My final MBA assessment on organisations and leadership: cultural change in the NHS

Hospital signpost

I once did an assessment on cultural change for my MBA organisations and leadership. I would like to share it with you as an example of how this sort of problem, in the NHS, might be approached. Please note that this case study is entirely fictional. I am posting this solution of mine as an example for teaching purposes. I was successfully awarded my Master of Business Administration from BPP Business School at the London Guildhall in September 2012.

Introduction

The case study of Reddix presents a failing NHS Trust where a number of clear problems have been identified, and external consultants have presented to senior management at the Trust a solution for implementing a “pervasive knowledge culture” (“PKC”). Managing change in the NHS has been the focus of much energy in the NHS in recent years, but thankfully clear guidelines exist as to how a successful cultural change should be approached. These are outlined by Maher, et al. on behalf of the NHS Institute for Innovation and Improvement (2010). This article will consider current thinking as to how Reddix could maximise its changes of a successful culture change, and also address specifically the types of steps which senior management would have to assume to create, develop and reinforce a PKC.

 

 

The need for a successful cultural change and creation of a PKC

 

The IT revolution” and knowledge management (“KM”) are still very much at the forefront of NHS management (NHS Department of Health, 2011), emphasising core principles of improved outcomes, people’s control of (and access to) information regarding their own health care, and the use of information for improved clinical outcomes. These are also stated proposals of the PKC implementation in Reddix. The NHS Modernisation Agency in 2005 wished to emphasise the role of knowledge management: “Knowledge management is a process that emphasizes generating, capturing and sharing information know how and integrating these into business practices and decision making for greater organizational benefit”. The external consultants to Reddix appropriately concluded that a “workflow management system” could be implemented to great effect in Reddix. However, change is often referred to as an ongoing and never-ending process, and organisational change does not always unfold in expected ways (Burke, Lake & Paine, 2008).

A clear explanation to existing staff at Reddix will be necessary as to the potential benefits of the change to a “distributed computing architecture” such that Reddix does not loose out any more in competitive advantage compared to other NHS Ttrusts; the clinical and support staff of Reddix (including doctors, nurses and other health practitioners) may not be aware that change is necessary, they may not agree with the proposed change, disagree as to how the change is being implemented, or feel that there is extra work for them as a result of these changes (NHS Department of Health, 1998). The advantages of workflow management are indeed comprehensively described elsewhere, as allowing “the automaton of a business process in order to support and complement the transition of information and tasks between organizational actors to improve the efficiency and effectiveness of healthcare” (definition after Dwivedi, et al., 2001). However, it is a well-recognised phenomenon in “knowledge transfer” within different units of an organisation, that whilst encouraging innovation, such knowledge can be difficult to spread where there are not already existing connections between organizational units (Tsai, 2001).

Before embarking on the change management, a PKC strategy should be formulated (Sensky, 2002). It is now recognised that the successful management of change is a key factor of organisational performance, and should filter down from the top of the organisation (Mullins, 2010). According to the framework by Maher, et al. (2010), the Reddix organisational change is a step change, as the structure and culture are fundamentally challenged and changed. These include typically survey research and feedback, “grid training”, and T-groups (to enhance emotional sensitivity within group members). Increasingly, it is recognised that “employment commitment” should be enhanced, loosely defined as “an individual’s psychological bond to an organisation (sic), including a sense of job involvement, loyalty, and a belief in the values of the organisation” (O’Reilly, 1989). People are a key factor, and the effective management of their emotions. Reeves and Knell (2009) suggest that “knowledge leaders understand that change provokes an emotional response, that successful change involves allowing people to feel angry, resentful and afraid, as well as excited, hopeful and energised”.

There are a number of aspects worth considering. The Reddix ‘Hospital Administration System’ is described as not being ‘fit for purpose’, and is unlikely to fulfill national targets of the NHS for full electronic access to records. Replacement of this outdated IT system is enormously important for providing Reddix with the ‘right tool’ to succeed (Anthony, Johnson & Sinfield, 2008). The fact that Reddix is one of the worst performing trusts in the UK could be a useful means of creating a need for cultural change; Robinson and Stern (1998) demonstrated that cultural changes tended to succeed when aligned with a company’s strategic goals overall. Adverse drug reactions have done considerable reputational and financial damage to the Trust, and are reported as being a cause of morbidity (at least) in 10% of patients. For the change to succeed, there will need to be a sense of ‘learning from failure rather than punishing’, so that people are willing to take risks. Learning through experimentation has often been mooted to be crucial within the discipline of innovation management (Martin, 2011). A possible way of improving motivation to succeed can be through non-monetary rewards such as words of recognition from team leaders (Amabile & Khaire, 2008). There are wider clinical governance issues, and concerns about information security which pose a potential risk in patient confidentiality, subsuming a plethora of potential legal and ethical issues (Guah & Currie, 2004; Nicolini, et al., 2008). On a practical note, there are many leading suppliers of ‘Healthcare Information Security’ (HIS) systems, emphasising security compliance, operational efficiencies, and mechanisms for performance audit (IBM, 2004). Such systems could readily be used for the long-term storage of data.

Evidence currently (Smith, et al., 2008) is that organisational culture is a major affecting the speed and frequency of innovation. The case study furthermore describes a cultural malaise evident within Reddix, with overworked and ill staff, and high employee rates and absenteeism, which may be costing the Trust money. The current NHS guidelines are indeed based on a number of influential papers in general management, both within and outside the NHS. There may be a sense of urgency in the implementation of a PKC, in that it should rapidly decrease the number of serious medical errors, and address better the explicit and tacit knowledge requirement requirements of the Trust as a whole. Whilst it is conceded that there is no imperative as such to complete the Reddix organisational change fast, the speed of technological progress and the need to correct the performance ‘shortfall’ could be pressures on senior management to carry out the PKC implementation quickly (Evans, 1991) to avoid Reddix falling further down the hospital league tables.

Reddix would ultimately have to re-orient their organisational culture and realign it with their new holistic organisation structure (that incorporates both new and redesigned existing operational processes and structure). Currie (2006) highlights that boundaries in the implementation of a PKC will include organisational boundaries as well as professional boundaries, exacerbating a ‘silo effect’. These boundaries pose in practice a serious threat to the successful implementation of the PKC. Kanagasabapathy, Radhakrishnan and Balasubramanian (date uncertain) propose that the development of ‘knowledge teams’ composed of knowledge workers from cross-functional areas of the organisation would be a good first step towards a fully distributed knowledge transfer system throughout the organisation.

Tacit knowledge is harder to share as it consists of ‘mental models and metaphors, intuitions and know-how’ (Hartley and Benington, 2006), however Nonaka (1994) advocates the utilisation of ‘self-organising teams’ to engender this culture. A potential obstacle to people embracing change is the necessity for the Trust to obey legal regulatory requirements, as often described for implementing ‘disruptive technologies’ in health care organisations (Christensen, et al., 2000). The proposed KM system would integrate the patient electronic patient records (EPR) that are held by the NHS with the process of physicians and GPs ordering medical tests or medications, and this would lead to better care especially through the integration of evidence best practice rules into the system (a previously identified problem).

Finally, it is essential that this new organisational structure is one that can facilitate innovation and creativity. Maher, et al. (2010) point out that “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”; they warn that creative ideas, in contemporary organisations, tend to be the product of social interaction.


Development of a PKC

Developing the change at Reddix is dependent on excellent human resources management. It is important that the people are kept informed of the goals of Reddix, such that they are clear about how their role contributes to these. Mullins (2010) reviews a number of important steps for the development or implementation of an organisational culture. A significant issue is who should lead the change, and a report refers to challenges facing senior executives to ensure that they are better prepared to lead technological change (Tranfield & Brazanga, 2007). The authors cite that change always involves risk, and they identify five challenges for leading IT change which would be directly applicable here in the development of a PKC:

  • Creating transformational value rather than just implementing IT projects;
  • Building capacity for ongoing change; being able to predict future needs and how IT can shape those models and deliver results;
  • Create a climate of open communication;
  • Managing confidence and trust (and understanding the impact of external changes);
  • Building personal capability, leading and confidence.

These suggestions are much easier said than done; the aforementioned document also queries the ability of senior management to make critical adjustments in response to external environmental changes, and the effects of suppliers meeting tough timescales and targets. In addition, Maher, et al. (2010) have advised that employees should be asked for precise examples and counter-examples of how to encourage an ‘open culture’. Drucker (2007) argues that we cannot manage change, only lead it; hence Drucker viewed change leaders as necessary. The general consensus is that, after the development of the PKC, there should be in place ‘PKC champions’ to facilitate PKC adoption (Caldwell, et al., 2008; Lukas, et al., 2007).

The notion of ‘change champions’ is an elegant compromise that harnesses a key advantage of the “follower-centred approach”: the ability to lower resistance to change and encourage the feeling of empowerment from those being requested to implement the change (Kee & Setzer, 2006). It might be that the resistance in Reddix largely stems from the particular poor morale and motivation of the workforce at Reddix, which should be specifically targeted by Reddix’s Human Resources Department. It could result from a general state of lack of enthusiasm found in areas of the public sector, called by Ian Birrell in a provocative Guardian article as (allegedly), “lethargy, complacency and incompetence” (article online in the Guardian, February 6th 2011).

Helen Bevan, Director of Service Transformation at the NHS Institute for Innovation and Improvement, has explicitly singled out certain factors for the change to be developed. First, she disputes that the change has to be fast, describing that it is more important having formal, senior management-led, review processes. Secondly, there has to be visible commitment from senior people and teams of people with ‘performance-integrity’ who are driven by measurable results. These are evidence-based guidelines deriving from a paper by Sirkin, et al. (2005). Reddix staff might be enthused by looking at the plethora of learning materials, which they could use themselves to further themselves in a culture of innovation and creativity, once operational capabilities are optimised. These are all free-of-charge to anyone working for the NHS.

For all the steps taken to develop a PKC, according to Smith, et al. (2008), the availability of resources is critical. Reddix will need to invest in a practical Healthcare Information Security system that would allow it to keep, in the form of secure logs, records of access to sensitive clinical data, in a format suitable for subsequent storage. Ongoing training will be needed for staff to use their new technology optimally. For the KM initiative to succeed, it is important that Reddix creates a ‘knowledge sharing culture’ embracing people, processes and technology. A great deal of thought has been put into this ‘human centred’ KM approach (e.g. Peters, 1994); a KM strategy will fail if motivation amongst employees is lost, for example through poor usability of the computer systems or irrelevance of features. Also, the external consultants emphasise that the clinical practitioners (nursing and medical staff) will need to grow in confidence in using the clinical information. For this culture in ‘continuous professional development’, it would be invaluable for Human Resources at Reddix to liaise with appropriate education and training faculties of the governing bodies of the nurses and doctors [such as the Royal College of Nursing or Royal Colleges of Physicians (UK).]

 


Reinforcement of a PKC

The creation of a ‘knowledge sharing culture’ is generally considered to be ‘a fuel for innovation’, based on Liao’s (2006) seminal research. An ethos of ongoing training should ideally be encouraged; leaders and experts at a Harvard colloquium on innovation recommended that leaders “encourage individuals to gain diverse experiences that will increase their creativity” (Amabile & Khaire, 2008).  A central plank of the reinforcement mechanism is to ensure optimal performance of the PKC, including team emphasis, continuous improvement and stakeholder empowerment; it is even argued that senior management should contemplate vigorous internal marketing in this context (Chourides, Longbottom & Murphy, 2003).

A careful watch has to be put on nurturing and supporting the ‘survivors’ of change. Sean Howard, an educational psychologist, recently (Howard, 2010) advised that that poor management of motivation after restructuring can be detrimental to the performance of survivors, leading to a rise in absenteeism, lower employment engagement, lower productivity, and ultimately poorer social care. Howard advises that managers should invest time and energy in engaging with their employees to help them to understand how restructuring will affect them in the future, and to explain how they fit into the reorganised organisation. Clearly, for Reddix, any explanations of the successes of the change will be pivotal. Finally, it has previously been recommended that evaluation is an important component of the improvement. As part of reinforcing the change, dissemination of the results, and consideration of the audience, method and format of communication of the feedback should be undertaken (Victorian Quality Council, 2006). These same authors propose that any success with all stakeholders should be celebrated – including what worked, what did not, and recommendations for the future.


Conclusion

The change proposed, for the implementation of a PKC, is entirely dependent on clear leadership and management focused on people, processes and technology. The PKC offers an opportunity to address all the identified problems concerning Reddix’s performance, but careful consideration should be given to how, after the articulation of a change strategy, how this cultural change should be created, developed and reinforced. Recent evidence-based guidelines from the NHS Institute for Innovation and Improvement can be applied to see to fruition the NHS IT strategy, but will only be successful if Reddix is able to commit resources, and there is clear communication amongst all the stakeholders about what is going on.

[Word count: 2522 words]


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Please do not quote this blogpost in any form without permission of the author. To do so would be a breach of copyright of me the author.

 

Please do not reblog.

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One response to “My final MBA assessment on organisations and leadership: cultural change in the NHS

  1. Reblogged this on What It Is…? and commented:
    Below is an excellent and clear account of the nature of culture change being implemented across NHS organisations as you read this, including my own. The nurturing of a Pervasive Knowledge Culture (PKC) across the NHS is increasingly recognised as a priority for organisation leaders, and marks a considerable departure from command and control techniques that characterise historical responses to financial and political pressures.
    I have reblogged this for the benefit of those who find themselves increasingly affected by the changes that ensue, but have not yet had it clearly laid out for them. A crucial element of PKC is that all involved should know the nature of the change so that they can better contribute to and benefit from the improvements in quality of care, which depend fundamentally on improvements in cross organisation communication and our own experience of work.
    You could also do worse than follow the author, Dr Shibley Rahman @legalaware

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