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Jason Leitch is Scotland’s National Clinical Director for Healthcare Quality and Strategy. In the following preview of his keynote at the IHI/BMJ International Forum on Quality and Safety in Healthcare: Europe (March 27-29, 2019 in Glasgow, Scotland), he describes why activating people's agency is essential for improvement.
What does agency mean to you?
I think it’s a new word for an old concept or maybe it’s just a word that we’re catching up with. As the authors of IHI’s Psychology of Change white paper note, it’s been used in other sectors before health and social care. Fundamentally, agency is the power and courage to make change.
When you’re making change, you have to know how to do it — what’s the toolkit you need, what are the individual improvement methods you might use. But that’s not enough. Whether you’re an individual, team, or system, you must have power and courage to do whatever it is you want to do — whether it’s introducing handwashing in a new environment or integrating health and social care systems across a country.
Why is activating agency so important in health care today?
Agency is a slightly intellectual concept, but I don’t know any other way in which an individual or set of individuals can make change unless they choose or are given agency by the system in which they work. It is how change is done whether you’re a nurse or a cleaner, whatever level you’re at in a health or social care system.
What happens inside those environments is that some people get together and say, in short, “Let’s make a change. Let’s change the way we make appointments on a Monday morning so that we have more time for emergencies. Let’s change the way we do peripheral cannulas inside neonatal intensive care because there are too many infections.” Usually, change happens because a group of like-minded, courageous individuals get together and decide to improve their system.
Some individuals make changes without asking anybody else because they have the power to do that inside their environment. Others come together and seek permission. It doesn’t matter that they do it in different ways because what they all have in common is courage to make change for the community they serve.
What are the benefits of activating agency?
When we activate agency, the system improves for those we serve, whether it’s a safety improvement, like a reduction in infections, or a system that gets more person centered. It may be a financial improvement. It may be creating a system that offers better value. It may be all of these, but the system in which the individual or team have taken agency is all about moving the dial in the direction of improvement.
Are you settling for the status quo without activating agency?
I’m not sure you’re settling. I think sometimes there is a frustration in not being able to take agency. It’s the hero version of leadership, the idea that if you don’t do the change, you must be a fool. You’re not a fool. You’re behaving completely logically because the system has created fear and stagnation. Most systems traditionally send the message, “If you put your head above the parapet to do something, you’ll get it chopped off.” It’s unusual to find people behaving actually badly. What’s more likely is you see people behaving completely logically inside a system that hasn’t created agency in them.
How can leaders activate agency?
There are two answers to that. There is a behavioral answer. How leaders behave matters.
I’m not sure he was the first person to say this, but I first heard Don Berwick say that the most important currency of leadership is time. How you spend your time as leader is important because the team around you see that. If you spend that time in performance control of your workers, and in suppressing change and failure, then that’s how the system will begin to respond. It won’t happen immediately, but over time that culture will seep into the way things are done. A leader can activate agency by saying, “How does this help the patient? How does this help those we serve? How is what you are doing as good as it can be? What can we do that might make it better?”
The other thing leaders can do is create an environment that allows improvement projects to blossom. Leaders effectively activate agency by building capacity for improvement, allowing teams to work together to solve problems themselves.
I hosted an event the other night with the CMO of NASA, who was in Scotland for 24 hours. When he was asked about the culture of NASA, he said that not failing is a criticism there because if you’re not failing, you are not innovating enough. The opposite of that is an environment in which you are stifled, in which innovation is criticized, and where people are unwilling to step up.
Editor’s note: This interview has been edited for length and clarity.