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Skip to 0 minutes and 4 seconds So I’m going to talk today a bit about what I describe as formative spaces within healthcare systems. Where people can reflect and think a bit about how they provide healthcare and think about ways in which they may be able to improve the way that they do so. This idea really came out of some research I did a while ago on regulation. One of the interesting things we found was that it was very important for professionals to have an opportunity to stop and reflect and think about how to improve some of the things that perhaps weren’t going quite so well for them in their practice.

Skip to 0 minutes and 36 seconds But often, how these spaces were crowded out by worries about the regulatory system, which really suggested that these spaces needed to be safe, but also formative and challenging. So if issues that weren’t going well, needed to be addressed, they were addressed. Recently in healthcare, there’s been interest in ideas around what’s known as Balint groups, where professionals come together in groups, and they talk about some of the challenges and issues they’re facing, ways of improving them. We have ideas around the notion of Schwartz Rounds, again, similarly where professionals step away from their day to day work and reflect on and talk about some of the challenges they’re facing.

Skip to 1 minute and 14 seconds And also, of course, many professionals have clinical supervision, where they talk to another professional about their practice and ways in which they can make improvements. So this is an interesting way in which individuals and teams can improve the way they provide care, but often these spaces require what’s known as psychological safety. So people need to be able to feel safe. And Amy Edmondson, from Harvard, has talked about the importance of psychological safety, in order for teams of nurses in her study to learn and improve how they’re providing healthcare.

Skip to 1 minute and 47 seconds More recently, I’ve also done research looking at how, in healthcare systems, people can step away from their organisation, and again, think about some of the challenges they’re facing in their organisation and think about ways in which they can actually address and improve these issues. Crucially, in our study on actual learning sets, people needed to be outside of their organisations in order to be able to be free to think and talk about issues in ways that perhaps they weren’t able to do so in their day to day jobs. I’ve also done some research on networks and healthcare systems.

Skip to 2 minutes and 18 seconds And one of the interesting features of effective networks was that they also created the space in which professionals, from different organisations and professional constituencies, could talk about ways of improving the healthcare services that they were providing. But often, in a way framed by wider policy and targets that they’re facing. We talk in a book, entitled Making Wicked Problems Governable, about talking shops and burning platforms. And often, in order for problems to be really addressed effectively, people need to have a burning platform to actually give them the motivation to address problems.

Skip to 2 minutes and 54 seconds The other issue to do with spaces is often they’re framed by issues of wider power and politics, and also by people’s anxiety and concerns about openly voicing changes they’d like to make. So people creating these spaces really to think about the politics and the potential emotional discomfort that people might experience openly voicing their concerns and ways in which they would like to improve healthcare systems. Another interesting study that’s been done is by Kate Kellogg who talks about the notion of relational spaces. She did a piece of research in which interns were trying to change the working hours that they spent in hospitals.

Skip to 3 minutes and 33 seconds And attempted to make changes in the face of resistance from middle managers who wanted to keep things as they were. She talks about this idea of relational spaces. This idea comes from the Civil Rights Movement in the US, where people trying to change the system often got together in spaces like church halls and talked about ways in which they would be able to or like to change the wider system. These relational spaces crucially were hidden away from people who might try and resist the changes. So Kate Kellogg, in her study of institutional change in surgery in the US, she uses this idea. And she talks about how, in these relational spaces, people can come together.

Skip to 4 minutes and 14 seconds They can experiment with new ways of being, new ways of thinking, new ideas and identities, free from worrying about what people who are trying to resist change might think and the ways in which they might try and prevent the change from happening. And in her study, she talks about how, by bringing together members from different constituencies across the organisational system in these relational spaces, people were able to bring about changes that were being resisted by middle managers. I’ve also done some research on a Kenyan network aiming to improve paediatric care, provided for children in the Kenyan healthcare system in district hospitals. And again in this network, we see another example of a very effective space being created.

Skip to 4 minutes and 56 seconds This is both a physical space, where people physically come together and talk about improving paediatric care, but also virtual spaces, where people can come together and share ideas. Professor Mike English and his colleagues at Kemri in Nairobi have developed a network which again seems to be very effective in terms of getting people to understand different pieces of evidence, guidelines. Getting people to buy into the idea that actually change is a good idea and also sharing learning about how people can improve healthcare systems. Again, this network seems to have been very effective, but partly because they were able to create psychological safety, a space in which people trusted each other and felt safe.

Skip to 5 minutes and 36 seconds But also it was effective because of the work of the leaders of the network, who were very effective in thinking about and negotiating the wider political system and involving key stakeholders in the network in order to bring about effective change. So one of the things the Kenyan healthcare network was able to do was create a collective identity movement. So there is a group of paediatricians who are committed and engaged in the idea of actually improving paediatric care, and paediatrics is a specialty within the Kenyan healthcare system. So the network created a space for doing that and seemed to be very effective as a result.

Skip to 6 minutes and 9 seconds So in conclusion, I think spaces in which people can reflect and think about and discuss ways of changing and improving healthcare systems, are very important. And I think we could look to how we might be able to create these spaces and healthcare systems. But we also need to be aware of the challenges and potential limitations of them, particularly around creating that psychological safety, so people feel able to actually openly, honestly discuss issues without fear of being subject to potential challenges or attacks as a result of doing that. And relatedly, we need to also think about the wider power in politics within organisational systems. Often things are the way they are because particular interests want them be that way.

Skip to 6 minutes and 48 seconds So we need to strategise and be rather skillful in the way we think about creating spaces and bringing about change and improvement in the healthcare systems around the world.

Creating spaces for innovation in clinical networks

Here we turn to the notion of organisational ‘spaces’ that might facilitate the development of networks and promote learning and exchange of ideas.

In this short lecture, Professor Gerry McGivern, at Warwick Business School, defines what is meant by ‘learning spaces’ and distinguishes between different types and the conditions that support them. Focusing on research conducted in US hospitals, he talks about ‘relational spaces’ in which reform-minded clinicians feel freer to innovate and take risks.

Talking point

  • Why is it important to create the kind of secure spaces for learning and communication described by Professor McGivern?
  • Can you think of examples of such spaces in your own organisations (or those you have knowledge of)? How, if at all, are they useful?

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This video is from the free online course:

Leadership for Healthcare Improvement and Innovation

The University of Warwick