To improve quality leaders must focus on relationships that facilitate change. Daloni Carlisle looks at a project to develop the right skills.
We have all heard of Generation X, the lost and disaffected generation born and brought up after the post-World War II baby boom ended. But what about GenerationQ?
GenerationQ is neither lost nor disaffected. It is a small (currently numbering 18 but about to treble in size) cohort of NHS managers, clinicians and patient advocates who have undertaken a new programme to hone their quality improvement skills.
It could be one to watch.
GenerationQ is the brainchild of the Health Foundation, which has for years been working on the conundrum of why it is so hard to achieve quality improvement that lasts beyond project funding and is adopted everywhere that could benefit.
“Our experience at the Health Foundation suggests there is a particular set of leadership skills that are needed for leading successful quality improvement,” says Penny Pereira, assistant director at the Health Foundation.
Leading the way
While there are many general leadership courses in the NHS, few focus on integrating the technical skills of quality improvement with an understanding of how to manage relationships – which is crucial to most improvement work. So the Health Foundation developed GenerationQ to bring these together.
Unipart Expert Practices delivers quality improvement technical development, while Ashridge Consulting delivers the theoretical learning around human relationships and leadership.
Participants are required to have backing and mentoring at executive level from their employer and, as well as submitting written assignments, also need to carry out improvement projects in their workplace and produce reflective writing about how their leadership style is developing.
Ms Pereira says: “GenerationQ brings together the technical skills around improving quality and the human skills that are needed for leaders to inspire continuous improvement, especially when there is so much uncertainty for people at the moment.”
It was these relationship skills that the first cohort of GenerationQ was keen to emphasise when it reflected on the two-year programme at its final meeting in January 2012.
Joining the members of this cohort for their final session was an interesting experience. Yes, they valued their new technical skill set but they were far more interested in discussing the fact that you can have the best tested, best evidenced health improvement intervention in the world and it won’t get implemented unless the leaders have the time and skills to focus on the relationships needed to bring about change.
As one member said: “When I started this, I thought it was going to be the theory of lean management and so on. But the interpersonal is going to stay with me as much as the scientific.”
The group talked about how the NHS is now too bureaucratic and process driven to allow for anything other than hierarchical relationships and how this has created destructive patterns of behaviour.
One doctor said: “I am learning to relate to other people. That sounds crazy as we ought to know that. In the old days I would chuck a hand grenade into the room and wait to see what happened and most likely there would have been a lot of shrapnel. Now I throw in a pebble and wait for the ripples.”
Cohort members explained how they had learned about interpersonal relationships in a structured way and put this into practice; how they had learned to stop issuing instructions and start listening to what people around them said, and how they had stopped being afraid of negative discussions.
They described how they had learned about and tested new organisational development models that challenge the traditional top-down approach to leadership by focusing on the concepts of “emergence” and the development of “shared meaning”. And as a result they had not only been able to advance large scale improvement projects but also to tap into the small, clinically driven improvements that go on all the time.
One manager said: “There is a real value in actively listening to people in that it helps them to reconnect with their internal drivers that brought them into the health service in the first place – and that can then be linked to change solutions.”
Group members also seemed to practise what they preached. The sense of calm and the space they allowed each other to speak as well as the lack of competition, either to be heard or to make the cleverest comment, was striking.
A series of interviews with members of GenerationQ sheds further light on how they put their newly acquired soft and hard skills into action. For example, Tom Smerdon, general manager for surgery at Great Ormond Street Hospital for Children, says: “I don’t think I am alone in struggling with change programmes that do not deliver their expectations. You can have all the right things in place – a methodology, project plans and so on – but still find yourself in a place where unpredicted things happen and projects go adrift.
“So I came to GenerationQ from the point of view of having an interest in the way creative change occurs, how people and teams adapt to change and how that generates change in a chaotic way.”
He wanted to explore how to engage staff effectively in a large scale change programme and harness their ideas to make it work. For example, the trust wanted to address the high number of children refused admission because of bed shortages. He held discussions with clinical leaders who said that yes, this was something they too cared about.
He says: “The thing that made the difference was getting the consultant surgeon, ward sister and admissions manager into a room together with the data and any resources they needed and asking them to come up with a solution. They came up with ideas that would never have emerged in a more structured project. People need space to be creative.”
In another project, Hilary MacPherson, consultant obstetrician and gynaecologist and associate medical director at NHS Forth Valley, had worked on restoring the relationship between consultants and GPs.
She says: “I think this is a relationship that has been unintentionally dismantled and replaced with a bureaucratic system that is not working. How can it not be right for a GP to
be able to talk to a consultant? How can it not be right for a consultant to give advice about the care of a patient, or to say ‘I need to see this patient, don’t go to accident and emergency but come to my clinic at 2pm’? What could be simpler?”
Her team tested a system that allows GPs to contact a consultant whenever they need to, using a single telephone number that diverts to the mobile phone of the consultant on duty.
“It worked very well,” says Dr MacPherson. “The consultants loved it, the GPs loved it and it helped us to avoid admissions.”
Every one of GenerationQ interviewed by HSJ professes to be a better leader as a result of the programme, better able to support quality improvement and better at relating to colleagues. They reported being more resilient and resistant to the knockbacks that are part and parcel of NHS life.
Mark Brassington, deputy programme director of Nottingham University Hospitals Trust’s Whole Hospital Change programme, puts it like this: “I have learned to ask myself about any group or team I am leading: what do these people need to be as successful and productive as they can be, as they bring about change? What are the needs of the people I am leading?”
Ms Pereira says this all adds up to a powerful lesson. “Yes, quality improvement leaders need to be credible around the harder, technical stuff. But GenerationQ brings forward the idea that relationship skills are also really important to create an environment in which improvement succeeds and demonstrates the difference it makes to individuals and the impact they make when you purposively develop these relationship skills.”
One GenerationQ fellow certainly agrees: “I think the Health Foundation got more for their money than they bargained for,” he says. “Yes we are calm, collected, more comfortable with uncertainty, better able to live with, manage through and achieve results in a challenging environment. But paradoxically, I think it is because we have less faith in top-down, conventional leadership actions – like strategies, action plans or organisation-wide improvement processes – and more faith in the power of conversation between two or three people who really want to make a difference, wherever they are in the organisational structures.”
Ms Pereira adds: “In an environment where there is uncertainty in terms of top-down structures, this bodes well for the ability of this group to have a profound impact on quality of care.
Find out more
The first cohort completed the GenerationQ programme in January 2012; two more are currently under way and recruitment for a fourth starts in 2013. Find out more about GenerationQ.