The Surprising Power of Liberating Structures: Simple Rules to Unleash A Culture of Innovation (26 page)

Two stories from the field linger for Michael: “A unit manager told me, ‘I used to come to work braced to find out what kind of trouble the nurses had gotten into. I was expected to fix it. Now when I come in, they tell me what they have done to fix anything that came up.’”

In the second story, a unit participating in the superbug project was starting a new cardiac program. Staff members took it on themselves to form a cardiac club. They knew they were the experts on planning a launch on their unit. After the fact, they told the project manager about creating the club.

“The interviews revealed much more than scientific proof,” Michael asserts. “Culturally speaking, I think we got beyond a point of no return. We will not be able to put the toothpaste back in the tube.”

Michael’s reading on some of the significant changes the project produced? “Now, locally grown ideas surface and frontline people on the unit take action. People can see their own ideas spread. That’s enticing. After experiencing the freedom and the results that you can achieve, I cannot imagine going back to the old way.”

Cultural Attributes, Opposing Yet Comingling

Michael and project coinvestigators are still trying to make sense of the larger cultural shift afoot. Most surprising, the new and old “behaviors” are comingling. One set is not displacing the other. A creative melding is under way.

For example, the interviews revealed that staff more often go to people with local know-how, ask more questions, and use stories to communicate what works. At the same time, dominant patterns persist: paying attention to rank in the hierarchy, “telling not asking,” and using hard scientific data to make decisions.

“Most welcome is the enhanced capability to work collaboratively while tapping the up-and-down functional expertise as needed,” Michael says. “More frontline staff see their role in the context of a larger system. As a result, managers can step back and responsibly encourage more self-organization while letting go of overcontrol. Nirvana.”

Frontiers Ripe for Liberation

“While the results of this study are very promising, this work has affected me in ways that other studies I have been involved with have not,” says Michael. “It is hard to recognize that many of the behaviors that are unintentionally drilled into you in medicine, such as ‘I talk, you listen,’ are contributing to problems rather than helping to bring about solutions. This work has changed the way I work and interact with others—I am far, far more likely to answer a question with a question. I’m sure it irritates some people to no end, but I am interested in their opinion and approach to the problem. Why should I think that I should be the one with all the answers just because I’m a doctor?”

This project demonstrated that expecting fundamental change to emerge from the bottom up was a sound and practical idea. The results were so persuasive that the project even made it into the popular media.
⁵
What’s more, even before the project’s end, study participants had started to apply Liberating Structures and Positive Deviance to new challenges, in and out of hospital settings.
Improv Prototyping
,
Discovery & Action Dialogue
, and
TRIZ
were widely employed in the study hospitals.

Without much direct help from Michael and the research team, diverse projects have blossomed in nursing homes, clinics, and NGOs across Canada.

Looking forward, Michael muses, “I find I am more attracted to complex problems—the impossible stuff. In part because I don’t believe that many things are impossible. Like surfing a big wave, if you don’t try to control everything, it’s a great ride.”

Dramatizing Behavior Change to Stop Infections:
Sherry Belanger

Sherry Belanger knew better than anyone that the behaviors that spread superbugs are resistant to change. She also knew that prevention ideas coming from outside rarely work. “Anything imposed on my staff—new policies, laminated posters, or free coffee coupons—will not work well,” Sherry says. “If it does not come from them, follow-through will suffer.” So she found a novel way to reduce infections in her unit:
Improv Prototyping
. “Improv is really fun, visual, and powerful,” Sherry says. “No one can watch it and not be influenced!”

Sherry Belanger is a nurse who serves as a patient-care coordinator on 4-East at Kelowna General Hospital (KGH) in British Columbia, Canada. She also is the energetic project manager of a core group working to stop the transmission of superbugs (antibiotic-resistant organisms such as MRSA, VRE, and C-difficile) that cause stubborn infections. In addition to using
Improv Prototyping
to motivate prevention within her unit and across hospital departments, the group employed
Social Network Webbing
to coordinate action and attract cross-functional participation
.

Within three weeks of returning from the kickoff meeting for the national
Improv Prototyping
project in Toronto, Sherry and her team had staged Improv scenes in one of the hospital units and with the senior leadership team.
⁶
Their debut with the top leaders was an especially big hit, Sherry recalls: “We wanted to get leaders talking about superbug prevention.” The playful approach Sherry’s team took unleashed serious attention, energy, and momentum among the managers beyond expectations.

From that early success, Sherry’s team members were ready, literally and figuratively, to act their way into promoting safer practice. The team visited units and groups across the hospital and often used
Discovery & Action Dialogues
to learn about challenges specific to each unit, which they then used to generate “the material” for
Improv Prototyping
. For example, on a drug rehab unit, staff wanted to help patients with infections safely visit the communal kitchen. The team’s dialogues yielded the plotline for a scene dubbed “Mr. Munchie” to highlight the issue and promote careful use of the kitchen facilities.

Another pair of Improv skits the team developed was called “Speaking Truth to Power” and came from its work with a group of second-year nursing
students. The aim was to help student nurses remind others about safe practice, particularly when the person being reminded holds a more powerful position.

Sherry recalls the scenes: “We asked for volunteers and two students stepped up to do the acting. Along with a member of our core group, they acted out two scenes. Scene 1: A student nurse is in an isolation room with a patient when a physician enters without isolation gear on, carrying the patient chart. The physician is very overbearing and brushes off the student. Scene 2: A replay of the scene with the student nurse inviting the physician to step aside, away from the patient, and helping the physician get into the isolation gown.” A lively group debrief followed the two scenes.

Three weeks later, a group of second-year students that had experienced the skits was doing part of their clinical rotation on Sherry’s unit. A physiotherapist stopped Sherry in the hall and let her know how impressed she was that one of the students had stopped a physician who was entering an isolation room without the proper gear. Just like the Improv scene, the doctor was rushing into the room, carrying the patient chart, without donning a gown or gloves.

“I went to find the student,” Sherry told us, “to let her know she was doing a fantastic job. Her name is Marisa.”

When Sherry spoke with her, Marisa said, “I didn’t even have to think about what I was going to say—it just came out. I might not have stopped him if I hadn’t seen the Improv. I realized that it is everyone’s responsibility to speak up to stop the transmission of superbugs.”

The physician did not comply with her attempt to stop him from going into the room unprotected, but Marisa was not intimidated. “When it comes to safety,” she told Sherry, “there should be no hierarchy. We should all do our part to protect ourselves and our patients. We shouldn’t be less important because we are students.”

The story spread through the hospital like wildfire.

Capturing everyone’s imagination is central to making progress with superbug prevention. To succeed, everyone, from doctors to student nurses to room cleaners, has to change his or her habits and routines. Marisa inspired many others to “speak truth to power.” Just as important, Marisa developed the real-life confidence to do the right thing to stop the transmission of superbugs.

Developing Competencies for Physician Education:
Diane Magrane

How to enable medical-school faculty to follow the lead of their students and nonphysician colleagues in undertaking a complex research project? When success requires that everyone on the research team discover what is working and together make changes, doctors have to follow and lead simultaneously. Here’s how Liberating Structures helped to guide a multidisciplinary study of how medical students can better attend to the spiritual needs of patients.

Diane Magrane, MD, is the director of the International Center for Executive Leadership in Academics at Drexel University College of Medicine, where she works with physician leaders who are so smart and so successful, they sometimes have difficulty learning new behaviors. So she often turns to Liberating Structures to engage fellow academic leaders and lays each one out like a teacher’s lesson plan. “Education cuts through the politics and the educator then becomes an inside advocate for new ideas,” says Diane
.