1. The life-cycle of improvement; and how to make it sustainable Dr. Martin Wale, Exec MD, QRS Vancouver Island Health Authority

2. The non-sustainable change: Does not solve the problem – and is therefore dysfunctional Creates the illusion of progress – and is therefore dishonest Brings improvement into disrepute – causing long-term damage to the process and future chances of success

3. How to do something different “Every system is perfectly designed to deliver the results it delivers” (Berwick) So change the system

4. First and Second Order Change First-order changeSecond-order Change Underlying mental modelUnaltered Altered Specific way we do something Changed Relationship to modernization Predominant current approach to improvement Enhanced approach; improvement with creativity and innovation Example Reduced DNA’s by patient agreeing date for follow- up appointment Question need for follow- up appointment in Acute Trust. Alternatives: by telephone, in primary care, or not required ImpactIncremental improvementInnovation © NHS Institute for Innovation and Improvement

5. Life cycle of an “improvement” Time Improvement

6. Life cycle of an “improvement” Time ImprovementImplement Sign-off Next initiative Measure { Plan

7. Intervention points Time Improvement Planning time Implementation rate Efficacy Fade

8. Life cycle of a “real” improvement Time Improvement Planning Implementation Efficacy Learning ? Efficacy

9. Conceptual and theoretical bases for spread of innovation From Greenhalgh et al (2005, fig. 3.5, p 82)

10. NHSI Methodology Co-production, co-production, co-production. And share credit. © NHS Institute for Innovation and Improvement

11. Learning phase “You have to go down blind alleys. But every once in a while you go down an alley and it opens up into this huge, broad avenue. That makes all the blind alleys worthwhile.” Jeffrey P Bezos, President & CEO, Amazon.com

12. Creativity – discipline cycles © NHS Institute for Innovation and Improvement

13. De Bono: mental valleys model © NHS Institute for Innovation and Improvement

14. De Bono: mental valleys model

15. Understand and reframe Understand stakeholders Observe & inquire Frame and reframe Understand themes –Relationship management –Communications –Measurement –Project management © NHS Institute for Innovation and Improvement

16. Understand Stakeholders Confirm sponsors, clarify roles Identify stakeholders and their roles –Including for the implementation phase Consider –What change in behaviour are you trying to produce? –How will you do this? Identify key connectors © NHS Institute for Innovation and Improvement

17. Stakeholder analysis model © NHS Institute for Innovation and Improvement

18. Observe & inquire People do not always do what they say they do People do not always do what they think they do People do not always do what you think they do People cannot always tell you what they need From IDEO “If you are not in the jungle, you are not going to know the tiger” Tom Kelley © NHS Institute for Innovation and Improvement

19. Observation Goals –To gain new and extended insight into the issue. –To examine solutions from other industries or healthcare systems. –To gain inspiration or new ideas Wide search Think about second order change Explore novel connections © NHS Institute for Innovation and Improvement

20. Observation Take notes & pictures Consider –? Observing for understanding –? Observing for inspiration Within the area Outside the area –Analogous situations –Extreme users © NHS Institute for Innovation and Improvement

21. Observation techniques Keep an open mind Talk, so people will talk Give people time to talk Design tools to open dialogue Don’t correct misperceptions Five why’s Draw it, show me, think aloud Sit and watch © NHS Institute for Innovation and Improvement

22. What to look for Pauses in action Things or qualities which prompt behaviour Work-arounds or adoptions Body language What people care about Surprising behaviours or uses of items © NHS Institute for Innovation and Improvement

23. Frame and reframe Don’t be afraid to shift your perspective or position Present alternatives Talk to people © NHS Institute for Innovation and Improvement

24. The Innovation Funnel © NHS Institute for Innovation and Improvement

25. Life cycle of a real improvement Time Improvement Planning Implementation Learning

26. Sustainability (finally)

27. The non-sustainable change: Does not solve the problem Creates the illusion of progress Brings improvement into disrepute So you need to know in advance, so you can fix it

28. Questions?

29. Sustainability Tool in action MAXGroup 1Group 2Group 3 8.5 Benefits 4.7 8.5 9.1 Credibility 3.19.16.3 7.0 Adaptability 7.0 6.5 Monitoring 6.52.46.5 11.4 Involvement/training 6.30.011.4 11.0 Behaviour 0.0 11.0 15.0 Senior Leaders 15.05.715.0 Clinical Leaders 6.70.015.0 7.0 Goals & Cultures 3.33.57.0 9.5 Infrastructure 3.30.03.3

30. Life cycle of a real improvement Time Improvement Implementation

31. Life cycle of a real improvement Time Improvement Efficacy?

32. Questions? Energy Time