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Leadership and culture for sustaining and spreading improvement Jean Penny.

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1 Leadership and culture for sustaining and spreading improvement Jean Penny

2 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 Improvement: 19 years and still learning

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

4  Recap  Culture  Sustainability  Spread, adoption and social movements

5  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

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7  is how things are done in the workplace  is heavily influenced by shared unwritten rules  Often reflects what has worked well in the past Think about the questions on culture

8 Unwritten rules are one of the most powerful parts of culture. They are described as 'unwritten' because they are:  not often openly discussed  rarely questioned or challenged because they are not frequently discussed  usually shared by most, if not all, the people who work within the team / organisation  provide a common way for people to make sense of what is going on around them  often influence people without them necessarily realising it  have a powerful influence on how people behave at work The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

9  Senior clinicians / managers know best  Knowledge is power  Everyone understands the jargon  Only someone in my profession / role understand the problem  Meetings constitute activity  Filling in a form makes it happen  It is wrong to be wrong....and wrong to admit to being wrong The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

10  Senior clinicians / managers know best  Knowledge is power  Everyone understands the jargon  Only someone in my profession / role understand the problem  Meetings constitute activity  Filling in a form makes it happen  It is wrong to be wrong....and wrong to admit to being wrong Discussion: What are the resulting behaviours as a result of these unwritten rules (behaviours are what you see, hear and feel)

11  Senior clinicians / managers know best  Knowledge is power  Everyone understands the jargon  Only someone in my profession / role understand the problem  Meetings constitute activity  Filling in a form makes it happen  It is wrong to be wrong....and wrong to admit to being wrong Discussion: What other unwritten rules does your team / organisation have? What are the resulting behaviours?

12 Find out about the values held Identify as many behaviours as you can. Look and listen  dress codes: uniforms, identity symbols  level of formality: in relationships and social events  working hours: balance between work and family  meetings: how often, how they are run, how long they last  decision-making: how is this done?  communication: jargon, how do you get to know about things?  rites rituals and traditions what always happens and what never happens?  disagreements and conflicts: how are they handled? Compare the stated values and behaviours Search for the unwritten rules that might account for the apparent discrepancy between the stated values and the behaviours Decide which unwritten rules matter Understand the background to the unwritten rules: how did they come into being and why do they persist The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

13  Patient centeredness  Belief in human potential  Improvement and innovation encouraged  Recognition in the value of learning  Effective team working  Communication  Honesty and trust The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007) NHS Institute for Innovation and Improvement

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15  The improvement itself and any changes in practice OR  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

16 Sustainability is the ability to withstand variation and evolve alongside other changes Sustainability is when  new ways of working and improved outcomes become the norm  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.

17  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 Lynne Maher, David Gustafson, Alyson Evans ©NHS Institute for Innovation and Improvement 2006

18 A score of 55 or over offers reasons for optimism Scores below this suggest you need to take some action and to 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

19 Think about your improvement work and consider the factors of sustainability  Where are your strengths?  What areas do you need to work on?

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21  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

22 Spread means that the learning that takes place in one area is actively shared and acted upon others i.e. that others have adopted Spread indicates ‘push’ Adoption indicates ‘pull’

23 Solution / change in organisation A Change principle Solution / change in organisation B

24  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?

25 Innovators Early Adopters Early Majority Late Majority Laggards Rogers E (2003) Diffusion of Innovations 5 th ed New York: Free Press 2.5%13.5%34% 16%  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!

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

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28 Core Characteristics  Energy  Mass  Passion  Commitment  Pace & momentum  Spread  Longevity NHSI The power of one the power of many m_joomcart&Itemid=194&main_page=document_ product_info&products_id=580 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

29 1. Frame to connect with hearts and minds  To connect with ideals, needs, values and aspirations 2. Energise and mobilise  Engagement to commitment to mobilisation 3. Organise for impact  To translate energy and passion into purposeful effective action 4. Change as a personal mission  Need every member to believe that their contribution no matter how big or small will make a difference 5. Keep forward momentum  Momentum = unstoppable = sustainability Martin Luther King said ‘I have a dream’ He did not say ‘I have a strategic plan’

30 Traditional 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

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

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33 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

34 34 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

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