This blog is written in WordPress, and on the WordPress dashboard, you can see a list of search terms people used to reach the site. One recent search term caught my attention – ‘RPIW improvement conflict‘.
I don’t know the context in which term was used, or where in the world it was typed, but it prompted me to reflect on conflict in improvement. I have come across five common concerns that can cause conflict in improvement work:
1. Finding a problem in the process is a criticism of me as a person
Often, staff have not developed the system they operate. People come in to a job, and are told what to do, or just learn it by watching others. This is how culture is transferred – culture reflects what people see, and what they do.
In health and social care, systems often accrete over years, like layers being built up on a pearl. Unlike a pearl, the result is not always good. Often workaround has been layered on workaround, and system on system. Different information systems may be introduced without removing old paperwork, or even old IT systems.
The effect is that most people work in a system they did not design, and often no one they work with designed it either. In some cases, no one designed it in its full form- it just happened.
Despite this, observations of work can upset people. You may have complained about the system for years, but having facts and figures to show that, as you suspected, much of your work has limited value for patients or clients, can be very upsetting. Sometimes people are surprised at how upset and angry they can feel.
The best response to this, in my experience, is to acknowedge the distress that the person feels, particularly if they are surprised by the strength of the emotion. Emphasise that they did not design the system, but that they are part of the team that are re-designing it, and who will continue to improve it in the future.
2. What we need is more staff / more money / more equipment – this improvement work is an excuse to avoid the real problem
If you are busy, and feeling under pressure, the obvious solution is to have more of what you already have – more staff, more equipment. Sometimes this really is the solution, but it is uncommon to find a situation where nothing can be improved with what is already in place. Everyone who works in improvement will have examples of services that were transformed by improving flow, reducing waste and so on without the additional resources that were thought to be obviously necessary.
Sometimes team members can accept that, if they work diligently to improve their service and key metrics still do not improve, then it will significantly strengthen their argument for additional resource. This can feel like a fudge, but often once people are engaged in a project, and begin to see meaningful quality improvements for their patients or clients, then the work often gathers a momentum of its own, and initial concerns fade.
3. It’s going to change how I work
On one level, practically everyone working in health and social care agrees that the point of their work is to benefit the people who use the service. This does not mean that there will not come a time when the reality of changed work will suddenly hit people.
Apparently small things can trigger upset – I have seen a change to a room, or altered paperwork, produce distress. I have found that this is usually a symptom of a general disquiet around change, and is rarely related to the specific event or issue to which it seems to be attached.
Acknowledging that change is difficult, that upset is common, and that it needs to be worked through seems to help. I never ignore this type of distress. A quiet word recognising how difficult change can be, accompanied by a re-statement of the purpose of the work, often seems to help. I try to validate the distress – ‘it’s not odd that you feel this way’, while supporting people to move on to what they want the service to be in the future.
4. The problems are in other services, not mine, so why pick on me?
It is much easier to see problems in other services. Sometimes the person has a point – there really might be a better place to start. Every service can benefit from a focus on continuous improvement, however, and few people feel able to sustain an argument that no improvement is possible. If you can encourage the person to see quality improvement as something they own, rather than something that is being imposed on them as a punishment, then they are both more likely to come around to the idea, and to go on to develop a culture of continuous improvement.
Another approach to this is to help people to collect data on their own service, and also to obtain feedback from internal and external customers. This invariably demonstrates that no service can possibly be perfect, and that there is scope for improvement.
5. The scope of this work is too narrow – we need to fix everything
Staff are sometimes desperate to improve their service. When you talk to the people in a work area, years of concerns and frustrations can pour out. When this happens, people are sometimes afraid not to try to address all of their concerns at once. If they have worked in an area for years, with no focus on improvement, it can feel as if this is their one and only opportunity to improve things. This is a downside of event-focused improvement work, where continuous improvement work may be less obvious.
There are techniques to identify the areas of improvement focus – observations, data analysis, Pareto charts, prioritisation matrices – but this is not usually the issue. Rather, it is a fear of future abandonment. The message is important – quality improvement is not something done to services by experts – it is part of the job of the people delivering the service, with appropriate support and encouragement by the whole organisation.
When people come to believe that they have the power to make continuous changes to improve the quality of their service, then concern about not tackling everything at once usually fades. Encouraging the worried people to talk to staff in other areas who have embraced continuous improvement can be valuable, and helps to reinforce the message that they are in control.
Thanks to Worker at openclipart.org for the logo used in this post.