Good governance of transformational change - an interview with Salma Yasmeen part 2

Part 2 of our interview with Salma Yasmeen, Executive Director of Strategy & Change and interim Deputy CEO at South West Yorkshire Partnership NHS Trust. We published part one on 29 November.

Daniel Taylor: In the first part of this interview, you spoke about the vital importance of listening to everyone involved in the change process – how co-production was the key to successful transformation, and how that’s built into your trust’s approach.

There's a great anecdote about JFK going to NASA headquarters when America was desperate to be first to the moon, about two or three weeks from the launch. He bumped into a janitor in the corridor and said, 'nice to meet you, what's your role here? And the janitor said, 'my role here is to put a man on the moon.'

I love that because it speaks to what you're talking about. If you create an inclusive environment, everyone will feel they have a stake in change.

Salma Yasmeen: Daniel, are we there for every change? If you ask every single staff member, then depending on the type of change, where we are in the journey, and how strongly they connect to it, their answer will be different. I don’t want to claim we're a utopian organisation. But most, if not all our staff could tell you their version of our trust mission, and how those values relate to their work. Because this leadership team has built on the ideas and values staff already had, and then worked with them to evolve those values.

I’d say our approach to change has two key components. We’re investing in the infrastructure to support change, but we’re also investing in an evolving culture to make that change genuinely inclusive.

We’ve even put the board through leadership development programmes. It means they understand quality improvement and can ask the teams who are doing the work the right questions. That gives them a deeper understanding of the challenges involved, and how they can best support the change they are looking for.

Investment in people is a key part of our approach. Every year, for the last three years, we’ve put about a hundred people through the IHI Open School. People from our volunteer workforce, as well as staff from every part of the organisation.

Once they’ve completed that training, they can join a growing network of change and improvement facilitators. So over time we’ll create a critical mass of people who understand exactly how to deliver systemic quality improvement. People with a shared language, and a shared approach.

The technical aspects of change – good project management, discipline and processes – are important. But so is involvement, and the human aspects of change. If we don’t pay enough attention to those, the change won’t stick. People won’t feel energised or empowered. We’ve worked hard to develop a blended, integrated approach, so we’re not worried about methodology. We want people willing to use a range of tools and frameworks to deal with the areas that they’re working on. We’ve introduced the PDSA approach at the most basic level; and then, as the change gets more complex or transformational, we can draw on a range of approaches and methodologies.

Daniel Taylor: You were talking about the main outcome for the patient records work being to release more time to care. Sometimes transformation – and this obsession with change and improvement – can feel exhausting to a workforce when it's not connected to why they do what they do.

Salma Yasmeen: Absolutely – and what gets in the way of successful and sustainable change is fatigue. People just get tired. They’re understandably sceptical about yet another project. Another initiative. Another new person with a new idea, who’s ignoring what’s already been shown to work really well.

So, a new leadership team that wants to ‘throw out the baby with the bathwater’ – not helpful. Good leadership teams want to understand and hold onto things that already work well and take them forward into the next phase of change, so it really connects to people’s histories. To that team and the efforts they’ve already made. And, at the same time, create enough energy for those people to take the next step. To create further change or improvement through a more evolutionary approach.

So ‘appreciative enquiry’ about what works well, and what is deeply valued, is very helpful. We might want to address a problem, but it’s more to do with building on things that are already delivering results.

Daniel Taylor: That's a really important point, because people's image of transformation is of a sparkly new thing. But sometimes really valuable transformation can build on existing work, or doing something in a new or very slightly different way.

Salma Yasmeen: Exactly. Change isn’t always about a ‘big bang’. We often achieve improvements through smaller, iterative changes. And it’s important to help people see how the ambition for improvement takes what they are doing already, and makes it better.

We mustn’t disempower people who are committed to making something better, because those are precisely the people we need. You can so easily lose them by saying ‘We’ve got this great new idea’ or ‘We’re doing this now’. They may already be doing that, quietly, somewhere in the organisation or system.

And we need to think about people who have reason to be resistant. Perhaps they’ve tried to make changes, even tried more than once, and failed. They could even have been innovators in an earlier transformation or change. We have to engage them very early on, and win their trust. Help them see that a lot of what they’re doing could still be connected to the next phase. That it could help drive the shifts that are needed.

It’s about seeing change in context – because the history, the relationship, and the perception people have with any related change is really important.

Daniel Taylor: You’ve talked about how mindset, intent, culture and systems all play a role in transformation. Is there one in particular that's key for you? Or is it just getting the right balance?

Salma Yasmeen: I don’t think one ingredient is more important than another – but resourcing the change process is really important. That’s why we built a change team. And why we’re continuing to invest in key people, so we have the champions we need to support the next phase. The optimisation phase. Because it’s important to help people take ownership of change themselves.

I think we’ve worked on the basis that change isn’t a linear process. It depends on the people involved – their histories, their relationship to the change, and the way they think about it. Culture plays a significant part; you need to create a culture that’s inclusive, agile and responsive. Where people feel that their ideas and their priorities matter. That they can be involved and invested in that journey of improvement.

It’s important to demystify change – to help people connect with what’s going to happen next. For example, the CEO has a regular newsletter that goes out to staff. So just before we went live with the clinical records system, I was invited to take over the weekly View. I focused on change, and our human response to it. I said we might all have different feelings, emotions and expectations about the new system on Monday (the day it was going live), and that was OK. But I also gave them the reassurance that we’d stay with people on the journey. That this wasn’t the end state. It was a big milestone, yes, but we’d continue to work with people in the future.

You can’t just say ‘Fine, we’ve done that bit, let’s move on.’ It takes time for transformational change to bed in. And it takes time to develop a culture of improvement that is open and transparent.

Daniel Taylor: I was once heavily involved in a two-year transformation programme with a local authority. The joke was that when I took the position, that two-year programme had actually been rolling for about six or seven years. So good transformation never ends. They even talked about renaming it as ‘the development programme’ or ‘the ongoing improvement programme’. But you’re right – change takes time, and it needs proper investment, leadership buy-in and effective governance.

Salma Yasmeen: Yes, and transformation happens over a longer time. But if you build a culture of learning and continuous improvement you can develop a language that helps describe the different stages of the journey, and manage expectations. We don’t want people thinking ‘Gosh, we’ve been transforming this forever, but we never get there!’ It’ll always be an ongoing journey, but you might have one phase or several that are transformational.

Just switching from one system to another may not be truly transformational, because it doesn’t deliver the outcomes or the benefits that would make it transformational. But that’s just the first phase – because then you start the optimisation phase. That’s about ongoing improvement. About empowering teams to understand that they’re in charge of the new system. That we want, and need, their ideas about continuous improvement as they learn how to use it well. Communication plays a key part at every stage of the journey.