Action Learning Groups and Cultural Change in Hospitals

• Abstract
• Introduction
• On Mental Models
• On Organisational Culture
• On the Critical Role of the Leader - Creating a Common Strategy Viewpoint
• On Action Learning
• Outcomes
• The Future of Action Learning
• References

Abstract

This paper focuses on cultural change and outlines how action learning groups can be used as a foundation within hospitals (or any organisation) to help to facilitate change. The paper highlights the importance of the organisation’s leadership (ie, the top team, middle management and front line supervision) being of one mind about the operating beliefs, values and edge that are required for organisational "success" - a "common strategy viewpoint". It describes the potential for action learning groups to enable and encourage all organisational members (staff, volunteers, doctors, etc.) to understand, engage and emotionally "buy into" the strategy viewpoint, and to develop and implement changes to business processes, behaviours and ultimately the culture of the organisation.

Introduction

It would not be surprising if rigorous empirical research revealed a significant difference between the ways hospital management viewed the world and the views of health care professionals who work within the hospitals. In fact, many employee surveys and cultural surveys show just this difference.

In the current era, health care managers of both public and private facilities are driven by the imperatives of accountability, budgets and such performance measures as occupancy rates, bed costs, step-down triggers, staff-patient ratios and labour utilisation costs. While not unaware of, or immune to these corporatist imperatives, health care professionals most commonly engage with the mental models (the framework of values, beliefs, assumptions and paradigms) that have guided their profession for ages past ie, care, compassion and the needs of patients.

This difference between management and professional clinical views is understandable given the primary day-to-day engagements of both groups: health care management - computer screens, profit and loss spreadsheets, expenditure requests, risk management, staff problems, etc; health care professionals - patients, families, treatment and care regimens, etc.

While not poles apart, the gaps between the prevailing approaches of health care management and health care professionals can lead to serious differences in perceptions about what is to be done (strategy) and how it is to be done (culture).

Stranded somewhere in the middle, and feeling the pressures from both, are the "middle managers", eg, nursing unit managers, team leaders, clinical directors, allied health managers.

This paper describes how "action learning groups" can be used within an organisation to encourage dialogue, learning and shared mental models, thus enabling changes to health care organisational business processes and culture. It describes some current views of leadership and culture and the potential for action learning groups to be used to bridge the gap between the opposing models and to relieve some of the stress experienced by those occupying the middle ground.

On Mental Models

Various researchers have identified the importance of bringing to the surface the underlying beliefs and assumptions that shape individual leader’s behaviours and organisational culture, eg, Senge (1990), Argyris (1993), Tichy (1999). Peter Senge, author of The Fifth Discipline, argued that an organisation’s ability to learn had become a key source of competitive advantage and listed "surfacing of mental models" as one of five related disciplines that contribute to organisational learning:

1. Personal Mastery - the discipline of continually clarifying and deepening personal vision, of focusing energies, of developing patience and of seeing reality objectively.
2. Surfacing of Mental Models - deeply ingrained assumptions, generalisations or even pictures or images that influence how people understand the world and how they take action. Often these mental models and their effect on behaviour are not apparent to those who hold them.
3. Building Shared Vision - this is a leadership skill that involves unearthing shared pictures of the future that foster genuine commitment and enrolment in creating that future rather than mere compliance. Senge warns leaders against trying to dictate a vision, no matter how heartfelt on their part.
4. Team Learning - the capacity of members of a team to enter into true dialogue, to suspend assumptions and genuinely start "thinking together" and "learning how to recognise the patterns of interactions in teams that undermine learning". For Senge this is where "the rubber meets the road" for, unless teams can learn, the organisation cannot learn.
5. Systems Thinking - The so called "Fifth Discipline", for Senge, is the discipline of seeing wholes, of seeing patterns of change and the structures that underlie complex situations, and of discerning high from low leverage change. Furthermore systems thinking is the "cornerstone" that underpins all the learning disciplines and how the members of learning organisations think about their world.

From our experience, well-implemented action learning groups are a highly effective way of building these five disciplines that Senge describes in his book.

On Organisational Culture

Organisational culture has been variously described as:

• The collective mental models of the people within the organisation
• The "way we do things around here" - the way people behave
• The collective programming of the "organisational mind" that governs the way an organisation processes information, its internal relations and what it values.
• The assumptions we live by but often don’t see
• The genetic code of an organisation or the "organisational DNA".

It originates with the organisation’s founders and leaders as their thinking and behaviours send signals that set the pattern for all the other members. In time this becomes all-pervasive and dictates how people will make decisions and how they will work together.

The culture of an organisation can be detected in:

• Cultural artefacts: visible organisational behaviours, rituals, myths and symbols.
• Espoused values: stated strategies, goals, philosophies, justifications.
• Policies, procedures and what gets rewarded and punished.
• Underlying assumptions: taken-for-granted values and perceptions that drive behaviour (both difficult to uncover and difficult to change).

Jim Collins and Jerry Porras, in their excellent book Built to Last (1996), describe their research into some of the world’s best and longest lasting organisations (ie, they have been leaders in their fields for more than 50 years), which revealed the critical importance of culture and the key variables that shape culture in an organisation. They describe how the "built to last" organisations fervently preserve their core ideology in specific concrete ways. The visionary companies translate their ideologies into tangible mechanisms aligned to send a consistent set of reinforcing signals. They indoctrinate people, impose tightness of fit and create a sense of belonging to something special through such practices such as:

• Providing orientation and ongoing training for members that has ideological as well as practical content, teaching such things as values, norms, history and tradition.
• Using on-the-job socialisation by peers and immediate supervisors.
• Creating home-grown management: Promoting from within, bringing to senior levels only those who have spent significant time steeped in the core ideology of the organisation.
• Creating and using a unique language and terminology (such as Walt Disney’s staff becoming known as "cast members") that reinforce a sense of belonging to an elite, special group.
• Exposing members to a pervasive mythology of "heroic deeds" and corporate exemplars - photos on walls, framed, "heroic" letters from customers, awards, etc.
• Corporate songs, affirmations, pledges, that reinforce psychological commitment.
• Using stringent hiring processes that intentionally screen and weed out inappropriate people, particularly during the probation period.
• Employing incentive and advancement criteria that explicitly link and reinforce corporate ideology.
• Making awards and fostering public recognition to reward those who demonstrate great effort consistent with the organisation’s ideology; as well as tangible and visible penalties for those who break ideological boundaries.
• Organising celebrations that reinforce success, belonging and specialness.
• Tolerating honest mistakes that do not breach core ideology; and imposing severe penalties, up to termination, for breaching the ideology ("sins").
• Developing "buy in" mechanisms - ways in which employees can become of the ownership of the organisation e.g. profit sharing, share / option allocations etc.
• Constantly providing members with written and verbal reinforcement of "who we are", "what we stand for" and "what we are on about" - reinforcing being part of something special.

Thousands of organisations have attempted to change their cultures, many to little avail. Many leaders want to re-shape the way things are done and the way their staff behave, so that their organisation can achieve their stated vision and dreams - they want to change the culture.

However, it is very clear from experience and practical results that culture is behavioural and relational. You cannot simply change it by decree, threat or "pulling levers". To change the DNA of an organisation requires the equivalent of a "paradigm shift" in science, a change in the way people see and understand their world, a change in what will constitute commonsense in the future. It requires a long, sustained, multi-pronged effort.

Action learning groups provide a mechanism for enabling people to "learn from and with each other" and, through this experience, to move into new intellectual and emotional waters, ie, to see things in a new way (mental model) and therefore to move forward. They offer a way to address the behavioural and relational requirements of cultural change.

On the Critical Role of the Leader - Creating a Common Strategy Viewpoint

The key leader of an organisation has a critical role to play in organisational culture change. The leader cannot decree or force people to change, but is critical to communicating, explaining, encouraging, supporting, pointing to and leading the way forward.

The old or prevailing organisational "genetic code" embodies the thinking of past leaders, but its inertia is tremendously powerful. The new code has to be consciously created by those leaders who aim to transform their organisation. This is what Jack Welch did at General Electric in the 1980s; David Murray has done at the Commonwealth Bank of Australia and what Peter Smedley is currently doing at Mayne Health, Australia, through acquisitions and groupings of services, reengineering the way Hospitals operate and relate to stakeholders, and supporting this with a massive advertising campaign with a new logo, corporate image and internal communication processes.

Noel Tichy (1999), from the University of Michigan, recommends that a leader create what he calls a "Teachable Point of View" - a statement in four parts aimed at teaching people the how and the why of a new direction or change and that incorporates:

1. Ideas: based on what it takes to win in the market place and how the organisation needs to operate as a consequence. Winning organisations are built on clear, current and appropriate ideas. These are the framework for action at all levels
2. Values: that support the business ideas and that people in the organisation will live by. Winning organisations have strong values and winning leaders live by those values privately and publicly.
3. Emotional Energy: that drives the leaders themselves and that can be communicated to create emotional energy in others. Winning leaders are high-energy people and create energy in others. A leader who does not quicken the pulse of workers in a positive way is not a leader.
4. Edge: the leader’s ability to face reality and champion tough decisions about products, investments and people. These are the "go-no go" lines in the sand that will govern organisational decision-making. Winning leaders never take the easy way out. Edge isn’t cruel - it’s honest.

To be successful, a leader must have the vision to see beyond the conventional wisdom and to shed certain long held beliefs. They must also comprehend the complexity of business yet make the message simple and understandable via the new organisational stories that they tell as they move through the organisation. Tichy argues that business is best understood by stories, not words on PowerPoint slides, and that there are three kinds of powerful leader stories:

1. "Who am I?" This is the story of the leader’s life journey and where it will go from here.
2. Who are we? This is the identity of the organisation today, not as it was 3-4 or more years ago.
3. Where are we going? This is the story of the hopes and dreams of the leader that together everyone will make come true.

If the ideas, the values and the stories are strong enough, the energy high and the edge sharp, the company will pass the "beer truck test". The beer truck test is quite simple, if a beer truck runs over you, will your organisation continue the process of change?

We have successfully used this methodology with an emerging local church in Adelaide, South Australia. Two dwindling churches had combined their resources and purchased a primary school facility being sold off by the government, with the view of creating a new Church presence in the community. They recruited a new Senior Minister to lead the change. Using a "teachable point of view" framework (or "common strategy viewpoint" process as we called it), we were able help the Senior Minister, the leadership team and the new congregation move toward a common understanding of "Who are we now? Where are we going? What are our core ideas, values, emotional energy and edge?" Small group meetings, dinners, weekend workshops, circulation of documents, preaching and other communication channels were all used to gradually move people toward a common understanding and commitment to the new directions for the combined church.

On Action Learning

Over the past decade or more, we have worked with a number of organisations, including hospitals, utilising a methodology built on action learning. Reg Revans, the modern-day father of action learning, (see 1972, 1982, 1983) describes action learning as simply a process where people come together to try out new ways of doing things (eg, behaviours, processes, systems) relevant to a specific issue or project. They observe and reflect upon what happens, learn from it and make modifications. It is a continuous and intentional process of learning from actions taken.

Figure 1 The Action Learning Process

Action Learning Wheel ©Phelan & Enderby 1995

Figure 1 is our portrayal of this learning process that other authors have also described. See, eg, Pedler (1985). The process seems simple but organisations generally do not operate this way. They certainly take action on problems but there is little reflection, deeper questioning or new learning. Problems are solved according to the tried-and-true methods of the past - often spelled out in the policy and procedure manual. This is known as the "Paradigm Effect" where all issues are interpreted and tackled according to a certain paradigm or view of the world (Covey, 1992). An issue tends not to be looked at afresh. Hence organisations tend to be bound by past learning rather than to evaluate properly the present reality and they rarely intentionally try out new things. They do not create opportunities for reflection and learning as, once the fire has been put out, it is perceived to be time to move on to the next issue. There are often significant disincentives to take risks. If anyone has read any of Scott Adams’s widely syndicated Dilbert cartoons, you will appreciate how widespread is the perception of the negative consequences of taking risks in organisations.

All properly functioning action learning groups create an opportunity for the members to come together in a supportive environment, to mutually explore a thorny problem that they have an investment in solving, to learn together and to encourage each other to make changes in the desired direction. This leads to a paradigm shift - a new mind-set, created to support the new direction and a preparedness to try to solve current issues by experimentation and fresh thinking.

We have worked with a number of organisations using action learning groups, including several major hospitals. Each of the hospitals has had cultural change objectives as the catalyst for experimenting with the methodology - one wished to introduce a new patient-care methodology; one had significant industrial relations issues that had to be worked through; another wished to pursue a hospital-wide process of re-engineering and cost cutting. All entailed an organic process of small groups (cells) meeting to discuss the issues and in the process learning to openly explore mental models (the beliefs, ideas, theories, assumptions, that each person was bringing to their perception of the problem).

We have found the following points to be helpful in implementing action learning groups:

1. Groups of around 6 people seem to work well.
2. Each group must have a clear purpose, understood by all, for coming together.
3. The task must be challenging - a problem for which there is no known one "right" solution. Action learning involves attacking problems (or opportunities) not puzzles, eg, How can we consistently deliver high quality care in a more cost-effective way to these patients? A problem has no existing solution, whereas a puzzle has a solution that isn’t presently known, eg, a crossword puzzle, etc. Puzzles are better tackled by experts rather than a group.
4. Individuals involved must have some emotional investment in wanting the problem solved, ie, the issue must be important to them. Members should feel that the purpose for coming together will contribute in some way to "making the world a better place".
5. There is no hierarchy within the group. Members have comparable competency levels in relation to the problem and are prepared to "learn from and with each other". It is not a typical committee.
6. Some action is taken after each meeting to test out thoughts. Action learning involves forward movement not just thinking. Action learning is learning by doing, which means experimentation, and, therefore, risks must be taken.
7. Discussions focus on real issues and group members’ actual experience. Meeting together involves exploring what is not known (doubt and ignorance) rather than telling each other what is already known. "We are not here to discuss what we know, but to discuss what we don’t know". It is about finding the edges of knowledge. Action learning poses questions from conditions of ignorance, risk and confusion, when nobody (including the experts) knows what to do next.
8. Discussions result in fresh questions - "What question, (that no-one currently knows the answer to), if answered, would move us significantly forward?"
9. There is trust and openness, a willingness to tell it how it really is. This is helped by members taking time to get to know each other personally as well as professionally. Members must be comfortable giving and receiving honest feedback. The heart of action learning is bringing people together to talk with each other in an authentic way, leading to fresh questions being asked about their experience and knowledge to date.
10. The organisational hierarchy really wants the problem solved, understands and sanctions the action learning process (allocates time and space to meet), and gives the group legitimacy, ie, "Ye shall all know that this group is favoured by the King". Some appropriate recognition and reward is seen to honour success.
11. There is a charter and a system to capture the learning (eg, a journal) - what happened? Why did it happen? What surprised you? Tell us what has to be done, what has been learned and how we can teach others.
12. The major resources that any manager has are his or her experience and knowledge of the work situation. Learning by managers consists mainly in developing new perceptions of what they are doing and in their changed interpretations of their past experiences (revised or new mental models). It is not any fresh programme of factual data, of which they were previously ignorant but which they now have at their command that enables them to surge forward.
13. The group process enables members to articulate and pursue what they think is important and worthwhile doing, to the point of tension between their mental models and what they think the organisation wants them to do.
14. At this point they will either wholeheartedly embrace the organisation’s values and vision, strive to change it, or depart the organisation. They are pushed to the point of action.
15. A facilitator is helpful in the early stages of a group’s formation. The role of a facilitator is to ensure the group remains relevant, and to ensure members relate to each other in a facilitative ("you tell me") way rather than an authoritative ("I tell you") way. The facilitative way is a lot harder than the authoritative way. It involves group members in a lot more listening to each other.

Outcomes

Each of the interventions we have been involved with based around action learning groups has produced significant results. Measurements of culture, "customer" satisfaction and other productivity measures have shown improvement in each of the studies. John Enderby’s (1997) doctoral research found that the most effective intervention for promoting a learning culture within a hospital, among 20 separate change interventions evaluated, was the use of action learning groups.

Of course action learning is not the "magic bullet" which, if fired, will slay the cultural change beast. It must be done with genuine commitment from the top, and results are certainly enhanced further if learning groups are supported by other human resources strategies. Two other processes that we have used in conjunction with action learning groups, and have found to be effective in helping to facilitate a change to the culture or DNA of an organisation, are:

• The "common strategy viewpoint" ("teachable point of view") process to explain and build ownership of the leadership’s view (mental model) of what is required to be successful.
• 360⁰ performance feedback (and coaching as required) for all management and supervisory staff to encourage useful focus on and alignment to what is required to achieve the vision and a common strategy viewpoint.

The Future of Action Learning

Action learning shows considerable promise for addressing strategic organisational or business challenges, while at the same time developing leaders, transforming organisations and changing corporate culture.

While the literature indicates that the use of action learning is on the rise, there is some opposition to it that stems from a lack of awareness of the power of action learning, and an unwillingness on the part of some organisations to allow outsiders, and even insiders, to probe into critical organisational issues and events. Others may object to action learning because it is a process rather than a product or quick fix. Furthermore, it does not come neatly packaged in a box or with a lock-step procedure from start to finish. Hence, it is demanding on interpersonal communication skills and the general breadth of knowledge and savvy of the managers or facilitators who will lead the process.

References

1. Argyris C. Knowledge and action: a guide to overcoming barriers to organizational change. San Francisco: Jossey-Bass; 1993.
2. Collins JC, Porras JI. Built to last. London: Century; 1996.
3. Covey S, The seven habits of highly effective people. New York: Simon Schuster New York; 1992.
4. Enderby JE. Creating, maintaining and documenting the culture of a learning organisation: a case study in organisational change. PhD thesis RMIT University, Australia; 1997.
5. Enderby JE, Phelan DR. Action learning groups as the foundation for cultural change. Asia Pacific Journal of Human Resources 1994:32(1); pp 74-82.
6. Pedler M. On the difference between P and Q. In: Pedler M (editor), Action learning in practice. Aldershot: Gower; 1985.
7. Revans RW. Action learning. London: Blond and Briggs; 1979.
8. Revans RW. The enterprise as a learning system. In: Revans RW, The origins of action learning. London: Chartwell-Bratt; 1982.
9. Revans RW. Action learning: its terms and character. In: Management Decisions 1983; 21: 77-88.
10. Senge PM. The fifth discipline: the art and practice of the learning organisation. New York: Doubleday Currency; 1990.
11. Tichy N. The mark of a winner. In: Hesselbein F, Cohen P, (editors), Leader to leader. New York: Jossey-Bass; 1999.

About the Authors
	Dean R Phelan BA; Grad Dip App Psych; MA(Hons), (Melb), MAPsS, AFAHRI Dean is the Managing Partner of TopWheel and an Organisational Psychologist by profession.
Dean works with the top management of some of Australia’s leading companies and organisations. He has extensive senior management experience in the private, public and not-for-profit sectors. He has facilitated many Top Team meetings and workshops to help managers re-focus their purpose and vision, and to move from vision to implementation. Dean has co-ordinated mergers, major organisational change programmes, building redevelopments and organisation-wide leadership alignment efforts. He has lead teams that have gone into a number of large corporations to re-engineer their HR functions, processes and contribution to the bottom line. Dean’s interests are in strategic planning & HR, organisational change and learning, leadership, executive coaching, performance management and research in areas related to the "people" side of the equation. Dean holds Board appointments for several companies and is the current Board Chairman of a large not-for-profit organisation. His experience also includes an appointment as Chairman of the Health and Medical Services Committee of the ILO (International Labour Organisation) in Geneva. Prior to founding TopWheel, Dean was: Executive Director of SIAG, an Australian firm providing outsourced IR / HR services. Director of Services and Redevelopment with Epworth, Australia’s largest private hospital. Group HR Manager (International) with Elders IXL Personnel Manager for the state of Victoria with the Westpac Banking Corporation. Dean’s international experience includes consultancy work in the UK, USA, Switzerland, New Zealand, Vanuatu and Poland. Dean has been a keynote speaker at national and international forums in the areas of action learning, change management and strategic HR management. A number of his papers have been published internationally.
	Gregory Birchall BA(Hons), BEd., MEd, (La Trobe), EdD (Colorado), MAHRI Greg is an educationalist and management development expert by background. He has been consulted by organisations around Australia and Overseas, including projects for the World Bank, the Asian Development Bank and AusAid.
Greg’s experience includes the management and delivery of training programmes at an academic level and for major organisations both in Australia and offshore. He has worked in both the private and public sectors. Major clients have included the Commonwealth Bank, Telstra / Pacific Access, Epworth Hospital, the Healthscope Hospital Group and COC Community Care. Prior to joining TopWheel, Greg was Director of MBA programmes and International Management for RMIT Business, with responsibility for programmes in Melbourne, Singapore, Malaysia and Hong Kong. He also lectured in the Doctor of Business programme and supervised doctoral and masters’ level research in the fields of organisational learning and change management. He has also run his own management consultancy firm, Columbine Management Systems Pty Ltd and was Principal Adviser and Head of the Research & Learning Division of SIAG Pty Ltd. Greg has been a Senior Lecturer at the Graduate School of Management at La Trobe University, Australia, and is currently an adjunct member at Macquarie University in Sydney, Australia. Greg has extensive international project experience, having worked in Indonesia, China, Solomon Islands, Nauru, Bahrain and the USA. Recent consulting projects have been concerned with organisational alignment, vision, mission and values, performance feedback and executive coaching and performance management systems. Greg holds a continuing appointment as the Capacity Building/Action Plans Advisor for the Indonesia-Australia Specialised Training Project Phase II, which provides management and skills training to government officials throughout Indonesia. The project is sponsored by AusAid.