Presentation given to IHI on 14th December 2022: Creating Tomorrow Today: Unleashing Learning as a Power for Transformation

1. IHI Forum 2022
14 December 2022
VA08: Creating Tomorrow Today: Unleashing
Learning as a Power for Transformation
Goran Henriks
Zoe Lord
Helen Bevan

2. VA08: Creating Tomorrow Today:
Goran Henriks
Zoe Lord
Helen Bevan
@GoranHenriks @zoelord1 @HelenBevan #IHIForum

3. Disclosure
No relevant relationships:
None of the planners, presenters, or staff for this educational activity have relevant financial relationship(s) to
disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or
distributing healthcare products used by or on patients.

4. After this session attendees will be able to:
1. Develop a new perspective and appreciation of
the role of learning in creating and sustaining change
2. Discover novel ways to help people grow,
generate capacity for change and keep learning
processes flourishing
3. Apply what you learned to support change and
improvement in your own context
@GoranHenriks @zoelord1 @HelenBevan #IHIForum

5. Helen Bevan & Goran Hendricks

6. 6 |
6 |
Hardcastle, A.C. et al.
The dynamics of
quality: a national
panel study of
evidence-based
standards 2015
Braithwaite and Glasziou May 2020
D’Avena A, Agrawal S, Kizer KW, et al.: Normalising High-Value
Care: Findings of the National Quality Task Force. 2020
% of quality indicators for healthcare received by participants
The challenge in numbers
Cardiovascular
disease
Diabetes
Depression
Osteoarthritis
0 10 20 30 400 50 60 70 80 90
Healthcare represents a paradox.
While change is everywhere, performance has
flatlined: 60% of care on average is in line with
evidence- or consensus-based guidelines, 30% is
some form of waste or of low value, and 10% is
harm. The 60-30-10 challenge has persisted for
three decades.
Despite impressive gains, notable shortcomings
persist in normalising consistent, high-value,
person-centered care. What is primarily missing is not
progress in measurement, but progress in results.
Changes in culture, investment, leadership, and even
the distribution of power are even more important
than measurement alone”

7. 7 |
We cannot continue with the way we are doing
things now
All service...at some level...is produced by
professionals in collaboration with those who
receive the benefit
John Maynard Keynes
The biggest challenge is not
to make people accept new
ideas….it is to make them
abandon the old ones
Transformation is
more often about
unlearning than
learning

8. Doing things
differently means
shifting from
“expert” to
“explorer”

9. 12
11
10
9
5
4
3
2
1
8
7
6
Via Sasha Karakusevic
Source: adapted from
What if we are in the wrong paradigm?

10. Paradigm: A set of
assumptions, concepts, values,
and practices that constitutes
a way of viewing reality for the
community that shares them
@GoranHenriks @zoelord1 @HelenBevan #IHIForum #CreatingTomorrowToday

11. Investing in health
through a life-course
approach &
empowering people
Tackling the major
health challenges of
noncommunicable &
communicable diseases
Strengthening people-
centred health systems,
public-health capacity,
emergency preparedness,
surveillance & response
Creating resilient
communities &
supportive
environments for health
& well-being
New paradigms: Advocating
intersectoral action for health equity
and well-being
www.euro.who.int/__data/assets/pdf_file/0017/330560/Advocating-intersectoral-action-ljubljana-report.pdf?ua=1

12. Moving to Quality 3.0 in health and care improvement
A multidimensional quality model: an opportunity for patients, their kin, healthcare providers and professionals to
coproduce health. Peter Lachman, Paul Batalden, Kris Vanhaecht 2022 f1000research.com/articles/9-1140
Quality 1.0
Quality 1.0 Quality 3.0
Quality 2.0
Thresholds
“How might we establish
thresholds for good
healthcare service?”
Illustrative themes:
• Development of
standards
• Inspection to assess
• Certification
• Guidelines
Organisation-wide
systems
“How might we use
‘enterprise-wide systems’ for
best disease management?”
Coproduction of health
“How might we improve the value
of the contribution that healthcare
service makes to health?”
Illustrative themes:
• Systems, processes
• Reliability
• Customer-supplier
• Performance
measurement
Illustrative themes:
• Logic of making a “service”
• Ownership of “health”
Kinship of coproducing
people
• Integration of multiple
knowledge systems
• Value-creating system
architecture

13. A different way of thinking about learning and capability

14. Our success is
measured in lives
and health
@GoranHenriks @zoelord1 @HelenBevan #IHIForum #CreatingTomorrowToday

15. Every system is perfectly designed for the results it gets
Version
2017-02-16
”For a good life
in an attractive region”
What kind of system do we want for the future?
@GoranHenriks @zoelord1 @HelenBevan #IHIForum

16. Microsystem
Patients and professionals
Meso
Primary care
Medicine
Surgical
Psychiatric
Makro
Governance
Before Today
Redesigning our welfare
system
From reactive to proactive
management
Beyond today’s patient
records
@GoranHenriks @zoelord1 @HelenBevan #IHIForum

17. Support
and
rehab
Primary
care
Specialised
care
Continuosly improve daily work and invest in innovations;
Innovate and learn everywhere at the same time – we need simple
rules to unite people in system thinking
Health in
daily life
@GoranHenriks @zoelord1 @HelenBevan #IHIForum

18. https://blogs.bmj.com/bmjleader/2021/02/01/creating-tomorrow-today-seven-simple-rules-for-leaders-by-helen-bevan-and-goran-henriks/
@HelenBevan @GoranHenriks @zoelord11 #IHIForum

19. https://blogs.bmj.com/bmjleader/2022/06/16/creating-tomorrow-today-seven-simple-rules-for-leaders-blog-four-
support-people-to-build-their-agency-at-every-level-of-the-system-by-helen-bevan-and-goran-henriks/

20. Creating tomorrow today: seven simple rules for leaders
We have created a set of “seven simple rules” for leaders who want to
create tomorrow today, based on our collective learning over seven
decades as leaders and internal change agents in the health and care
systems in England and Sweden and the work we have done with
leaders in health and care in many other countries.
• Read blog one: our approach to creating the simple rules.
• Read blog two: Define our shared purpose here
• Read blog three: Root our transformation efforts in a sense of
belonging
• Read blog four: Predict and prevent: start at an earlier stage
(“upstream”) in the intervention or care process
• Read blog five: Support people to build their agency at every level of
the system

21. @GoranHenriks @zoelord1 @HelenBevan #IHIForum

22. “Is it possible to move from an approach of just stability to an
approach where we become successful in change?“
Albinsson 1998

23. Are you ready – to “take” a new perspective?
If we think differently today, can design a new tomorrow?

24. Reference: @katebhilton at #IHIForum
The know-do gap

25. Production Industries
Quality Improvement
Learning health systems:
“An “engineering” paradigm
• Linear / highly specified
• Variation unwarranted
• Objective / quantifiable
• Technical skills paramount
• Low context-specificity
• Low complexity organisation
Reference : Al Mulley MD MPP
Professor of Medicine and of Health Policy and clinical practice
The Dartmouth Institute, Visiting professor, UCL

26. Thinking to learn and change
Test on the smallest scale possible to learn.

27. Foundations of the science of improvement
Source: Associates in Process Improvement

28. What methods* do we use?
Lens of Improvement Science Tools & Methods
Understanding Variation Run Charts
Shewhart Charts
Frequency Plots
Pareto Charts
Appreciation of a System System Maps (Linkage of Processes)
Flow Diagrams
SIPOC
Theory of Knowledge PDSA cycles
Planned Experiments
Psychology Observation/Shadowing
Interviews
Focus Groups
*Sample of common tools and methods from improvement

29. Person-centred thinking
• Iterative / experimental
• Variation warranted
• Subjective / qualitative
• Relational skills paramount
• High context-specificity
• High complexity organisation
Learning health systems:
the “service giver” paradigm
Service industries
Reference : Al Mulley MD MPP
Professor of Medicine and of Health Policy and clinical practice
The Dartmouth Institute, Visiting professor, UCL

30. Respecting complexity at the level of the organisation/system
Uncertainty about Outcomes
Disagreement
about
Value
of
Outcomes
High
High
Low
Low
Control
Chaos
Complexity
Adapted from R. Stacey, P Plesk
Reference : Al Mulley MD MPP
Professor of Medicine and of Health Policy and clinical practice
The Dartmouth Institute, Visiting professor, UCL
Implications for leaders
• In ‘control’ you can manage like an
architect or engineer
• In ‘complexity’ you manage with
awareness of human dynamics and
emergence
• The ‘complexity/chaos’ border is
where creativity happens

31. Respecting complexity at the level of the person
Uncertainty about outcomes
Disagreement
about
preferences
High
High
Low
Low
Control
Chaos
Complexity
Evidence-based
Adapted from R. Stacey, P Plesk
Reference : Al Mulley MD MPP
Professor of medicine and of health policy and clinical practice
The Dartmouth Institute, Visiting professor, UCL
The need for simple rules
• The care needed and wanted
– no less but no more
• Informed by what is possible
and valued
• Manifest respect for what
matters to the person

32. What is best for Esther?
• Be responsible for your work, give
feedback to the step before you
and make it easier for the next
step!
• We do it together

33. Acute setting: Learning from
indications, interventions and
outcomes of care in ITUs
Community setting: Learning from
shared decisions about elective
and complex care
Learning health systems–
at the frontlines across settings
Reference : Al Mulley MD MPP
Professor of Medicine and of Health Policy and clinical practice
The Dartmouth Institute, Visiting professor, UCL

34. Shifting our paradigm:
Single-loop and double-loop learning
Single-loop - results of our
practice don’t fit theory and we
interpret the need to change or
fine-tune our practice.
Double-loop - do we need to
change our underlying theory
and practice.
Source: Argyris, C. (1977, Sep/Oct). double-loop learning in organizations. Harvard Business Review, p115-125
Theory
Practice
Results
single-
loop
double-
loop

35. 35
https://blogs.bmj.com/bmjleader/2021/02/01/creating-tomorrow-today-seven-simple-rules-for-
leaders-by-helen-bevan-and-goran-henriks/

36. Unleash learning as a power for transformation

37. Unleash
learning as a
power for
transformation

38. A system in transformation:
requires and creates a lot of learning
Single Double Triple

39. Single-loop and double-loop learning
Presentationsrubrik
39
• Single-loop learning is like a thermostat that learns when it is too
hot or too cold and then turns the heat on or off. The thermostat is
able to perform this task because it can receive information (the
temperature of the room) and therefore take corrective action.
• Double-loop learning involves changing the setting on the
thermostat (i.e., changing the objective of the system). Double-
loop learning calls for changing the objective itself. Indeed, double-
loop learning is not only about changing the objective, but involves
questioning the assumptions about that objective, the ways of
discovering and inventing new alternatives, objectives, and
perceptions, as well as ways of approaching problems.
• Double-loop learning is an educational concept that involves
teaching people to think more deeply about their own assumptions
and beliefs. It was created by Chris Argyris in the mid-1980's

40. Triple-loop learning: Moving beyond institutional limits
40
• Our strategic thinking in health & care is mostly
single-loop (what/how are we doing?) or double-
loop (why/how do we do what?) We have to make
time & space for triple-loop learning (rethinking our
thinking)
• A diversity of models, methods and theories are used
that disrupt established institutional frames (which
maintain single and double-loop thinking).
• Single and double-loop learning is appealing to
organizations that want to be in control, whereas
triple-loop learning acknowledges that in complex
systems, control is usually an illusion.
Source: Ben Zweibelson
Triple loop learning: moving beyond the pale of the institutional limits

43. Unleash learning as a power for transformation
The habit of collaborative learning
The only way we may ever get at the knowledge we need for large
scale change is through collaborative learning with others.
Improvement oriented individuals, organisations and systems start
from the premise that it is better to be open and curious than
defensive.
The habit of change
No matter how much we know, improvement only comes about when
we do something differently. People, givers of care and leaders who
are successful at improvement know that improvement requires
change.
EVIDENCE-BASED QUALITY IMPROVEMENT, PRINCIPLES, AND PERSPECTIVES, Paul Plsek,
https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.203.3566&rep=rep1&type=pdf

44. Using methods to learn and change behavior, attitudes,
and culture
Source: Developed by the Associates in Process Improvement based on work on ABC – (Antecedent Event, Behavior and
Consequences) used by safety engineers (see Thomas R. Krause, John H. Hidley, and Stanley J. Hobson, The Behavior-Based
Safety Process (New York: Von Nostrand Reinhold, 1990).

45. Improve work processes
Level 3:
Triple-loop
Enable a healthier life
Level 2:
Double-loop
Develop primary care
Level 1: single-loop
Develop clinical processes
Organising for learning - value network actions
Join us!
Join in!
Join up!
Transfer power to service
users, families and
community rather than
keeping it in the system
Transformation
by examples
Person centered
redesign

46. Triple-loop leadership to deliver a different tomorrow
Accelerated learning of new skills
and development of systems at
all levels; i.e. "self-care", new
design of clinical meetings, new
regional structures
. A leadership that focuses on
service at home through and
with families and communities
and primary/open care
A leadership that works in partnership with
stakeholders beyond classic care limits
A leadership that is increasingly
working with health and social
systems to improve health
A leadership that enables
everyone to do their best work
and respond to ever-changing
demands and expectations
Building a learning system for today and tomorrow: so that the system is continually expanding
its capacity to create its future. It's about valuing the time and creating the conditions &
connections so people in the system can test, fail early, share, learn & grow together