HiNZ, 19 Nov 2019, Hamilton

Trust building, thinking, and learning tools to create an inclusive culture of innovation and collaboration


The second HiNZ workshop on this topic again brought together a committed group of healthcare professionals from across the country.

After a short round of introductions and a summary of the results achieved since the first workshop in 2018, participants outlined two sets of complementary problem statements:

  1. How to initiate change: Analysing constraints and overcoming cultural inertia
    • Teaching, learning, and change in a capacity constrained environment
    • Challenging the executive team to understand change and the cultural context needed to support business as usual as well as innovation initiatives
    • How to get management to open up to bottom-up disruptive change; how to get traction
    • How to maintain an inclusive culture of innovation in a context where teams have limited technological literacy and where technology is not seen as an important driver of improvements
    • Managing people’s response to change
  2. Describing the target: Characteristics of an inclusive culture of innovation and collaboration
    • What is the best environment to nurture innovation and psychological safety
    • The role of language; avoiding slogans (Deming)
    • Encouraging a collaborative mind set and culture

Both sets of problem statements were discussed in parallel in two groups. The results are summarised below and have also been added to this presentation, which includes the introductory slides for the workshop as well as a synopsis of the results from the HiNZ workshop in 2018.

Group A: How to initiate change

Healthcare in many countries has a fundamentally hierarchical power structure with three silos that have their own power pyramids i.e.

  1. administration,
  2. clinicians,
  3. and nurses.

Specifically, we discussed the power differential between those in the administrative ELT (Executive Leadership Team) within DHBs and those stakeholders or initiators of change on the front line. It all depends on the porosity of the layers in organisations and the ability for knowledge to flow freely without regard to organisation charts, power differentials, and formal reporting lines. The ability to freely raise issues and come up with suggested improvements depends on psychological safety.

For example, the ability of a nurse to observe a problem or error in the treatment of a patient and feel uninhibited and free to discuss this with a senior clinician who may have overlooked the problem. In her book, The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth, Amy Edmonson tells an account of a young nurse in a Neonatal Intensive Care Unit and her recent training in the use of a medicine used to promote lung development in high-risk babies. The young female nurse observed how the older male clinician on her ward had failed to order a prophylactic surfactant and he had left before she had summoned the courage to ask him about it. She had witnessed the specialist berating another nurse the week before for questioning his orders. There was no psychological safety in her work environment despite there being a high-risk of the death of neonatal twins in this case.

“Psychological safety was by far the most important of the five key dynamics we found. It’s the underpinning of the other four.” Julia Rozovsky, “The five keys to a successful Google team.” – Edmondson, Amy C. The Fearless Organization

If a young nurse did not feel brave enough to speak out about a potential life-threatening omission then it is hardly surprising that many in NZ DHBs have difficulty making innovative suggestions to those at the top of the administrative pyramid about none life-threatening improvements to other processes. We discussed within our working group small projects that had succeeded and how members of the ELT had noticed and asked how it had happened. This provided an opportunity to engage the ELT in changes that could lead to substantial innovations as trust built.

The group concluded that it was important to find “Champions of change” (sponsorship) that are equipped with a sense of ownership and a mandate to market the need for change.

Group B: Describing the target culture

In this discussion we built on the results from the previous workshop in 2018, to focus on outlining suitable values, operating principles, and implementation guidelines for an inclusive and collaborative culture:

  • Appreciate the value of long-term thinking – objectives that require concerted efforts over periods of 3 years to 30 years and beyond.
  • Appreciate the need for local autonomy for operational decisions – objectives that require immediate action within a week or shorter time frames.
  • Non-hierarchical governance and flatter structures – appreciate the loss of agility and the loss of innovative ability that occurs when most ideas and decisions have to be communicated and endorsed via hierarchical reporting lines on a monthly, quarterly or yearly basis.
  • Consider corresponding reductions in compensation gradients to avoid informal hierarchies and social power gradients from interfering with the free flow of knowledge within the organisation.
  • Appreciate the value of tacit knowledge, and that it takes a person around two years to develop the tacit knowledge needed to become fully productive in an organisation.
  • Design roles and responsibilities around the intrinsic motivations, interests, and strengths of individuals rather than around cookie-cutter job descriptions.
  • Implement an advice process to improve organisational learning and decision making.
  • Encourage staff to work on important tasks/deliverables in buddy pairs, which not only reinforces the habit of seeking and giving advice in a collaborative context, but also pro-actively minimises “single head of knowledge” problems.
  • Structure the organisation using service/product line engineering principles, such that teams are categorised by the dominant time horizon of decision making (work stream) within the team:
    • Service delivery – business as usual, focused on daily operations,
    • Service design/development/change – focused on monthly and quarterly releases,
    • Service ecosystem and platform analysis/design/development – focused on objectives with a long-term time horizon and on monthly and quarterly releases of service platform extensions/improvements,
    • Experimentation – temporary teams tasked with developing new knowledge that is relevant for service ecosystem and platform extensions/improvements.
  • Complement product line engineering principles with further thinking tools to create an inclusive neurodiversity friendly culture.
  • Design and implement appropriate formal and informal feedback loops between teams within each work stream and between the four work streams – these feedback loops constitute the governance framework of the organisation and enable regular a review shared values and related actions.
  • Catalyse knowledge transfer and organisational learning across the organisation by encouraging staff to migrate permanently or temporarily (at least 3 months) to another team within the same or within in a different work stream – however take great care to avoid situations where a person is simultaneously responsible for deliverables as part of two or more work streams, as this inevitably reduces focus and quality, and may lead to burn-out.

Group C: The important role of language

After the lunch break both groups shared results and then continued discussing the implications, and in particular the role of language in being able to diagnose, describe, and treat organisational dysfunctions. One of the first steps towards addressing organisational dysfunction involves compiling a dictionary of definitions of symptoms and functional attributes that reflect the specific context of the healthcare sector.

In the coming months the group intends to collaborate on suitable definitions for the following terms:

  1. Bullying
  2. Burn-out
  3. Coding error
  4. Coding variability
  5. Data change audit trail
  6. Diagnosis update
  7. Domain specific metric
  8. Fear
  9. Feedback loop
  10. Governance
  11. Groupthink
  12. Intrinsic complexity
  13. Manipulation of metrics
  14. Neurodiversity
  15. Organisational silo
  16. Organisational learning disability
  17. Psychological safety
  18. Shared understanding
  19. Social power gradient
  20. Spurious complexity
  21. Tacit knowledge
  22. Time horizon
  23. Trust
  24. Wellness

Next steps and references to related guidance

What we have noticed at S23M with clients and in other industries is that before an organisation can begin to start engaging more stakeholders in innovation beyond just a few high up the chain of command, they must first establish psychological safety so those close to the action can also offer up ideas.

Guidance for developing an inclusive and collaborative culture:

The ability to start establishing safe zones is dependent on trust that is hard-won and easily lost. S23M offers regular Open Space workshops that allow staff to come together in a safe environment to freely exchange knowledge, and to arrive at a shared understanding of the problems before them.