Presentation on theme: "Transforming the system to improve quality and reduce costs"— Presentation transcript:
1 Transforming the system to improve quality and reduce costs 18th May 2012Helen Bevan@helenbevanJim Easton
2 Programme 9.00 Welcome, introductions and warm up Helen Bevan Jim Easton9.30The generational challenge for improvement: rethinking quality and cost improvement: improving improvement: introducing the NHS Change Model10.40Aligning intrinsic motivation for changes with drivers of extrinsic motivation and connecting with shared purpose11.45Innovation for quality and cost improvement at scale12.15Lunch1.00Engagement to mobilise and leadership of change1.45System drivers, rigorous delivery and transparent measurement2.30Improvement methodology3.00Building alignment: why the sum is so much greater than the parts4.00Close
3 Introductions: finish the sentence Introduce yourself to others on your table by finishing these three sentences:The change initiative that I am currently working on that I would like to reflect on today is ...The problem we are addressing is ...The strengths we are building on are...Your answer to each question should literally be one sentence
6 Four Harmspatients200,000£430millionSo many of you will already know that in 2011, we began work with a pilot community called Safety Express. There were over 130 organisations that participated in the Safety Express programme with a collective aim to make improvements. Their commitment to reducing four harms came out of a shared understanding that these four harms were affecting the lives of at least 200, 000 people every year and that reducing them, even by only 50% could result in significant reductions in harm and cost with an estimated national productivity margin of £430million.
7 (in patients with catheters) Pressure ulcersFallsUrinary infections(in patients with catheters)VTEAbsence of harm fromThe composite of harms we have been focusing on in ‘Safety Express’ includes pressure ulcers, harm from falls, CA-UTIs and VTE. These were selected because:They are common harmsThey were identified as being important to patients and their carersEvidence suggests that significant improvements can be made to deliver reductions in all fourPatients who have one of these harms may be at higher risk of one (or more) of the other harmsWhere we have focussed our efforts in reducing one, we may have had a negative impact on the others e.g. We may deliver a successful intervention to reduce VTE or pressure ulcers but in doing so increase fallsDelivering harm free care involves one plan to deliver against four common harms across a health economyHarmfreecare
8 Why we selected these harms common harmsimportant to patients and their carerssignificant improvements can be made to deliver reductions in all fourpatients who have one of these harms may be at higher risk of one (or more) of the other harmsWhere we have focussed our efforts in reducing one, we may have had a negative impact on the others e.g. We may deliver a successful intervention to reduce VTE or pressure ulcers but in doing so increase fallsDelivering harm free care involves one plan to deliver against four common harms across a whole community
9 Urine Infection (catheters) Protected from all four harms?PressureUlcerFall(with harm)Urine Infection (catheters)VTEHarm free care?Patient 1noyesNoPatient 2Patient 3YesPatient 4Patient 5
10 Urine Infection (catheters) Protected from all four harms?PressureUlcerFall(with harm)Urine Infection (catheters)VTEHarm free care?Patient 1noyesNoPatient 2Patient 3YesPatient 4Patient 5One in five
11 One plan – four harms Risk Assessment Risk Management Pr UlcerRisk AssessmentRisk ManagementNutrition & HydrationMedicationEquipmentContinenceFallsCA-UTIVTEThe changes we will introduce are based on empirical evidence, widely recognised in best practice guidelines but simplified for execution. This simplification should not be misinterpreted as ‘dilution’. Our experience of improving healthcare quality has clearly shown that focussing a small number (3-4) key interventions and figuring out strategies for local implementation are key to breakthrough improvement. The rationale is clear, find the key interventions which make the biggest difference and implement reliably for every patient, all the time.However, in requiring that four clinical specialist areas work together with frontline teams to create a single plan for harm free care this design concept forces teams to agree on a single model, for example, in the active risk management domain clinical specialists in pressure ulcers and falls are moving towards intentional or hourly rounding to manage ‘risk’, by combining their requirements in a single rounding proforma we can deliver against multiple agendas with the ultimate design being a form which is elegantly designed to accommodate ALL areas.
12 www.harmfreecare.org Guide Measure Stories E learning 2 Couple of slides of examples of website pages: (please note the doctor photo to be replaced)
13 Four key messages underpinning the NHS Change Model To achieve large scale change, we need the intrinsic motivation of connection to shared purpose, engaging to mobilise, transformational leadership skillsHowever, we also need drivers of extrinsic motivation; transparent measurement and holding to account, incentivising payment systems, performance management systems if we are going to create change across the systemWhat happens if we don’t align intrinsic and extrinsic factors is that the extrinsic factors kill off the energy and creativity that is necessary for deliveryWe need an aligned approach
14 Anatomy of change Physiology of change DefinitionThe shape and structure of the system; detailed analysis; how the components fit together.The vitality and life-giving forces that enable the system to develop, grow and change.FocusProcesses and structures to deliver health and healthcare.Energy/fuel for change.Leadershipactivitiesmeasurement and evidenceimproving clinical systemsreducing waste and variation in healthcare processesredesigning pathwayscreating a higher purpose and deeper meaning for the change processbuilding commitment to changeconnecting with valuescreating hope and optimism about the futurecalling to action
15 Compliance Commitment Managing dualityComplianceStates a minimum standard of performance/ target that everyone must achieveUses hierarchy, systems and standard procedures for co-ordination and controlThreat of penalties/ sanctions/ shame creates momentum for deliveryCommitmentStates a collective goal that everyone can aspire toBased on shared goals, values and sense of purpose (“us and us” rather than “us and them”) for co-ordination and controlCommitment to a common purpose creates energy for deliverySource: Helen Bevan
16 Deficit based Asset based Approaches to changeDeficit basedwhat is wrong?solving problemsidentifying development and improvement needsgaps and deficiencies to be filledAsset basedwhat is right that we can build on?exploiting existing assets and resources“positive deviance”amplifying what works
19 “Paradoxically, the most important first task in creating a successful quality and cost improvement strategy is not to identify the size of the challenge or to work out which areas of service delivery offer the greatest opportunity for change.Rather, it is to create a deeper meaning in the challenge that lies ahead, to link the cost improvement programme to the higher purpose of the organisation or NHS system. The framing for quality and cost improvement isn’t just about cost and quality improvement. We want to think deeply about the meaning of what we are asking people to do in an era of quality and cost improvement. Fundamentally, it is about the higher purpose of the NHS and the calling that each of us has to serve that purpose.
20 W need to connect with purpose; NHS Constitution gives us the platform
21 Energy generators Connection How far someone sees and feels a connection between what matters to them and what matters to the organisationContentHow far the actual role, job, task that someone does is enjoyable to them and challenges themContextHow far the way that the organisation operates and the physical conditions within which someone works makes them feel supportedClimateHow far “the way we do things around here” encourages individuals and teams to give of their bestSource: Stanton Marris
22 Energy generatorsConnectionHow far someone sees and feels a connection between what matters to them and what matters to the organisationContentHow far the actual role, job, task that someone does is enjoyable to them and challenges themContextHow far the way that the organisation operates and the physical conditions within which someone works makes them feel supportedClimateHow far “the way we do things around here” encourages individuals and teams to give of their bestWhich of these four Cs generates the most energy for the healthcare workforce?Which C is the most energy sapping?Source: Stanton Marris
23 Four sources of energy Energy Description Intellectual Energy of analysis, logic, thinking, rationality. Drives curiosity, planning and focusEmotionalEnergy of human connection and relationships. Essential for teamwork, partnership, alignment and collaborationSpiritualEnergy of vitality, passion, the future and sense of possibility. Brings hope and optimism and helps people feel more ready and confident to build the futurePhysicalEnergy of action, making things happen and getting them done. Key part of vitality, maintaining concentration and commitmentSource: adapted from Steve Radcliffe
24 Conclusions about energies for quality and cost improvement in healthcare Tendency to focus on intellectual energyconnecting intellect to intellect keeps us in our comfort zoneit isn’t transformationalWe will achieve greater results if we link physical energy to emotional and spiritual energy
25 Guess who understood the importance of spiritual energy? “Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.” Aneurin Bevan, founder of the NHS
26 “Large scale change is fuelled by the passion that comes from the fundamental belief that there is something very different and better that is worth striving for”Leading Large Scale Change (2011)NHS Institute for Innovation and Improvement
27 “Turn your face to the sun and the shadows fall behind you” Māori whakatauki
28 “Money incentives do not create energy for change; the energy comes from connection to meaningful goals”Ann-Charlott Norman, Talking about improvements: discursive patterns and their conditions for learning, March 2012
31 Key questionsIs the ‘higher purpose’ for my change initiative clear and recognised by our leaders, workforce and partners?Are our quality and cost improvement proposals explicitly framed as a connection to the higher purpose?
33 Innovation Review by Chief Executive of the NHS “It is widely accepted that more of the same will not do. More radical changes in the way services are delivered and how people work will be required. We need to plot a sustainable course for the future of the NHS. Innovation can help provide the route-map, improving quality at the same time as driving productivity and efficiency in a difficult financial environment” Department of Health (2011). Innovation, health and wealth: accelerating adoption and diffusion in the NHS. Page 4. cationsPolicyAndGuidance/DH_131299
34 Types of innovation Process innovation Service innovation Strategy innovationSource: Kathryn Baker
35 Think about some examples of each from your own experience TaskWhat are the differences between process, service and strategy innovations?Think about some examples of each from your own experience
36 Examples of process innovation Redesigning the appointment process in the GP surgeryReinventing the triage process in Accident and EmergencyMaking it easier for patients to order repeat prescriptionsRedesigning the job application process within recruitment and selectionIntroducing a rapid turnaround “one stop shop” for outpatient testing
37 Strategy innovation“the question today is not whether you can reengineer your processes; the question is whether you can reinvent the entire industry model”Gary Hamel
38 Examples of strategy innovation Transforming the paradigm of urgent and emergency care across the communityDesigning radical new integrated models of health and social care for people with long term conditionsShifting power: patients, families and communities as co-creators and producers of healthBuilding new approaches to large scale change based on mobilising principles from social movements and community organising
39 Examples of service innovation Creating new specialist services in the community, eg, intravenous therapy, deep vein thrombosis, complex wound clinicsIntroducing hyperacute stroke services across the cityCreating a “virtual” induction for all newly appointed clinical staffRadical redesign of the clinical pathway for people who break their hipsIntroducing “virtual wards” for intensive support outside of hospital
40 Kinds of service innovation IntegrationSimplificationSubstitutionSegmentationParker H Making the shift: a review of NHS experience. Health Services Management Centre and NHS Institute for Innovation and Improvement
41 Substitution: providing higher value, lower cost care for patients/service users through location substitution: substituting high tech clinical environments for community based settingsskills substitution: enhancing the skills of specific groups of staff to undertake roles previously undertaken by those with a higher skill level, for instance enabling nurses to prescribe drugs, a role that was previously only carried out by doctorstechnological substitution: maximising the use of new technologies in the service. A specific type of technological substitution is channel shiftclinical substitution: moving from a medical care model to community care or family or self care modelorganisational substitution: looking at a wider range of providers to those who have traditionally delivered NHS care, for instance voluntary and community groups and social enterprises.
42 Current prevalence in quality and cost efforts Risk Type of innovationCurrent prevalence in quality and cost effortsRiskContribution to large scale changeHow to spreadProcessServiceStrategy
43 What are the implications for the ways I need to spread them? Key questionsWhat combination of process, service and strategy innovations do my improvement plans require?What are the implications for the ways I need to spread them?What levers are available to me to spread innovation in my current context?How do I use them?How am I linking spread of innovation to other components of the change model?
45 Engagement to mobilise and leadership of change
46 Communicating versus mobilising SPECTRUM OF APPROACH/ACTIVITYaims to generate understanding and share informationcommunicates a messageawareness is successSegments and targets different audiencesmedia and tools are typically centrally designed and managedstrong promotion of service (NHS) valuesaims to generate commitment to actioncreates a causeaction is successOften unites disparate audiences focused on connectingmedia and tools are locally co-designed/ implementedservice values with personal values, leading to committed action
47 Leaders ask their staff to be ready for change, but do not engage enough in sensemaking Sensemaking is not done via marketing...or slogans but by emotional connection with employees Ron Weil
48 A challenge“What the leader cares about (and typically bases at least 80% of his or her message to others on) does not tap into roughly 80% of the workforce’s primary motivators for putting extra energy into the change programme”Scott Keller and Carolyn Aiken (2009)The Inconvenient Truth about Change Management
49 Leaders as “signal generators” “As a leader, think of yourself as a “signal generator” whose words and actions are constantly being scrutinised and interpreted, especially by those below you [in the hierarchy]” “Signal generators reduce uncertainty and ambiguity about what is important and how to act” Charles O’Reilly, Leaders in Difficult Times, 2009
50 FramingIs the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to actionSnow D A and Benford R D (1992)
51 If we want people to take action, we have to connect with their emotions through values So Emotions help us understand what we value in the world.Why did the story of Alice work ?So why was this story powerful?Why do we respond differently when we hear about Alice rather than when we see the policy data and financial balance sheet?So public narrative when used intentionally for a purpose to connect with others to move to action is a powerful skills set and leadership gift. When we hear stories that make us feel a certain way those stories remind us of our core values. We experience our values through emotions. Then we are prepared to take action on those values. Through our emotions we are more likely to take actionResearch by Martha Nussbaum a Moral philosopher, tells us that people who have a damaged (a-mig-da- la) Amygadla the part of the brain which controls emotions, when faced with decisions can come up with many options from which to choose but cannot make a decision because the decision rests upon judgements of value. If we cannot feel emotion we cannot experience values that orient us to the choices we must makeShortly we will be thinking about the lived experiences that have moved you to action…we’ll be drawing on those a few minutes as you start to craft your own stories.actionSource: Marshall Ganz
52 But not all emotions are equal......... Action motivators Action inhibitorsinertiaurgencyOvercomeangerapathyhopefearsolidarityisolationSo when we are confronted with others who display action inhibitor emotions we enable them to move to action by using stories to engage their hope and move to actionEmotions tell us what we value in the world.INERTIA , (being in autopilot, stagnation, no progress ) and to overcome this creation of a sense of URGENCYAPATHY (without feeling, moving to ANGER the sense of outrage the story of Alice felt by me)FEAR, how some of you may be feeling now faced with this campaign training ,but there is HOPE as an action motivator to move us to actionISOLATION I must be the only one not getting this training ,they picked the wrong one ,I can’t express my true views etc .But this can move to SOLIDARITY when shared with others those next to you on the table the rest of your pioneering pilots’. The interest we share with othersSelf-doubt (I can’t do it, im the wrong person for this campaign ,this can twist into action motivating emotion through the belief in the value of YCMAD .Counter the self doubt ,move into what we can do rather than what we cant do .So the story appeals where strategy doesn’t (Questions to Consider):Has anybody felt these emotions before? Have they inhibited you from doing anything, from taking action?Have you been in a moment that your community felt with URGENCY? Has anyone felt that in your communities – ANGER? Have you felt HOPE, SOLIDARITY AND YOU CAN MAKE A DIFFERENCE (YCMAD)?you can make a differenceSelf-doubtSource: Marshall Ganz
53 Two films on harm free care Key principle in mobilising narrative is “show don’t tell”Show what is possible rather than tell people what to doMake a connection with emotions through valuesCall people to actionWatch both films from a “show don’t tell” perspective
54 Leadership styles matter Primary objectiveDirectiveImmediate complianceVisionaryProviding long-term direction and vision for employeesAffiliativeCreating harmony among employees and between the leader and employeesParticipativeBuilding commitment among employees and generating new ideasPacesettingAccomplishing tasks to high standards of excellenceCoachingLong-term professional development of employees
55 Leadership styles used: the dominance of pacesetting
56 Climate dimensionsWhat it feels like when the climate is goodFlexibilityThere are no unnecessary rules, procedures or practices; new ideas are easily acceptedResponsibilityEmployees are given the authority to accomplish tasks without having to constantly check for approvalStandardsChallenging but attainable goals are set for the organisation and its employeesRewardsEmployees are recognised and rewarded for good performanceClarityEveryone within the organisation knows what is expected of themTeam commitmentPeople are proud to belong to the organisation
58 Transformational leadership: why do large scale change efforts fail? They get designed using the same mindset, beliefs and rules as have been used beforethey get designed as top down, often structural, solutions rather than transformation of complex adaptive systemslack of a holistic model or perspective which links components togetherA “voltage drop” occurs between radical change aspirations and the reality of implementation:organisations are neither capable of, nor ready for, the breadth and depth of changeoperational and financial reality gets in the way of re-inventing the system
59 Transformational leadership: why do large scale change efforts fail? They fail to mobilise clinical and managerial leadersLack of emotional engagement and alignment of incentives with core valuesScale and pace:it typically takes far longer than the planning horizons of leadersdiffusion approach does not go to plan - we are able to generate change (“pilots”), but unable to generalise it
60 Transformational leadership: why do large scale change efforts fail? They fail to mobilise clinical and managerial leadersLack of emotional engagement and alignment of incentives with core valuesScale and pace:it typically takes far longer than the planning horizons of leadersdiffusion approach does not go to plan - we are able to generate change (“pilots”), but unable to generalise itIn around 80% of cases, failure can be traced back to the early stages: change programmes are most likely to go wrong as a result of the way they are initially conceptualised and planned
61 Anatomy of change Physiology of change DefinitionThe shape and structure of the system; detailed analysis; how the components fit together.The vitality and life-giving forces that enable the system to develop, grow and change.FocusProcesses and structures to deliver health and healthcare.Energy/fuel for change.Leadershipactivitiesmeasurement and evidenceimproving clinical systemsreducing waste and variation in healthcare processesredesigning pathwayscreating a higher purpose and deeper meaning for the change processbuilding commitment to changeconnecting with valuescreating hope and optimism about the futurecalling to action
62 Leading large scale change: ten key principles Moving towards a new vision that is better and fundamentally different from the status quoIdentifying and communicating key themes that people can relate to and that will make a big differenceMultiples of things (‘lots of lots’)Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholdersMutually reinforcing change across multiple processes/subsystems
63 Leading large scale change: ten key principles Continually refreshing the story and attracting new, active supportersEmergent planning and design, based on monitoring progress and adapting as you goEnabling many people to contribute to the leadership of change, beyond organisational boundariesTransforming mindsets, leading to inherently sustainable changeMaintaining and refreshing the leaders’ energy over the long haul
64 Key questionsWhat leadership strengths can we build on to deliver our quality and cost goals?How can we develop leadership skills for transformation?What does our focus need to be?How does our strategy for building transformational leadership and engaging to mobilise link with other components of the change model?
66 National CQUIN (pay for quality performance) NHS Safety Thermometer CQUIN – IncentiveNational CQUIN (pay for quality performance)NHS Safety Thermometer
67 The NHS Safety Thermometer …. 4The NHS Safety Thermometer ….Operational definitionsGetting startedUsing data for improvementBest in classMeasuring baselines and improvement over time has been a crucial part of the programme80,000 patients surveyed to date (January 2012)
68 Key questionsTo what extent are you using these components to drive your change?How do we balance the risks and benefits of applying these components?How does our strategy for building these three components link with other components of the change model?
69 Utilise an evidence-based quality improvement methodology
70 Are you utilising an evidence based quality improvement methodology? What’s the difference/ relationship between an improvement methodology and a change model?
71 Are you utilising an evidence based quality improvement methodology? This might include one or more elements of the following:LeanSix SigmaThe EFQM Excellence ModelNHS Institute approach to Large Scale ChangeInstitute for Healthcare Improvement (USA) Model for ImprovementWe don’t recommend one improvement approach above the others because:whilst from a research evidence viewpoint, all the approaches can demonstrate impact, none of them stands out as being more successful in healthcare than any of the othersYou should build on what you are already using (strength or asset based)all the methodologies enjoy some common featureseach has particular strengths for different problemsthey may be used in combination, particularly where change is required at different scales simultaneouslyYou may want to create your own approach that combines a number of the methodologies
72 Key questionsTo what extent are you using an evidence-based methodology to drive your change?How does our strategy for building this component link with other components of the change model?