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

An interview with Salma Yasmeen, Executive Director of Strategy and Change and Interim Deputy CEO at South West Yorkshire Partnership NHS Trust.

Daniel Taylor: What role should boards play in making sure change isn’t just transactional but transformational?

Salma Yasmeen: Boards need to create the right conditions for transformational change. And for an open, honest culture of improvement. One that includes the diverse perspectives of all their members. That’s vital if they’re going to fully support the change process and deliver its strategic objectives.

The board’s approach to change sets the tone for its delivery at every level. Conversations have to be open and honest. They must allow new and emerging aspects and insights to be recognised and incorporated. And they must encourage change leaders to be open to diverse voices, insights and perspectives. Those voices can and should inform the process. Because they will make it truly transformational, not just transactional.

A key part of that is including innovation. New ways of working, or delivery, that make things better for the end user.

Daniel Taylor: What role does governance play in this?

Salma Yasmeen: The board sets the tone and creates the right conditions for transformational change. So it’s up to them to ensure good governance, and genuine involvement at all levels. They need to manage risk, and create robust project processes. That goes for change processes, too. They need to recognise the human aspect of change. What’s happening for real people, doing the job they do every day.

In practice, it’s not enough just to focus on process and governance. Of course they’re important, but your change team needs to draw on the widest possible range of skills and abilities, from every part of the organisation. And it’s vital to involve the people most affected by that change as early as possible. You really need to capture the insights of service users, carers, their families, and their wider communities and also involve them to co-produce solutions.

If people in the front line are involved in change from the outset, it’s far more likely to be sustainable. Because they recognise the challenges – but they also understand the opportunities for change.

Daniel Taylor: Is this something you’ve learned from experience in your own trust?

Salma Yasmeen: When our chief executive joined the trust, five years ago, he took time to listen to the staff. What he heard was that change had felt very ‘top-down’ to people on the front line. So he ensured that both the board and the leadership team were committed to an approach with a broader perspective. One that delivered inclusive change; that genuinely empowered staff at every level.

Working with the board, a key part of my role was developing a framework that could support innovation, change and improvement right across the organisation. That’s an integral part of our quality and improvement strategy. It’s also how we support and understand the change process.

There are three levels of change at the heart of this approach. The first is that anyone and everyone can make change happen. Whether they are a healthcare assistant, a front-line nurse, a porter or a cleaner. Anyone might have an idea that could improve the way they are working, or the way care is delivered. So if they could do something different, and better, with no risk, no cost, and no unnecessary complications, we encouraged them to make that happen.

But we also wanted an infrastructure for that – a way for people to communicate their ideas, or to check with colleagues that they weren’t duplicating effort. So we brought in a crowdsourcing platform that’s become an integral part of our approach. It enables staff in every part of the organisation to connect and talk to each other. We were happy for people to make changes, but we encouraged them to share what they’d done. To share the learning. Or even to check in with a suggestion to see what others thought about it.

Daniel Taylor: How has that developed? Has it enabled significant change to happen?

Salma Yasmeen: To be honest it took several years to make an impact, and then COVID hit. We’ll reignite that – we’ve got about 2,000 staff connected – but it was already delivering results. For example, before COVID our chair ran a challenge around sustainability. If we’re going to take that seriously it’s more about winning hearts and minds than just focusing on carbon footprint. We’ve already been reducing waste and plastics for quite a while.

There was a great response from staff at all levels – and in particular from a group who really got involved. They've helped inform and shape some of the priorities. As a result we're working on a completely fresh approach to sustainability, with a much broader outlook. It will connect into all the work we’re doing. Including our work with partners in the community.

Daniel Taylor: What about leading transformation that involves elements of partnership work?

Salma Yasmeen: That was our second level of change – working in partnership with external teams. Those could be primary care networks or the local authority, for example. If we want to create a more integrated pathway, we’re facing exactly the risks we want to avoid: cost and complexity. So that’s where you might need some governance. You have to get managers behind it, and you might need expert help.

That’s why we have an integrated change team, and try to operate an integrated network across the organisation that supports change. The team includes people with skills in project management, change management, and quality improvement and assurance. And we’re training more of them. The ambition is to make this simply ‘the way we work’.

The third level of change is Trust level change This is often complex or emergent work – or both. This level of change has board level oversight at all stages. For example, we had to be sure our new clinical records system included a strong, integrated approach to governance. It was a complex, high-cost, high-risk strategy that touched almost every part of our organisation. So it had executive-level sponsors. It reported regularly to our executive management board and the trust board. And it was sponsored by the chief executive.

It wasn’t led by the tech team; it was run as part of larger change project. That’s because we saw that the only way to move successfully to a new system was to get buy-in from everyone in the organisation. So, we had more than 400 people involved in selecting the system. And people in every clinical team telling us how they were using it, what was getting in the way of delivering and recording good care, and what could be even better.

Daniel Taylor: What role did communication play in a transformational change this significant?

Salma Yasmeen: Communication played a really important part, because we mapped out the journey in stages and phases. We managed risk, so the board had a full understanding of who was getting involved and how. They gave us the support we needed to communicate the changes on a regular basis. That, in turn, allowed us to develop a shared language, and a shared understanding of each step in the change process, which also helped to manage expectations about the results from the first phase of implementation.

But we were ambitious too. We wanted to deliver more time for actual care. And we wanted our system to capture input from carers and service users, not just from our own staff. But we needed a safe transition to begin with. We needed to start with the system as it was, and then move forward step by step, in an ongoing journey of improvement.

Doing it that way has kept our staff on board with the process for the first 12 months, despite the discomfort and frustration while it wasn’t working as they wanted it to. And they’re still involved in an optimisation process. That will go on for as long as it’s needed.

The board created the right conditions for positive change by providing the right resources, supporting the right processes, and achieving the right level of clinical engagement. All the way through the programme. And, as I’ve said, we took care to get feedback from end-users, too. People like service users, governors and members.

So that’s one example of how we handle large-scale change. We take the same approach to strategic and emergent change. Take the work we've been doing with partners to develop integrated governance arrangements. They were informal to start with, and now they’ve been formalised. That’s in response to the government White Paper, and the establishment of integrated care systems as formal bodies. We’ve been on that journey for a couple of years, in each of the places we provide services. The board regularly discuss these evolving partnerships and the trust’s role within them. Our intentions are clear: to deliver joined-up care in communities and to reduce health inequalities. We keep an absolute focus on that purpose.

Daniel Taylor: How important are information flows between the team leading the change and the board, both ways, during significant change? Especially when partners are involved?

Salma Yasmeen: In our work with partnerships we’ve always kept the board appraised. That’s enabled them to consider what we’re doing, the way we’re shaping those partnerships, and the arrangements we’re helping to put in place for governance, so we can deliver even better joined-up care. That was always the main aim. As a result we’re seeing far better integration in places, in provider collaboratives, in alliances, and in the integrated care systems we are involved with. It’s been a journey! In the early days it was important to hold our nerve – to create enough space for that partnership work to evolve and to emerge with a clear purpose. That’s still important now.

It’s really important for boards to focus on people, involvement and innovation – but to balance that by managing risk and performance. We need an appetite for risk that allows innovation and transformation to happen. And we have to understand that ideas and insights may emerge that will lead us on a slightly different path. We need to let that happen but in a safe and supported way.