Beware the Einstein quote! So often a presentation has that black and white photo with some amazing comment from the genius himself. How many of them really can be attributed to him remains to be analysed. However, I saw one recently that I hope is real. It suggests that if you have one hour to solve a problem then the first 50 minutes should be used defining the problem, as then the solution will come easily. Maybe this should be the mantra for all organisational change and, in particular, when making changes to a digital function.
The whole idea that change is now constant in what we as CIOs do is an accepted norm. Change is what we do; indeed I wonder if the whole debate over my CIO title could be reopened as Change and Information Officer. I have been in my current role for two and a half years. One of the first things asked of me when I came into this role was to move through a large scale organisational restructure, moving from a series of local teams to a set of single national functions. We described this as a "transition". However, I made a mistake and learnt a lesson the hard way. Transition to the new functions was relatively straight forward; an ambitious new operating model was agreed and put in place and a large proportion of the team changed the way they worked, the person they worked for and in a few cases the work they did. But, transition did not lead to transformation, we had missed the old adage that form should follow function and we had concentrated too much on what the form should be.
The leadership of the structure had swelled, as now with a national ambition, the structure required a wider governance model, but that leadership team had become unwieldy - 13 senior technology professionals with a single goal and destination but each with a different route map to get there. Therefore, two years after the first restructure began I asked my leadership team to consider how we could work differently, what was the function we were trying to achieve at a national level and what would be the best form to adopt in order to optimise our chances of success.
Patients and organisational culture
Maintaining sight of the reason for being here should be easier in healthcare. We believe we are all here to make patients better, or to keep people healthy. Making sure that the technology professionals can also have this as their goal is important to me, a battle I feel I am losing is to remove the language that describes the silo separation as the business and IT, but we will keep trying to change this.
It's not just a language issue, although that does hinder the removal of silos. There is a significant cultural gap too between what a nurse is here to do every day and what a digital professional is here to do. Some of the transition within the new operating model design brought about a leap of change and created a clearer alignment between technology and healthcare that was a new experience for all. As we begin to look at how we can continue to evolve and improve this, it is a testament to where we have got to that the CIO team want to protect this structural benefit, with a new vehemence, an outcome that is great to witness.
I believe organisational change should involve a journey set out on together. My senior team began considering how and what to change with two key drivers; first the most senior structure in health was changing and I wanted to reflect this in our own structures and secondly a reduction in the size of the most senior management team, making it more agile in its decision-making and easier to enable good governance to be implemented. As a CIO with 13 direct reports I knew I wasn't able to pay as much attention to areas that I really should. I have a great team of people as a set of leaders and therefore can change the structure to enable those leaders to really take on responsibility without me meddling in their day-to-day delivery.
The inherent problem though with making this change was that I was asking a team of leaders to suggest a new structure that would see some of them no longer part of the most senior team. From September 2016 to December 2016 the team worked through a series of options, all of which were viable, but a few of these suggestions simply didn't meet the set criteria we had to adhere to in order to achieve our defined goals.
The call of do nothing as an option was made several times! As the suggestions evolved it became clear that we could not create a new structure that everyone would be bought into. I wanted the journey we would all be on to evolve, but, that wasn't going to happen immediately. Even though the structure has now changed there are still people within the team who are not happy with the outcome we have, what is impressive and shows the engagement that has been achieved is that the team is now starting to work with it and see where it takes us. A maturing team is able to see the difference this makes and understand the reasons why it has been implemented. I know we are all driven by the same aim to improve patient outcomes, so despite objections I know we will all pull together to work through this complex change. An analogy was presented to me recently on this, 'a bit like being stood up in the middle of a bus when you really want the aisle seat near the door', was how one member of the team described the new journey I was asking them to embark on with me.
Training and recruitment
The total staff count in the organisation is 287 with a recruitment drive to bring in a further 49 staff before the end of the Spring this year. The percentage of staff going through a training programme in the last 12 months is over 70%. The average spend on training for staff has risen by just over 50% in the last two years. All of these statistics should make for an organisation that is becoming a team, and yet, because of the unsure nature of organisational change the team has yet to really become complete.
The engagement initiatives put in place to try to create the team are quite significant - a closed group message forum known as eHealth moments, a video introduction of all staff, a randomised coffee meet and greet, all staff meetings, team meetings and a host of other team-based initiatives and more that we want to continue to add to. And yet a set of staff with 10 years of 'hurt' as one member of the team described it to me need something different to become a team again.
That initial change, because it focused on the form rather than the function, hasn't made the difference that was needed, this means that we need to find new ways to revitalise the appetite for change. It's clear to me as the leader of this organisational change that there is still more to do, and the best place to learn what this is will be from the staff themselves. We have a responsibility for system interoperability in health, but to get there as one team member said recently, we need "human interoperability". Educating the team and indeed ourselves as CIOs in the art of successful change and indeed the organisational need to continuously change is one area we are focusing on.
Our organisation's all staff survey and internal follow ups with Office of the CIO staff indicate that, "new ways of working are needed, not because the team can't function, but because leadership needs to get better". That's a hard story to put to your leadership team who have worked so hard trying to make the changes needed, trying to deliver, trying to engage staff. Every member of staff needs to know how they are delivering for the patient was another key comment made, and this suddenly hit us all as the answer. How do we get the team to see the benefit they are making, more and more we must make every deliverable traceable back to the patient. With this in mind the new structure is evolving, this time with the patient at the centre, when we talk about delivery of technology we are going to push much harder to ensure that the change that digital is making, always links back to the patient.
For a little time now we have suffered from what we have started to call the 'sexy project' syndrome. How have some projects achieved this title? Well, entirely because these projects clearly and obviously have a clear patient focus, or at the very least an immediate clinician benefit. We are now working through a change programme that will describe everything that is delivered through digital will have this in mind, we need to remove the appearance of a league table of projects with some being seen as lower league projects - everything we do is 'Premier League'!
Recently Ireland opened the doors of its first digital hospital, a maternity hospital in Cork. The team involved in the go-live on the ground went to quite some effort to ensure that the whole of the digital function was able to be credited with the go live not just the project team directly deploying the systems.
Another core message for the digital function to build on is that we are all part of the health service, while appreciating that currently the wider health system is going through a big change and reform process. The phrase and brand being used is "building a better health service". As we evolve the structure we are striving to build this into what we become.
The work done to get here in this new change has been focused upon defining the team as a way to avoid the silos of previous structures. Bringing together the traditional service management and technology office functions under one leader and one organisational function that has an identity defined as 'Customer Experience' is already reaping significant rewards, if for no other reason than it is one less 'wall' to jump over to deliver an integrated service.
An added complexity for our organisation is a concept that was introduced at its inception and is yet to be truly defined. As well as being the CIO of the health system I am also the most senior person of a new organisation known as eHealth Ireland. The new function has been described, perhaps a little unfairly, as the digital health service life boat. By design eHealth Ireland was to be the new organisation that manages all things eHealth when the reform of the health service comes to fruition. This though signals to the team quite clearly that while we are going through change now it will not be the last change we go through.
One of the outcomes of our structural changes will be a clarity of governance and decision making within the digital arena. This has to occur to support the new structures the entire health system is putting in place these changes see a devolved nature applied to governance throughout the system. The phrase coined for this has been 'earned autonomy'. If we were to compare our structures to a PLC, we would see a non-executive board compared to our eHealth Ireland committee. The previous full senior management team are now best compared to an executive team and the new most senior function is perhaps best described as the operating board. This is a useful comparator, but, because of the nature of the legal terms used here not one we can use to help clarify language unfortunately.
Decisions are now made at the most senior level, the executive team can implement these decisions and the eHealth Ireland committee can provide advice, guidance and where necessary steer the process. While we now have a three-tier management function. I am confident that we have one that has an agility of process and connect within it.
Communication and 'Radical Transparency'
A colleague helping us with the cultural change necessary to see this adopted is using the phrase "Radical Transparency" to describe how we communicate the changes we are making. We know we need to finish the journey we have started with all of our staff and our stakeholders, something that the first time around we perhaps did not do as well as we should have, it is very hard to get this part right.
Many health systems internationally have undergone significant structural and organisational change. All change is described as focusing on delivering better services for the patient. However, the evidence of the results of this change is at best mixed and often points to very limited impacts on health outcomes while there are significant costs and risks associated with implementation. Digital systems within health are even more representative of this trend, change is constant, we understand this but, change has to have an end in mind.
A significant historical retrospective study of all NHS reorganisations by Nigel Edwards of the King's Fund made a number of observations about repeated reorganisations: "The evidence outside the healthcare sector shows that no more than 25-30% of mergers and acquisitions succeed. Given the greater complexity and level of risk in healthcare, this success rate would be optimistic. While modest savings can be made over time, dysfunctional effects of reorganisation include a loss of focus on services, delays in service improvements and a difficulty in transferring good practice within the merged organisation." This comment can be as equally applied to 'just' the digital element as it can to the whole mega structure of health.
In my career in health I have worked for so many acronym organisations that even I got weary of the change; FHS (Family Health Services), NHS IA (Information Authority, NPfIT (National Programme for IT), CFH (Connecting for Health), HSCIC (Health and Social Care Information Centre) and now the UK has the latest incarnation, NHS Digital. In my role in Ireland I want to make sure that when change does happen it is not perceived as "new names, same door handles".
Recently the same King's Fund author commented: "Structural changes are one of the few big levers available to policy makers, who find it very difficult to intervene in the 'black box' of clinical decision-making. That is probably the biggest reason why it is so often overused." I have always asserted that working in healthcare technology is the most complex role there is; as a CIO you need to understand what the delivery of healthcare is and the clinical input into this as well as staying afloat in your own digital world. I do wonder then if Nigel's comment can be even more applicable when we look at digital organisations.
Five ways to achieve success in change management
We have set ourselves five success criteria to apply during the changes we are making, all are underpinned by a new heightened communications principle.
1. Maintain clarity of the purpose for change and be sure to not enable problems not associated with the change to become attached to it.
2. Ensure we have the right organisational design principles in place and seek expert advice on this at all stages of the change.
3. Aim to create a single culture for digital delivery in health in Ireland and place effort on repairing damage done to culture over the last decade.
4. Avoid a structure that has reliance on geography, all roles within the team can be located anywhere within the system, the structure and culture must be able to continue to evolve regardless of geography.
5. Learn and apply the lessons from the last two years, there has been success in how the business relationship is now managed, new structures must not break this.
In December 2014 when I moved into my new office in Dublin and became the CIO of the Irish health system I wrote a simple set of actions I wanted to achieve in the first 100 days. At the bottom of this list though I added, 'Don't break anything!' The first 100 days were successful, the ensuing two years have seen us achieve a great deal. But, we did break some structures along the way, we now can see this and set about not just repairing them but enhancing and improving them, setting us up for the next three years so we can achieve all that we want to.
To conclude, back to the great man himself - Albert Einstein may well have said, "Man will never stand in the same river more than once, the river flows and changes all the time and therefore man must become able to observe, evaluate, recognise and adapt to change to evolve and be successful". However, he is also the most misquoted genius ever.