Jean Penny All working life in NHS Diagnostic Radiographer and teacher

North East Leading Improvement for Health and Well-being Programme Improvement Methods Workshop 2

Jean Penny All working life in NHS Diagnostic Radiographer and teacher
Improvement roles since 1994 BPR Leicester Royal Infirmary National Patients ‘Access Team NHS Modernisation Agency 2002 – 2005 NHS Institute for Innovation and Improvement Awarded OBE for services to NHS 2003 Visiting Professor University of Derby 2008

Introductions Who are you? Where are you from?
Which of the 10 work streams are you working on 3

Improvement workshop 2 Recap Sharing and learning Variation
Sustainability Spread and Social Movements

“All models are wrong but some are useful” W Deming
Sharing and learning “All models are wrong but some are useful” W Deming

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

Deming’s System Of Management
Knowledge of Systems Theory of knowledge Knowledge about Variation Knowledge of Psychology W Edwards Deming (1994) The New Economics

Discipline of improvement
4 equally important parts of improvement People User and public involvement Diagnostic tools e.g. Process and systems thinking Process What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

Act Plan Study Do What are we trying to accomplish?
Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives Model for Improvement What are we trying to accomplish? How will we know that a Measuring processes and outcomes change is an improvement? What change can we make that will result in 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 organisational performance 2nd ed, Jossey Bass Publishers, San Francisco 9

Understand the Complexity of Your Project
Macro Meso Micro ©Profound Knowledge Products, Inc All Rights Reserved

Use driver diagrams to set your ‘big dots’ and ‘little dots’
Figure 1: Breakthrough Goals and Drivers Use driver diagrams to set your ‘big dots’ and ‘little dots’ Executing for System-Level Results: Part 2 by Tom Nolan IHI Senior Fellow

Discussion: Sharing and learning
Achievements and reflections What went well? What could have been better? Surprises: good and bad! What would you do differently next time? Who / what has helped Who / what has not helped Ah Ah moments (when the penny drops) What have you learnt Anything linked to your improvement work, anyway you have applied your learning Engaging others Linking strategy to frontline change Measures Tests of change ideas Reading Changes to thinking Talk with others on your table Prepare a flip chart for feedback

Variation Understand causes of variation and how to respond appropriately Understanding tampering - how leaders, despite their good intentions, can increase variation

Discussion: variation in everyday life
How long does it normally take you to get to work? Why does it vary? – list the causes

Two types of variation Special Cause or Exceptional Variation
intermittently apparent not part of a process due to assignable causes usually few, not many can usually be identified Unpredictable variation Common Cause or Routine Variation affects process most of the time part of the process due to chance causes many factors often unknowable noise in the system Predictable variation Look at your journey to work

What to do about variation?
Routine common cause variation don’t react to individual results look at the average and the range (limits) improve the whole process if these not acceptable Exceptional special cause variation investigate each point outside the limits look for the special cause and do something about it almost always something to find opportunities to learn

Variation Variation is part of any process: there can be several causes Some of these are not immediately obvious, some may never be known Routine variation is often more than we expect or predict The system, not individual skills, determines performance Some measures will always be above average, some will always be below average The mean and range of variation can be predicted from observations Theory (e.g. statistics) can help us predict what might happen

Frequency Distribution Number of times observed
Probability-based boundaries Frequency Distribution Standard deviation 2 SD 95.46% 95.46% 4.54% Number of times observed (Number, rate, percentage, proportion) 2 std. devs. 2 std. devs. Value observed

Probability-based boundaries Frequency Distribution Standard deviation 2 SD 95.46% 95.46% 4.54% Number of times observed (Number, rate, percentage, proportion) Value observed

Probability-based boundaries Frequency Distribution Standard deviation 2 SD 95.46% 95.46% 4.54% Number of times observed (Number, rate, percentage, proportion) 2 std. devs. 2 std. devs. Value observed

Statistical Process Control (SPC) Chart
Observed value Time

“exceptional” variation
Identifying two types of variation using SPC (Statistical Process Control) charts “exceptional” variation “routine” variation Look for a run of seven points all above or all below the centre line, or all increasing or all decreasing any point outside one of the control limits

SPC is first and foremost, a way of thinking, with some tools attached
Wheeler D (2000) Understanding Variation SPC Press

Run charts Seven one side DO Seven down (or up)
90 80 70 Average based on first 10 days 60 Seven down (or up) Minutes to get to work 50 40 DO 30 20 10 1 4 7 10 13 16 19 Day Look for a run of seven points all above or all below the centre line, or all increasing or all decreasing 26

Sources of variation in a clinical system
Staff Process Patients age sex race education motivation disease unclear guidelines differ complications anaesthetics skills illness holiday motivation training shifts GP Kit Information Discharged! rooms not the same supplies machines not transcription transport applications 80% is under our control

Define the problem PPPP Ishikawa (Fishbone) Diagrams People Place
Causes of Variation PPPP Procedures Policies 28

Discussion: Your improvement work
Consider your improvement work what might be the causes of variation? Use the fish bone diagram “Every System is perfectly designed to deliver the result it gives” “If you always do what you have always done.. You will always get what you have always got”

Managing transitions

An emotional journey Morale Fun? Anger Continuous improvement Lost
Denial Learning Despair Understanding Clues

Process of transition

Change is different from transition
Change is situational: new site, new boss, new team roles, new policy. Transition is the psychological process people go through to come to terms with new situations Change is external, transition is internal. Bridges, W. (2003) Managing transitions: Making the most of change, 2nd ed London, Nicholas Brearley.

Unless transition occurs, change will not work
transition starts with an ending the neutral zone is the no-man’s-land between old reality and new transitions end with a new beginning ENDING NEUTRAL ZONE BEGINNING

Start with an ending “Most organisations try to start with a beginning, rather than finishing with it. They pay no attention to endings. They do not acknowledge the existence of the neutral zone, then wonder why people have so much difficulty with change”.

Managing endings help everyone to understand why
what is actually going to change? define what’s over and what isn’t identify who’s losing what accept the reality and importance of subjective losses don’t be surprised at “overreaction” acknowledge losses openly and sympathetically expect and accept signs of grieving mark endings treat past with respect show how endings ensure continuity of what really matters give information and keep doing it

Help people to understand why change is happening
“People responsible for planning and implementing change often forget that while the first task of change management is to understand the destination and how to get there. The first task of transition management is to convince people to leave home. You’ll save yourself a lot of grief if you remember that”

Three phases of transition: Neutral zone
ENDING NEUTRAL ZONE BEGINNING

Neutral zone is most dangerous time in transition process
anxiety rises and motivation falls productivity suffers and absenteeism rises old weaknesses reemerge staff are overloaded, systems are unreliable, priorities get confused, information gets miscommunicated people become polarised, consensus breaks down, teamwork is undermined

Getting through the neutral zone
help people understand why create temporary systems give structure to changes people cope better with significant change which is part of a larger whole than lots of unrelated small changes

get people involved and working together What ever works: task forces, project teams, Anything to make and strengthen intra-group connections encourage creativity schedule time-outs for reflection, reviews etc encourage experimentation embrace setbacks as well as successes

don’t set over ambitious targets, set short-range goals and review them restrain natural impulse to push prematurely for certainty and closure train managers and leaders to function successfully in the neutral zone

Three phases of transition: Beginnings
ENDING NEUTRAL ZONE BEGINNING

New beginnings happen when transition process allow
explain basic purpose behind outcome paint a picture of how outcome will look and feel lay out a step-by-step plan for phasing in outcome give each a part to play in both plan and outcome itself

Beware interpretation of written word relate to past experience
discuss if do not agree - no discussion if agreement different ways of participation - remember there are no right or wrongs, just differences

Sustaining and spreading improvement

? Measurement is vital to show sustainability (or not!) Performance
Idea ? Bad Performance Good Time Before Now Later

Most change initiatives fail Peter Senge, 2001
PriceWaterhouseCoopers surveyed 200 leading companies (Global) They ran a total of 10,640 projects per year Only 2.5% (254) delivered the desired business benefits Source: Boosting Business Performance through programme and Project There is considerable evidence of high failure rate in projects sustaining their efforts (as much as 70%) Daft & Noe 2000 These frustrations are not unique to the NHS!

Evaluation of Improvement Initiatives in England showed…..
In England we found that around 33% of improvement projects had reverted to their previous way of working when evaluated 1 year after the project had formally ended. Around 33% had maintained the improvement but it had not been adopted by others in the organisation Around 33% had maintained the gain and there was evidence of adoption out side of the core change area. Complexity of sustaining healthcare improvements: what have we learned so far (2004) NHS Modernisation Agency, Research into Practice report 13

What do you want to sustain?
The improvement itself and any changes in practice Consistent achievement of goals and targets 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

Static versus dynamic view of sustainability
Static (maintaining) Maintain behaviour Continue with new systems Continuous achievement of targets and goals Sustainability perceived as a condition Dynamic (developing) Fluid - receptive to new ideas Adapt to a continuously changing environment Changes unfold with time in a manner unique to the context Sustainability perceived as a process Complexity of sustaining healthcare improvements: what have we learned so far (2004) NHS Modernisation Agency, Research into Practice report 13 Available from NHS Institute

What is meant by sustainability?
Sustainability is when new ways of working and improved outcomes become the norm Sustainability is when 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.

Sustainability: ability to withstand variation and evolve alongside other changes

Discussion: What are the factors that will help sustainability?

The NHSI Sustainability Model
An easy to use tool to help NHS improvement teams: Identify & understand key barriers to sustainability for their specific situation Know what they can do to overcome those barriers Monitor progress toward sustainability over time .. To predict the likelihood of sustainability ©NHS Institute for Innovation and Improvement 2006

The ten factors of sustainability
Create a plan before, during and after implementation of your improvement initiative Lynne Maher, David Gustafson, Alyson Evans ©NHS Institute for Innovation and Improvement 2006

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

Using the NHS Sustainability Model
Designed for use at the level of a ‘local’ project: a specific planned, or ongoing improvement project Not designed to assess whether a department with multiple projects, whole organisation or health community is likely to sustain change in general For use at the beginning and then periods throughout the project Can be used as a ‘diagnostic’ for the project lead Diagnostic score used for improvement rather than judgement Much better if multiple members of the team use it Increases understanding and promotes conversation. The score is useful The insight and ensuing conversation from the team is extremely valuable

How to apply model Identify the level of each factor that best describing your local project. It may not exactly describe the situation Do this for each factor Factor Tick Factor Level Benefits beyond helping patients. We can demonstrate that the change has a wide range of benefits beyond helping patients, for example by reducing waste, creating efficiency or making people’s jobs easier We can demonstrate that the change has some benefits beyond helping patients such as reducing waste and making jobs easier, but not a wide range. We can demonstrate that the change has one or two benefits beyond helping patients The benefits that we have identified are only directly related to helping patients. We have not identified any other benefits that this initiative could bring. ©NHS Institute for Innovation and Improvement 2006

How to apply model Score each factor then add scores across all 10 factors Look at the total score Look at the factor with the greatest level of potential for improvement Factor Tick Factor Level Benefits beyond helping patients. We can demonstrate that the change has a wide range of benefits beyond helping patients, for example by reducing waste, creating efficiency or making people’s jobs easier We can demonstrate that the change has some benefits beyond helping patients such as reducing waste and making jobs easier, but not a wide range. We can demonstrate that the change has one or two benefits beyond helping patients The benefits that we have identified are only directly related to helping patients. We have not identified any other benefits that this initiative could bring. 8.5 4.7 4.0 0.0 ©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 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

Potential scores Process Staff Organisation 16 14 12 10 8 6 4 2
Benefits beyond helping patients Credibility of the evidence Adaptability Of improved process Effective system to monitor progress Staff involvement and training to sustain process Staff behaviours towards sustaining change Senior leadership engagement Clinical leadership engagement Fit with orgs strategic aims and culture Infrastru- ture for sustainability ©NHS Institute for Innovation and Improvement 2006

Actual scores Process Staff Organisation 16 14 12 10 8 6 4 2 Benefits
Benefits beyond helping patients Credibility of the evidence Adaptability Of improved process Effective system to monitor progress Staff involvement and training to sustain process Staff behaviours towards sustaining change Senior leadership engagement Clinical leadership engagement Fit with orgs strategic aims and culture Infrastru- ture for sustainability ©NHS Institute for Innovation and Improvement 2006

Work on the scores with greatest potential for improvement
16 14 12 10 8 6 4 2 Benefits beyond helping patients Credibility of the evidence Adaptability Of improved process Effective system to monitor progress Staff involvement and training to sustain process Staff behaviours towards sustaining change Senior leadership engagement Clinical leadership engagement Fit with orgs strategic aims and culture Infrastru- ture for sustainability ©NHS Institute for Innovation and Improvement 2006

Build on your strengths
16 14 12 10 8 6 4 2 Benefits beyond helping patients Credibility of the evidence Adaptability Of improved process Effective system to monitor progress Staff involvement and training to sustain process Staff behaviours towards sustaining change Senior leadership engagement Clinical leadership engagement Fit with orgs strategic aims and culture Infrastru- ture for sustainability ©NHS Institute for Innovation and Improvement 2006

Example-portal diagram

Use the NHS Institute sustainability model and guide together
The Sustainability Model is a diagnostic tool that will identify strengths and weaknesses in your implementation plan and predict the likelihood of sustainability for your improvement initiative. The Sustainability Guide provides practical advice on how you might increase the likelihood of sustainability for your improvement initiative.

Using the model and guide
Improvement team work through the sustainability model Did they all agree? If not why not? Which are the two lowest scoring factors? What actions could be taken to increase the score? – use the Sustainability Guide Use it to promote discussion and value how people may see things differently

Discussion: sustainability
Consider the factors of sustainability and the model Where are your strengths? What areas do you need to work on? Could you use the model and guide?

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 any part of the organisation is actively shared and acted upon by all parts of the organisation i.e. that others have adopted Efforts will meet only limited success if one views the process as that of spreading best practices Spread is an active term and indicates ‘push’ Spread is the result of the adoption process, not the other way round Adoption is a receptive word and indicates ‘pull’

Spread acceleration model
Sending Describe the new practice Target the potential implementers Communicate Receiving Matching opportunity to current processes, systems or practices Deciding whether to adopt or reject Implementing Re-inventing new ways Unlearning old ways Monitoring progress The idea and the people Fraser S (2002) Accelerating the spread of good practice, Kingsham Press UK

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 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 adopter revert to the old ways? Uncertainty How certain can an adopter be of positive results from the change? Fraser S (2002) Accelerating the spread of good practice, Kingsham Press UK

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

Diffusion of innovations (Rogers)
“the process by which an innovation is communicated through certain channels over time and among members of a social system”

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?

Moving Through Emotional Stages of Change
Success and feedback Ideas, plans, supports Awareness; both technical and emotional Maintenance Action Contemplative Precontemplative Source: DiClemente and Prochaska

Behaviour Change Model (Prochaska and DiClementi)
Stage Characteristics Precontemplation Ignorance is bliss Not currently considering change: denying, ignoring or avoiding Contemplation Sitting on the fence Apprehensive about changing Beginning to consider changing but not ready to commit just yet Preparation Listening to the waters People begin to find out, make plans and envision the future Need support with the start up planning Action Commit to the change Performing or practicing the change Regular contact and support at this stage increases the change of sustaining the change Maintenance Continued commitment to the change Change feels comfortable Relapse Something has triggered resumption of old behaviours

The View of Spread v. Adoption
Push ideas outward to others Pull ideas into myself My agenda at the centre of a larger organisation My agenda at the sharp end of delivering care Use of organisational structure and hierarchy to communicate about change Use of social systems to communicate about change A focus on tools, techniques and processes A focus on relationships and facilitation Source: Fraser and Plsek, 2003

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

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

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’

Frame to connect with hearts and minds: to create ‘pull’
Reduce pressure ulcers by 8% in 6 months Reduce sickness absence by 3% ‘Your skin matters’- lets reduce pain and suffering and have no avoidable pressure ulcers Support staff wellbeing so they are fit and well to care

Need both according to the objective and context
How is it different? 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

Need both according to the objective and context
How is it different? Traditional tactics Executive sponsor Project board / teams Defined deliverables and process Project plan, targets, measurable timescales Reports, minutes, monitoring Seeking approval Hierarchical Movement approach Activist Core team voluntary, connectors Big aim – open approach Simple rules, opportunititisic, unpredictable Celebration, communication, blogs Empowered to get on with it Non – hieratical Need both according to the objective and context

Discussion: plan for spread and adoption by asking yourself......
What is it that you want to spread? Who do you want to spread to? What do you expect people to do- change behaviour/ learn new skills? Which are the most appropriate tactics: traditional or movement? If you have multiple target audiences, then complete this activity for each one. 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 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 adopter revert to the old ways? Uncertainty How certain can an adopter be of positive results from the change? Fraser S (2002) Accelerating the spread of good practice, Kingsham Press UK

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