To understand how to make improvement, it’s important to understand power because power is more than a person’s position or title. The following excerpt from the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper explores power as key to an individual or group’s ability to choose to act with purpose.
All people exercise power in varying degrees and have prejudices and biases, both implicit and explicit. It is critical to see and act on the ways that prejudice and power combine to generate inequity at individual, interpersonal, and system levels. In health care, this includes removing disparities in access, utilization, and outcomes across race, gender, age, sexual orientation or gender identity, socioeconomic status, religion, and other characteristics historically linked to discrimination or exclusion.
From this perspective, leaders need to look at improvement projects and ask, to what extent are power disparities underlying causes of the problem? The unequal and inequitable distribution of power is the result of choices of individuals and groups in positions of power at the expense of those not in power. The outcomes generate systems of oppression, or the cultural values and habits that support the advancement of one group (e.g., white people, men, senior leaders, physicians) through the oppression of another group (e.g., people of color, women, frontline staff, patients). People who identify with an in-power group experience the benefits of a system designed for their advancement, while those in the out-power group do not.
To activate people’s agency, this reality must be accounted for not only in co-design and co-production, but also in the distribution of power. Power is not a position or title that a person has within an organization; it’s not a thing, quality, or trait. Power is relational; it is produced by a set of interdependent relationships that can be changed to achieve a specified aim. Power is generated as people bring to bear their skills, knowledge, experience, and capacity to act, individually and together, to achieve an aim.
The following four questions illustrate the interdependent and relational nature of power, and each question is illustrated in a now-familiar example:
What change do we want? (What is our interest?) Example: In the surgical safety checklist improvement project [referenced in the Psychology of Change Framework to Advance and Sustain Improvement white paper], what change does Dr. Rose want? He wants to reduce harm to patients by having surgical teams use the safety checklist 100 percent of the time.
Who has the assets to create that change? Example: Surgeons, anesthesiologists, surgical nurses, surgical technicians.
What do they want? (What is their interest?) Example: Surgeons may want to be in charge or may feel powerless to imagine responsibility for the patient any other way. Nurses and technicians may want to feel able to speak up on behalf of the patient. They all want the best possible patient outcomes.
What assets does our improvement work offer that they want or need? Example: Dr. Rose and his improvement team have an asset that can help all parties connect to their common purpose: the asset of creating forums to unleash intrinsic motivation, co-design people-driven change, and co-produce in authentic relationship the best possible patient outcomes.
By exploring people’s interests and inviting them to articulate what they have to gain and lose, improvers can determine strategies to address the power dynamics and sources of resistance that serve as barriers to improvement. In this example, as in most improvement contexts, Dr. Rose and his team built what [Marshall] Ganz describes as “power with,” which means that they focused on a common interest (i.e., the best possible patient outcomes) to distribute power across professional groups by combining their assets in new ways.
But not everyone’s interests are met all the time; some people experience (and resist) real loss with change. For instance, some surgeons at Dr. Rose’s organization initially resisted a perceived loss of control due to the adoption of the checklist, asserting “power over” surgical teams to maintain the status quo. However, this dynamic shifted as surgical teams shared power by activating more and more staff to use the checklist, creating new pressure on and influence over the initially resistant surgeons. As Everett Rogers suggests, this reflects how improvement efforts that build “power with” others can over time assert “power over” resisters — fundamentally changing the power relationship to advance wide-scale adoption.
Distributing power is one way to build power (i.e., the ability to achieve a shared purpose) and facilitate team-based care. By definition, distribute power means that many people within a system, across boundaries and levels, work together to create the conditions to accomplish a shared purpose, with each person playing a necessary, interdependent role in the work. As Frederic Laloux notes in Reinventing Organizations, people can hold different levels of positional power, and yet bring to bear their ability to contribute to the common aim. For example, a senior leader brings the asset of decision-making authority to commit resources to an improvement effort, while frontline staff bring knowledge of the improvements tested. Despite differences in positional authority, both are necessary for success.
To learn more about the other essential elements of improvement, download the free IHI Psychology of Change Framework to Advance and Sustain Improvement white paper.
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