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PROactive Management of Integrated

Services & Environments


The proof of the pudding is in the eating. From imagination to insight, from ideas to innovation, there will be very limited benefits unless appropriately implemented. Just because one has a roadmap does not mean anyone is going to follow it. Any change, even if it originates bottom up rather than top down, is bound to generate some resistance from some people.  If there is no challenge or scepticism perhaps the change is not a meaningful one and not worth spending time and energy on. It is important to remember that there will be variation in the degree of reluctance to embrace any change. It is important, therefore, to expect and prepare for resistance and to keep in mind staff sensitivities about established practice. It is crucial to suspend judgement about the present, to harness any resistance and transform it into propulsion for the Enact phase.

Enact involves a continuous cycle of execution and evaluation along with external exposure to embed an improvement culture.

Execute: make it happen

Evaluate: critically analyse the journey

Embed: culture of continuous improvement

Execution: Execution is the engine that keeps the cycle going. As the dominant culture creates the mind-set within which staff behave, without execution all the engagement will gradually fade into insignificance. To purposefully execute the vision of eliminating reliance on force, encouraging and engaging staff to come up with ideas has to be followed up by the leadership removing barriers to implementation of those ideas. This might involve cutting through red tape, creatively resourcing requirements or escalating an issue to the next level while continuously feeding back to frontline staff what is happening. If we still do not get results a courageous conversation is called for, with someone asking why or why not?  When an organisation creates a culture that embraces fluently-flowing dialogue, irrespective of hierarchy, it gains a key enabler for execution and emergence from situations where the change engine has got stuck. In spite of the groundwork in envision and enable phase, generating proof of concept followed by a scale up to proof of feasibility has its challenges. To overcome them, the PROMOTE (PROactive Modelling Of Therapeutic Environments) framework provides practical tools and guidance for idea generation, development and innovation deployment.

Evaluation: Fundamental to progress is continuous evaluation, whether it be establishing baseline at the enquiry stage, measuring progress on the ground or tracking organically evolving innovations. Numbers tell the story we want to hear so it is important that organisations are ready to dig deep and consider all versions of reality. Quantitative evaluation, though helpful, is not the main source informing our journey. Force is a continuum and its use in coercive practice is often originates in genuine concern for the patient. It stretches from the covert, subtle hints in conversation about what might happen if a patient does not take their medication to the overt, physical intervention that may be needed to maintain safety. In attempting to eliminate reliance on force figuring out who, what, where, when, why and how may be even more important than incident figures. This does not mean flouting governance or the statutory duty to provide incident data, rather that we dig deeper into the data to continuously learn and improve. We should be able to pick up changes not just in how many physical interventions take place, but what led to each intervention, how it was carried out and what followed it, etc. As practice evolves we expect the evaluation and focus will shift from one parameter to another, depending on where the organisation is on their journey to create humane services that do not rely on force but on positive, proactive care. Clear line of sight from board to ward is essential to ensure steady progress. However making the key performance indicators relevant at every level, from individual patients and clinicians to entire health care systems is challenging. PROGRESS (PROactive Governance of Recovery Settings and Services) provides a framework for intelligent selection of metrics, bringing them to life and making them meaningful at every strata.

Embed: Holding the gains and evolving as required is essential to maintaining the initiative. Repeated cycles of ‘Plan – Do – Study – Act’ will generate new standards which need incorporation into business as usual. The two key challenges to sustainability are initiative decay, where things slip back over time and that of improvement islands, where change in one area does not spread elsewhere. However we do not want change that is absolute in its sustainability. A sustainable change today could become resistance to change tomorrow.  Instead we want change that is sustainable till a new idea comes along. And the way to expose oneself to a larger pool of ideas is to get out there and get it out there. All organisations involved in mental health will be some way along the journey to create humane services. There is a lot of knowledge and experience that we can all gain from and contribute to. The aspiration to create a new discourse is like building a massive, multi-dimensional jigsaw. We do not know where we will find the next piece that will fit in, the answer might lie in a local charity down the road or right across the globe, where the parameters of care might be quite different. As we start to feel we are getting somewhere with our jigsaw a new dimension will evolve which will take the organisation and the care provided at the frontline onto a different plane.  Developing and nurturing partnerships are therefore of key importance. A competitive stance between care organisations is pointless, the power of the information age is such that innovations get rapidly replicated, so if one has to compete, one should compete on collaboration. Others will mirror ones collaborative stance and all can benefit from sharing of successes. Exposing our services to external scrutiny and recognition will only improve them further. Exposure for our key pathfinders to potential partners will also enrich their leadership journeys and create conduits through which knowledge and wisdom will flow.

Cross-pollination is at the heart of adaptive mutations, otherwise known as innovations. New insights from organisations which have been on their own journey of self-discovery will provide the new tools or concepts for further re-innovation and emergence onto a higher plane. PROMISE Global provides such a platform so we can benefit from each other’s successes. The principal objective of this global alliance is how together we can expedite the transformative journeys of the frontline of our mental health organisations. The frontiers of our organisations will no longer be a barrier to jointly redefining the frontiers of humane care.

 Enact: Initiative to Implementation

PROCESS - Organizational Change Model