How appreciative inquiry could influence service improvement

“NEVER BEFORE has there been such a strong call for a culture of continuous improvement in the private and public sectors across the global economy,” says David Shaked, an innovative business thinker who ran a one-day session on appreciative inquiry and service improvement for clinicians, managers and Experts by Experience from Trusts across the MERIT partnership.

The MERIT steering group recognises a need to maintain momentum and build on the successes of the programme to date. As a result, the organisational development strategy was produced, with its central themes of appreciative inquiry and service improvement, an innovative approach intended to engage clinicians and develop leadership for service improvement.

The workshop exposed participants to a strengths-based approach to change, incorporating some theory, and encouraged them to see the links with lasting service improvement, in order to develop fresh ideas and ways of thinking.

As an introduction to his session, David asked participants to interview one another about a service improvement which had made a real difference, or of which they were especially proud. Service users were asked to consider how they personally experienced or noticed the change, whilst clinicians and managers were encouraged to describe what they were able to change and how. Telling stories – with their unique mix of personal perspectives, memories, hopes and aspirations – is one of the most effective ways to identify how and why approaches were successful.

David has over 20 years’ experience of quality improvement work, and has practised and taught various strength-based approaches. He encourages people to set aside traditional approaches which suggest there is a theoretical ‘perfect state’ for services or processes, and that the task is therefore to identify and eliminate the gap between the existing and perfect states. Ordinarily, this would mean finding and eradicating root causes for those gaps, but David argues that, at best, this takes us back to the status quo (‘good’) where service users’ and carers’ expectations are met but rarely exceeded.It is unlikely to help us exceed expectations (‘great’).

Instead, David suggests that we identify what works in our organisations and do more of it, allowing good practice to spread and focusing on our strengths.

And this is what MERIT and the other NHS New Care Models programmes are all about. OK, it’s not like playing a computer game in Sandbox mode, where nothing we do will have an impact on the future, but we are able to be more experimental and we are able to bring together the strengths and experiences of our four partner Trusts into one place and pick the best of our experiences, so that we can replicate them.

Wherever you look – from the determination in our Recovery workstream to make service users and carers take a genuine stake in the community, the electronic shared health record project in our Clinical Care workstream, or our innovative plans to create new and interesting job roles under discussion in our Workforce workstream – that is precisely how we are seeking to make powerful, lasting changes, not for ourselves, but for our service users.

The great advantage of David’s approach is that it can fit management models which we already work with. Many staff will have experienced the ‘fishbone diagram’ approach to root cause analysis: instead of identifying and eliminating negatives, we could instead look for things that went right. The ‘seven types of waste’ model is also sometimes used to identify shortcomings in our workings, but David prefers a ‘seven signs of value’ approach which turns the deficit model on its head: rather than looking for defects, we could look instead at what a perfect outcome may look like.

None of this is easy: David likens appreciative inquiry approaches to a trip to the gym. Certain muscles have to be used regularly, or we can find it hard to use them, and so it is with our appreciative inquiry skills. But it is also important to reframe and refocus our approaches, maybe by changing our language to concentrate on strengths rather than shortcomings.

Participants took David’s advice to heart: group discussions identified a range of ways in which they could use the approaches he described. These will affect the way we gather information and the questions we ask to do so, and also the way we use what we find.