Cultivating Innovation: A Guide for Healthcare Leaders

Culture for Innovation
Creating the
Guide for Executives
Lynne Maher
Paul Plsek
Helen Bevan
COVER_1:Layout 1 18/11/09 09:59 Page 2

© Copyright NHS Institute for Innovation
and Improvement 2009
The Creating a Culture for Innovation: Guide
for Executives is published by the NHS
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ISBN: 978-1-907045-56-1

This Guide for Executives is aimed at senior healthcare leaders. It provides 31 practical tips for leaders
who want to contribute positively to the culture for innovation in their organisations and systems.
A more in-depth practitioners guide, Creating the Culture for Innovation, provides much more
detailed advice and guidance, a host of additional examples, and information about an online staff
survey that can be used to assess, benchmark and understand the culture for innovation.
“Strategies and processes alone are not sufficient to drive the
degree of change we are seeking… the NHS should focus on
tackling the behaviours and cultures in the system that stand
in the way…”
David Nicholson, Chief Executive of the NHS
NHS Annual Report 2009
Executive summary
The ability to innovate is important for the future success of NHS organisations and health systems,
especially as resources become constrained. We have identified seven key dimensions of culture that
distinguish highly-innovative organisations. These dimensions form a framework which leaders can
use to assess the culture for innovation within their own organisation.
Leaders have a disproportionately large effect on the cultures
of organisations and systems. By their behaviours, leaders create
the conditions that either hinder or aid innovation.
Creating the Culture for Innovation Guide for Executives 1
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Introduction
2

There may never be a more important time for leadership in the NHS. There have been impressive
improvements in outcomes and services over the past decade but this has also created ever-rising
patient and public expectations for something even better. The current global financial picture means
that over the coming years we need to deliver an even higher quality NHS providing even better
patient experiences of care, but with less resources. Innovation is needed to deliver these
expectations. That means we will need leaders who can support and create a culture in their
departments, organisations and health systems that channels the energy of all staff into thinking
differently.
But, in a recent study1
, two-thirds of NHS staff respondents stated that they were not adequately
supported by senior leaders to undertake innovation and improvement activities. Today’s successful
leaders need to rise to the challenge to build and utilise the confidence, skills, wisdom and experience
of their entire workforce for the task ahead.
Evidence from high-performing organisations around the world suggests that there are seven key
dimensions of cultures that enable innovation. This guide is a resource for senior leaders who wish
to assess and enhance the cultures of their organisations and systems along these dimensions.
A more comprehensive practitioners’ guide is also available. Visit our website for more information,
www.institute.nhs.uk/innovation
1 Visit our website for more information on the full report, NHS Innovation and Improvement Survey 2009 Report
at www.institute.nhs.uk/innovation
Innovation and the NHS today

This Guide for Executives is part of a series of resources for innovation from the NHS Institute for
Innovation and Improvement (see box).
It is an overview aimed at senior healthcare leaders and introduces:
• the seven dimensions that impact on organisational culture for innovation
• a sampling of tips, tools and examples to help you address gaps in the culture of your organisation
or system
• the NHS Institute’s survey tool and other approaches for assessing the culture for innovation
within your organisation or system.
“Department of Trade and Industry (DTI) reports from 2003-2005
find that, in general, innovation has a positive and significant
impact on productivity and firm performance.”
DTI 2007
A word about terminology…
Throughout this guide we will use the terms ‘organisation’ and ‘system’ interchangeably. You should interpret
this as it relates to your leadership role. For example, as a Chief Executive or Director in a provider organisation,
you may be mainly interested in creating the conditions for innovation in your organisation. Commissioners, or
clinical or managerial leads of pathways of care, will be interested in creating the conditions across a system that
spans organisational boundaries. The concepts, tips and tools apply equally well to each setting. Further, as we
describe in the more comprehensive guide, they also apply to departments, teams, meetings and any setting
where individuals must work together to innovate.
4 Creating the Culture for Innovation Guide for Executives
Guide to creating the culture for innovation

Resources available from the NHS Institute for Innovation and Improvement…
Thinking Differently is a comprehensive guide, aimed primarily at front-line staff, that provides a three-step
process and 14 tools for stimulating innovative thinking. It is written in an engaging style and filled with images
and examples that bring the concepts to life.
Making a Bigger Difference is a resource that describes a thinking process and tools to help assess how
innovative an idea is and to stretch thinking about what might be even more innovative. There is a version
targeted for commissioners and one for front-line staff and leaders in provider organisations.
Creating the Culture for Innovation is the third in the series and describes the necessary elements of
organisational culture that evidence shows are critical to enabling innovation. More than a concepts-only
resource, it describes how to assess organisational culture and what actions leaders can take to change things.
There are two versions of this resource: an executive summary (which you are reading now) and a comprehensive
version with even more tips, tools and examples.

Performance Gain
Underpinning
thinking about the
“way it has always
been”
Incremental change
Small – medium
Largely unchallenged and unchanged
Step change
Medium – large
Fundamentally challenged and changed
The terms ‘innovation’ and ‘improvement’ are commonly used interchangeably and there is little
value in analysing this in detail. What really matters is whether the change makes a small or large
difference – that is, whether it is an incremental or step change in performance and thinking.
The NHS Institute’s guide, Making a Bigger Difference, defines ‘innovation’ as:
Innovation: Doing things differently, and doing different things,
to create a step change in performance
What do we mean by innovation?

Both incremental change and step change are useful and desirable. However, because a step change
challenges “the way it has always been,” organisational culture is an even stronger factor in
determining whether the change occurs.
What about the spread of change?
Spread is a related, but independent issue that, in the end, dictates the overall impact of a change. While an
incremental change may have only a small impact in the setting in which it is first implemented, it can have a
large impact on the health system or the NHS as a whole if it is subsequently spread and adopted by others.
Further, while a step change can make a big difference in the site that implements it, it might make very little
difference in the system as a whole if it not widely spread. Organisations and systems with cultures that support
innovation (as we describe them in this guide) also tend to be more successful at spreading change.
“Without innovation, public services costs tend to rise faster than
the rest of the economy. Without innovation, the inevitable
pressure to contain costs can only be met by forcing already
stretched staff to work harder.”
Mulgan G. & Albury D. (2003) Innovation in the public sector. Strategy Unit, London.

8
Seven
dimensions of culture
in an innovative
organisation or
system

The characteristics of highly innovative organisations have been widely studied. While the bulk of the
literature comes from outside the public sector and health, the few studies that do cover this context
are consistent with the larger findings from other industries. This is not surprising. People are people
and the organisational cultural factors that they experience as enabling or disempowering with
regards to innovative thinking are characteristic of a social system, regardless of industry.
We have captured the common themes across these studies as 27 constructs organised under seven
dimensions (see diagram below).
The culture for innovation framework
• Emotional support
• Balanced assessment
• Learning from failure
rather than punishing
• Trying new things
• Funding
• Time
• Authority to act
• What, but not
how
• Specific call for
innovation
• Tie to strategic plan
• ‘Stretch’
• Clear case for need
• Flexibility
• Deliberate process
• Training
• Encouragement for
skills development
• Aligned with organisational
goals
• Recognition
• Intrinsic motivation
• Individualised
• Honouring
everyone’s input
• Diversity
• Trusting, open
environment
• Team based work
Relationships Risk Taking
Resources
Knowledge
Goals
• Wide scope search
• Uncensored, unfiltered,
unsummarised
• Free-flowing
Rewards
Tools

Risk Taking is about establishing an organisational climate where people feel free to try out
new ideas. While it is obviously important to avoid taking inappropriate risk, a healthy
organisational culture seeks a balanced assessment that avoids prematurely rejecting ideas
due to over-estimation of risk. It also requires leaders who show they are quick to provide
emotional support to those willing to try something new, regardless of whether the idea is
eventually judged a success or ‘failure’. Leaders in innovative organisations demonstrate that
they are more interested in learning from failure than in punishing it.
The Resources dimension considers the broadest sense of the word. The climate for
innovation is enhanced if people know that they have the ‘resource’ of authority and
autonomy to act on innovative ideas. While innovative ideas do not necessarily need a lot of
money or time to develop, staff can become demoralised if these traditional resources are not
available and can feel that there is no point in putting forward a new idea. The presence of
concrete resources signal that the organisation is taking innovation seriously.
Broad-based Knowledge is the fuel for innovation. We create better conditions for innovation
when information, both from within and outside the organisation or system, is widely
gathered, easily accessible, rapidly transmitted, and honestly communicated. Since we cannot
know in advance what knowledge might stimulate an innovative idea, censoring, filtering or
over-summarising information detracts from this dimension.
Organisational and system leaders – whether team leads, managers, directors, executives, or
commissioners – signal that innovation is highly desirable by setting aspirational Goals in
specific areas and challenging others to find ways to realise the vision. Linking these to strategic
priorities and being able to articulate a clear, multi-faceted case of need, further signals the
importance of the call for innovation. However there is a caution. Innovative thinking is stifled
when leaders go beyond statements of what needs to be achieved and also become
prescriptive as to how it must be achieved.
Seven dimensions of culture for innovation

Rewards for innovation are symbols and rituals whose main purpose is to recognise innovative
behaviour. They signal how much value is given, or not, to the efforts of individuals and teams
who come up with new ways to help the organisation or system achieve its strategic goals.
Because it is all about encouraging more of this sort of behaviour, the best recognition is that
which appeals to people’s intrinsic and individualised motivation. The most successful
recognition schemes avoid a one-size-fits-all approach and are instead based on a deeper
understanding of what makes people do what they do. For example, frequent personal
expression of appreciation is often more important to people than financial reward.
In high-performing organisations, innovation is the product of the deliberate use of practical
Tools. Imagining that innovation will happen on its own if we just have the right culture would
be as naive and irresponsible as imagining that financial controls would naturally emerge
without some deliberate structures. While everyone is capable of innovative thinking, most of
us have been socialised to be more conservative in our thinking in the work environment,
especially in health care where there are legitimate risks that must be managed. Leaders,
therefore, need to consider how they build capability and capacity in deliberate methods for
creative thinking.
The Relationships dimension refers to the patterns of interaction between people in the
organisation or system. Innovative ideas are rarely the product of a lone genius. Even when
they might appear to be, delving further into the story nearly always reveals that the idea was
formed over time and through multiple interactions with others that fuelled the process.
Therefore, environments where staff are routinely exposed to a wide range of different
thinking, from a wide-range of people, with a wide range of backgrounds and points of view,
provide rich soil for the growth of innovation. Of course, it is more than just exposure; one can
be ‘exposed’ to a diverse group of people while riding on a train and not be stimulated to
innovate. There must be a sense of common purpose; of being in a ‘team’ with others. This
team environment must also enable those with different thinking to trust that their input will
be honoured and explored, rather than immediately argued against.
These seven dimensions of culture provide leaders with a lens that
can help them take steps to enhance the conditions for innovation.

Think of the seven dimensions as a sort of window, or portal, through which innovative ideas either
flow freely or are blocked. The wider the opening of the portal, the more innovation flows through
an organisation or system.
Portal charts, like the one opposite, graphically illustrate this concept.2
• A value of 0 indicates that the behaviours and practices corresponding to that dimension
neither aid nor hinder innovation.
• Negative scores indicate the presence of behaviours and practices that tend to hinder
innovation.
• Positive scores indicate the presence of behaviours and practices that tend to aid innovation.
• Larger positive or negative numbers indicate more aid or hindrance respectively.
The scores are plotted on each scale and then connected with lines to create a ‘portal’ (see example
opposite).
We will briefly describe two approaches for collecting the assessment data needed to create a portal
chart for an organisation or system. The more in-depth companion guide provides further details and
supporting materials.
2 Portal charts are also referred to as spider diagrams because they resemble a spider’s web. We find the metaphor of a portal better suited to
our needs here. The lines coming out from the centre correspond to each of the seven dimensions and provide a scale from -5, through 0, to +5.
A way to visualise the conditions for innovation: portal charts

Assessing conditions for innovation: how to read a portal chart
Here we see depicted a culture where there are strong goals for innovation (+4), fairly strong rewards (+3), pretty
good resources for innovation (+2) and supportive relationships (+2). So far, it sounds good. The tools, processes
and methods of the organisation neither hinder nor aid innovation (0), which may be OK, but is not very assertive
for innovation. Of even more concern, risk taking is somewhat discouraged (-2) and lack of knowledge somewhat
hinders innovation (-2.5).
We conclude, based on our seven dimensions framework, that despite the strong goals and rewards for
innovation, other factors in the culture will limit innovative output. To put it another way, the portal is not exactly
wide open for the free flow of ideas. The leaders of this organisation or system clearly have some work to do to
create better conditions for innovation. Stronger language about goals and more rewards will have only limited
impact if risk taking and knowledge sharing are not also addressed.
Risk Taking
ResourcesRelationships
Tools
Rewards Goals
-5
0
+5
Knowledge

Informal assessment.
A straightforward, informal approach involves creating a facilitated organisational conversation
around the seven dimensions. A good dialogue can be had in 1.5 to 2 hours, with as few as 10 or
as many as 150 people arranged in small discussion groups.
Set up a meeting of a representative cross-section of staff in the organisation or system under
consideration. Begin by explaining the importance of a culture for innovation and briefly describing
the seven dimensions. While senior leaders should open the meeting, we strongly suggest using a
trained group facilitator, who might be a member of your service improvement team or
HR/development team, to lead the remainder of the session. This might be a somewhat sensitive
discussion as staff share their views on the culture of the organisation or system and it is best that
someone other than the leader guides the dialogue to ensure that everyone is comfortable and feels
fairly heard.
With staff arranged in small groups of six to eight individuals with similar roles (i.e., separate groups
for nurses, doctors, administrative staff and so on) the facilitator takes everyone through the seven
dimensions one at a time, asking each individual to rate privately the organisation or system on that
dimension. (There are materials to support this in the in-depth companion guide.) After going
through all the dimensions, individuals then discuss their ratings within their small group to create
a group rating. Consensus in the small groups is typically easy to achieve, as staff in the same job
category tend to see the culture similarly.
Insights and differences of viewpoint then emerge as the small groups feed back their ratings to the
whole group. The facilitator helps draw out similarities and differences among the ratings to create
an overall portal chart for the organisation or system, along with a set of notes to capture the
discussion.
Then, in a second round of discussion, staff can provide input on what they would like to see leaders
do to enhance the culture for innovation. Leaders should meet after the session to review the portal
chart and staff suggestions, along with the tips in the subsequent section of this guide.
Assessing the conditions for innovation in your organisation or system

Informal Assessment
Benefits
• Provides a quick assessment of the culture of the organisation as perceived by the attendees.
• The discussion provides a rich depth of understanding.
• Bringing people together will create an environment of cross team/profession learning, which links
immediately to the relationship dimension of the framework.
• Participants will communicate the message that creating a supporting culture for innovation is seen as
important by the senior leadership team.
Considerations
• Small groups might not be representative of the larger organisation or system.
• This approach results in a subjective rating that is difficult to compare over time.
• May be subject to the bias associated with discussion-oriented group-consensus processes; e.g., can be
dominated by a few outspoken individuals.

Assessment using the NHS Institute’s online survey
We have developed a 29-item survey (see appendix), and a supporting website, that enables
organisations and systems to assess their culture for innovation in a more formal way. This tool is free
to NHS organisations and available to others for a charge. Details are available on the NHS Institute’s
website at www.institute.nhs.uk/innovation
Someone from the organisation or system takes on the role of administrator in order to
create the email invitation list. Our research has shown that active senior leadership communication
in encouraging staff participation in the survey is critical to ensuring a large and representative
sample.
The online tool also allows leaders to create a list of relevant demographic identifiers that can be used
to look for patterns in the responses. For example, leaders can see if doctors, nurses and managers
perceive the climate for risk taking differently, or if the assessment varies across departments in an
organisation or across organisations in a system. These insights will help leaders select, from among
the tips offered in the subsequent section of this guide, actions that will have the greatest impact.

Assessment by Survey
Benefits
• Can be used for large numbers of staff; i.e., invitations can be sent to an entire health system, pathway,
organisation, team, or department.
• Compared to the informal assessment, the survey provides a more consistent measure over time from a
potentially large sample of staff.
• Results are automatically provided in graphic format (portal chart) and can be segmented by different
groupings (e.g., porters, doctors, community nurses, administrative staff).
Considerations
• Requires a survey administrator to manage the process.
• Need to consider the timing for doing this in order to avoid ‘survey fatigue’ if staff are also being polled for
a variety of other purposes (e.g., staff satisfaction survey) around the same time.

31 tips for creating
the culture for
innovation
18

Whether you have used the informal assessment or survey approach, you will now have some insight
into the culture for innovation in your organisation or system, which you can use in discussion with
your leadership team to decide what actions you will take. As illustrated in the previous portal chart
example (page 13), leaders typically find one to three dimensions that should be strengthened to
improve the culture for innovation in their organisation or system. The tips in this section will get
you started.
If you have not yet completed an assessment with staff, or are being introduced to this guide for the
first time, you might want to read through all the tips to get an overview of the variety of ways in
which leaders can influence the culture of their organisations and systems.
How to use this section
Consider the information provided here as a ‘starter for ten’.
For even more practical information, tips, and examples, see the
more in-depth companion guide.

If you already have an organisational culture assessment, proceed along the following lines:
1. Review the results of the whole assessment. Look at those dimensions for which you have a positive
score and identify those that require improvement. Talk about what you can do to sustain those areas with a
positive score.
2. Review (on pages 10-11) each of the dimensions you want to focus on as a result of the assessment
process. Together with a group of relevant leaders, decide if you need to work on the dimensions overall, or
just some specific aspects of them. Having a clear idea about the areas you most need to work on before
reading the tips will help you stay focused on what will really make a difference. Avoid being distracted by a
tip that looks interesting, but in fact isn’t what you most need to do to make a real difference.
3. Read all the tips associated with your dimensions of focus to see the range of things that you
might try. Discuss the following as a team:
• What is the basic idea behind this tip?
• How do we think it would work in our context?
• How might we adapt it to fit?
• How might we combine thoughts from several tips in crafting something unique for our situation?
• What additional ideas do we have beyond the ones here?
• How will we actually implement something? Who will we need to work with to do this?
Really give it some thought. Your context matters. Be flexible and adaptable in your thinking.
4. Use a disciplined, reflective learning approach – for example, a Plan-Do-Study-Act (PDSA) cycle –
to test your intervention.
When trying to bring about change in social systems such as organisations, you never know whether or not
something will work until you try it out. Plan and undertake a small test of change. For example, try it out in
one area, with one team or one department or for just one week. Seek feedback on whether it has made a
difference to the view of your staff. Reflect on the learning, modify the intervention as required and test again,
maybe on a larger scale, in order to spread the change. For more information on PDSA cycles please refer to
the NHS Institute for Innovation and Improvement, Improvement Leaders’ Guides, www.institute.nhs.uk

21

Tips for improving
the risk taking
dimension
22

Share widely how the organisation or system has taken reasonable risks on innovative ideas
in the past. If staff don’t see leaders actively supporting reasonable risk taking, they may get the
impression that it isn’t supported. The solutions are simple. For example:
• be transparent about how risk is assessed in the organisation. Consider how you can keep staff
informed about this
• publicise new ideas that are being tested, outline the anticipated benefits and risks, and describe
the roles of senior leaders in supporting these
• talk about hard decisions made at board level to support innovative pilots and new ways
of working
• be seen speaking openly about innovative ideas before you are sure that they work.
Establish a process to publicise and learn from ideas that ‘fail’. Make it routine and acceptable
to talk about ideas that were tried but ‘failed’. Work from the mindset that the only ‘failure’ is the
failure to learn, and that not sharing and learning from things that don’t go as planned is waste and
lost productivity.
Go out of your way to provide emotional support for innovators. Leaders who understand
and recognise the potential in staff make it their business to know the individuals and teams who
are doing innovative things and personally connect with them. Go out to the person’s work area, or
to the department or team, and take an interest. Show that you know what they are doing, ask
what they are learning, and ask what you can do to help. Keep the lines of communication open
through periodic walk-arounds or telephone calls.
Tips for Improving the Risk Taking Dimension
“The fastest way to succeed is to double your failure rate.”
Thomas Watson, founder IBM

Reverse a negative, worse-case scenario culture by establishing new conversation practices
when innovative ideas are presented. When presented with a new idea, people can be quick to
point out what might go wrong, ask for strong evidence to support the new idea, or note that it
would not work under certain circumstances. Take the lead in reversing this behaviour and mindset
by acting differently and encouraging others to do the same. For example, when presented with
new ideas:
• create a rule that the benefits of the idea are listed first before any discussion about what could
go wrong
• recognise that the new idea may not work for every patient group or situation. However, ensure
that any decision is made on the benefits for the majority rather than not using the
idea because it does not benefit everyone in every situation. Design for 80% rather than 20% of
your organisation and recognise that you will need to support some patients differently
• ask for the evidence that supports the status quo approach. Ask that the new idea be judged fairly
to the same standard of evidence that we allow for the status quo practice.
Don’t use humour to lighten the mood when discussing the risks associated with an
innovative idea. It almost never works and often has the opposite effect. The box below
describes all-too-often-heard comments meant to be light-hearted in approaching the risk taking
associated with innovation.
Some things are just not funny
We cringe at some of things that we have actually heard senior leaders say…
“Jane tells us she is sure it will work, and we’ve told her we are sure she can find work elsewhere if it doesn’t
(ha ha ha)”.
“Yes, I can remember we learned a lot from a past failure of an innovative idea. Of course that bloke no longer
works here (ha ha ha)”.
The reaction is often nervous laughter and people making eye contact with one another around the room. This
affirms that they believe that this gallows humour is actually true about the organisation.

Don’t do this! If you are in a room where someone does, immediately speak up and say something
in a serious tone like, “Actually, Jane’s confidence in leading the way on this innovative idea is exactly
the sort of thing we support around here, and we certainly wouldn’t want people like her to leave”.
Feed the rumour mill to positive effect. As you try some of these tips realise that, your new
behaviour is likely to take others by surprise. Invariably, this will start a buzz around the organisation.
This will have a positive effect in terms of improving the conditions for innovation, for it has been
said that the ‘rumour mill’ is often the most efficient internal communications vehicle in any
organisation.
Capitalising on ‘failure’
When developing the Airblade, the energy-efficient hand drier for public restrooms, the engineers at Dyson,
noticed that the machine was trapping a lot of air inside and became curious about this 'failure' of their design.
They wondered what they could do with this high-speed air. They considered lots of potential uses before looking
at the typical electric fan, which uses rotating blades to hack air into pieces that are then propelled out into the
room. They had found an opportunity....and the bladeless fan has been created.
Tips for Improving the Risk Taking Dimension

Tips for improving
the resources
dimension
26

Reinforce the expectation that individuals and teams should feel they have authority to act
on innovative ideas and seek to understand why they might feel they do not. Do you know
the reasons that staff might not feel able to act on new ideas? Many leaders don’t, nor do they
know the process that staff have to go through in order to gain permission to try something new.
Do a ‘spot check’ during individual meetings or walk-arounds by asking staff to tell you about ideas
they have where they feel they need more permission to act. Be clear that you are very open to
feedback. Be careful to provide emotional support and show genuine appreciation of their efforts
and any difficulties they face. Be prepared to do something and communicate back to staff to raise
their feeling of empowerment.
Turn strategically important innovation efforts into formal organisational projects with
allocated resources. The most obvious way to provide resources for innovation is simply to focus
innovative thinking on areas where resources already exist. For example, if you already have people
who are focusing on safety, challenge them to massively overachieve their own aspirations by
thinking differently about this area.
Link innovation efforts to waste-reduction techniques that free up resources. In a context
of limited resources, it may be necessary to create head room for innovation by first embarking on
productivity improvement and then allocating some of the savings to support innovative new ideas.
In doing this, remember that it is important to acknowledge the contributions of staff in both the
waste-reduction efforts and the innovation efforts.
Seek resources from non-traditional channels. ‘Think outside the box’ a bit and you may find
that there are more resources for innovation that you could access. For example, become a test site
for a national or regional initiative or secure funds from foundations, social enterprises, or even the
National Lottery. Local industries, universities, voluntary sector organisations, and members of the
community might also be willing to volunteer their time and skills to help with innovative efforts.
Tips for Improving the Resources Dimension
Helping hands. NHS organisations have benefited from students of
journalism and photography who have provided their time for free and
used the work they have undertaken as part of their academic assessment.

Tips for improving
the knowledge
dimension
28

Start a ‘not invented here’ programme where leaders, managers and staff are supported
to seek out knowledge and ideas from outside health care that can be adapted to address
key organisational challenges. Each of us have several encounters a week with people, businesses
and services where we experience good flow as customers, have interactions that create exceptional
positive experience, or see high levels of productivity via technology or job design. Leaders can
capitalise on the myriad experiences of staff by drawing attention to the need to apply ideas and
principles from elsewhere to the work we do. While a general awareness raising might be useful, a
more focused effort will have greater benefits. For example, “This month, we are seeking ideas that
we could adapt from elsewhere that will allow service users to gain greater access to services out of
normal hours”.
Encourage staff to look for and share new ideas from other health care organisations,
internal departments, or partners along pathways. Just as the previous tip encouraged greater
knowledge flow from outside health and social services, this tip suggests the same but with an
internal focus. Requiring managers and clinical leads to regularly seek out and adapt ideas from
other areas also encourages the more rapid spread of innovation and combats the ‘pockets of
excellence’ phenomenon that we unfortunately see so often.
I’ve been noticing…
You know that you are making progress in the Knowledge dimension when you regularly hear staff say things
such as:
• “I have a friend who works in a neighbouring hospital and what she says they do is…”
• “I read about something really great in the Nursing Standard (or BMJ or HSJ)…”
• “I was at a meeting with some colleagues from community services and the way they handled a similar
situation is…”
• “I went to X-ray with a patient and I noticed that they did this great thing that I think we should consider…”
Tips for Improving the Knowledge Dimension

Regularly share and celebrate innovations that are already happening in your organisation
or system. For example, develop an annual ‘innovation day’ or innovation focus within your regular
newsletter, in which teams, departments or organisations in your health economy display some of
their most innovative new ways of working and pose challenges seeking innovative ideas to solve
their problems.
Share board information more widely and use knowledge from the workforce to support
the board. Look at all of the information reviewed at board level and ask: “Why can’t this
information be shared more widely to stimulate broader thinking and create more urgency for
change?”. Sharing detailed performance information can also call attention to so-called ‘positive
deviance’ – departments, teams, or individuals who seemingly have discovered something that
enables them to excel on a particular dimension of performance that might be adapted and spread
more widely (see box).
The surgeon who knows something.
Mining the data in its Quality Observatory, a team in the South East Coast identified a consultant at one hospital
site who was achieving outstanding results. His hip replacement patients had good, safe outcomes, with much
shorter lengths of stay and higher satisfaction, at reduced cost and with higher staff morale than comparable
sites. His better practices have now been evidenced with data, which also demonstrates the wide variation among
surgeons, and work is underway to spread these practices.
Source: Samantha Riley, Head of the Quality Observatory, South East Coast SHA and member of the Academy
for Large-Scale Change.
“Innovation is fostered by information gathered from new
connections; from insights gained by journeys into other
disciplines or places; from active, collegial networks and fluid,
open boundaries.”
Margaret Wheatley, author

31

Tips for
improving the
goals dimension
32

Identify and publicise widely the strategic issues where there is a clear case for the need
for innovation and where an extension of the current way of working is clearly inadequate
to meet the need. While continual, incremental improvement is the ethos of the health system, this
can also lead to a culture of complacency. The mindset “of course we can always do a bit better”,
while good, leads to change that often does not fundamentally challenge the status quo approach.
In other words, it is not really very innovative and does not achieve breakthrough results. The key in
articulating targets that stimulate innovation is to stick strictly to defining the ‘what’ and the ‘why’,
but steadfastly avoid specifying the ‘how’.
Set out organisation or system-wide challenge topics that call for innovative ideas in
specific areas of need. This straightforward approach builds on the previous tip but goes a step
further to create an ‘innovation focus list’. In the spirit of focusing, this list should be specific as to
topics and no more than five to seven items. For example, commissioners in a PCT might say, “We
want innovations that will: cut teenage pregnancies by 70%, reduce admissions for people with
diabetes by 50%, etc.”.
Articulate stretch goals in the language of “how might we…?” In many organisations, the
word ‘target’ or ‘goal’ implies that there will be negative consequences associated with not meeting
it, even if one falls short by only a small amount. The natural reaction is to want to avoid setting
oneself up for negative consequences. Often, more thinking energy is devoted to arguing against
the specific target than is given to coming up with innovative ideas. A simple way to avoid this is to
state innovation goals and targets in the form of a question that begins: “How might we…?” (see
box). This invites enquiry and creativity, rather than resistance and debate.
Tips for Improving the Targets Dimension
“How might we…?”
• We have reached our 18 weeks wait target, so how might we reduce that by half again?
• Our operating costs in theatre are much better now, but how might we cut them by an additional 30%?
• Many people with diabetes in our practice have achieved control of their blood sugar levels. How might we
maintain that outcome with half the number of visits to health professionals?

Consider goals, contracts, annual appraisals, personal development plans, or job
descriptions that require people to try out a number of innovative ideas annually and
report back on what they have learned. This tip suggests simply setting the general goal of
asking for innovation of any kind. But avoid setting people up for failure and frustration. If you set
such a goal, make sure you also provide tools and skill building, along with the resource of authority
to act on ideas.
Test for alignment of organisational or system-level goals for innovation by asking staff
where they think innovation is most needed. The objective is to see whether you are
communicating clearly enough to raise people’s awareness of the need for innovation so that they
are constantly on the look out for innovative ideas. If they cite back to you the areas where you have
set goals for innovation, then you have evidence of good communication. Otherwise, you are not
fully capitalising on the power of goals to create a culture for innovation.
“Don’t stop. Keep moving towards new targets, new goals,
new improvements.”
Stuart Rose, CEO Marks & Spencer

35

Tips for
improving the
rewards
dimension
36

Seek to understand and work with what intrinsically motivates innovators. You may need
an array of ways to recognise accomplishments and a way to match these to an understanding of
what is meaningful to each individual you wish to recognise. The vast majority of people do not do
what they do in order only to get more money.
What motivates you?
• Many front-line staff feel that monetary rewards for ideas should be directed at purchasing equipment or
further enhancing the service because their personal values are deeply centred on caring for patients.
• A staff nurse who developed a new needle disposal system was delighted to have help in writing an article
for publication in a professional journal. This was something that she felt she could not have done alone but
seeing her name on the page made her feel very proud.
• Two team members were supported in attending a conference on innovation and improvement. Their
experience was so good they could not stop talking about it and the new ideas they had learned.
Many have enquired if this recognition is available for others.
To gain insight into the intrinsic motivation of others, leaders can initiate conversations as they walk
about or interact with small groups. Use open-ended discussion starters such as:
• “What was the best recognition you ever had in a work situation?”
• “What could we do to make you feel recognised and supported for the work you have done.”
Tips for Improving the Rewards Dimension
“[If] rewards don’t follow suit, then the lasting innovation culture
you seek will be fleeting at best.”
Troy Geesaman, Innovation and Strategy Director at the product design firm Iaga

Set up structures and processes to enable peer, patient and carer recognition for
innovation. Don’t think of rewards and recognition as only being top-down, or something that
comes only from ‘an organisation’. For many staff, being recognised by peers, patients and carers is
very important and meaningful. Comments from peers and patients could be incorporated into an
internal newsletter article, the local press, or an internal awards ceremony.
Reward and recognise ‘failed’ attempts at innovation where you can celebrate learning. If
individuals and teams who try a new idea that fails are shunned, even just a little or in seeming jest,
they are less likely to try to innovate again. Whatever you decide to do for rewarding innovation in
your team, organisation, or health system, make sure that you design something to also recognise
‘attempts with learning’. When the culture is such that it seems just as easy to talk about these
examples as it is to talk about successful innovations, you will have gone a long way towards creating
the culture for innovation.
Grand prizes and competitions create a few winners, but also lots of losers. Instead seek
to reward all legitimate innovations and attempts. Establish reasonable, but explicit and
transparent, criteria for what you want to call an ‘innovation’ or an ‘attempt with learning’ and then
recognise as many or as few examples as meet the criteria. If there are 37 examples that meet the
criteria, recognise them all equally. If there are only 2 that meet the criteria, recognise those and call
for more like them (see box).
Firm criteria, variable number of winners
Countries around the world offer prizes annually to firms that demonstrate excellence in quality. Several of these
awards programmes follow the philosophy of being firm on a set of criteria and then recognising as few or as
many organisations as meet these. For example, over the years, the Japanese Deming Prize has seen years when
as many as eight awards were given, as well as a year when no award was presented because no organisation
rose to the standard. Similarly, the number of winners of the American Malcolm Baldridge Quality Award has
varied from two to seven.
Failure is an integral part of the innovation process, provided that
it is seen as an opportunity for learning and moving on to a next
iteration of the process.

39

Tips for
improving the tools
dimension
40

Develop a cadre of people who can facilitate creative thinking and innovation processes.
Creative thinking is something that everyone can do. Providing training and facilitation resources to
build the capability of staff sends a visible message that innovative ideas are desirable. Consider it a
natural extension of the improvement teams, advisors, and toolkits used by many organisations.
Require innovators seeking resources to explore how innovative their idea really is and
how they might make it even more innovative. Consider each and every idea for change that
comes to your attention as a ‘teachable moment’ that offers you the opportunity to further develop
the culture for innovation. If someone is seeking resources, even if it is only the resource of your
authority to proceed, encourage them to also stretch their thinking further.3
Plan to introduce new tools or methods for innovation periodically. Spread their use widely
in simple ways that help everyone see how they might use them, and publicise their many
applications. If you are already using a few tools for deliberate creative thinking and innovation, or
after you have implemented some of the tips above, plan to keep the focus on innovation fresh by
injecting new things into the mix. This continually communicates the value you place on new
thinking. Keep it simple and seek to introduce new tools and methods as part of daily work rather
than always imagining that some sort of formal training is needed (see example).
Bringing innovation into day-to-day work of staff.
The NHS Institute’s Thinking Differently guide describes a tool called ‘Breaking the Rules’ that can easily be
integrated into the daily life of an organisation or system. Challenge staff for a month to purposefully notice all
the ‘unwritten rules’ and traditions all around them. An easy way to spot these is to pretend that one is a man
from Mars who is totally unfamiliar with health care processes and systems and keeps asking why things are as
they are. For example, “Why is it that when patients turn up we ask them to wait in an area, when actually they
came to see a clinician?” The answer might be, “Well we have to manage the flow of demand in some way.”
To which a response might be, “Is a waiting area the only way to manage the flow of demand? How else could
you do it? How is it done elsewhere?” This invites organisational conversation with new thinking as we seek
constructive and innovative ways to ‘break the rule’ about always having waiting areas for patients.
3
The NHS Institute’s publication, Making a Bigger Difference, describes the 4Ws tool that is a structured approach to this. This
guide is available in two versions: one for front-line staff and leaders and another for commissioners. www.institute.nhs.uk
Tips for Improving the Tools Dimension

Tips for improving
the relationships
dimension
42

Create many opportunities for diverse individuals to work together and learn more about
each other’s ways of thinking. One of the simplest things that leaders can do to build relationships
that favour innovation is to create more and more opportunities for multi-disciplinary interaction.
Give a challenge to a multi-disciplinary team of nurses, doctors, managers, housekeepers and porters
AND provide good team facilitation that focuses on being explicit about creating a trusting, open
environment where everyone is curious and respectful of what the other thinks. You may get a
completely different set of ideas that would not have emerged from any of the individual staff
groups.
An example of mental model frustration:
I say “Let’s be a high performing team”, and you readily agree that that sounds like a good idea. But if my
mental model of a ‘team’ is a sailing crew where I am the captain calling out orders which I expect you to
follow, while your model of a ‘team’ is a football side where everyone is flowing and the ball is being passed
around for each player to try to create something, then we might find that we are not working so well together
as a team! You will be frustrated with me for being directive and I will be frustrated with you for acting as if I
am supposed to be passing you the ball.
Use one of the many personal style instruments as a way to get people to honour
differences between themselves and others as refreshing and useful. There are literally dozens
of simple style instruments that provide a structure and a language for beginning the exploration of
one another’s difference in a more objective way (e.g., the Myers-Briggs Type Indicator®; your Human
Resource’s Team will know of others). The knowledge and learning potential of this type of exercise
is invaluable and creates great team-building discussions. This process gives everyone a better
appreciation for differences within teams, avoiding potential frustration and enabling more
understanding going forward.
Start an ongoing dialogue about what ‘teamwork’ or ‘a trusting and open environment’
means and what it really looks like. Another sort of diversity in teams is a difference in what are
called ‘mental models’: the images that humans naturally create in their mind’s eye when they hear
a word. If individuals have different mental models, it can lead to conflict and frustration when they
try to work together (see box).
Tips for Improving the Relationships Dimension
In a true team, the old saying is often true: “The product of the
whole can be greater than the sum of the parts”.

Bring in non-traditional team members precisely for their potentially very different points
of view. By ‘non-traditional’ we mean, for example, service users, carers, people in the community,
people from the private sector, someone who knows little about how you currently do things,
university students, designers, engineers, family members, and so on. Be sure to prepare your staff
for how to receive these new team members. If the fresh perspective is greeted with genuine
openness, curiosity, and a desire to see where it takes us, new approaches to issues are possible.
Our team is a real mix of NHS improvement specialists, non healthcare improvement specialists and people
new to improvement but very familiar with the hospital and the NHS. The team includes staff with improvement
backgrounds in the NHS who have a balance of clinical and non-clinical expertise. In addition we have staff
members who have come from the Royal Air Force, the Automotive Industry and the Financial Service Sector.
The diversity of the team gives it strength and builds in challenge and creativity. Having some clinical expertise
within the team is extremely helpful and lends credibility to our work. We often buddy up NHS and non-NHS
people on pieces of work to make sure that nothing is overlooked and to provide fresh insights from a range
of different perspectives.
Sue Stanley
Director of Service Improvement
Northampton General Hospital NHS Trust
Increase the use of job shadowing, short-term work rotations and longer-term
secondments to increase individuals’ awareness and valuing of different ways of thinking
and working. These structures from workforce development enable one to gain a more diverse
perspective by “walking a mile in someone else’s shoes”. For example, having doctors spending time
shadowing a nurse, or the Finance Director shadowing a porter might provide new insights into
how, together, they might do things differently to benefit patients and carers, as well as each other.

45
“Your only real path to innovation is through people.
You can’t really do it alone”.
Tom Kelly, CEO of the design firm IDEO
“Leadership is not about what you say, or even what
you do. Leadership is how you make people feel.”
www.ryanjacoby.com
“Undervaluing and under investing in the human side
of innovation is a common mistake.”
Moss Kanter. R. (2006) Innovation The Classic Trap. Harvard Business Review. P 73
Creating the Culture for Innovation Guide for Executives

Conclusion
46

“With the tightening financial climate there’s no doubt the NHS is facing
challenges unprecedented in its history and especially so with the ambitious goals
we still need to achieve for the service.
Innovation is no longer one of those ‘nice things to do’ if we have a bit of time
to spare. It’s business critical and all of us in the NHS need to be looking for new,
improved ways of using our resources to deliver the best services, every day.
By innovating however I don’t mean we need to lock ourselves in darkened
rooms, grow pointy heads and invent. We should be ‘stealing’ great ideas
wherever we see them – from those in our networks, the global health system
and industry.
Of course some of the best innovators we have are working for us right now,
especially in front line care. As leaders we need to create an atmosphere in which
they can feel encouraged, supported and free to try out new ideas that can make
a real difference.
If we seize the challenge today, the coming years might not only be the most
challenging times the NHS has seen, but also the most exciting”.
David Nicholson, CBE
Chief Executive of the NHS England
Speaking at the 2009 graduation ceremony of the NHS Institute’s Graduate Management Training Schemes.
The culture for innovation framework and the 31 practical tips in this guide provide a good start for thinking
about how you and your leadership team can ‘seize the challenge’ and ‘create an atmosphere’ for innovation.
There may never have been a more important task for healthcare leaders.

Appendix:
NHS Institute’s Culture for Innovation Survey Statements
Risk Taking
1 My direct supervisor supports me if I want to try something new.
2 If I suggest a new idea and it fails, I know that I will not be made to feel humiliated.
3 In my department the general tendency is to try new things rather than hold on to the
status quo.
4 Senior leadership is willing to take a risk on new ideas that might make things better.
Resources
5 My direct supervisor provides me the time to work on a promising new idea.
6 In my department we seem to find the resources we need to fund innovative ideas.
7 I feel that I have reasonable authority to try out an innovative new idea.
8 Senior leadership makes sure that there is both the availability of time and of money to
support innovation.
Knowledge
9 If I don’t have the information I need, I feel comfortable asking my direct supervisor for it.
10 We are generally kept informed of activities in other departments that affect our work.
11 There is a lot of information available to me about what other organisations are doing to
meet the same sorts of challenges we face.
12 Senior leadership openly shares information that is important to me and the work I do.
Goals
13 I know what the priorities or goals are in my department.
14 My direct supervisor makes it clear that innovative new ideas are highly desirable.
15 Priorities come down to me without pre-determined solutions, leaving me plenty of room
to contribute my own ideas.
16 Senior leadership has made it clear that innovative new thinking is required to meet some
of our organisational goals.

Rewards
17 I am certain that I would receive recognition or praise from my direct supervisor if I put
an innovative idea forward.
18 The recognition that we get here for coming up with new ideas does motivate me
personally to be more innovative.
19 We celebrate and say thanks when someone tries out a new idea, even when it is not
successful in the traditional sense.
20 Senior leadership actively seeks out and recognises innovative thinking.
Tools
21 My organisation has trained me in methods to support creative, new ways of thinking.
22 My department uses specific methods to generate creative ideas around the challenges
we face.
23 I am capable of generating creative ideas.
24 Senior leadership actively demonstrates innovative new thinking in its own work.
Relationships
25 In my organisation, people who think differently are respected for their point of view.
26 The teams that I work on tend to have people with a diverse mix of skills and styles.
27 In general, there is a high degree of honest and open communication between
departments.
28 Senior leadership models high levels of cooperation and trust among colleagues.
Overall
29 My department has an underlying culture that supports innovation.

50
“It is not that things are difficult that we do not dare,
it is because we do not dare that things are difficult.”
Seneca
Creating the Culture for Innovation Guide for Executives
Notes

For further information please visit
NHS Institute Product Code: IN049
ISBN Number: 978-1-907045-56-1
Copyright © NHS Institute for Innovation and Improvement 2009
All rights reserved
“Without innovation, public services costs tend to rise
faster than the rest of the economy. Without innovation,
the inevitable pressure to contain costs can only be met
by forcing already stretched staff to work harder.”
Mulgan G. & Albury D. (2003) Innovation in the public sector. Strategy Unit, London.

Cultivating Innovation: A Guide for Healthcare Leaders

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