Table 3 Interactions between Best’s simple rules for Large System Transformation

Blending designated/distributed leadership influences other rules by…

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Implicitly/explicitly requiring distributed leaders to disseminate and gather feedback in their part of the system, but leaders must understand that this is part of their role

Providing a blend of leaders with experiential knowledge, who know and can share history, though this does not guarantee that they will actively engage with it

Providing resource/expertise for engagement. Dedicated leaders provide recognisable ‘figureheads’ for change programme, driving strategy, though separate leadership team risks change being seen as ‘someone else’s business’, reducing engagement.

Distributed leaders trusted insiders, can engage with their staff, increases capacity for engagement, opportunistic/ naturalistic.

Leaders must have the knowledge, skills, credibility and capacity to engage effectively.

Providing a wider pool of experience, knowledge and capacity on which to draw.

Designated leaders can set agenda and strategy for involvement, though need to ensure not seen as the sole leads for involvement. Distributed leaders may understand patients better, select more appropriate approaches, able to involve opportunistically.

Leaders require knowledge, skills and capacity to involve patients effectively.

Feedback Loops influence other rules by…

Informing leaders how the current approach to leadership is working, and whether changes are indicated

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Judicious quant and qual measurement of baseline and progress, providing an account of history on which to draw later

Enabling quant/qual feedback to be gathered from and shared with stakeholders to maintain momentum, evidence ‘you said, we did’ and encourage continued engagement

Enabling quant/qual feedback to be gathered from and shared with patients to inform involvement activities, maintain momentum, evidence ‘you said, we did’ and encourage continued involvement

Attending to History influences other rules by…

Enabling leaders to apply learning from past change, and to ensure sensitivity to political/ organisational issues.

Enabling leaders to learn from previous approaches to capturing and using measures.

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Enabling leaders to learn from previous approaches to engagement. History can be actively discussed with stakeholders to engage and collectively deliver change.

Enabling leaders to learn from previous approaches to involvement. History can be actively discussed with patients to inform involvement and collective decision making.

Engaging Stakeholders influences other rules by…

Encouraging stakeholders to take on distributed leadership roles, and identify potential designated leaders

Enabling more appropriate and complete identification and gathering of measures to inform the change, and effective approaches to sharing

Enabling gathering different stakeholder accounts of ‘history’ to build complete picture

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Drawing on stakeholder knowledge of approaches to reach and involve patients. Stakeholders may have more opportunity to reach patients in their routine practice. Can advise on the approach and lead/participate in patient involvement work.

Involving patients influences other rules by…

Encouraging patients to take on distributed leadership roles, e.g. chair involvement groups (ladder of participation).

Enabling measurement of baseline and progress from a patient perspective, and identify measures which are most important to patients.

Enabling gathering patients’ accounts of ‘history’ to build complete picture

Evidencing importance of the change to people system cares for. This may encourage stakeholder engagement in the change.

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