Who Produces Change?

I had the chance recently to talk about Lean to medical students visiting from another European country. A colleague delivered a good introduction to Lean, focusing on waste, 5S and quality improvement science.

Some of the students were clearly unconvinced. My colleague hit the nail on the head by asking the students if they would feel able to point out waste if they saw it: most of them shook their heads.


Hierarchy is important in health care. Experienced staff often welcome comments from people who are looking at systems with new eyes, but more junior staff may fear that what they say will be regarded as criticism. Others feel that it is not their role to identify system problems, or to try to change things.

A King’s Fund report commented,

‘One of the biggest weaknesses of the NHS has been its failure to engage clinicians – particularly, but not only doctors – in a sustained way in management and leadership. Individuals within the service, and its providers, need to be given both the ability and the confidence to challenge poor practice. Management and leadership needs to be shared between managers and clinicians and equally valued by both.’

This reminded me of a paper by Samia Chreim and colleagues that looked at leadership behaviours in health care. I can’t post a link to the full paper, but the abstract is available at this link. Their findings will not come as a surprise to people who work in health and social care: ‘legitimacy, authority, resources and ability to influence’ were spread across people in different roles, and working in varying parts of the organisation. Roles changed over time, and in different contexts.

In order to influence change, Chreim argued,

‘Change leaders need to build a winning coalition of agents with complementary skills and resources that support the change. Successful change leadership involves investing time in finding common ground across stakeholders and in building credibility and trust.’

This means that one-off events, such as our contact with the group of medical students, are unlikely to produce change – and we did not really expect it to do so. The students were, however, going to visit several hospital areas which had undertaken Lean work, and would be free to talk to staff. If they spoke to people who had been involved in Lean work, and who had produced change in their own services, then they may conclude that change does happen, that it can be lead by people at all levels, and that a Lean framework can help to support change to happen.

We asked them to feed back to us at the end of their visit. Will they have the confidence to make suggestions for further change, based on their fresh pairs of eyes?  I hope so. If we are to produce lasting quality improvement in services we have to give people confidence that they will be taken seriously, and that their ideas can have an impact. If we do that, we can turn today’s student visitors into future staff who choose to come to work in local services because they believe that quality is taken seriously.

Photo source: pixabay.com

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