1. Embedding Improvement Science in Training Programmes:
Why Bother?
Professor Jean Penny,
University of Derby

2. Jean Penny Improvement: 19 years and still learning
All working life in and with NHS
Diagnostic Radiographer and teacher
National improvement roles 1994 – 2008
Improvement educator and advisor 2008 – present
Awarded OBE for services to NHS 2003
Visiting professor University of Derby 2008
Improvement:
19 years and still learning

3. Embedding Improvement Science in Training Programmes: Why Bother?
Healthcare will not realise its full potential unless change (improvement) making becomes an intrinsic part of everyone’s job, every day, in all parts of the system.
Batalden, P. B et al.
Quality and Safety in Health Care 2007;16:2-3

4. Embedding Improvement Science in Training Programmes: Why Bother?
What is Improvement Science?
Why bother embedding it into training programmes? 4

5. Question
Who likes change?

6. What is Improvement Science?
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. What is Improvement Science?
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. What is Improvement Science?
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. What is Improvement Science?
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. Share the problem not the solution
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

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

13. 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

14. Challenge the paradigms14

15. The Model for Improvement
Understanding the problem. Defining what you’re trying to do
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 the improvements that you seek ?
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

16. Charts vs. Tables 16

17. How often you measure can also have an effect on how you look at the results
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
0.5 1
1.5 2
2.5 3
3.5 4 5 6 7
Months
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Weeks
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
Mike Davidge NHS Institute for Innovation and Improvement

18. The Model for Improvement
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 the improvements that you seek ?
Act
Plan
Study Do
What have others done? What does the evidence say? 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 2nd ed, Jossey Bass Publishers, San Francisco

19. Transferring solutions is rarely effective. Transfer change principles…
Solution / change in team / organisation A
Solution / change in team / organisation B

20. PDSA cycle for learning and improvement
Act
Plan
objective
questions and
predictions (why)
plan to carry out
the cycle (who,
what, where, when)
What we plan to do next is …. (state next plan)
We planned to ( state the basic plan)
In order to ….. (tie it back to the aim)
what changes
are to be made?
next cycle?
Study Do
complete the
analysis of the data
compare data to
predictions
summarise what
was learned
carry out the plan
document problems
and unexpected
observations
begin analysis
of the data
Looking at what happened, what we learned from this was….. (lessons learned)
What we did was….. (brief description of actions)

21. Measurement: Big dots and little dots
The Model for Improvement breaks things down into small steps and works on 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

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

23. Embedding Improvement Science in Training Programmes: Why Bother?
What is Improvement Science?
Why bother embedding it into training programmes? 23

24. Improvement in pre-registration education: aim – to raise awareness to improvement for better safer care
To develop health and social care students who are curious about how they could improve their service, and who are receptive to different ideas and able to bring about the necessary changes by applying a variety of tools and techniques in their own context
2006

25. Some key lessons
‘my duty, part of my professional role, I should get involved’
‘be prepared to extend role and take on new responsibilities’
‘small problems have a big impact on patients’
‘anyone can take part – we’re all responsible’
‘I have the skills’
Tribal consulting, External evaluation 08/09

26. It is making a difference......
‘…..I have interviewed over 100 applicants of newly qualified staff …..One of the questions asked was " Service development is everyone's responsibility, …have you been involved in any changes happening while you have been on a placement?
It was obvious …that one particular University's candidates had all identified an area for improvement in practice .. and had tested and evaluated them during their stay there. Some of their ideas were still in use and others were not. Some of the ideas were interesting and made us think about looking at those areas for improvement ourselves.
…..it was very clear that the candidates from other local universities had not been involved in any changes
……we employed those that could clearly discuss how to introduce and evaluate a change in practice or improvement to patient care’. 
Nurse Manager, Neonatal Unit, North of England, March 2011

27. Barriers and challenges
Engagement of key stakeholders
Barriers in engaging with practice
Engaging Faculty and colleagues
Resources
Time
Funding
Human Resources and Extra work
Rooms
Timescale / Timing
University structures i.e. plan everything in advance
Difficult time as currently revalidating
Difficulty getting everybody in the same room at the same time
Attitudes
Student Attitude and receptiveness
Staff Attitude and receptiveness
Tribal Consulting, External evaluation of 08/09

28. 2012 review: Engaging Faculty and colleagues
The main challenge to sustainability is ensuring that key faculty and senior academics truly understand and value improvement as a concept. When this happens improvement is prioritised and sustained in an ever pressurised curriculum.
Replies from 33 universities (69%) of the 48 universities on the NHSI contact list

29. Final messages about improvement
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
Learn from things that do not work
Link frontline changes to strategic objectives

30. Embedding Improvement Science in Training Programmes: Why Bother?
Healthcare will not realise its full potential unless change (improvement) making becomes an intrinsic part of everyone’s job, every day, in all parts of the system.
Batalden, P. B et al.
Quality and Safety in Health Care 2007;16:2-3

31. Embedding Improvement Science in Training Programmes:
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
Act
Plan
Study Do
Embedding Improvement Science in Training Programmes:
Why Bother?
Professor Jean Penny,
University of Derby

33. Educating for capability
‘Competence: what individuals know or are able to do in terms of knowledge and skill
Capability: extent to which individuals can adapt to change .... and continue to improve their performance’
‘These days there is so much knowledge available that we risk drowning in it Learning about how things are interconnected is often more useful than learning about the pieces’
Fraser Greenhalgh (2001) Coping with complexity: educating for capability