Each new edition of The Edge will include a collection of resources on a key topic of interest to change activists in health and care. We call this the “classics”; unlike our other knowledge sections, much of this writing is more than 12 months old. These are knowledge resources that stand the test of time.

The first topic for our classics column is “commitment versus compliance”. At the heart of the following pieces is a debate about whether compliance mechanisms such as performance targets, inspection regimes, regulations and standardised care help or hinder improvement in health and care. The alternative approach is commitment, based on improving performance by encouraging shared goals, shared values and sense of shared purpose.

The seminal article on this topic was written nearly 30 years ago by Robert Walton, “From control to commitment in the workplace”. He says that frontline staff do not respond effectively or creatively to change when they are set tightly specified goals from on high. Rather, Walton champions an approach where leaders seek to enable their staff to lead their own changes, to build the commitment of the frontline and create the conditions where that commitment can flourish.

Mac McIntire (2014) states that the most effective way for an organisation to achieve superior performance is to move beyond compliance to build a committed workforce that thinks “outside the box”. We also like Mac McIntire’s, “ladder of commitment” model.

In their large scale study of incentives in organisations, McKinsey researchers, Lesley, Loch and Schaninger (2006) found that creating an environment that encourages openness, trust and challenge and broad, meaningful stretching aspirations are far more likely to motivate the workforce to improve than other things that people tend to think of as performance incentives, such as key performance indicators, standardised control or “stick and carrot” approaches.

This seems to also apply in a health and care environment; in the context of clinical engagement, there is a correlation between clinicians who are engaged and motivated and high performance in almost every dimension, including patient outcomes and mortality (NHS Institute for Innovation and Improvement 2009).

Simon Guilfoyle (2012) outlines the negative unintended consequences of a performance system based on numerical targets and argues for a “systems” approach whereby the performance management approach is part of a wider systematic approach to measurement and change and where metrics are aligned.

Dov Seidman (2012) writes in a private sector context. Whilst he acknowledges an increasing reliance on regulatory and performance controls across industries which may have negative consequences, he says that lobbying aggressively against risk controls is the wrong tactic. Rather, leaders should shift from a “governance, risk and compliance” mind-set to a “governance, culture and leadership” mind-set. You can also watch a three minute film that Seidman made on, “Why inspiration beats coercion” (Seidman 2013) which is also the source of my favourite quote on this topic,

The last era of management was about how much performance we could extract from people; the next is all about how much humanity we can inspire” (Seidman 2013).

Roger Dean Duncan (2014) says the dichotomy between commitment and compliance is a false one. Our workforce has to comply with policies and regulations to ensure safety and delivery but they also have to understand and agree with the higher purpose behind the rules. Leaders need to build a system motivated by love rather than fear.

So, from reading these “classics”, my conclusion is that commitment versus compliance is not a choice we should be making. We have to work with both. However, we can’t get compliance by doing compliance. We have to start on a higher plain, by focussing on shared values, a sense of common purpose and the courage to do the things we know are right. Leaders who focus on meaning also get compliance, without focussing on it.

This classics piece was written by Helen Bevan. Helen will be leading a discussion on compliance versus commitment in the first of our monthly “transformation talks” web seminars. These sessions are open to everyone, will be held online, last for one hour and be interactive. Look out for more details about our first session that will be happening on: 26th November 2014 from 1-2PM GMT and don’t forget to save the date!

The topic of our next classics column is, “Applying ideas from social movements to health and care improvement”. Please let us know about your favourite knowledge pieces on this topic in the comments box below, or via the Spotter’s Column. We also welcome your suggestions for future topics for our “classics” column and resources you would like to see included.