National Leading Health and Wellbeing Programme 2nd July 2014 Leadership and culture for sustaining and spreading improvement Jean Penny

Jean Penny Improvement: 19 years and still learning All working life in NHS Diagnostic Radiographer and teacher Improvement roles since 1994 BPR Leicester Royal Infirmary 1994 - 1999 National Patients ‘Access Team 1999 - 2002 NHS Modernisation Agency 2002 – 2005 NHS Institute for Innovation and Improvement 2005 -2008 Awarded OBE for services to NHS 2003 Visiting professor University of Derby 2008 Jean.penny@btinternet.com Improvement: 19 years and still learning

“All models are wrong but some are useful” W Deming “A promise to learn A commitment to act” D Berwick 3

Agenda Recap Culture Sustainability Spread, adoption and social movements

Messages about improvement from improvement session 1 Work with your team /colleagues: value differences Really understand the problem Develop aims and measures: What are you trying to achieve? Measure for improvement: How will you know a change is an improvement? Gather change ideas: What changes can you make that will result in the improvement you want? Test change ideas (PDSA cycles) before implementing and learn from things that do not work Link frontline changes to strategic objectives Share achievements and learning with others

Culture for improvement

Culture is how things are done in the workplace is heavily influenced by shared unwritten rules Often reflects what has worked well in the past Think about the questions on culture

Unwritten rules and behaviours Unwritten rules are one of the most powerful parts of culture. They are described as 'unwritten' because they are: not often openly discussed rarely questioned or challenged because they are not frequently discussed usually shared by most, if not all, the people who work within the team / organisation provide a common way for people to make sense of what is going on around them often influence people without them necessarily realising it have a powerful influence on how people behave at work The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

Some unwritten rules Senior clinicians / managers know best Knowledge is power Everyone understands the jargon Only someone in my profession / role understand the problem Meetings constitute activity Filling in a form makes it happen It is wrong to be wrong ....and wrong to admit to being wrong The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

Behaviours = culture Discussion: Senior clinicians / managers know best Knowledge is power Everyone understands the jargon Only someone in my profession / role understand the problem Meetings constitute activity Filling in a form makes it happen It is wrong to be wrong ....and wrong to admit to being wrong Discussion: What are the resulting behaviours as a result of these unwritten rules (behaviours are what you see, hear and feel)

Behaviours = culture Discussion: Senior clinicians / managers know best Knowledge is power Everyone understands the jargon Only someone in my profession / role understand the problem Meetings constitute activity Filling in a form makes it happen It is wrong to be wrong ....and wrong to admit to being wrong Discussion: What other unwritten rules does your team / organisation have? What are the resulting behaviours?

Gain a deeper understanding Find out about the values held Identify as many behaviours as you can. Look and listen dress codes: uniforms, identity symbols level of formality: in relationships and social events working hours: balance between work and family meetings: how often, how they are run, how long they last decision-making: how is this done? communication: jargon, how do you get to know about things? rites rituals and traditions what always happens and what never happens? disagreements and conflicts: how are they handled? Compare the stated values and behaviours Search for the unwritten rules that might account for the apparent discrepancy between the stated values and the behaviours Decide which unwritten rules matter Understand the background to the unwritten rules: how did they come into being and why do they persist The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

An improvement culture is.... Patient centeredness Belief in human potential Improvement and innovation encouraged Recognition in the value of learning Effective team working Communication Honesty and trust The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

Sustaining improvement

What do you want to sustain? The improvement itself and any changes in practice OR Continuous improvement and a commitment to finding a better way of working – a culture change Complexity of sustaining healthcare improvements: what have we learned so far (2004) NHS Modernisation Agency, Research into Practice report 13

What is meant by sustainability? Sustainability is the ability to withstand variation and evolve alongside other changes Sustainability is when new ways of working and improved outcomes become the norm not only have the process and outcome changed but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support.

The ten factors of sustainability Process: Benefits beyond helping patients – making job easier Credibility of evidence – obvious, evidence based, believed Adaptability of improved process – continuous improvement Effectiveness of system to monitor process – communication of results Staff Staff involvement and training to sustain process Staff attitudes towards sustaining change - involvement and empowerment Senior leadership engagement – responsibility and advice Clinical leadership engagement – responsibility and advice Organisation Fit with organisation’s strategic aims and culture – history of improvement, consistency of improvement goals with strategic aims Infrastructure for sustainability – staff, facilities, equipment Lynne Maher, David Gustafson, Alyson Evans ©NHS Institute for Innovation and Improvement 2006

Scores: maximum score 100 A score of 55 or over offers reasons for optimism Scores below this suggest you need to take some action and to work on improving the two factors that have the biggest potential for improvement. Re score in about 6-8 weeks ©NHS Institute for Innovation and Improvement 2006

Activity: Discussion on sustainability Think about your improvement work and consider the factors of sustainability Where are your strengths? What areas do you need to work on?

Spread, adoption and social movements

The goal is to spread sustainable improvement: The factors are similar! Leadership People who influence (at all levels) Support at senior level Ownership of initiative Effective relationships (multi-professional) Staff engagement Incentives Readiness of improvement Local context Nature of initiative Evidence of improvements Process of implementation Integration into practice Dedicates resources Note: No rank order Relative importance of each factor varies from one initiative to another The New Improvement Wheel (2005) NHS Modernisation Agency Research into Practice report 14

Spread verses adoption Spread means that the learning that takes place in one area is actively shared and acted upon others i.e. that others have adopted Spread indicates ‘push’ Adoption indicates ‘pull’

Change principle Change principle Solution / change in organisation A Seek to spread a change principle and enable others to work out the specifics for their context (assisted wheel re-invention) Change principle Change principle Solution / change in organisation A Solution / change in organisation B

Creating attraction for change The concept of resistance to change is negative and emotionally draining We all change naturally; at our own pace with our own rationale Don’t speak of ‘us’ and ‘them’ consider the ‘What’s in it for me’ factor Spread can be better understood through ‘attractors’ How can I make my change more naturally attractive to others?

Adopter categorisation Roger’s adopter categories are based on studies of when an individual adopted a specific innovation Nearly everyone is a “laggard” at some time; with a very rational reason! Adopter categorisation 2.5% 13.5% 34% 34% 16% Innovators Early Adopters Early Majority Late Majority Laggards Rogers E (2003) Diffusion of Innovations 5th ed New York: Free Press

Factors to describe an idea Relative advantage How clear and how much is this new idea/practice better then current situation? Compatibility How closely does new idea/practice reflect beliefs and values of potential adopter(s)? Complexity How easy is it to understand the new practice/idea? Communicability How easily can it be shared with others? Observability How visible is the new practice or idea and its results? Trailability How easy is it to test the new idea? Reversibility How easily can the potential adopter revert to the old ways? Uncertainty How certain can an potential adopter be of positive results from the change? Fraser S (2002) Accelerating the spread of good practice, Kingsham Press UK

Social movements

Social movements A social movement is a voluntary collective of individuals committed to promoting or resisting change through a co- ordinated activity to produce a lasting and self –generating effect and creating as they do a shared sense of identity Core Characteristics Energy Mass Passion Commitment Pace & momentum Spread Longevity NHSI The power of one the power of many http://www.institute.nhs.uk/index.php?option=com_joomcart&Itemid=194&main_page=document_product_info&products_id=580

5 principles of Social Movements Frame to connect with hearts and minds To connect with ideals, needs, values and aspirations Energise and mobilise Engagement to commitment to mobilisation Organise for impact To translate energy and passion into purposeful effective action Change as a personal mission Need every member to believe that their contribution no matter how big or small will make a difference Keep forward momentum Momentum = unstoppable = sustainability Martin Luther King said ‘I have a dream’ He did not say ‘I have a strategic plan’

Need both according to the objective and context How is it different? Traditional programmatic approach A planned programme of change with goals and milestones Centrally led Talks about motivating people Change done to people or with them – leaders and followers Driven by formal systems Movement approach Change is about releasing energy Largely self directing and bottom up Talks about moving people People change themselves and each other – peer to peer Driven by informal social networks systems Need both according to the objective and context

What are the three key messages you have got from this session What are the three key messages you have got from this session? One action as a result Think quietly by your self for a few minutes Then find two others and share

Recap of improvement methodologies

Act Plan Study Do What are you trying to accomplish? Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Model for Improvement What are you trying to accomplish? How will you know that a change is an improvement Measuring processes and outcomes What changes can you make that will result in an improvement? What have others done? What hunches do we have? What can we learn as we go along? Act Plan Study Do Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco 33

Leadership framework for improvement 1. Set Direction: Mission, Vision and Strategy Make the future attractive Make the status quo uncomfortable 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 4. Generate Ideas Understand organisation as a system Read and scan widely, learning from other industries and disciplines Benchmark to find ideas Listen to patients Invest in research and development Manage knowledge 5. Execute Change Use Model for Improvement for design and redesign Review and guide key initiatives Spread ideas Communicate results Sustain improved levels of performance 2. Establish the Foundation Reframe operating values Build improvement capability Prepare personally Choose and align the senior team Build relationships Develop future leaders Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

 Goodbye, thanks And good luck!