1. National Leading Health and Wellbeing Programme 14 march 2014 Leadership for improvement Jean Penny

2. 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

3.  Linking strategic goals and frontline improvements  Measuring for improvement not judgement  Developing and testing change ideas

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

5.  Find two other people who you have not worked with before  Watch the slideshow  Remember as many images as possible ◦ The countdown slide is not one of the images!  No writing down or conferring!

6.  Any improvement is a change ◦ not every change is an improvement ◦ but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

7.  Any improvement is a change  any change is a perceived threat to security ◦ there will always be someone who will look at the suggested change as a threat Eliyahu Goldratt

8.  Any improvement is a change  any change is a perceived threat to security  any threat to security gives rise to emotional resistance ◦ you can rarely overcome emotional resistance with logic alone  Eliyahu Goldratt

9. “ Anyone who thinks you can overcome emotional resistance with logic was probably never married”

10.  Any improvement is a change  any change is a perceived threat to security  any threat to security gives rise to emotional resistance  emotional resistance can only be overcome by a stronger emotion Eliyahu Goldratt

11.  What to change? ◦ Pin point the core problems  What to change to? ◦ Construct (simple) practical solutions  How to cause the change? ◦ Induce the appropriate people to invent such solutions ◦ they must own the problem Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

13.  Have a goal  Be honest and understand where you are today  Have a plan  Never underestimate the power of small positive changes. Tiny incremental changes add up and make a large impact  Commitment to continuously improve August 2012

14. Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 The interventions / change ideas that contribute directly to secondary drivers Secondary Drivers: Contribute directly to primary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 ? Primary Drivers: Contribute directly to the strategic aim The strategic aim (and big problem) Linking strategic goals and frontline improvements

15. Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 The interventions / change ideas that contribute directly to secondary drivers Secondary Drivers: Contribute directly to primary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 ? Primary Drivers: Contribute directly to the strategic aim The strategic aim (and big problem) Linking strategic goals and frontline improvements

16.  If I had one hour to save the world, I would spend 59 minutes defining the problem and one minute finding a solution A Einstein

17. First define the problem  Audits / data  Root Cause Analysis (5 Whys)  Process Mapping  Brainstorming  Pareto Analysis  User and staff stories and anecdotes etc etc  Ishikawa (Fishbone)

18. What are the problems for users, carers and staff and what are the causes of the problem? Ishikawa (Fishbone) Diagrams PPPP PeoplePlace ProceduresPolicies

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

20. AspectImprovementAccountabilityResearch Aim Improvement of careComparison, choice, reassurance, spur for change New knowledge Methods: Test Observability Tests are observableNo test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent biasMeasure and adjust to reduce bias Design to eliminate bias Sample Size “Just enough” data, small sequential samples Obtain 100% of available, relevant data “Just in case” data Flexibility of Hypothesis Hypothesis flexible, changes as learning takes place No hypothesisFixed hypothesis Testing Strategy Sequential testsNo testsOne large test Determining if a Change is an Improvement Run charts or control charts No change focusHypothesis, statistical tests (t-test, F-test, chi square), p-vlaues Confidentiality of the Data Data used only by those involved with improvement Data available for public consumption and review Research subjects’ identities protected Robert Lloyd Executive Director IHI adapted from Solberg L, Mosser G, Mcdonald S (1997) Three faces of performance measurement: Improvement, accountability and research Journal of Quality Improvement Vol. 3 No 3

21. http://www.institute.nhs.uk/productive_general_practice/general/knowing_how_w e_are_doing.html

22. 22 Charts vs. Tables

23. Run charts: measurement for learning 0 10 20 30 40 50 60 70 80 90 Day 1 4710131619 Seconds to answer phone Seven one side Seven down (or up) Change Just like a TPR chart

24. Average length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0 0.5 1 1.5 2 2.5 3 3.5 1234567 Months Mike Davidge NHS Institute for Innovation and Improvement Patient length of pre-ward stay Stroke Ward from 01/2007 to 07/2007 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Patients

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

27. How is a paradigm formed?

28. Streams of thinking Valleys

29. Creativity: The connecting and rearranging of knowledge to generate new, often surprising ideas that others judge to be useful. Innovation occurs when a creative idea is put into practice. Vast majority of creative thoughts are never acted upon: Creativity without innovation

30. Breaking the rules  Identify the underlying assumptions, mental models, unwritten rules and thinking that maintain the status quo.  Then deliberately think around them to create new ideas for service delivery  Ask ◦ Why is that step there? What are the unwritten rules behind what is going on here? ◦ What aspects of the rule can we break? And what aspects of the rule would we want to keep and why?

31. You are creative?

32. Lets be creative! Pick up your pen and turn each box into a different object

33. Coffee Some Idea’s Pyramid from above Mouse hole

34. Stepping stones  Off beat ideas and wild scenarios can serve as catalysts or mental stepping stones to help us make an intuitive leap to a really good idea  Scenario: A mysterious virus has affected all who work in the Ambulance Service. So they are unable to work. Everyone else is completely unaffected.  How are you going to do to link users to the care they need? Be Creative !!! http://www.institute.nhs.uk/building_capability/new_model_for_tra nsforming_the_nhs/thinking_differently_guide Attention Escape Movement

35. White hat Data, facts and information Yellow hat Positives, benefits, good things Black hat Negatives, warnings, pitfalls Green hat Creative possibilities, new ideas Red hat Feelings, intuitions Blue hat Control or direction in thinking Attention Escape Movement De Bono (2000) Six thinking hats Penguin London Use on one idea

36. Imagination Creativity Doing and changing Innovation 400 ideas generated 75 ideas harvested 20 ideas developed 8 ideas tested 4 ideas implemented Practicality, Impact, Cost, Outcome Attention Escape Movement

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

38. Solution / change in organisation A Change principle Solution / change in organisation B

39. PDSA cycle for learning and improvement Act what changes are to be made? next cycle? Plan objective questions and predictions (why) plan to carry out the cycle (who, what, where, when) Study complete the analysis of the data compare data to predictions summarise what was learned Do carry out the plan document problems and unexpected observations begin analysis of the data

40.  We planned to….. ( state the basic plan)  In order to ….. (tie it back to the Aim)  What we did was….. (brief description of actions)  Looking at what happened, what we learned from this was….. ( lessons learned)  What we plan to do next is …. (state next plan) © Paul Plsek PDSAPDSA

41. Repeated PDSA cycles work towards the AIM PDSA Data Driven Change Change in Team Culture Hunches Theories Ideas Aim What am I trying to achieve? How will I know a change is an improvement? What changes can I make that will result in the improvement Need to start small!!

42.  The Model for Improvement breaks things down into small steps and works of the ‘little dots’ – at the frontline  These small steps should be part of the answer to the question of how to move the big dots  Align all improvement projects to strategy

43. Macro Meso Micro ©Profound Knowledge Products, Inc. 2008 All Rights Reserved

44. Ask yourself What are the problems that cause the bigger problem? What are you trying to achieve? (aim for each driver) How will you know a change is an improvement ? ( outcome measures for each driver ) Drivers Which in turn contribute directly to the ‘bigger’ aim Aim The ‘big’ dots Ask yourself What is the big (possibly strategic) problem you are addressing? What are you trying to achieve? (aim) How will you know a change is an improvement ? (outcome measures) Ask yourself What changes can you make that will result in the improvement you seek? What are the change ideas / interventions/ solutions to test with PDSA cycles before implementing? How will you know a change is an improvement? ( process measures for each intervention ) Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Interventions The ‘small’ frontline dots Contribute directly to the drivers Activity: Process and outcome measures?

45. 1. Set Direction: Mission, Vision and Strategy Make the status quo uncomfortable Make the future attractive 3. Build Will Plan for improvement Set aims/allocate resources Measure system performance Provide encouragement Make financial linkages Learn subject matter 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 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 2. Establish the Foundation Prepare personally Choose and align the senior team Build relationships Develop future leaders Reframe operating values Build improvement capability Source: Robert Lloyd Executive Director Performance Improvement Institute for Healthcare Improvement January 16, 2007

46. AffectionTrust DistrustRespect Extent to which I believe you care about me Extent to which I believe you are competent and capable LOW HIGH Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill

47.  Think quietly by your self for a few minutes  Then find two others and share

48.  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

49. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo