Means to an end: transformation and improvement in healthcare

It was the ancient Greek philosopher Heraclitus who first observed the paradox that the only constant is change. For him, change was a universal state of being, and the deep understanding of that concept was the true path to enlightenment.

However, Heraclitus is also known as ‘the weeping philosopher’ as he was prone to depression and melancholy. So it could be argued that this enlightened state he reached offered him little in the way of solace.

Our emotional relationship with change can be problematic. Without the deep understanding of its constancy as described by Heraclitus, change can manifest as something frightening and threatening, best avoided really. Unfortunately, even for those enlightened souls fortunate enough to get it, the concept of change risks inflicting a nihilistic outlook: “What’s the point trying anything new? It’s all just going to change again anyway.”

Time for transformation

Time for a new word then. Not change…that’s too scary  – what we want now, is TRANSFORMATION!

Transformation sounds somehow more desirable. It sounds big and ambitious and purposeful. Who doesn’t want a bit of transformation?

So is transformation desirable, and is it achievable? And if it is desirable and achievable then how on earth do you set about delivering it?

The question really got me thinking about ends and means.

Making it better

Even though we might dutifully organise ourselves to ‘deliver’ transformation, that really isn’t an end in itself, is it? What we are really looking for is for the thing (whatever it is) that’s going to be transformed to be better at doing whatever it does now.

Not even the most broad-minded of us will consider ourselves to have been successful in our transformational endeavours if the thing we were trying to transform ends up being worse than what we started with.

This might seem obvious, but if the intention is really to make the thing you started with better, then transformation is indivisible from improvement. And viewed through an improvement lens, the concept of transformation becomes, well, transformed.

Improvement lens

In health and social care, the language of transformation has become intertwined with the language of governance and assurance: ‘boards’, ‘PIDs’, ‘programmes’ and ‘assurance reports’.

In his marvellous report into transforming systems, The Revolution will be Improvised, Richard Vise warns against throwing “programme boards, sign-off procedures and reporting back-processes” into the space. But he also recognises the inevitability of this approach because this is where leaders feel comfortable and, as we know, changing is scary.

Contrast this with the NHS Delivery and Continuous Improvement Review, which recommends a shared NHS improvement approach founded on core components that are in the DNA of all evidence-based improvement methods.

These focus on the need for building shared purpose, recognising the importance of culture and critically, of leadership, investing in capability building and weaving improvement into our management approach at every level. This approach, pointed at any problem, has the potential to be far  more transformative than the governance of transformation.

Continuous and discontinuous improvement

There are two main ways to view transformation in an improvement context: continuous and discontinuous.

For those systems, organisations or teams with  a culture of continuous improvement, transformation becomes a state of being. This awareness that transformation is a constant in the endless pursuit of continuous improvement is a true state of enlightenment – a form of organisational nirvana – though not yet  the reality for most of us.

More commonly, discontinuous improvement is the pursuit of a specific aim or objective. It’s about travelling from here to somewhere better – it’s a journey and is a means to an end. This is where, for most of us, our transformation efforts reside.

Programming the sat nav

As with most journeys, the route and mode of travel are critical to success but, fundamentally, the destination is the consistent purpose, whatever potholes may litter the route.

So that’s the first big transformation lesson – there must be a clear aim to the endeavour and it’s the job of leaders to set that out and keep setting it out.

The importance of being able to clearly articulate what needs to be made better and set that out for everyone is the first and most critical step on the road to transformation.

Unfortunately for leaders of transformation, this isn’t just as simple as punching a postcode into your sat nav and forgetting about it. This particular sat nav has a mind of its own and is likely to want to pick its own destination or forget where it’s going or decide it’s actually quite nice here after all. To keep focussed on the end point we have to keep putting the postcode in – again and again.

Framing an aim that is clear, concise, and compelling can be a much-neglected part of the transformation process. Change management expert John Kotter  says that it is in this phase that more than 50% of transformation endeavours fail.

Aim guides actions

The aim shouldn’t just be a rallying cry, it must also be used to guide the actions associated with getting to a new, improved state.

In the culmination of W.Edwards Deming’s lifelong work, his System of Profound Knowledge provides a meaningful, practical thought framework by which this can be achieved.

The System of Profound Knowledge prompts transformation leaders to ask themselves four interrelated questions, the answers to which will help inform the road best travelled on the improvement journey. They are:

• Theory of knowledge: do you understand by what method you expect to achieve your aim?
• Understanding variation: do you understand your current performance in relation to your aim and what might drive variation in that performance?
• Appreciation of system: do you understand the connections between the component parts of your system that will help you achieve your aim?
• Psychology: do you understand how you expect to harness everyone’s efforts in pursuit of your aim?

Even more simply, it’s about asking five things:

• Where are we going?
• Why are we going there?
• How will we get there?
• How will we know we’ve arrived?
• Who else needs to come too?

The answers to these questions will help the transformers understand who needs to be involved, how to harness their efforts, the activities they will need to be engaged in to deliver change, and whether those activities have been successful in propelling the system towards its destination.

All five questions are equally important and must be asked and reflected on multiple times throughout the journey to keep the transformation on the road.

Desirable destination

Circling back to the original questions then: is transformation desirable and achievable, and if so, how on earth do you do it?

The reality is that transformation is happening all around us every day whether we like it or not.

However, if we want to harness collective efforts to transform something for the better then transformation will only be as desirable as the destination is perceived to be. And our efforts to get there will only be as successful as the route, means, mode and method of conveyance.

Clear why and how

Transformation leaders have to be clear on both the ‘why’ and the ‘how’ if they’re to have any chance of making something better. Leaders also have to recognise that transformation is an emotional and psychological undertaking, as well as a technical one, and pay attention to this.

But the reality is that once we reach our destination, the world around us will have changed too, and the destination might not feel like the end point we hoped for. So to reach transformation nirvana, it may be worth considering if the true destination to plot into the sat nav is to be better at keeping on getting better. And accept that in this case the destination is always just around the next turn.

Dan Grimes is System Director of Improvement and Transformation at Merseycare NHS Foundation Trust.