17 December 2018

Activating agency

Over the last few weeks I have been reminded that, at its heart, quality improvement work is really all about connections, relationships and purpose. We may need the technical skills of quality improvement and the systematic method to navigate and learn our way through some really complex problems. But the true opportunity in quality improvement lies in bringing people together and unleashing their potential around a common purpose.

The word ‘agency’ isn’t yet in common healthcare parlance, even if we see the word ‘improvement’ frequently overused for all manner of activities. And yet, agency is really what we seek most of all. Agency refers to the ability of an individual or group to choose to act with purpose.

As our health and care systems in England and across the globe face the significant challenge of having to provide high quality care year on year whilst seeing demand increase and resource remain the same, or often reduce, it can be easy to feel powerless in this struggle, or to tighten control from the centre of organisations. There are no easy solutions, and it can feel like a huge weight to bear for leaders. However, our opportunity comes from recognising the true value of our greatest asset – our people, including staff, service users, carers and citizens – in helping us find the path to better healthcare and health of the population.

A team of people with agency can achieve quite remarkable things – whether this be the #Hellomynameis campaign for more compassionate care, the global What Matters to You movement in healthcare, or even the non-violence civil disobedience led by Mahatma Gandhi in India ninety years ago. Agency can help bring positive change of previously unimaginable scale at an incredible pace, but it needs both power and courage.

For organisations that are truly on a continuous improvement journey, the use of quality improvement is fundamentally about devolving power – inviting those closest to the point of care to help us find solutions to our most complex challenges, providing them with the skills and support to change the system for the better. The unrelenting drumbeat of quality improvement, the story-telling by teams that are seeing results and the constancy of purpose that is needed from leadership may sometimes feel almost cult-like, but is so important for creating the conditions to give people courage to try something different in what can often be difficult circumstances.

Based on our last five years of work at East London NHS Foundation Trust (ELFT), I am increasingly convinced that all quality improvement needs to be designed around one simple question: What matters to you? If we genuinely start each improvement effort with this simple question, asked with both service users and staff together, and use this to ignite a dialogue about what truly matters, we can start to connect people and create a community with common purpose. We begin then to move away from ‘us’ and ‘them’, to simply ‘us’. Quality improvement offers a way to help us break out of our silos and start to come together, united by a shared goal and bringing the best that each of us have to offer to help us get there.

Some of my most memorable moments over the last five years have been through observing individuals, who might ordinarily have felt powerless in the system, start to feel a sense of power within themselves. Administrative staff identifying and testing change ideas to reduce waiting times and distress for young people who need access to mental health expertise; domestic staff bringing their knowledge of the ward environment to help discover ways to reduce incidents of aggression and violence; service users voicing ideas and influencing the team about what would aid their recovery and journey through the service. The flattening of the traditional hierarchy that quality improvement can bring, and the effect on an individual’s sense of agency can be startling.

There is also a collective agency that is palpable. An energy and sense of optimism as people encounter positive experiences of other people exercising power and courage. Quality improvement nurtures this through bringing people together in learning systems to share their experiences and ideas, through our focus on story-telling, which can inspire so many others to gain the courage to act, and through our intentional and frequent celebration of the amazing things we see taking place every day.

And there is agency at the level of the system. We are certainly feeling the effects of this at ELFT, where people increasingly sense that the structures and culture within which they operate are giving them permission, licence and freedom to exercise their power and courage. This needs authentic and positive reinforcement by leaders over a long period of time, to build a sense of psychological safety. It also needs tangible changes and signals to demonstrate that things can actually change in response to need, and that the power resides in all of us to bring change. Campaigns like “Breaking the Rules” can really help give people an outlet to voice their ideas, and demonstrate that leadership are intent on creating agency at the system-level.

So, if you’ve seen quality improvement so far as simply projects that help improve quality of care, I urge you to look beyond this. See the true potential of quality improvement in helping us connect more deeply to what really matters (to us and those around us), to strengthen our relationships within our teams and with those we serve, to bring people together around common purpose and discover ways to change the system for the better. And most of all, to activate agency… in individuals, in groups and in the whole system.


You can read all past QI Essentials posts here.

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