Catalyze Innovation that Advances Health

Dialogue Tool for Leaders

Dialogue-Tool-for-Leaders

Once your team has done an assessment of how you promote innovation, the following tool can be used to facilitate a discussion about the results. It describes the factors that lead to a negative or positive rating on each of the 7 dimensions of a culture of innovation.

Dimension

Factors that lead to a negative rating on this dimension

Factors that lead to a positive rating on this dimension

Risk TakingFormal leaders and opinion leaders fear failure. There is little or no support or encouragement for new ideas and we don’t try very often. Assessment of the risk of a new idea is inaccurate; we fear the worst and that is the end of the idea.Leaders provide public and private emotional support and encouragement to those that want to try out new ideas. We take reasonable risks, are always trying new things, and learn from what others might call ‘failures’.
ResourcesIdeas for change must be ‘approved’ by many others before they can even be tested out. All resources are tied up in delivering services in the way we always have; no resources are available for innovation.Authority or autonomy to act, protected time, and money is available for individuals and teams who wish to innovate. Some funding is available for unusual opportunities, experiences etc.
KnowledgeWe speak only about what is happening in our own organization or team and are not curious about what others do because we think we are different. Information is given on a need to know basis, as determined by leaders.Knowledge is gathered from a wide range of sources and is freely available or quickly sent out to staff. It is circulated widely for comments and to stimulate thinking. Staff are encouraged to learn from those outside of health.
GoalsWe primarily react to targets set by others. We typically work to achieve these by minimal change; or we spend most our time arguing why they cannot be met. Targets are set and focused without little encouragement for new thinking. Plans stipulate how targets must be met. We often “hit the target, but miss the point”.Leaders make clear that innovation is highly desirable. We have aspirational goals that are clearly linked with project, operational or strategic plans. Innovative ideas are actively sought, and in many areas leaders say that they are the only way that some of the targets will be met.
ToolsWe have little awareness of tools and techniques to support creative thinking. There is no method or approach for innovation. If challenged to innovate we would have difficulty.We have a conscious and deliberate process for innovation and have invested a lot in building capability. We know how to set our minds to be innovative and we have a proven record of delivering innovative solutions.
RecognitionTeams and individuals who want to improve something feel isolated and discouraged from trying new approaches. Very little thanks or recognition for good ideas. What recognition there is is superficial and, frankly, demotivating.Innovative teams and individuals are recognized fully for their efforts with things that are important to them; e.g., protected time, help from other areas, greater influence, etc. We recognize and celebrate learning even if ideas are not successful in the traditional sense.
RelationshipsThe team, organization or department does not promote team-based working and does not support the development of networks across teams organizations and disciplines. People feel controlled. There are high level of lack of trust, respect and honesty.We have high levels of honesty, respect and open communication; even across groups and disciplines. Many highly motivated teams with a good mix of skills and styles. Teams supported in an ongoing ‘team’ development. Good networks of intrinsically motivated people working together for a common aim.

 

Tips for Improving the Risk-Taking Dimension 

Risk taking is about establishing an organizational climate where people feel able to try out new ideas. While it is obviously important to avoid taking inappropriate risk, a healthy organizational culture seeks a balanced assessment that avoids prematurely rejecting ideas due to over-estimation of risk. It also requires leaders who show they are quick to provide emotional support to those willing to try something new, regardless of whether the idea is eventually judged a success or ‘failure’. Leaders in innovative organizations demonstrate that they are more interested in learning from failure than in punishing it.

  • “Management’s job is not to prevent risk but to build the capacity to recover when failures occur… if we aren’t always at least a little scared, we’re not doing our job.” Ed Catmull, cofounder of Pixar and president of Pixar and Disney Animation Studios.
  • “The fastest way to succeed is to double your failure rate.” Thomas Watson, founder IBM
  • “The innovator has for enemies all who have done well under the old law.” Nicolo Machiavelli
  • “Man cannot discover new oceans unless he has the courage to lose sight of the shore.” Andre Gide
  • “Often the difference between a successful person and a failure is not one has better abilities or ideas, but the courage that one has to bet on one's ideas, to take a calculated risk - and to act.” Andre Malraux
  • “Only those who risk going too far can possibly find out how far one can go.” TS Eliot

Capitalizing on 'failure'

When developing the Airblade, the energy-efficient hand drier for public restrooms, the engineers at Dyson, noticed that the machine was trapping a lot of air inside and became curious about this 'failure' of their design. They wondered what they could do with this high-speed air. They considered lots of potential uses before looking at the typical electric fan, which uses rotating blades to hack air into pieces that are then propelled out into the room. They had found an opportunity.... and the bladeless fan has been created.

  • Share widely how the organization or system has taken reasonable risks on innovative ideas in the past. If staff don’t see leaders actively supporting reasonable risk taking, they may get the impression that it isn’t supported. The case study below illustrates the classic point that “perception is one’s reality”.

We don’t see it the same: A large acute trust convened a group or senior leaders, managers and front-line staff to discuss where the trust stood on the seven dimensions of culture in an innovative organization. The three groups sat on separate tables for the initial discussions. When each group reported out on the risk taking dimension, it became evident that there was a large difference of opinion among them.

The senior leaders who had rated the organization highly on risk taking were genuinely surprised that the managers and front-line staff had rated it lower. “We have long debates about things at board meetings, and these often result in our support of innovative pilots of ideas that have not been tried anywhere else before”.

But a member of front-line staff asked how she would ever know about these discussions. “You have to understand it from our position in the organization”, she said, “the first we hear of new ways of working is after they have been fully tested and are being spread more widely. At that point, it doesn’t seem like much of a risk to us; but more like a top-down, management-controlled culture. It certainly doesn’t suggest to me that my team would be welcomed to try something new and innovative. And we almost never hear about ideas that were piloted but did not work, even though that learning might have been useful to us”.

The leaders took her point and resolved that they needed to do a great deal more communication about all the reasonable risk taking and learning that they perceived was already going on in the organization, and how they welcomed more of it.

If the issue in your setting is about a difference in perception, the solutions are simple. For example:

  • Be transparent about how risk is embraced and assessed in the organization. Consider how you can keep staff informed about this.
  • Publicize new ideas that are being tested, outline the anticipated benefits and risks, and describe the roles of senior leaders in supporting these.
  • Talk about hard decisions made at the board level to support innovative pilots and new ways of working.
  • Don’t be afraid to be quoted saying things like, “It’s never really been done like this before, and we know that it might not turn out exactly as planned, but we’re willing to give it a go on a trial basis, with good monitoring and contingency plans, and we support those who want to learn about the process.”
  • Be seen speaking openly about these before you are sure that they work.
  • Get front-line staff involved in planning pilot efforts, and ask them to share with colleagues their experience of being supported in prudent risk taking.
  • Establish a process to publicize and learn from ideas that ‘fail’.
  • Make it routine and acceptable to talk about ideas that were tried but ‘failed’. Work from the mindset that the only ‘failure’ is the failure to learn, and that not sharing and learning from things that don’t go as planned is waste and lost productivity.

Every attempt at innovation should have some form of an After Action Review but this is even more important with ‘failures’. Gather the group together who participated in the planning and testing of the idea and work through a series of questions such as these:

  • What did we set out to do?
  • What did we actually do?
  • What did we expect to happen?Why did we expect that to happen, what was our theory?
  • What actually happened?
  • What have we therefore learned?
  • What should we do now?
  • Who should we tell about what we have learned?

A leader, director, organizational leader, improvement adviser, manager, or clinical lead could initiate this conversation. Many organizational safety programs use After Action Reviews as an essential part of their learning. Ask those involved in your organization’s safety efforts if they can help you.

Did You Know? After Action Reviews were developed by the US military in the mid-1970s but became common during the 1990 Gulf War. Its use was popularized and spread to other setting by Harvard professor David Garvin’s writings, as summarized in his book Learning in Action: A Guide to Putting the Learning Organization to Work (Harvard Business School Press, 2000). It is now used widely in innovation and improvement efforts in many industries.

  • Go out of your way to provide emotional support for innovators. Leaders who understand and recognize the potential in staff make it their business to know the individuals and teams who are doing innovative things and personally connect with them. Go out to the person’s work area, or to the department or team, and take an interest. Show that you know what they are doing, ask what they are learning (reinforcing the principle “the only failure is failure to learn”), and ask what you can do to help.

Think of the difference in emotional impact on a more junior member of staff between having a senior leader seek her or him out to see how things are going, versus the anxiety that might be associated with being asked to come give a formal report to the board.

  • Be systematic as a leadership team about this and keep the lines of communications open. Assign leaders to be ‘supporters’ or ‘sponsors’ of specific innovations. Schedule periodic walk-arounds or phone calls to keep the lines of communications open.

These supportive behaviors will also help you create the climate for innovation in the Resources and the Recognition dimensions. They give you the opportunity to reinforce the authority to act, identify any resource constraints that might be blocking progress, and provide recognition and appreciation.

Reverse the negative, worst-case scenario culture by establishing new conversation practices when innovative ideas are presented. Most organizations do not do a balanced assessment of risks when evaluating a new idea against the status quo. When presented with a new idea, people can be quick to point out what might go wrong, ask for strong evidence to support the new idea, or note that it would not work under certain circumstances. This almost immediately kills the enthusiasm for the new idea and makes the individual who raised it feel deflated.

Take the lead in reversing this behavior and mindset by acting differently and encouraging others to do the same. For example, when presented with new ideas:

  • Create a rule that the benefits of the idea are listed first before any discussion about what could go wrong. (This is a principle behind Edward de Bono’s Six Thinking Hats ®; see the NHS Institute’s publication Thinking Differently for more information.)

Recognize that the new idea may not work for every patient group or situation. However, ensure that any decision is made on the benefits for the majority rather than not using the idea because it does not benefit everyone in every situation.

  • Review critically the current process that the idea relates to. Ask for the evidence that supports the status quo approach. Ask that the new idea be judged fairly to the same standard of evidence that we allow for the status quo practice. When examined more closely via this challenge, teams often find that the new idea can offer benefits that the current process does not.
  • Rather than dismissing an idea as imperfect, challenge others to think about how they might further develop it to address its weakness.

Research indicates that the behaviors of formal organizational leaders have a disproportionately large effect on organizational culture (Schein 2004). Health leaders in an area can have the same effect on the culture of a health economy. If a leader starts responding differently upon hearing new ideas, others are likely to follow.

Role model personal, courageous risk taking in order to learn more about how to improve the culture. Consider exposing yourself a bit by frequently asking others for feedback on your own behavior and the culture of the organization. You might use a version of any of the questions on the culture for innovation survey as a guide. For example, you might ask staff during a walk-around “If you suggest a new idea and it fails, do you think that would make you reluctant to suggest even more ideas in future?” Appeal for an honest response, an explanation as to why they feel as they do, and suggestions for what they would like to see different.

  • Make a point of sharing the impressions you get from doing this with everyone, even if they are somewhat personally embarrassing for you. Experience indicates that people often give credit to a leader who is personally sincere and clearly trying to make things better.
  • Don’t use humor to lighten the mood when discussing the risks associated with an innovative idea. It almost never works and often has the opposite effect. The example below describes all-too-often-heard comments meant to be light-hearted in approaching the risk taking associated with innovation.

Some Things Are Just Not Funny. We cringe at some of things that we have actually heard leaders say…

“Jane tells us she is sure it will work, and we’ve told her we are sure she can find work elsewhere if it doesn’t (ha ha ha)”.

“Yes, I can remember we learned a lot from a past failure of an innovative idea. Of course that bloke no longer works here (ha ha ha)”.

The reaction is often nervous laughter and people making eye contact with one another around the room. This affirms that they believe that this gallows humor is actually true about the organization.

Don’t do this! If you are in a room where someone does, immediately speak up and say something in a serious tone like, “Actually, Jane’s confidence in leading the way on this innovative idea is just exactly the sort of thing we support around here, and we certainly wouldn’t want people like her to leave”.

  • Feed the rumor mill to positive effect. As you try some of these tips realize that your new behavior is likely to take others by surprise. Invariably, this will start a buzz around the organization. This will have a positive effect in terms of improving the conditions for innovation, for it has been said that the ‘rumor mill’ is often the most efficient internal communications vehicle in any organization.

More tips that can also help you enhance the Risk Taking dimension can be found in other sections…

  • Re-enforce the expectation that individuals and teams should feel they have authority to act on innovative ideas and seek to understand why they might feel they do not. (Resources)
  • Start a ‘Not Invented Here’ program where leaders, managers, and staff are supported to seek out knowledge and ideas from outside health care that can be adapted to address key organizational challenges. (Knowledge)
  • Reward and recognize ‘failed’ attempts at innovation where you can celebrate learning. (Recognition)
  • Distinguish between, and channel into appropriate processes and methods, issues that need (a) adoption of existing better practices from elsewhere, and (b) truly new ideas. (Tools)

Tips for Improving the Resources Dimension

The resources dimension considers the broadest sense of the word. The climate for innovation is enhanced if people know that they have the ‘resource’ of authority and autonomy to act on innovative ideas. While innovative ideas do not necessarily need a lot of money or time to develop, staff can become demoralized if these traditional resources are not available and can feel that there is no point in putting forward a new idea. The presence of concrete resources signal that the organization is taking innovation seriously.

  • In a recent survey, only 11% of front-line staff felt that they had enough time within their roles to dedicate to innovation. Source: NHS Institute (2009)

Re-enforce the expectation that individuals and teams should feel they have authority to act on innovative ideas and seek to understand why they might feel they do not.

Do you know the reasons that staff might not feel able to act on new ideas? Many leaders don’t, nor do they know the process, assuming that one exists, that staff have to go through in order to gain permission to try something new.

Do a ‘spot check’ during individual meetings or walk-arounds by asking staff to tell you about ideas they have where they feel they need more permission to act. Ask them about the process they believe they need to go through to get this permission. In our experience, we have found examples where staff are required to go through a long and complicated process, or they have no idea what the process is. Be clear that you are very open to feedback and truly want to have an honest dialogue about any past ‘signals’ that might have been sent by leaders. Also make it clear that it may indeed be that, in some circumstances, they do need permission. In any case, both you and they will learn more about how to take innovative ideas forward.

In the end, the goal is to remove misconceptions and perceived barriers. Be prepared to do something and communicate back to staff to raise their feeling of empowerment.

In doing this, realize that the very act of coming forward with innovative ideas represents some level of risk-taking. Consistent with that dimension, be careful to provide emotional support and show genuine appreciation of their efforts and any difficulties they face.

The advice here, while framed above in the context of an organization, applies as well to commissioners who might start a similar dialogue asking the organizations they work with if they feel that they need permission to be innovative, and why. Commissioners need to work with providers to decrease the perceived barriers to innovation, which might involve altering such commissioning levers as payment and tariff schemes.

Caution: Something to Think Honestly About.

This tip may require some honest, self-reflection in a leadership team. The premise of the suggestion is that leaders will want members of staff to feel that they have the authority to try out innovative ideas. But this might not actually be the case. Leaders vary greatly in their need to feel that they are in control of things, and in what they would classify as being ‘too risky’. It is important to explore this and gain consensus in your leadership team before telling staff that they have authority to act on their innovative ideas. You may do more harm in the long run if you tell staff that they are empowered, but then have a leader who takes it all back by her or his actions than if you had not said anything to staff at all.

Turn strategically important innovation efforts into formal organizational projects with allocated resources.

The most obvious way to provide resources for innovation is simply to focus innovative thinking on areas where resources already exist, or where there is a strong strategic imperative and resources could be identified. This might occur in one of two ways:

  1. Select existing priority goals and ask staff specifically for innovative ideas in these areas. For example if you already have teams who are focusing on safety, challenge them to massively overachieve their own aspirations by thinking differently about this area. This request might be initiated by commissioners, boards, or departmental and team leaders. The key is to recognize that staff are an important resource and often have ideas from their experience of delivering services. While it is an example of top-down, directed innovation, there is nothing wrong with this. The presence of resources and the clear call for innovation signal to staff that there is an uncommon willingness on the part of leaders to hear about and provide resources for innovative ideas on this particular topic, and that can be quite motivating.
  2. Consider whether an idea suggested by someone in the organization or system is so powerful in terms of its potential impact on quality, patient experience, productivity, costs, or prevention that it deserves to be raised to the level of a strategically important project in the next planning cycle. This is bottoms-up innovation that is then supported top-down with the necessary infrastructure such as authority to act, time and budget.

An innovative organization, health economy or other system should have a portfolio containing both types of innovation.

Link innovation efforts to waste-reduction techniques that free up resources.

In a context of limited resources, it may be necessary to create head room for innovation by first embarking on productivity improvement and then allocating some of the savings to support innovative new ideas. Leaders can signal their strong support for innovation, and perhaps increase staff buy-in to needed changes in other areas, by explicitly ring-fencing some of the savings that come from waste reduction efforts in order to fund innovative new ideas. For example, commissioners might make funding of an innovative pilot contingency on savings elsewhere. Or, organizational leaders might retain some headcount from a process redesign effort that reduces the number of staff needed in one area in order to re-direct the newly freed up staff onto innovation projects.

It is important to acknowledge the contributions of staff in both the waste-reduction efforts and the innovation efforts.

Remind everyone that the innovation work would not have been possible without the hard work of those involved in the productivity improvement efforts that freed up the required resources. This also provides a great opportunity to build a sense of teamwork across an organization or system.

Seek resources from non-traditional channels.

Existing budgets and projects should not be the only channel of resources you consider. ‘Think outside the box’ a bit and you may find that there are more resources for innovation that you could access. Also expand your thinking about resources beyond the monetary to include people and expertise (see box below).

Finding resources to help you innovate…

  • Become a test site for national initiatives, as these sometimes have additional resources in terms of expert help or small amounts of funding attached to them.
  • Contact your SHA about ‘innovation funds’, for which you can bid.
  • You may be able to secure funds from voluntary sector organizations, or even the National Lottery.
  • Local industries might be willing to volunteer their time and skills to help with innovative efforts. For example, in work done at the NHS Institute, hospital porters were supported by Nationwide Building Society, Orecal, IDEO (a leading design firm), Tesco, and Royal Mail to create new ideas about how they could provide a better customer service.
  • Contact university professors to see if you can arrange a mutually beneficial scheme where students provide support for innovation projects (e.g., designing websites, collecting or analyzing data or undertaking specific communications exercises) that also provides them practical work experience to go along with their course of study. Several NHS organizations have benefited from students of journalism and photography who have provided their time for free and used the work they have done as part of their academic assessment.
  • Members of the community including patients and their families might also be willing to volunteer their time and skills; either in lending a true service users’ perspective to innovation projects, or in helping complete needed tasks (e.g., designing a communication brochure). There are many such success stories documented in NHS Institute publications associated with Experience Based Design.

More tips that can also help you enhance the Resources dimension can be found in other sections…

  • Go out of your way to provide emotional support for innovators. (Risk Taking)
  • Start a ‘Not Invented Here’ program where leaders, managers, and staff are supported to seek out knowledge and ideas from outside health care that can be adapted to address key organizational challenges. (Knowledge)
  • Set out organization- or system-wide innovation challenge topics that call for innovative ideas in specific areas of need. (Goals)
  • Consider goals, contracts, annual appraisals, personal development plans, or job descriptions that require people to try out a number of innovative ideas annually and report back on what they have learned. (Goals)
  • Distinguish between, and channel into appropriate processes and methods, issues that need (a) adoption of existing better practices from elsewhere, and (b) truly new ideas. (Tools)

 

Tips for Improving the Knowledge Dimension

Broad-based knowledge is the fuel for innovation. We create better conditions for innovation when information, both from within and outside the organization or system, is widely gathered, easily accessible, rapidly transmitted, and honestly communicated. Since we cannot know in advance what knowledge might stimulate an innovative idea, censoring, filtering or over-summarizing information detracts from this dimension.

  • “Innovation is fostered by information gathered from new connections; from insights gained by journeys into other disciplines or places; from active, collegial networks and fluid, open boundaries.” Margaret Wheatley, author

Start a ‘Not Invented Here’ program where leaders, managers, and staff are supported to seek out knowledge and ideas from outside health care that can be adapted to address key organizational challenges.

Each of us have several encounters a week with people, businesses and services where we experience good flow as customers, have interactions that create exceptional positive experience, or see high levels of productivity via technology or job design. The simple fact is that most of us simply do not think about how the principles of successful operations in these other services might be applied to the work we do ourselves. Capitalize on the myriad experiences of staff (and even their friends, partners and families!) by drawing attention to the need to apply ideas and principles from elsewhere to the work we do.

While general awareness raising is useful, a more focused effort will have even greater benefits. For example, “This month, we are seeking ideas that we could adapt from elsewhere that will allow service users to gain greater access to services out of normal hours”. In addition to supporting the Knowledge dimension, this sets a goal, implies that there is little risk in suggesting an idea as these are welcomed, suggests that resources will be available to support some work, and provides an opportunity to recognize those who contribute. Commissioners could further encourage this sort of knowledge seeking when they work with providers seeking funding for services.

Bringing the knowledge of outsiders into the your team or organization to generate innovative ideas.

The NHS Institute regularly invite non health related organizations to input their ideas on specific topics such as improving access for GP Surgeries, health and fitness for older populations, and creating a service delivery oriented process for hospital portering teams. Contributors have included an award winning water company, a concierge service, phone network providers, retail organizations, and hotel representatives.

Encourage staff to look for and share new ideas from other health care organizations, internal departments, or partners along pathways.

Just as the previous tip encouraged greater knowledge flow from outside health and social services, this tip suggests the same, but with an internal focus. Requiring managers and clinical leads to regularly seek out and adapt ideas from other areas also encourages the more rapid spread of innovation and combats the ‘pockets of excellence’ phenomenon that we unfortunately see so often. Transferring ideas that work in a different location into your own area is a particularly important type of innovation for the NHS because there are so many examples of excellent practice available.

A good example is the recent development of 8 High Impact Actions for Nurses (Mugglestone and Baxter 2010, Maher and Fenton 2010). Based on the knowledge that within the NHS there are many examples of excellent improvements that have been made by individuals or teams of nurses and midwives, a call for evidence of all these good examples resulted in over 600 submissions within a three-week period. In addition to the actual submissions, visits to the website to look at the submissions were in the thousands. The submissions were assessed and synthesized to create those that are believed to have the highest potential to increase quality, improve patient experience and reduce cost. This work has created massive interest and there is widespread evidence of adoption of good ideas from case studies that have been developed in each of the eight high impact areas.

I’ve Been Noticing…

You know that you are making progress in the Knowledge dimension when you regularly hear staff say things such as:

  • I have a friend who works in a neighboring hospital and what she says they do is…
  • I read about something really great in Journal of American Medical Association
  • I was at a meeting with some colleagues from community services and they way handle a similar situation is…
  • I went to X-ray with a patient and I noticed that they did this great thing that I think we should consider…

Regularly share and celebrate innovations that are already happening in your organization or system.

For example, develop an annual ‘innovation day’, or an innovation focus within your regular newsletter, in which teams, departments or organizations in your health economy display some of their most innovative new ways of working and pose challenges seeking innovative ideas to solve their problems. This also stimulates innovative thinking by promoting some friendly competition among departments and teams. The periodic event becomes part of the pattern of organizational life where departments and teams know that they will be able to showcase something they have done. Everyone will be naturally curious as to how what they have done compares to peers. This idea also links with the Rewards dimension of culture; but we encourage you to read the caution there about awarding top prizes.

In addition to sharing what has already been done, such an event can also be used to stimulate wider thinking about challenges that have yet to be successfully addressed. Departments and teams could post their challenges on a board with a large space for others to post ideas and suggestions. These might become the topics for future knowledge searches to learn more about how other organizations and industries address similar challenges.

Share board information more widely and use knowledge from the workforce to support the board.

While the preceding tips focus mainly on sharing knowledge about innovative solutions, this one looks more at sharing information about current performance and challenges that need to be addressed.

Look at all of the information reviewed at board level and ask: “Why can’t this information be shared more widely to stimulate broader thinking and create more urgency for change?” Boards often have information that they are reluctant to share widely for fear that it will overwhelm or upset the workforce. This creates a culture of parent-child interaction and contributes to what Harvard professor John Kotter (2008) calls the ‘complacency’ that works against the urgency for change that often fuels innovation. Sharing detailed performance information can also call attention to so-called ‘positive deviance’ – departments, teams, or individuals who seemingly have discovered something that enables them to excel on a particular dimension of performance that might be adapted and spread more widely.

The Surgeon Who Knows Something.

Mining the data in its Quality Observatory, a team in the South East Coast identified a consultant at one hospital site who was achieving outstanding results. His hip replacement patients had good, safe outcomes, with much shorter lengths of stay and higher satisfaction, at reduced cost and with higher staff morale than comparable sites. His better practices have now been evidenced with data, which also demonstrates the wide variation among surgeons, and work is underway to spread these practices. Source: Samantha Riley, Head of the Quality Observatory, South East Coast SHA and member of the Academy for Large-Scale Change.

While there is certainly some information at board level that must be kept confidential, in our experience far too much information is held at senior levels. This may well be holding back the organization from the innovation that would make it more successful in serving the patients, carers and public who depend upon it. Consider adding a question to each board agenda item that encourages a few minutes of reflection on the information just shared with the board to ask if it shouldn’t be more widely shared.

Open the knowledge window for staff by linking to knowledge management resources that exist in your organization, region, or at national level.

Recently, the Department of Health has asked NHS organizations at every level to appoint knowledge management leads. This has stimulated the development of numerous knowledge management and sharing resources across the country. Each of these can be sources of innovative ideas, or pieces of ideas that can be combined to create local innovations.

Some available knowledge management resources in the NHS…

NHS Live is a free, national learning network which aims to stimulate innovation from the NHS frontline, to encourage innovative partnerships and networks, and to create mechanisms for the diffusion and adoption of innovation. The NHS Live community currently has a membership of 11,000 frontline enthusiasts, innovators and improvers from across the NHS. The NHS Live project directory enables you browse projects by key word and by your local area. Visit www.institute.nhs.uk/nhs_live for more information.

NHS Institute Alert is a current awareness bulletin, highlighting latest research and opinion to NHS staff working in the areas of innovation and improvement. The aim is to improve practice by raising awareness of the latest evidence for a wide range of topics including, innovation, improvement, patient experience, patient safety and cost and quality. Visit www.institute.nhs.uk/nhs_alert for more information.

NHS Evidence allows everyone working in health and social care to access a wide range of health information to help them deliver quality patient care. NHS Evidence has a fast, free and easy to use search engine to help users search for the information they want. It ranks search results from credible medical sources according to relevance and quality and allows users – through My Evidence – to personalize a search and register to receive the latest health information. It awards an Accreditation Mark to organizations who meet high quality standards in developing health information. Visit www.evidence.nhs.uk for more information.

In addition to tapping into emerging knowledge sharing resources, consider creating your own informal mechanisms for people to share what they know. For example, ask anyone who goes away to a meeting or conference to purposefully search for and then write up 2-3 ideas that they can bring back to the organization. These short summaries could be published in existing newsletters, captured on websites, or simply shared verbally at managerial, clinical, or other staff meetings.

More tips that can also help you enhance the Knowledge dimension can be found in other sections…

  • Identify and publicize widely the strategic issues where there is a clear case for the need for innovation and where extension of the current way of working is clearly inadequate to meet the need. (Goals)
  • Distinguish between, and channel into appropriate processes and methods, issues that need (a) adoption of existing better practices from elsewhere, and (b) truly new ideas. (Tools)
  • Bring in non-traditional team members precisely for their potentially very different points of view. (Relationships)
  • Increase the use of job shadowing, short-term work rotations, and longer-term secondments to increase individuals’ awareness and valuing of different ways of thinking and working. (Relationships)

Tips for Improving the Goals Dimension

Organizational and system leaders – whether team leads, managers, directors, executives, or commissioners – signal that innovation is highly desirable by setting aspirational goals in specific areas and challenging others to find ways to realize the vision. Linking these to strategic priorities and being able to articulate a clear, multi-faceted case of need, further signals the importance of the call for innovation. However there is a caution. Innovative thinking is stifled when leaders go beyond statements of what needs to be achieved and also become prescriptive as to how it must be achieved.

  • Don’t stop. Keep moving towards new targets, new goals, new improvements” Stuart Rose, CEO Marks & Spencer
  • “Many people fail in life, not for lack of ability or brains or even courage but simply because they have never organized their energies around a goal.” Elbert Hubbard, innovator in the field of marketing, 1880.

Identify and publicize widely the strategic issues where there is a clear case for the need for innovation and where extension of the current way of working is clearly inadequate to meet the need.

While continual, incremental improvement is the ethos of the health system, this can also lead to a culture of complacency. The mindset “of course we can always do a bit better”, while good, leads to change that often does not fundamentally challenge the status quo approach. In other words, it is not really very innovative and does not achieve breakthrough results.

At the same time, challenging and changing everything at once is a recipe for chaos. Somewhere in between the two extremes lies great opportunity for strategically focused innovation. Identifying those opportunities and attaching a stretch goal that captures the imagination can stimulate lots of innovative thinking.

Stretch Goals and Innovation.

The classic example from NASA (the US space program) was President Kennedy’s challenge in 1963 that “we will put a man on the moon and bring him home safely by the end of the decade”. At the time, few of the technologies required were available and there were many unanswered questions. But this clearly articulated stretch target spurred massive innovation in several fields that not only benefited the space effort but also led to products that we take for granted today (for example, both cardiac pacemakers and health care telemetry had their origins in NASA innovations).

The key in articulating targets that stimulate innovation is to stick strictly to defining the ‘what’ and the ‘why’, but steadfastly avoid specifying the ‘how’. The aim is actually to have people initially react saying that it cannot be done. This then provides the opportunity to lead them to realize that what is holding them back is the way that they are thinking about it.

An example of clear statements of ‘what’ and ‘why’ linked to a strategic goal is provided in the box below. The clarity of the goal, the strength of the case, and the size of gap invites people to think differently about approaches to the problem. For example, ideas about innovative partnerships with others in the health service, as well as organizations in other sectors or individuals in the community, come instantly to mind.

Setting Targets that Encourage Innovation in the Health Service

Key Principle: Clearly articulating the ‘what’ and ‘why’, but avoiding specifying the ‘how’.

Situation: 40% of unplanned admissions to our Acute Trust are alcohol related, and the percentage is rising at an alarming rate. Data also indicate that alcohol plays a role in many cases of staff abuse by patients. We have identified reduction of alcohol-related unplanned admissions as one of our strategic priorities.

What (stretch goal): We want to go beyond simply slowing the growth in alcohol-related admissions. How might we cut the actual number of unplanned alcohol-related admissions in half in 2 years?

Why (the case): We have made incremental improvements, but these are merely slowing the rate of increase. The absolute numbers of alcohol-related admissions already place an unsustainable burden on us from a finance, staff safety, and staff morale perspective. The rising burden of unplanned alcohol-related admissions will only grow more intolerable as we enter a period where resources will be further constrained. We must do something radically different now.

Set out organization- or system-wide innovation challenge topics that call for innovative ideas in specific areas of need.

This straightforward approach builds on the previous tip but goes a step further to create an ‘innovation focus list’. In the spirit of focusing, this list should be specific as to topics and no more than five to seven items. For example:

  • A Foundation Trust might say, “We need truly innovative ideas in the areas of: eliminating waiting, reducing stillbirths in a certain ethnic group, truly equipping and empowering patients and carers in their own self-care after discharge, etc.”
  • Commissioners in a PCT might say, “We want innovations that will: cut teenage pregnancies by 70%, reduce admissions for people with diabetes by 50%,”

The specificity of the goals and targets implies attention and resource-availability. Going further, leaders could set up specific structures and processes to enhance the invitation to innovation; for example, identifying a specific senior executive as the sponsor for each item on the list, or setting up a webpage or email box that will accept ideas and respond back to the initiator.

Articulate stretch goals in the language of “how might we… (do something that today seems impossible)?”

In many organizations, the word ‘target’ or ‘goal’ implies that there will be negative consequences associated with not meeting it, even if one falls short by only a small amount. The natural reaction is to want to avoid setting oneself up for negative consequences. The best way to do so is to debate the specifics of the goal. Often, more thinking energy is devoted to arguing against the specific target than is given to coming up with innovative ideas.

A simple way to avoid this is to state innovation goals and targets in the form of a question that begins: “How might we…?” (see box). This invites inquiry and creativity, rather than resistance and debate. It also signals that you have simply chosen a round number to shock the thinking and you don’t really mean anything more exact than that. In the end, if we achieve a 43% reduction in something that we set a goal of 50% on that is still something worth celebrating!

How Might We… Statement Examples…

  • We have reached our 18 weeks wait targets, how might we reduce that by half again?
  • Our operating costs in theater are much better now, but how might we cut them an additional 30%?
  • Many people with diabetes in our practice have achieved control of their blood sugar levels. How might we maintain that outcome with half the number of visits to health professionals?
  • How might we achieve a 25% reduction in falls across the whole community?

Review current goals and targets and seek to remove overly-prescriptive means that are embedded within them, or make it clear that you are very open to alternative means that accomplish the same goal.

For example, a target to “Reduce by 10% unplanned admissions of people with diabetes by implementing the XYZ model of care” leaves only a little space for innovative thinking. Of course, if there is good evidence for the XYZ model of care and others have routinely achieved satisfactory results with it, then this is perfectly good goal statement for the spread of an innovative practice that will lead to improvement. This is a good thing. But leaders can enhance the conditions for further innovation by saying instead…

“The goal is to reduce by 10% unplanned admissions of people with diabetes. The XYZ care model has been shown effective in achieving this, and we might indeed decide to implement it here. But before we take that decision, let’s also consider other approaches. How might we achieve a 10% reduction in unplanned admissions for people with diabetes?”

Such thinking might result in an even better approach, or some innovative building on the proposed care model. Further, even if clinical leaders and front-line staff decide after thinking about it that the XYZ care model is actually a good approach, the difference between leaders telling them they must do it versus leaders inviting them to input and chose for themselves will likely have a positive impact on ease of implementation and eventual sustainability.

Consider goals, contracts, annual appraisals, personal development plans, or job descriptions that require people to try out a number of innovative ideas annually and report back on what they have learned.

A basic principle behind many of the tips in this section is to say what is expected in a high-level sense, and avoid over-specifying the details. Building on that, this tip suggests simply setting the general goal of asking for innovation of any kind.

How do you define an ‘innovative idea’?

The companion guide in this series, Making a Bigger Difference, provides an approach. However, the aim of this goal is not to accumulate or judge ideas, but rather to stimulate thinking and create a conversation that encourages even more innovation. Leaders will learn something about the capability for innovation in their organizations by having this conversation and reflecting on the items that are put forward as examples of innovation. Likewise, commissioners will learn something about the innovativeness of providers in their health community. If you are truly creating the conditions for a difference, you should see a difference in the depth of challenge to status quo thinking over time.

Avoid setting people up for failure and frustration. If you set such a goal, make sure you also provide tools and skill building, along with the resource of authority to act on ideas.

Test for alignment of organizational or system-level goals for innovation by asking staff where they think innovation is most needed.

One of the purposes in setting goals for innovation is to communicate the need for innovative thinking. There is a timeless principle in communication that says: “if they didn’t ‘get it’ you didn’t communicate it properly”.

The objective is to see whether you are communicating clearly enough to raise people’s awareness of the need for innovation so that they are constantly on the look out for innovative ideas. If they cite back to you the areas where you have set goals for innovation, then you have evidence of good communication. If they say they don’t know if innovation is really needed, or they cite completely different areas, then you have evidence that the innovation goals you have set are not necessarily accomplishing the objective of stimulating innovative thinking. You may need to communicate again, or do it better. Or, you may have targeted areas that simply do not seem that important to others. In any event, you are not fully capitalizing on the power of goals to create a culture for innovation.

More tips that can also help you enhance the Goals dimension can be found in other sections…

  • Turn strategically important innovation efforts into formal organizational projects with allocated resources. (Resources)
  • Start a ‘Not Invented Here’ program where leaders, managers, and staff are supported to seek out knowledge and ideas from outside health care that can be adapted to address key organizational challenges. (Knowledge)
  • Grand prizes and competitions create a few winners and lots of losers; instead seek to reward all legitimate innovations and attempts. (Recognition)
  • Distinguish between, and channel into appropriate processes and methods, issues that need (a) adoption of existing better practices from elsewhere, and (b) truly new ideas. (Tools)

Tips for Improving the Recognition Dimension

Recognition for innovation can be done through symbols and rituals whose main purpose is to acknowledge innovative behavior. They signal how much value is given, or not, to the efforts of individuals and teams who come up with new ways to help the organization or system achieve its strategic goals. Because it is all about encouraging more of this sort of behavior, the best recognition is that which appeals to people’s intrinsic and individualized motivation. The most successful recognition schemes avoid a one-size-fits-all approach and are instead based on a deeper understanding of what makes people do what they do. For example, frequent personal expression of appreciation is often more important to people than financial reward.

  • [If] recognition don’t follow suit, then the lasting innovation culture you seek will be fleeting at best.” Troy Geesaman, Innovation and Strategy Director at the product design firm Iaga
  • Enhancing innovation… entails a dramatic departure from many traditional management practices. Rather than rewarding only success and punishing failure, companies should reward both.” Robert Sutton. The weird rules of creativity. Harvard Business Review (2001)
  • The best ‘end of project’ awards cleverly capture the heart of the achievement.” Tom Kelly, CEO at the design firm IDEO.

Keep it simple and sincere.

Recognition can come in many forms; the more direct, straightforward and heartfelt, the better. A simple ‘thank you’, delivered personally out in the staff member’s or team’s environment, along with a description of the idea in your own words that shows that you really took the time to understand what they are suggesting goes a long way. Taking the time to explain what will be done with the idea, or what you want them to do with it next, is another simple thing to do. If the idea cannot be taken up, providing a thoughtful explanation as to why tells them that the idea was given consideration, while also providing some coaching as to how to come up with an even more useful idea next time around.

Be genuine and sincere in your efforts to recognize staff ideas. They can detect if you are simply going through the motions and don’t seem to really mean it when you say that you appreciate their efforts. It would be better to say nothing at all than to say something that comes across as insincere.

Seek to understand and work with what intrinsically motivates innovators.

While “it’s the thought that counts” does indeed count for something, standardized awards may leave the receiver feeling theirs has been a superficial rather than significant accomplishment in the eyes of the organization. In order to stimulate more innovation, we need more people who feel a deep bond of appreciation from their organization.

3M’s HR Policy Stimulates Innovation By Giving Innovators What They Really Want…

Studies of innovators across a variety of sectors indicate that what many would like most is more time to work on innovations because they personally value the excitement and challenge of trying to do something different. Understanding this intrinsic motivator, the industrial firm 3M, for example, has a human resources policy that allows all staff to take up to 15% of their time on the job to work on innovative ideas, and then provides even more allowance of time for the most promising ideas.

This tip simply suggests that while, as a practical matter, you might ask a small group to come up with ideas for recognition of innovation, that group needs first to go out and talk with lots of people who might be the potential recipients of such recognition. It also suggests that you may need an array of ways to recognize accomplishments and a way to match these to an understanding of what is meaningful to each individual you wish to recognize.

When we think of ‘recognition’, monetary prizes often come to mind first. While few people would refuse to accept a monetary reward, there is a great body of evidence to indicate that the vast majority of people do not do what they do in order only to get more money (Kohn 1990). Rather, there are many other intrinsic motivators; that is, factors internal to a person and having to do with their values and perspectives.

What motivates you?

  • Many front-line staff feel that monetary recognition for ideas should be directed at purchasing equipment or further enhancing the service because their personal values are deeply centered on caring for patients.
  • Two team members were supported in attending a conference on innovation and improvement. Their experience was so good they could not stop talking about it and the new ideas they had learned. Many have inquired if this recognition was available for others.

To gain insight into others’ intrinsic motivation, initiate conversations as you walk about or interact with small groups. Use open-ended discussion starters such as:

  • What was the best recognition you ever had in a work situation?
  • What could we do to make you feel recognized and supported in the work you have done?
  • What motivated you choose to work in the health care sector versus others?

Talk to lots of people. Listen appreciatively. While you will no doubt hear diversity in the responses, you will also begin to see patterns. Use these insights as input to the design of any recognition effort.

Set up structures and processes to enable peer, patient and carer recognition for innovation.

Don’t think of recognition and recognition as only being top-down, or something that comes from ‘an organization’. For many staff, being recognized by peers, patients and carers is very important and meaningful. Comments from peers and patients could be incorporated into an internal newsletter article, the local press, or an internal awards ceremony.

There are a variety of ways to systemically encourage such recognition. For example:

  • Place wall posters about recently introduced innovations in patient care areas and include a comment wall where patients and carers can write whatever they wish. A selection of these comments can be read aloud at staff meetings on a regular basis.
  • Set up periodic, but casual, showcase events where several individuals and teams are given support to create a poster board where they can talk about what they have done. Setting up the stands for a few hours in areas where lots of staff, patients and carers naturally pass and giving staff time to man the stands (perhaps rotating through in shifts to spread the recognition around) encourages casual, ‘buzz-y’ conversation.
  • Set up periodic ‘open house’ times where places with innovative practices are available to showcase what they have done. Publicize these well and encourage participation.

Big Brother’s Diary Room Comes to the NHS…

Wrightington, Wigan and Leigh NHS Trust borrowed the ‘diary room’ idea from TV’s Big Brother to capture on-the-spot experiences from patients and carers in order to gather feedback and prioritize changes. The team borrowed a camera from the trust’s digital imaging department and put posters up to invite patients and carers to take part. In the genito-urinary medicine clinic, the team made audio recordings instead so that patients could participate without feeling uncomfortable. In addition to getting many ideas for improvement from patients and carers, the recordings also provided a source of very positive feedback to staff on changes that had already been made. In the light of its success, the team is now beginning to visit patients at home to record their personal stories. These will be played to the trust board to help shape future commissioning plans.

The possibilities are endless. The point is simply to put your leadership effort to use facilitating this sort of interaction, in addition to the more common formal recognition efforts that leaders should, of course, continue to do.

Reward and recognize ‘failed’ attempts at innovation where you can celebrate learning.

Recall the discussion under risk taking about how important it is to have a new mindset about ‘failure’.

Failure is an integral part of the innovation process, provided that it is seen as an opportunity for learning and moving on to a next iteration. If individuals and teams who try a new idea that fails are shunned, even just a little or in seeming jest, they are less likely to try to innovate again.

Whatever you decide to do as a structure and process for recognizing innovation in your team, organization, or health system, make sure that you design something to also recognize ‘attempts with learning’. When the culture is such that it seems just as easy to talk about these examples as it is successful innovations you will have gone a long way towards creating the conditions for innovation.

Grand prizes and competitions create a few winners and lots of losers; instead seek to reward all legitimate innovations and attempts.

While it is common to have competition schemes where someone wins the prize over everyone else—and we are not totally against such schemes—it is important to step back for a moment to recognize a potential consequence. Many more teams and individuals ‘lose’ the competition than win. The potential unintended message is: “Your efforts weren’t good enough”.

A better (or additional) approach is to establish reasonable, but explicit and transparent, criteria for what you want to call an ‘innovation’ or an ‘attempt with learning’ and then recognize as many or as few examples as meet the criteria (see box). If there are 37 examples that meet the criteria, recognize them all equally. If there are only 2 that meet the criteria, recognize those and call for more like them.

Firm criteria, variable number of winners.

Countries around the world offer prizes annually to firms that demonstrate excellence in quality. Several of these awards programs follow the philosophy of being firm on a set of criteria and then recognizing as few or as many organizations as meet these. For example, over the years, the Japanese Deming Prize has seen years when as many as eight awards were given, as well as a year when no award was presented because no organization rose to the standard. Similarly, the number of winners of the American Malcolm Baldrige Quality Award has varied from two to seven.

The companion publication in this series entitled Making a Bigger Difference (available from the NHS Institute in a version for commissioners and one for staff and leaders of provider organizations) provides one approach to setting criteria for innovative ideas. The ‘harvesting by criteria and dot voting’ tool in another companion guide, Thinking Differently (also available from the NHS Institute), also provides guidance on this.

A final word…

It is important to have some criteria to define what you mean by ‘innovation’ and how it is different from incremental improvement or change of any kind. Calling every change an ‘innovation’ risks demotivating the stretch, or paradigm-altering, change that we need more of.

More tips that can also help you enhance the Recognition dimension can be found in other sections…

  • Go out of your way to provide emotional support for innovators. (Risk Taking)
  • Link innovation efforts to waste-reduction techniques that free up resources. (Resources)
  • Start a ‘Not Invented Here’ program where leaders, managers, and staff are supported to seek out knowledge and ideas from outside health care that can be adapted to address key organizational challenges. (Knowledge)
  • Regularly share and celebrate innovations that are already happening in your organization or system. (Knowledge)

Tips for Improving the Tools Dimension

In high-performing organizations, innovation is the product of the deliberate use of practical tools. Imagining that innovation will happen on its own if we just have the right culture would be as naive and irresponsible as imagining that financial controls would naturally emerge without some deliberate structures. While everyone is capable of innovative thinking, most of us have been socialized to be more conservative in our thinking in the work environment, especially in health care where there are legitimate risks that must be managed. Leaders, therefore, need to consider how they build capability and capacity in deliberate methods for creative thinking.

  • 46% of respondents of the NHS Study on Innovation and Improvement said they would like to receive more support in learning about tools for innovation and improvement. Source: NHS Institute.

Distinguish between, and channel into appropriate processes and methods, issues that need (a) adoption of existing better practices from elsewhere, and (b) truly new ideas.

Consistent with what we have said about the goals dimension, innovation happens best when it is strategically focused. The complex organizations and systems of health care cannot sustain simultaneous, paradigm-altering change to every thing we do. It would be chaos, and there is no need to do so.

Within an organization or health system there will be services that are operating well. These may still benefit from incremental improvement and/or adoption of well-proven ideas from other NHS or international health care organizations. Methods from improvement science are already being applied in most health care organizations and systems in such situations.

It is important to have a deliberate process for identifying those strategically important few issues where fundamentally new thinking is required, in order to focus resources and efforts onto these. This should take place as part of existing operational and strategic planning structures (e.g., commissioning, the annual planning cycle). You should develop your own simple process for this, but the items in the box provide general guidelines. Build considerations such as these into a simple proforma that you can integrate into your existing planning processes.

Guidance for Identifying Issues for Application of Innovation Tools and Methods

  • Ask someone to conduct a deliberate search for ideas and better practices around the challenges you face as an organization or system to see if there is something that you can learn from elsewhere. You may need to be innovative in the way you adapt the idea to fit your context, but if the basic concept behind the idea will help you achieve your goal then a great deal of work has already been done and you have less risk because you will know that the idea has been done elsewhere. Ideas data bases for health care already exist (e.g., The Health Care Innovation Exchange sponsored by the US Agency for Healthcare Research and Quality <http://www.innovations.ahrq.gov/>).
  • If the goal for improvement is small (e.g., single digits percentage-wise), or if you simply need to solve some problems that have crept in over time and get the service back to a level of performance that it has achieved before, you may require incremental improvement or adoption of existing better practices and should consider using traditional performance improvement methods. However, even when the current gap in performance is relatively small, you might still want to place a certain challenge in the ‘innovation needed’ category. If you know that the pressure to improve even more will simply continue year-on-year, you might want to consider launching at least some exploratory idea generation to see if you might jump to a fundamentally new level of performance through innovation.
  • If the goal for performance is far from current levels and there are no existing better practices that you can adapt, this might be an area for strategically focused innovation. Compile a full list of these and do a simple, first-draft business case on each in order to prioritize your needs.

Develop a cadre of people who can facilitate creative thinking and innovation processes.

Creative thinking is something that everyone can do (Plsek 1997). Providing training and facilitation resources to build this capability in staff sends a visible message that innovative ideas are desirable. Consider it a natural extension of the improvement teams, advisers, and tool kits used by many organizations.

There are many useful tools for stimulating idea generation. The NHS Institute for Innovation and Improvement has several publications and masterclasses describing such methods and a program to certify innovation practitioners.

It is important to note that idea generation alone is not the whole of the innovation process. Tools and processes for further development, testing, implementation and spread of ideas are equally important. A variety of publications and other resources from the NHS Institute provide guidance on this as well. Visit www.institute.nhs.uk

Require innovators seeking resources to explore how innovative their idea really is and how they might make it even more innovative.

Consider each and every idea for change that comes to your attention as a ‘teachable moment’ that offers you the opportunity to further develop the culture for innovation. If someone is seeking resources, even if it is only the resource of your authority to proceed, encourage them to also stretch their thinking further.

Here’s a simple tool for guiding this reflection called a 4Ws table:

 Current ApproachProposed New Idea
Whowho is involved directly in delivering the care?Specifically, who else might do something (esp. patients themselves)?
Whatwhat specifically do they do?What else we might they do, or what might they do very differently?
Whenwhen it is available?Specifics of when else might we offer this?
Wherewhere is it done?Specifics of where else might we extend the idea?

Asking innovators to construct such a table to present their ideas almost always stimulates further innovative thinking. It need not be an extensive analysis. After using this tool the first few times, you will find that you can easily do this analysis in a 10-minute discussion. This simple tool and organizational ritual can go a long way toward creating conditions that favor more innovative thinking.

Plan to introduce new tools or methods for innovation periodically. Spread their use widely in simple ways that help everyone see how they might use them, and publicize their many applications.

If you are already using a few tools for deliberate creative thinking and innovation, or after you have implemented some of the tips above, plan to keep the focus on innovation fresh by injecting new things into the mix. This continually communicates the value you place on new thinking. Keep it simple and seek to introduce new tools and methods as part of daily work rather then always thinking that some sort of formal training is needed.

Bringing Innovation Into Day-to-Day Work of Staff.

The NHS Institute’s Thinking Differently guide describes a tool called ‘Breaking the Rules’ that can easily be integrated into the daily life of an organization or system. Challenge staff for a month to purposefully notice all the ‘unwritten rules’ and traditions all around them. An easy way to spot these is to pretend that one is a man from Mars who is totally unfamiliar with health care processes and systems and keeps asking why things are as they are. For example, “Why is it that when patients arrive we ask them to wait in an area, when actually they came to see a clinician?” The answer might be, “Well we have to manage the flow of demand in some way.” To which a response might be, “Is a waiting area the only way to manage the flow of demand? How else could you do it? How is it done elsewhere?” This invites organizational conversation with new thinking as we seek constructive and innovative ways to ‘break the rule’ about always having waiting areas for patients.

The basic idea here is to enhance the culture for innovation by encouraging more flexible mindsets, and to imbed a few simple methods for innovative thinking into the organization’s or system’s culture on a regular basis. To achieve these goals, make sure that you also set up a mechanism to capture some stories of how the new methods have stimulated concrete change and publicize these widely. Your local communications staff can probably help with this.

More tips that can also help you enhance the Tools dimension can be found in other sections…

  • Establish a process to publicize and learn from ideas that ‘fail’. (Risk Taking)
  • Turn strategically important innovation efforts into formal organizational projects with allocated resources. (Resources)
  • Set out organization- or system-wide innovation challenge topics that call for innovative ideas in specific areas of need. (Goals)
  • Consider goals, contracts, annual appraisals, personal development plans, or job descriptions that require people to try out a number of innovative ideas annually and report back on what they have learned. (Goals)

Tips for Improving the Relationships Dimension

The relationships dimension refers to the patterns of interaction between people in the organization or system. Innovative ideas are rarely the product of a lone genius. Even when they might appear to be, delving further into the story nearly always reveals that the idea was formed over time and through multiple interactions with others that fueled the process. Therefore, environments where staff are routinely exposed to a wide range of different thinking, from a wide-range of people, with a wide range of backgrounds and points of view, provide rich soil for the growth of innovation. Of course, it is more than just exposure; one can be ‘exposed’ to a diverse group of people while riding on a train and not be stimulated to innovate. There must be a sense of common purpose; of being in a ‘team’ with others. This team environment must also enable those with different thinking to trust that their input will be honored and explored, rather than immediately argued against.

  • “Your only real path to innovation is through people. You can’t really do it alone”. Tom Kelly, CEO of the design firm IDEO
  • Leadership is not about what you say, or even what you do. Leadership is how you make people feel.” www.ryanjacoby.com
  • “Undervaluing and under investing in the human side of innovation is a common mistake.” Moss Kanter. R. (2006) Innovation: The Classic Trap. Harvard Business Review.

Create many opportunities for diverse individuals to work together and learn more about each other’s ways of thinking.

One of the simplest things you can do to build relationships that favor innovation is to create more and more opportunities for multi-disciplinary interaction. Simply put, if you give a group of nurses a challenge to address, they are likely to approach it in ways traditional to nurses. The same would be true for groups of doctors, managers, housekeepers, or admin staff. Give the same challenge to a multi-disciplinary team of nurses, doctors, managers, housekeepers, and porters AND provide good team facilitation that focuses on being explicit about creating a trusting, open environment where everyone is curious and respectful of what the other thinks, and you may get a completely different set of ideas that would not have emerged from any of the individual groups alone. The more opportunities you provide for this sort of working, the easier and more productive it becomes. It creates a mindset shift that becomes part of the prevailing culture over time.

In a true team, the old saying is often true: “The product of the whole can be greater than the sum of the parts”.

The next three tips, while useful on their own, can also be considered team-building exercises that could be productively combined with this one.

Use one of the many personal style instruments as a way to get people to honor differences between themselves and others as refreshing and useful.

Sometimes you need to ‘break the ice’ in opening up conversations about the different ways that people think. If I simply tell you my perception of how I think of you, you might feel that I am judging you; and beside, I might have it all wrong.

There are literally dozens of simple style instruments that provide a structure and a language for beginning the exploration of one another’s differences in a more objective way. See the box for one example, and consult with your Human Resources Team who may have access to similar instruments.

Typically, one reads and responds (agree-disagree) to a series of statements, or selects or ranks preferred items from a menu of choices. These responses or choices are scored in some way that then results in a conclusion from the survey instrument. It makes a great team-building discussion if everyone completes such an instrument, gets some general feedback from a facilitator to help them interpret their own results, and then shares this information with everyone. The process gives everyone a better appreciation for differences within the team, avoiding potential frustration and enabling more understanding going forward.

Style Instrument Example: The common Myers-Briggs Type Indicator® (MBTI) gives one feedback on her or his preferred ways of processing thoughts (mainly alone or mainly by bouncing it around with others), coming to decisions (mainly through logic or mainly through emotion), and other things. One receives feedback on one’s ‘type’ that most people find eerily accurate. A key point is that there is no right or wrong. Each type has its strengths and pitfalls. Each type is useful in some situations and less useful in others. Complete thinking is best accomplished by some combination of all types. That is the value in working together as a team.

Note: The MBTI is a copyrighted instrument that requires the payment of a licensing fee. There are many other, similar instruments. For example, the booklet Managing the Human Dimension of Change, part of the NHS Institute’s Improvement Leaders’ Guide series, contains an instrument that works just as well for team building that is free to use.

Start an ongoing dialogue about what ‘teamwork’ means and what it really looks like.

Beyond styles and preferences, another sort of diversity that can be explored productively in teams is differences in what are called ‘mental models’. Mental models are the images that humans naturally create in their mind’s eye when they hear a word.

Mental models drive thinking, but if we have different mental models this can lead to conflict and frustration as we try to work together.

For example, I might say, “Let’s be a high performing team”, and you might readily agree that that sounds a good idea. But if my mental model of a ‘team’ is a sailing crew where I am the captain calling out orders which I expect you to follow, while your model of a ‘team’ is a football side where everyone is flowing and the ball is being passed around for each player to try to create something then we might find that we are not working so well together as a team! You will be frustrated with me for being directive and I will be frustrated with you for acting as if I am supposed to be passing you the ball.

The box provides a simple exercise that you can do with a task team, leadership team, or any group of staff to begin an on-going organizational dialogue.

Exercise: What Do We Mean By ‘Team’?

A team-building exercise that can expose mental models is simply to ask everyone to think silently for a minute or two about what image, example, or analogy they would use to illustrate a high-performing team. Ask them to actually draw a picture, or at least write a few words to describe a specific example. Stress that they must think of a concrete example, not a list of characteristics. Enforce a short period of silence. Don’t let anyone say anything or give their example yet, as this might bias others or cause them to not say what they are really thinking in order to fit in. Now, ask everyone to reveal his or her paper simultaneously and allow everyone to see everyone else’s picture. Only then begin going round the group for people to explain why they have selected their example. Point out differences and similarities and note that while there is no right or wrong, it certainly is important that we have at least a somewhat similar image in mind if we are to work productively as a team.

Start an on-going dialogue about what it means to have a ‘trusting and open environment’.

Using a similar interactive process to that in the preceding tip, you might also work on the environment regarding relationships by exploring patterns of behavior rather than analogies. For example, ask people to describe specific behaviors that they think of as examples, or counter-examples, of a ‘trusting and open environment’. Talk about ways to encourage more of the behaviors that others perceive as contributing to a positive environment.

Bring in non-traditional team members precisely for their potentially very different points of view.

By ‘non-traditional’ we mean, for example, service users, carers, people in the community, people from the private sector, someone who knows little about how you currently do things, university students, designers, engineers, family members, and so on. Be sure to prepare your staff for how to receive these new team members. If health care staff respond to every suggestion that these outsiders bring with defensive explanations about why it is the way it is and how it simply must be that way, the fresh input will soon stop. On the other hand, if the fresh perspective is greeted with genuine openness, curiosity, and a desire to see where it takes us, new approaches to issues are possible.

Our team is a real mix of NHS improvement specialists, non healthcare improvement specialists and people new to improvement but very familiar with the hospital and the NHS. The team includes staff with improvement backgrounds in the NHS who have a balance of clinical and non-clinical expertise. In addition we have staff members who have come from the Royal Air Force, the Automotive Industry and the Financial Service Sector. The diversity of the team gives it strength and builds in challenge and creativity. Having some clinical expertise within the team is extremely helpful and lends credibility to our work. We often buddy up NHS and non-NHS people on pieces of work to make sure that nothing is overlooked and to provide fresh insights from a range of different perspectives.

Sue Stanley, Director of Service Improvement, Northampton General Hospital NHS Trust

Increase the use of job shadowing, short-term work rotations, and longer-term secondments to increase individuals’ awareness and valuing of different ways of thinking and working.

These structures from workforce development enable one to gain a more diverse perspective by “walking a mile in someone else’s shoes”. For example, having doctors spending time shadowing a nurse, or the Finance Director shadowing a porter might provide new insights into how, together, they might do things differently to benefit patients and carers, as well as each other. The more you are able to do of this sort of thing, the more staff begin to value and trust one another. This creates a climate where everyone feels more comfortable sparking off colleagues to create ideas that neither party could have previously imagined on their own.

[i] All of the information on the Elements of a Culture of Innovation, Assessment, and Tips for Leaders were adapted from Maher, Lynne, Paul Plsek, Jenny Price, and Mark Mugglestone, (2010), “Creating the Culture for Innovation: A Practical Guide for Leaders” published by the National Health Service (NHS) Institute for Innovation and Improvement in the United Kingdom; and by Plsek, Paul, (2014) “Accelerating Health Care Transformation with Lean and Innovation: The Virginia Mason Experience”, CRC Press.

Paul Plsek is MI2's Innovator-in-Residence. He has designed and facilitated Thinking Differently sessions in some of the largest health care organizations in the US (e.g., Kaiser-Permanente), as well as for health care organizations in the UK, Sweden, Norway, Denmark, Canada and Australia. (The UK-based NHS content we have adapted in this tool kit has many examples and references that are specific to England). Paul has authored or co-authored several books and numerous peer-reviewed papers on creative thinking and complex systems theory and their applications in health care.