Leadership Framework for Improvement

Name: Leadership Framework for Improvement
Uploaded: 2017-07-17T00:27:04+00:00
Duration: PTM36S59
Channel: Candace Butler
Description: Leadership Framework for Improvement

National Leading Improvement for Health and Well-being Programme Improvement Methods Workshop 1

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

NHS Institute - Six stages of improvement
Start out Establish rationale and gain support Define and scope Start in right area and develop structure Measure and understand current situation Understand change to achieve aims Design and plan activities Plot and implement Test change ideas before implementing Sustain and share learn Throughout the initiative Stakeholder engagement and involvement Sustainability Measurement Risk and issues management Project documentation and gateway criteria Google – NHSI quality and service improvement handbook

Knowledge about Variation Knowledge of Psychology
Deming 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 Process User and public involvement Diagnostic tools e.g. Process & systems thinking What Change management Project and programme management How Discipline of Improvement in Health and Social Care (Penny 2003)

Model for Improvement Act Plan Study Do What are we trying to
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 6

Defining status and position: PESTLE
Political – what are the key political drivers of relevance? Economic – what are the important economic factors? Social – what are the main social and cultural aspects? Technological - what are current technology imperatives, changes and innovations? Legal - what current and impending legislation factors? Environmental - What are the environmental considerations, locally and further afield?

Tools and techniques: PESTLE & SWOT

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

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline 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 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 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 Interventions The ‘small’ frontline dots Contribute directly to the drivers

Reduce surgical site infections
Primary Drivers Secondary Drivers Appropriate use of prophylactic antibodies Maintain normothermia Reduce surgical site infections Maintain glycaemic control in known diabetes Reducing harm in perioperative care Use recommended hair removal methods Use of the WHO Surgical safety checklist Improve team work and communications Ref. Patients Safety First

Measurement: Big dots and little dots
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

First define the problem
Root Cause Analysis (5 Whys) Process Mapping Ishikawa (Fishbone) Brainstorming Data Pareto Analysis And more..... 13

Define The Problem Secondary Care Primary Care Social Care
Process Mapping The patient journey Who does what to the patient? Define which group of patients Define the scope (beginning and end) Identify everyone involved Together, write it down or draw it Other (sub-) processes Transport Communication An example Process Map: Secondary Care Primary Care Social Care Tertiary care 14

Analysing a process map
How many steps? How many hand-offs? What is the approx. time of or between each step? Where are possible delays and why? Where are the problems for users, carers and staff? How many steps do not “add value”? WASTE! “Lean thinking is not a manufacturing tactic or a cost reduction programme, but a management strategy that is applicable to all organisations because it has to do with improving processes. All organisations – including health care organisations – are composed of a series of processes, or sets of actions, intended to create value for those who use or depend on them (customer/patients)” IHI: Going Lean in Health Care 2005 Ask why 5 times!! 73

What is Waste? Lean Principles Motion – unnecessary
movement e.g. having to walk up and down the ward to obtain appropriate supplies Processing waste – “stuff” we have to do that doesn’t add value. E.g continuing to care for patients in hospital when they could be discharged Inventory – “stuff” waiting to be worked on e.g. patients on a waiting list What is Waste? Lean Principles Overproduction – too much “stuff” e.g.. requesting unnecessary tests and X-rays Waiting – people waiting for “stuff” to arrive e.g. waiting for a ward round Defects – “stuff” that is not right and needs fixing e.g. a leaky tap Injuries – damage to people e.g. stress Transportation – moving “stuff” e.g. moving patients from ward to ward Mark Rahman NHS Scotland

What is the problem? What are the causes of the problem?
Ishikawa (Fishbone) Diagrams People Place PPPP Procedures Policies 17 17

Use Pareto Principle to identify cause(s) of problem to work on first
‘The Rule’ ‘The Law of the Vital Few’ For many phenomena, 80% of the consequences stem from 20% of the causes Observation that 80% of income went to 20% of the population Vilfredo Pareto, 1906 18 18

Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives The more specific the aim, the more likely the improvement Repeated clarification - without it aims drift Meet needs of external customers 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 Model for Improvement: moving the little dots 19

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

Managing The Human Dimensions Of Change
Ways of helping others to change: Building trust and relationships Creating rapport Managing conflict Negotiation Effective communication

Personal styles What are your fears about change?
How do you behave under stress? Personal styles Controls emotions Analytical formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Tell Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Personal styles Controls emotions Analytical Driver Ask Tell Amiable
formal measured + systematic seek accuracy / precision dislike unpredictability and surprises Driver business like fast + decisive seek control dislike inefficiency and indecision Ask Tell Amiable conforming less rushed + easy going seek appreciation dislike insensitivity and impatience Expressive flamboyant fast + spontaneous seek recognition dislike routine and boredom Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Fears about change Analytical Driver Amiable Expressive
not enough information making a wrong decision being forced to decide Driver loss of control failure lack of purpose Amiable damaged relationships confrontations not being recognised for efforts Expressive being ignored being asked for detail being linked with failure Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Under stress Analytical Driver Expressive Amiable will withdraw
will become autocratic Expressive will become offensive/sarcastic Amiable will submit Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

Personal styles Controls emotions Analytical Driver
Highly detail orientated Can have difficulty making decisions without all the facts Tend to be highly critical Very perceptive Objective focused Know what they want and how to get there Sometimes tactless and brusque Hardworking, high energy. Does not shy from conflict Ask Tell Expressive Amiable Natural sales people and story tellers Warm and enthusiastic but can be competitive Good motivators and communicators Can exaggerate, leave out facts and details Kind hearted people who avoid conflict Can blend into any situation Can appear wishy-washy and have difficulty with firm decisions Can be quiet and soft spoken Shows emotions Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London

How to recognise personal styles
The Driver: Command Specialist Perceived positively as: Perceived negatively as: Decisive Pushy Independent One man/woman show Practical Tough Determined Demanding Efficient Dominating Assertive An Agitator A risk taker Cuts corners Direct Insensitive A problem solver Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 12

The Expressive: Social Specialist Perceived positively as: Perceived negatively as: Verbal A Talker Inspiring Overly dramatic Ambitious Impulsive Enthusiastic Undisciplined Energetic Excitable Confident Egotistical Friendly Flaky Influential Manipulating Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 13

The Amiable: Relationship Specialist Perceived positively as: Perceived negatively as: Patient Hesitant Respectful Wishy Washy Willing Pliant Agreeable Conforming Dependable Dependent Concerned Unsure Relaxed Laid Back Organized Mature Empathetic Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 14

How to recognise personal style
The Analytical: Technical Specialist Perceived positively as: Perceived negatively as: Accurate Critical Exacting Picky Conscientious Moralistic Serious Stuffy Persistent Stubborn Organized Indecisive Deliberate Cautious Merrill D, Reid R (1991) Personal Styles and Effective Performance, CRC Press, London 15

Another way of looking at it
Finding the balance Another way of looking at it Task focus Analytical Driver Get it right Get it done Aggressive Passive Get along Get appreciation Expressive Amiable People focus

Discussion 4: The Importance of Personal Styles
Indicate A person’s interests & priorities Behaviour and actions Strengths and weaknesses Use this insight to Choose effective ways to communicate ideas Know how to work better with that person Think about Your strength Your team strength How the team can be more effective The style who may cause most difficulty

Trust: Caring & Competency
HIGH Affection Trust Distrust Respect Adapted from P Scholtes (1998) The Leaders’ Handbook; McGraw Hill Extent to which I believe you care about me LOW HIGH Extent to which I believe you are competent and capable

Measuring for improvement (not judgement) http://www. institute. nhs

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 35

The Three Faces of Performance Measurement
Aspect Improvement Accountability Research Aim Improvement of care Comparison, choice, reassurance, spur for change New knowledge Methods: Test Observability Tests are observable No test; merely evaluate current performance Test blinded or controlled tests Bias Accept consistent bias Measure 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 hypothesis Fixed hypothesis Testing Strategy Sequential tests No tests One large test Determining if a Change is an Run charts or control charts No change focus Hypothesis, 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

Charts vs. Tables 37 37

What does this tell us?

Given two different numbers, one will always be bigger than the other!
What does this tell us? Given two different numbers, one will always be bigger than the other!

What does this data tell you?
Mean = 24.4 5 10 15 20 25 30 1 2 3 4 6 7 8 9 11 12 13 14 16 17 18 19 21 22 Weekly production volume July Aug Oct Sept Week 40

Aim The ‘big’ dots Drivers Interventions The ‘small’ frontline 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 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 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 Interventions The ‘small’ frontline dots Contribute directly to the drivers

Discussion 5: Measuring for Improvement
Think about Question 1 of The Improvement Model and the primary and secondary drivers of your improvement work What ARE you trying to achieve? How will you KNOW that a change is an improvement? How can you display measures for improvement on run charts to share with others – the big dots and the little dots? Link improvement measures to strategic measures 42 42

Developing change ideas: Creativity and innovation
“Impossible” is not a fact……… It is an opinion 43

Edward deBono’s Mental Valleys Model for Thinking
“Creative thinking involves breaking out of established patterns (valleys) in order to look at things in a different way.” de Bono Streams of thinking Valleys

First and second order change
First-order change Second-order change Underlying mental model Unaltered Altered Specific way we do something Changed Changed

Creativity and innovation: definitions
Creativity: The connecting and rearranging of knowledge — in the minds of people who will allow themselves to think flexibly — 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

Deliberate innovation process
£££££ 400 ideas generated 75 ideas harvested 20 ideas developed 8 ideas tested 4 ideas implemented Doing and changing Innovation Imagination Creativity

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

Three Deliberate Mental Processes
Movement Attention Escape Paul Plsek

Reframing by wordplay GP surgery
A way for people to get information and help for them to stay healthy Health records A way for certain bits of information about health history and needs are instantly available Access to..... A way of getting those with health needs (patients) together with those who can help (providers)

Stepping Stones are… ideas or wild scenarios which may serve as catalysts or "stepping stones“ to help make an intuitive leap to a really good idea. By doing this useful concepts and ideas can be developed Judgement is suspended and thinking is more free connections or associations made between seemingly unrelated pieces of information

Discussion 6: Stepping stones brainstorm
Rules of brainstorming Criticism is ruled out There are no bad ideas at this stage Go for quantity Encourage wild ideas Build on the ideas of others One conversation at a time Imagine All staff in the ambulance service have been struck down with a mystery illness that means the whole ambulance service is unavailable for the next year. What could you do to get adult patients to the care they need? ‘The way to get good ideas is to get lots of ideas and throw the bad ones out’ Linus Pauling Nobel Prize winning chemist

Imagination Creativity
Innovation Process £££££ 400 ideas generated 75 ideas harvested 20 ideas developed 8 ideas tested 4 ideas implemented Doing and changing Innovation Imagination Creativity

Tool: Dot Voting Activity Vote for the ideas you like best
Identify the top 10 Idea Idea

Edward de Bono’s Six Thinking Hats™
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 DeBono E (1985) Six Thinking Hats Black Bay

DeBono’s 6 hats: different approaches
DeBono E (1985) Six Thinking Hats Black Bay Thinking Leading Doing analytical objective factual WHITE analyse work with detail look at both sides seek facts not emotionally involved micro manage leads by objective knowledge wins hearts and minds understanding, guts caught in emotion manages instinctively typically weak on facts emotional works on hunches and intuition RED trust own instinct with people sensitive to others feelings positive judgement opportunity potential YELLOW develops people by being enthusiastic publicly positive lacks antenna for things gone awry see the bright side identify possibilities encourage others negative judgement won’t work because BLACK seeks to minimise risks and dangers can damper enthusiasm often avoids opportunity pragmatic/realism ‘fire hose’ act conservatively may judge too soon innovate create stretch generate ideas see things others don’t creativity brain storming thinking widely GREEN leads by innovation adapts leading edge approaches may fail to take others with them forgets to be pragmatic or finish the job orchestrating organising order and structure BLUE self direction empowers others enables others to get on with the job order and structure sort prioritises think ahead

Change principle Change principle
Transferring solutions is rarely effective, Transfer change principles… Change principle Change principle Solution / change in organisation A Solution / change in organisation B

Speaking in PDSA Language
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) P D S A © Paul Plsek

Innovation and improvement
Continuous improvement ‘there has to be a great deal of continuous improvement surrounding innovation’ Cole R (2001) From continuous improvement to continuous innovation QMJ Vol. 8, No.4 Aim Innovation Time

Use resources Boaden, Harvey, Moxham Proudlove (2008) Quality Improvement: theory and practice in healthcare NHS Institute for Innovation and Improvement Improvement Leaders’ Guides NHS Evidence specialist collection on innovation and improvement NHSI: Thinking Differently Google: Thinking Differently book NHS Paul Plsek: Directed Creativity Roger von Oech: Creative Think

Improvement workshop 2 Please complete your feedback forms for us
At Improvement workshop 2 Be prepared to share What you have done What you wish you had done differently What you have learned about improvement Next time Managing transitions Variation Engaging others Sustainability and spread

Leadership Framework for Improvement

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