciative.

Mark Hayes is chief clinical officer at Vale of York Clinical Commissioning Group