Good governance of transformational change - an interview with Salma Yasmeen part 3

The third part of our interview with Salma Yasmeen, Executive Director of Strategy and Change and Interim Deputy CEO at South West Yorkshire Partnership NHS Trust. The first and second parts of this interview are still available.

Daniel Taylor: Earlier you talked about change agents, and taking over the CEO’s newsletter a week ahead of a big change. I was thinking about how you have to guide people through change, because that can be intimidating and challenging. So leadership isn’t just an executive thing, you need it on the ground too. How important is that visible role modelling?

Salma Yasmeen: I think fundamentally important. We had people on the programme team who understood the technical side, and people from the integrated change team. But our core support came from clinical and operational leaders running service level improvement teams. And because they were modelling the change they probably had a greater impact than I did. Getting ownership and oversight of change at CEO and board level shows it’s important to all of us. We're all impacted. We all want to hear if things aren't going well, and we want the change to be informed by those that it impacts which is why leadership at every level is key to successful change.

Board-to-ward communication, and doing the leadership rounds, are both vital, so our non-execs were part of the governance group. One was on the programme board, which reported to the executive team, and then into the board. She had a strong background in digital transformation and she was involved right the way through, offering incredibly helpful challenges and insights. I was the SRO who chaired that board, but I did it jointly with our clinical and operational executives. Hearing their voice was critical to ensure safety.

A change programme must have leadership at every level. So I think we always need a clinical and operational sponsor as part of the exec team. And a digital sponsor if it’s a digital programme. We always think about who the visible sponsors are, because that can send out a strong signal. But it’s important for the change team themselves to communicate – to run workshops, lead conversations, and understand the human elements and to ensure visible clinical and operational leadership at every level.

Daniel Taylor: Yes, the tiering of that leadership is so important, and getting that balance right.

Salma Yasmeen: When I did PRINCE2, years ago, they said you should spend more time planning than implementing. During the pandemic people pivoted and changed very quickly. But it’s not sustainable. People are exhausted. And it's not necessarily hard-wired. Once the adrenalin rush is over we want to get back to what’s familiar, and we don’t always appreciate the unintended consequences. When you need to save lives, there’s no choice. But two years in, people are tired. We’d love to go back to a safe world, with no existential threats, but we have to live in a different context. It’s so important to support people through that and for some people change is what energises them if they are involved and feel they can make a difference. What is important is to ensure that support is available and spaces to enable people at every level of the organisation or system to reconnect to their core purpose through creative reflection and or connections through networks.

Daniel Taylor: There's a great Abraham Lincoln quote: ‘Give me six hours to cut down a tree, I'll spend the first four sharpening my axe.' I love that because planning and preparing right makes the task so much easier.

Talking about pace of change – and I know this sounds bad – there was almost an adrenalin rush with the pandemic, because it was such an existential threat. The scale was unbelievable, and there were urgent things that had to happen to avert real crisis. Everyone was bound together, because everyone was united by one common goal and purpose.

But as we come out of that, people struggle to cope with the intense energy it has taken. And we’re beginning to see the different impacts on individuals and on groups. So how much transformation can people continue to cope with? At what level? At what pace? And how much extra capacity will it take to support changes and improvements in this ‘new normal’? these are all key considerations to enable us to move forward collectively.

Salma Yasmeen: Our board takes that very seriously: we’ve constantly reviewed and revised our strategy over the last couple of years. I remember a wise coach say that when you’re driving change in complex environments you have to keep looking from the horizon to the bonnet and back again.

I thought that was a really good analogy. You've got to keep an eye on what's right in front of you. The system pressures. The operational pressures. What front-line staff are dealing with. As well as helping people with these everyday challenges on the way to the transformational change – the recovery – we’re talking about. Because we never stopped delivering care and services during the pandemic.

Before the pandemic, once or at the most twice a year, we’d review our priorities. That doesn’t mean anything became less important. It’s just that we might say something was going to take collective effort across the organisation. So we’d either speed up or slow down that process. Whatever would best support our collective energy and focus. Looking at all our corporate and clinical teams, we might ask how much change we could realistically do, given what else they were dealing with. That way we could sort our goals into low, medium, high and critical categories.

Since the pandemic, if I'm honest, we're probably doing this every quarter. Part of that has to be about checking in with front-line staff and the pressures they're dealing with. We need to be really clear about what’s needed, and keep a focus on it. There’s a huge amount of transformational change going on. Mental health teams right across the country are transforming community services to handle that increasing demand. To wrap integrated, joined-up teams around people in primary care.

And yet – at the same time – front-line teams are dealing with that rising demand. Even while they’re working with partners to develop these new, joined-up teams. And we've got a workforce shortage, haven’t we? Fundamentally its about being open and honest about what to prioritise and what the impact of that choice is.

Daniel Taylor: So many challenges! It really needs careful consideration and constant revisiting. And yes, it’s also about going down onto the wards and getting that honest feedback.

Salma Yasmeen: Exactly – and boards play a fundamental part in that. We have to understand those competing priorities and help the organisation make clear decisions. We work in a unitary board, so we make collective decisions – about what’s prioritised and about what we accept can’t be done right now, because we need to pivot and move our resources.

The vaccination programme, for example. We had to resource that, so we prioritised it. And we prioritised our EPR (Electronic Patient Record) and resourced that. So we’ve ensured a real focus on health inequalities as we work to recover services inclusively. We’ve really had to think about capacity around data insight; about capturing the feedback from our communities so we can deliver on our recovery efforts. And making sure that data’s available to front-line teams who may have to prioritise people on waiting lists.

Daniel Taylor: When you think about people’s fatigue, and resistance to change in general, governance often seems to create too much process. Too much structure. It can look like a disabler: more barriers, more bureaucracy, more work. But you can govern in a lean way that still supports change and transformation. Is that your view?

Salma Yasmeen: Absolutely. Good governance really thinks about resourcing involvement and inclusion. Ensuring all those voices – clinical staff, services users, carers and the community – are at the heart of the change process. That everyone’s thinking about the risks that are appearing, and how to mitigate them.

Good, inclusive governance, with people working together at different levels, delivers a massive benefit we don’t often talk about. It builds a growing community of people with a shared understanding of what’s happening. And a shared language to talk about challenges, and possible solutions. Which means you can intervene early – or reframe what happens next – based on what might emerge, or what new insights might suggest. It really helps if you can simplify the governance tools. Develop them once, and use them at all levels.

Going about it the wrong way makes it transactional. Burdensome. It doesn’t allow that open, honest ‘frontline to board’ or systems conversation and/or oversight. You must be able to go to the board and say ‘Look, we’re behind on these milestones, and these are the implications. It’s going to take a bit longer.’ As it turns out we did that several times. There were technical aspects that needed more work, more resource, and it was going to cost significantly more.

The board had to be aware of that and make the right decisions. After all, we’re using public money so every penny counts, and we had to understand why we were spending it. But because the issues were picked up early, because we could have that open and honest conversation, we could give the programme the resources it needed.

Daniel Taylor: That’s so important – I’ve seen it on some of the digital projects I’ve worked on. And you spoke earlier about the importance of flexibility – that in transformational work you often find things you didn’t know at the outset that can change the picture. So the board has to be agile about its decision-making, and have the right information at the right time.

Salma Yasmeen: Which comes back to my first point about balancing scrutiny and challenge with support. Because you need either a really good unitary board, or one that draws on all the local perspectives, and all the local knowledge. Non-exec colleagues may well come up with solutions and options no-one else has thought of. It doesn’t just introduce a level of rigour. It also makes it possible to have an honest conversation – to be honest brokers.

Of course, that’s only possible if you’ve done the groundwork, if you’ve built partnerships, in our case both inside and outside the organisation in our systems. And it takes time to achieve that and for those partnerships to evolve. Truly transformational change requires a shared language, and almost always happens incrementally. That’s how teams take ownership of the change and feel empowered to continue the process. And in my view that’s the key to success in culture change, in continuous improvement and in transformational change.