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"Sharing power means even more people have the capacity to make improvement."
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Changing the Balance of Power: Applying Radical Redesign Principles Beyond Patient Care

By Derek Feeley | Thursday, October 1, 2015

Derek Feeley is Executive Vice President at IHI and part of the IHI Leadership Alliance team. In this blog post, he challenges health care leaders to share power with patients and with their employees to meet the challenges of the current health care environment. He invites you to follow him on Twitter @derekfeeleyIHI.

Derek Feeley

I’ve recently been reading Edgar Schein’s book Humble Inquiry: The Gentle Art of Asking Instead of Telling. In it, Schein talks about how asking questions empowers the other person in the conversation and temporarily makes the asker vulnerable. Schein argues that “[asking] implies that the other person knows something that I need or want to know. It draws the other person into the situation and into the driver’s seat... and, thereby, opens the door to building a relationship.”

Schein’s concept of “humble inquiry” applies to the efforts of the IHI Leadership Alliance to challenge typical power dynamics in health care as we kick off year two of our work together. The Leadership Alliance is a group of around 40 health care organizations committed to achieving care better than we’ve ever seen, health better than we’ve ever known, at a cost we can all afford.

In the first year of the Alliance, we reviewed the “10 simple rules” for redesign of the health system put forth in the Institute of Medicine (IOM) 2001 Crossing the Quality Chasm report, and asked what new rules we need to address the current set of challenges in health care. As a result, we developed guiding principles for health care transformation that we call the “10 New Rules for Radical Redesign in Health Care.”

One of the new rules about which I feel particularly passionate is Change the balance of power. This rule is about “co-production.” There are a number of ways to define co-production, but in this context it essentially means partnering respectfully with patients to build upon their strengths – to "do with, not to" them in order to improve care.

One example of co-production from my days as head of NHS Scotland – Scotland’s national health care system – helps to illustrate what changing the balance of power can accomplish. Instead of having a government agency develop an initiative to support patients with chronic conditions (such as diabetes and arthritis), we gave a modest grant to the Long-Term Conditions Alliance Scotland. Using what they had learned from the lived experience of their members, they created a self-management strategy for chronic conditions in Scotland called Gaun Yersel (or "Go On Yourself," for those of you unfamiliar with the Scottish vernacular, which is a phrase used to cheer on a person embarking upon a challenge). It's unlikely that the government would ever have given a nationwide initiative such a colloquial name, but we also wouldn't have seen such progress without giving control to those who live with long-term conditions every day. They doubled the awareness of self-management practices in two years.

While we clearly have much work to do to change the balance of power with patients and their families, I’ve also been thinking about what it would mean to apply the rule to staff inside our health care systems. What would happen if we altered the power dynamics within our organizations?

Changing the balance of power within our health systems would mean helping people beyond the leadership level understand how their work relates to the organization’s strategy and vision, and ensuring that they feel confident about making decisions at the local level in alignment with the organization’s overall strategy.

How do we create an environment that supports this? How do we make it easier for people to do the right thing and not just the easy thing? How do we make people feel safe to test changes, fail fast, and make the adjustments necessary to make progress?

Edgar Schein would say “asking instead of telling” will help us change our workplace cultures. This requires humility. Instead of telling staff what to do, it means asking them what they think is best. It takes strong leadership to be vulnerable enough to accept that none of us have all of the answers.

Yes, changing the balance of power means leaders have to give up some power, and that might seem daunting. I think, however, that it is essential, especially in our current health care environment. Resources are scarce, and we cannot afford to waste will. Sharing power means even more people have the capacity to make improvement. Can we co-produce the radical redesign necessary to provide fundamentally better care and outcomes for individuals and communities? Let’s hope so, because leaders simply cannot do it alone.


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