In this article we’re looking at how leaders and learning organisations can help people to get closer to transformational change, and more specifically, how healthcare leaders can inspire a culture shift within their organisations. We’ll be focusing on the Viriginia Mason (VM) Institute, who’s goal is to provide the ‘perfect patient experience.’
The VM Institute created the Virginia Mason Production System® (VMPS) in 2002, with this very aim in mind. The methodology is based on the principles of the Toyota Production System, with its goal to create a lean management system. The VM institute helps healthcare organisations to support continuous improvement and promotes a lean culture within organisations across the globe.
Recent studies have shown that leaders can help inspire culture shifts within organisations. Good leadership is linked to positive patient safety outcomes and studies have shown that a board’s commitment to QI can also be linked to enhanced patient care.
Consistency is cited as being vital for embedding quality within healthcare organisations and having a vision that you can share with your teams is a realistic and achievable. There are many inspirational leaders in the healthcare space who live and breathe quality and who have helped lead culture shifts within their rganisations.
Celeste Derheimer, sensei (expert) at the VM Institute explains:
“Every time a leader engages the people who do the work in conversation and listens rather than coming up with solutions — or even better — asks great questions, the leader is helping to shift the culture just a little bit.” 
Why are there often reservations of culture change and what are they?
Reservations towards culture change are common and can present themselves in many ways. An oft asked question is how to get culture change started, combined with a sense that this will be a difficult step. Winning round people who are resistant to change can pose problems for leaders, but often making that first step towards change can be the most difficult one.
Thinking from the VM Institute cites that resistance to change is a system issue and that the burden of work can wear leadership down. Celeste Derheimer explains: “The patient is at the top, always. But we also need to understand how to reduce the burden of work for all team members. It starts with leaders asking them, “What do you think?” 
The VM Institute’s ‘Respect for People’ is a well-respected initiative and, helps to counter disrespect among workers, which Dr. Leape from the Harvard School of Public Health observes as “a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’’ 
The Health Foundation set out in its report, the Improvement Journey  : ‘Furthermore, trusts that are under severe pressure, and trapped in cycles of crisis followed by short-term fixes, are often also psychologically ill-prepared for systemic, long-term change. Facing a series of existential threats, they might adopt a highly bureaucratised form of management that leads to defensive, reactive behaviour and superficial displays of compliance rather than genuine efforts at improvement.’ 
A closed mindset, resistance to change and disrespect amongst teams can all pose challenges and create resistance to a change culture. Happily, with a range of tools and support available, leaders can be supported in their quality innovation journeys.
How to change the mindset of a leader of improvement
Leaders of improvement can sometimes need support in their endeavours. This can be achieved through undertaking and engaging with continuing professional development. The VM Institute has a wide range of offerings and methods – helping support leaders through healthcare’s most challenging issues: from improving patient quality and safety to creating and sustaining system transformation. “This intensive learning experience uses hands-on exercises to enable participants to deepen their lean learning, refine their skills and build the capacity to teach, coach and mentor others in the tools and methods of a lean management system.”
Within the VM’s Institute’s Rapid Process Improvement Workshop – people often witness changes in leaders attending the sessions. Some may start out with an attitude of ‘why am I here’ but Celeste Derheimer explains: “That’s what makes this lean work so valuable. Before getting together as a team, people assume that if they do their job well, then their colleagues who are part of a process later in the patient’s care will be fine. But when they get together for the RPIW, they see how their work has a strong impact on their colleagues’ work down the line.”
In the ‘Improvement Leaders’ Guide’ by the NHS Institute for Innovation and Improvement, a senior leader of Improvement explains: ‘Leading improvement - basically it’s all about the leader having a mindset change from one of firefighting to one of continuous improvement.' 
How do I manage culture change?
Going back to the VM Institute and Celeste Derheimer  - who talks about the challenge faced by leaders who want to manage culture change and make improvements in an organisation, Celeste asks: ‘How can you get executives, providers and staff to adopt a mindset of continuous improvement? How do you even get started? It’s that burden of work — often a system issue— that has worn them down. This philosophy and methodology [VM RPIW] can lift them up again, with its focus on respectful leadership, concepts and tools that work and an emphasis that the patient comes first. There’s a positive shift in attitude every time a person is shown respect, every time a person is asked, “How do you think we can improve the process?” 
There are lots of tools to help you manage culture change as a healthcare leader. The Kings Fund sets out 10 steps for quality improvement , and there are many other tools and experiences you can draw on. If you are wanting to create a structure, framework and a vision to help you on your QI journey there are a wide range of training tools you can use, such as Life QI which help you develop your teams’ skills, coordinate teams and measure results.
(Image from Sonia Sparkles - https://soniasparkles.com/improvement/)
Studies show the link between a good leadership approach and compassionate care and patient safety, while a culture of quality which is successful and sustainable relies on commitment from leaders. So, for Quality Improvement and transformational change to happen within a healthcare organisation, it needs to be embraced by its leaders and for leaders to be committed to change. As summed up the Kings Fund, good leaders:  “…promote continuous development of the knowledge, skills and abilities of staff in order to improve quality of patient care, safety, compassion and the patient experience.”
Here’s some more words of wisdom from the VM Institute: “Every time a leader engages the people who do the work in conversation and listens rather than coming up with solutions — or even better — asks great questions, the leader is helping to shift the culture just a little bit. This happens in sponsor development sessions, RPIWs, Lean for Leaders training and other lean activities. Every event contributes to engraining the concepts and tools into the way people do their work, which in turn creates that culture shift” Celeste Derheimer, VM Institute.
“At the Virginia Mason Institute, for example, the entire executive team, including the board of directors, is required to undergo deep training in the Virginia Mason Production System®, and to participate in training trips to Japan for in-depth studies of Toyota and other Lean companies. Training and development in improvement methodologies as well as new coaching and facilitation methods for the leadership team are essential to ensure that they are prepared for and committed to continuous improvement. For our participants, training in a quality improvement method was a crucial step to ensure board ownership and leadership of the improvement journey”. 
The Power of a Shared Vision
The main improvement process is to develop and share a new ‘vision’ which can then be communicated to your team. By outlining how you hope to achieve this vision and demonstrating improvement aims, you can encourage your team to buy into your quality vision. Communicating your vision is vitally important, and by making sure that your visible and focused leadership are aligned with your vision is even more important. 
In the UK, there is part of a five-year partnership with Virginia Mason Institute and five NHS trusts to support them to develop a ‘lean’ culture of continuous improvement which puts patients first. [Not sure if you want to highlight this – please do take out if so!]
You can also use tools such as Life QI to help you share your vision and QI plan and also to find other examples of the great work going on and to help shape the work you do
The results when a culture shift begins to happen
Although the first steps towards change can seem daunting, you may be surprised at the extent of which positive change and a shift in culture can help lead to improvement. A good example is the East London Foundation Trust (ELFT). The board there have a strategic, long-term, board-level commitment to QI and have developed a culture of improvement and organisation-wide improvement programmes.
With an aspiring mission, clear vision and a strong set priorities in place, the scale of ELFT's quality improvement work has grown significantly over the past four years, such that now almost 300 teams (clinical and non-clinical) across all areas of their operations are using systematic, continuous improvement methodology to tackle complex issues and testing ideas that could lead to significant, positive change. 
In 2012, the Surrey and Sussex Healthcare NHS Trust (SASH) team began their continuous improvement journey with the development of their clinical leadership model. The partnership with Virginia Mason Institute Sensei began in 2015, which drew upon their collective strengths and the trust was recently awarded an Outstanding rating by the Care Quality Commission (CQC). Driven by their hard work and team commitment, from leadership all the way to the front line of care delivery, has paid off. Chief Executive Michael Wilson said "The trust had a very clear strategy, vision and values which underpinned an exceptional culture which placed patients at the heart of all they did, in all areas."
There are so many good examples of successes within healthcare, where leadership have helped inspire a cultural shift which has, in turn, led to enhanced patient safety.
 - https://www.health.org.uk/publications/reports/the-improvement-journey
 - As per note 7 above
 - https://qi.elft.nhs.uk/wp-content/uploads/2019/05/The-improvement-journey_1.pdf
 - (https://blog.lifeqisystem.com/elft-use-life-qi-to-drive-quality-improvement-at-scale).