The Challenge


The Clinical Excellence Commission (CEC) is one of five pillars of NSW Health and is the lead agency for patient safety and quality improvement in the NSW public health system. The CEC provides quality improvement toolkits and frameworks that guide large scale transformations in NSW Health to ensure patients experience healthcare that is safer.

The CEC’s approach to safety and quality capability development was undergoing review to ensure that it provided guidance fit for purpose for the challenges of modern health systems. As part of this process, CEC wanted to ensure the theory of change that underpinned safety and quality capability development are reflective of the latest research evidence. Academic scholarship in the field of Organization Development and Change is continually being updated, especially with respect to the transformation processes and leadership actions that drive positive change in large and complex systems, such as healthcare. There was a desire to ensure that this latest thinking is incorporated in CEC’s implementation approach to safety and quality.

The objective


This project addressed the question, how can the CEC best support the large-scale and ongoing transformational changes required to make healthcare safer?

Our approach


The UNSW Health@Business research network worked with the CEC to conduct an evidence-based review of the globally available empirical evidence on positive change and transformation.

This approach yielded the following insights:

  • What are the predominant theories of change? Two theories underpin modern change research – programmatic change and generative change. Programmatic change refers to transformation that is initiated either centrally, by setting desired outcomes and then design implementation plans that are cascaded throughout the organisation. In contrast, generative change takes a systems perspective, focusing on facilitating positive interactions between the human and technical elements of a health system.
  • Which is more successful? With success defined as where desired outcomes are realised, programmatic change is associated with a low rate of success, whereas generative change has a far higher rate success.
  • What about impact on staff? Several studies also show that generative-based change facilitates positive attitudes to change, enhances wellbeing, and improves psychological safety.
  • How to promote generative change? Fostering generative change requires three elements:
    1. a supportive dialogue (and mentoring) from executive leadership that articulates and enables a culture of generative change,
    2. leader development mechanisms that promote the beliefs, mindsets, and actions within leaders that help them cultivate leadership within their teams, and
    3. measures that quantitatively assess the advancement of leadership within teams (i.e., measuring leadership outcomes at the level below leaders) enabling success to be recognised and, where required, corrective coaching/mentoring interventions.
  • Achieving a transition to generative change will require whole system thinking with careful attention to policy, culture, workplace practices, and allied leader development interventions.



When it comes to large-scale transformations in healthcare, this review gives CEC an evidence-based foundation on what works best. The insights delivered will clarify discussion and provide helpful guidance for approach to safety and quality programs going forward.