How do we ensure the successful uptake and spread of provider innovation across the NHS? Chair: Saffron Cordery, Deputy Chief Executive, Director of Strategy and Policy, NHS Providers Speakers: Tim Horton, Assistant Director (Insight & Analysis), The Health Foundation Professor Tom Downes, Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals NHS Foundation Trust Dr Dominique Allwood, Interim Associate Medical Director (QI), Imperial College Healthcare NHS Trust

The successful uptake & spread of provider innovation Tim Horton, Assistant Director, The Health Foundation

09.10.18 The successful uptake & spread of provider innovation

The replicability problem 09.10.18 The successful uptake & spread of provider innovation The replicability problem

09.10.18 The successful uptake & spread of provider innovation The RIPPLE clinic A community-based clinic to reduce isolation & anxiety for people with severe COPD Acts as a catalyst for increased community involvement by blending patient education with social activities Reduces isolation & anxiety and improves ability to self-manage, potentially reducing admissions

Complex interventions are context-sensitive 09.10.18 The successful uptake & spread of provider innovation Complex interventions are context-sensitive Organisational systems & culture Human behaviour & relationships Dynamism & unpredictability

The RIPPLE clinic Some aspects of context… 09.10.18 The successful uptake & spread of provider innovation The RIPPLE clinic Some aspects of context… Depends on relationships with other services – mental health, smoking cessation, etc. Different transport requirements and recruitment challenges for urban v. rural communities Clinic social activities evolve around patient preferences (e.g. bingo or yoga?)

Different contexts may require adaptation 09.10.18 The successful uptake & spread of provider innovation Different contexts may require adaptation

We asked adopters from Health Foundation programmes… Have you made adaptations to the intervention during the process of implementing it in your own setting?  17% 81% No Yes Don’t know 94% No Yes Don’t know If so, would you say these adaptations were necessary in order to implement the intervention successfully in your own setting?

Adoption is hard work, even when an idea has been successfully piloted First key message… Adoption is hard work, even when an idea has been successfully piloted

To adapt, need to know what’s core v. peripheral 09.10.18 The successful uptake & spread of provider innovation To adapt, need to know what’s core v. peripheral

09.10.18 The successful uptake & spread of provider innovation The RIPPLE clinic What might be ‘core’ to making the intervention work? Does the intervention need to be led by a secondary care team? Does it matter where the clinics are held? Do participants need to engage in all aspects of the clinic? (mental health, physical exercise, etc)

Innovators can’t always ‘see’ their own context 09.10.18 The successful uptake & spread of provider innovation Innovators can’t always ‘see’ their own context

So early stages of spread are about testing and learning… 09.10.18 The successful uptake & spread of provider innovation So early stages of spread are about testing and learning…

The RIPPLE clinic What did the teams discover? 09.10.18 The successful uptake & spread of provider innovation The RIPPLE clinic What did the teams discover? The clinic didn’t have to be led by a hospital-based team Clinics had to be in social, not clinical settings Some aspects (social inclusion) were more important than others (e.g. physical exercise)

We asked innovators from Health Foundation programmes… Would you say you have learned new things about your intervention from adopters’ experiences of implementing it?  No 91% Don’t know Yes 90% Yes No If so, have you in any way changed how you describe and communicate the intervention as a result? 

09.10.18 The successful uptake & spread of provider innovation The RIPPLE clinic “I think we’ve learned from the other sites. I like to think of the project as an ongoing, organic thing that grows and changes…There are things coming out that are making us re-think the model…” Colin Gelder (Consultant) University Hospitals Coventry & Warwickshire NHS Trust

Second key message… As an innovation spreads, adopters generate new learning that can help improve it

Challenge to the traditional view of innovation & adoption 09.10.18 The successful uptake & spread of provider innovation Challenge to the traditional view of innovation & adoption More balanced division of labour between innovator & adopters Generation of knowledge throughout the innovation cycle

We need greater emphasis on supporting adoption 09.10.18 The successful uptake & spread of provider innovation We need greater emphasis on supporting adoption Project management Relationship building Training Data analytics Realistic timescales Peer learning Double running costs Evaluation

We asked adopters from Health Foundation programmes… With hindsight, which of the following changes do you think would have made the biggest difference for helping you to adopt the intervention? providing more opportunities to share learning doing more to support readiness allowing more time to implement providing more training and support closer working relationship nothing more guidance on the methods greater freedom to adapt providing a more detailed written description

Some key points for organisational leaders 09.10.18 The successful uptake & spread of provider innovation Some key points for organisational leaders New interventions or ideas often have to be adapted to new contexts. Just because a provider up the road has done something doesn’t necessarily mean you can ‘lift and shift’ it to your organisation in a few weeks; it may require a journey to build readiness and then adapt, iterate and refine the intervention. Adoption is hard work and takes time. Teams need to be supported to do the hard work of translating innovations into their own setting (project management, clinical backfill, analytics, etc) and they need to be given sufficient time for their work to bear fruit. Building organisational improvement capability will help. The adoption of innovations (as well as in-house improvement initiatives) can be supported through equipping staff with the skills and infrastructure to help them identify opportunities, and test, implement and adapt solutions.

Thank you

Flow Coaching Academy programme Tom Downes Clinical Lead for Quality Improvement Sheffield Teaching Hospitals @sheffielddoc 9th October 2018

A complex system problem

2003 Toyota Corolla

The Big Room (Obeya)

Time from ‘hospital care complete’ to arriving home 2012-15: reduction of 40,000 bed days

Respiratory medicine 20% reduction in length of stay

Team Coaching Improvement Science QI Pathways

Benchmarking and visits Flow Coaching Roadmap Change Ideas Brainstorming Change Concepts Benchmarking and visits Process/Value Stream Map Fishbone Spaghetti Diagrams Selection criteria & Multivoting Global Aim Driver Diagram Specific aim Standardise Themes ‘Post-it Frenzy’ Change idea Build a Big Room A P S D Define measures A P S D A P S D Pre-Phase Coached weekly meetings Patient stories System data Reflective learning

FCA Northern Ireland FCA Birmingham FCA Devon FCA Northumbria FCA Bath FCA Imperial FCA Sheffield FCA Yorkshire

Growth in number of FCA coaches over the first 5 years

The initial spread process as co-innovation The spread challenge, The Health Foundation 2018

Diabetic foot care 25% reduction in length of stay

Percentage of patients dying in hospital with a diagnosis of sepsis May 2016 to January 2018

Tom.Downes@sth.nhs.uk @sheffielddoc www.sheffieldmca.org.uk/flow

Our experiences of adopting the FCA Model Dr Dominique Allwood Associate Medical Director, Imperial College Healthcare NHS Trust Consultant in Public Health Medicine @DrDominiqueAllw dominique.allwood1@nhs.net

How it’s worked……. Adopter went to innovator site to train in the intervention During 2016/17 six participants went up to Sheffield to train as Flow Coaches Set up and coaching in three big rooms for past 18 months Now Faculty on our own programme, training 24 coaches Innovator has provided materials and guidance for year 1 Sent updated materials to use for the programme delivery Regular calls between Sheffield and Imperial and Senior lead in set up phase, and between programme lead in implementation phase Innovator comes out to support adopter to implement Faculty from Sheffield come to every session for the first year to support roll out Provide support and feedback to local Faculty Adopter undertakes local adaptation and learning Adopter site programme team meet regularly to plan and review Liaise with other sites to share learning

Benefits of being an adopter Similar success stories to the innovator - but sometimes faster! An maybe more nuanced ? Learning from central team and other adopter sites – ‘what to do and what not to do’ = wisdom

And also some of the challenges Adopting from an organisation where culture and understanding is potentially different Balancing quality assurance with quality improvement Finding strategic fit in the organisation Joining up with other programmes of work unique to Imperial (no one can tell you how to do that bit!) Overcoming local context specific issues e.g. multi-site working to allow individuals and teams in big rooms to operate across different sites

What we value and would like more of to support adoption…… Guidance on ‘process’ Sharing & learning with peers Evaluation data