The Berwick Reality

The NHS has had a wakeup call. The operational failings in Mid Staffordshire NHS Foundation prompted Ministers and NHS leadership alike to contemplate the causes and conditions for patient safety and care, and the subsequent Berwick report has called for a “wide systemic change” within the organisation.

Professor Don Berwick highlights the NHS’s culture – organisational habits and attitudes – as the primary cause of systemic failures. His assertion states that rather than punishing people for human error, the solution lies in building an environment where people trust one another and are encouraged to be transparent about mistakes. Now the big question on everyone’s mind is: how can this be achieved, and more importantly, how can you do it within a paradox?

The Paradox of change

The paradox at play here is that the design of the system prohibits the free flowing intent of the human capital within it. In other words, the desire of matching the carer to the cared for is fractured by the systemic structure designed to enable it.

Organisations are formed to deliver an inherent intent or goal.  In the NHS’s case, and within a broader agenda, it is to care for the sick.  It attracts and retains human capital to execute against that intent. The challenge occurs when regulating, for this intent has the opposite effect of demotivating and alienating those for whom it is intended. Finding an appropriate harmony that connects the task (job/ system) requirements with the human capital (self/ teams) requirements is the holy grail for any organisation.

The paradoxical theory of change comes from Gestalt psychology and states that change occurs when one becomes what one is, not when one tries to become what one is not. Therefore, only by accepting how people are, with unconditional positive respect, can change be enabled. For example, how many people within the NHS, especially on the front line, are being asked to be what they are not because of the systems designed to regulate them?

The key to working with complex organisational change is simplicity, another aspect of the paradox. Articulating key principles which speak to people’s experience in an organisation provides meaning, and helps people connect positively with the change. The notions of ‘thriving’ and ‘surviving’ mindsets and practices of openness, choice and awareness of others, enhance how people relate to each other and are the basis for the compassionate accountability required in the NHS.

Refreshing the culture of the NHS

The purpose of the NHS is clear. What is unclear, however, is our understanding of ‘how’ to refresh the culture of the NHS.

For individuals and organisations to change, the people in them need to be fully present and open to experience. When we are in the ‘now,’ we remain open to possibility and can author our lives, making conscious choices for how we can change. When feelings and senses are numbed through defensiveness or fear, it is impossible to create new patterns of behaviour or organisational cultures. The art of change therefore lies in promoting an atmosphere of safety and acceptance, from individuals who feel safe enough to fully express themselves through to teams fostering the conditions for collaboration required for exceptional performance. Below are four principles that will help facilitate such change with the organisation.

Adopt positive intentions
(The core attitudes of an emotionally healthy organisation)

An organisation can foster positive intentions by stating its values and living by them, showing respect to everyone, seeking to help and support others and treating people fairly. During difficult times such as an economic downturn, the natural human response is to move into survival (or task) mode, which stems from an attitude of conserve, protect, fight and defend (rigidity). A more helpful conscious strategy would be for organisations to adopt a thriving (or human) attitude of collaboration, openness and opportunity (flexibility). Attitudes tend to be self-fulfilling, so an organisation that promotes positive intentions internally with staff and externally with customers is likely to create the same. Positive intentions are also crucial for helping to motivate people, minimising defensive behaviours and enabling people to develop and grow.

Create an atmosphere of openness
(Providing the conditions for change to take place)

An organisation can facilitate an atmosphere of openness by keeping people informed, sharing information, encouraging the expression of feelings, giving constructive feedback and finding solutions to problems rather than seeking someone to blame. There are many examples of how a lack of openness and truth has led to the demise of organisations. The Challenger Shuttle disaster (1986); the Enron fraud scandal (2001), the Iraq intelligence dossier (2002) and the Sub-prime mortgage and banking collapse (2007) are all examples of how catastrophic failure can be traced back to a lack of openness and truth.

Encourage accountability
(The necessary attitude for choosing to make a change)

Organisations can do a lot to help people feel more in control and responsible for their working lives, such as giving people choices, including them in decision making and empowering people to act autonomously. A distinguishing feature of the high-performing (emotionally intelligent) organisation is that everyone feels fully accountable.

Value and appreciate others
(The willingness and motivation to commit to change)

Showing regard for, belief in and appreciation towards others is one of the easiest and most powerful ways to raise organisational, team and individual morale (and emotional intelligence). Evidence suggests that organisations that foster a culture of value will have happier and more productive employees.

Embracing these four principles will help organisations such as the NHS:

• Create an environment of trust where people feel they can be open about problems and mistakes
• Help individuals rise above defensiveness and blame to find solutions
• Raise the overall level of motivation, morale and performance of the individual, teams and the organisation.