Transforming the system to improve quality and reduce costs 18th May 2012 Helen Bevan @helenbevan http://twitter.com/helenbevan Jim Easton

Programme 9.00 Welcome, introductions and warm up Helen Bevan Jim Easton 9.30 The generational challenge for improvement: rethinking quality and cost improvement: improving improvement: introducing the NHS Change Model 10.40 Aligning intrinsic motivation for changes with drivers of extrinsic motivation and connecting with shared purpose 11.45 Innovation for quality and cost improvement at scale 12.15 Lunch 1.00 Engagement to mobilise and leadership of change 1.45 System drivers, rigorous delivery and transparent measurement 2.30 Improvement methodology 3.00 Building alignment: why the sum is so much greater than the parts 4.00 Close

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

The NHS Change Model

Our case study

Four Harms patients 200,000 £430 million   So 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.

(in patients with catheters) Pressure ulcers Falls Urinary infections (in patients with catheters) VTE Absence of harm from The 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 harms They were identified as being important to patients and their carers Evidence suggests that significant improvements can be made to deliver reductions in all four Patients who have one of these harms may be at higher risk of one (or more) of the other harms Where 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 falls Delivering harm free care involves one plan to deliver against four common harms across a health economy Harmfreecare

Why we selected these harms common harms important to patients and their carers significant improvements can be made to deliver reductions in all four patients who have one of these harms may be at higher risk of one (or more) of the other harms Where 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 falls Delivering harm free care involves one plan to deliver against four common harms across a whole community

Urine Infection (catheters) Protected from all four harms? Pressure Ulcer Fall (with harm) Urine Infection (catheters) VTE Harm free care? Patient 1 no yes No Patient 2 Patient 3 Yes Patient 4 Patient 5

Urine Infection (catheters) Protected from all four harms? Pressure Ulcer Fall (with harm) Urine Infection (catheters) VTE Harm free care? Patient 1 no yes No Patient 2 Patient 3 Yes Patient 4 Patient 5 One in five

One plan – four harms Risk Assessment Risk Management Pr Ulcer Risk Assessment Risk Management Nutrition & Hydration Medication Equipment Continence Falls CA-UTI VTE The 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.

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)

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 skills However, 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 system What 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 delivery We need an aligned approach

Anatomy of change Physiology of change Definition The 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. Focus Processes and structures to deliver health and healthcare. Energy/fuel for change. Leadership activities measurement and evidence improving clinical systems reducing waste and variation in healthcare processes redesigning pathways creating a higher purpose and deeper meaning for the change process building commitment to change connecting with values creating hope and optimism about the future calling to action

Compliance Commitment Managing duality Compliance States a minimum standard of performance/ target that everyone must achieve Uses hierarchy, systems and standard procedures for co-ordination and control Threat of penalties/ sanctions/ shame creates momentum for delivery Commitment States a collective goal that everyone can aspire to Based on shared goals, values and sense of purpose (“us and us” rather than “us and them”) for co-ordination and control Commitment to a common purpose creates energy for delivery Source: Helen Bevan

Deficit based Asset based Approaches to change Deficit based what is wrong? solving problems identifying development and improvement needs gaps and deficiencies to be filled Asset based what is right that we can build on? exploiting existing assets and resources “positive deviance” amplifying what works

Our shared purpose

“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.

W need to connect with purpose; NHS Constitution gives us the platform

Energy generators Connection How far someone sees and feels a connection between what matters to them and what matters to the organisation Content How far the actual role, job, task that someone does is enjoyable to them and challenges them Context How far the way that the organisation operates and the physical conditions within which someone works makes them feel supported Climate How far “the way we do things around here” encourages individuals and teams to give of their best Source: Stanton Marris

Energy generators Connection How far someone sees and feels a connection between what matters to them and what matters to the organisation Content How far the actual role, job, task that someone does is enjoyable to them and challenges them Context How far the way that the organisation operates and the physical conditions within which someone works makes them feel supported Climate How far “the way we do things around here” encourages individuals and teams to give of their best Which of these four Cs generates the most energy for the healthcare workforce? Which C is the most energy sapping? Source: Stanton Marris

Four sources of energy Energy Description Intellectual Energy of analysis, logic, thinking, rationality. Drives curiosity, planning and focus Emotional Energy of human connection and relationships. Essential for teamwork, partnership, alignment and collaboration Spiritual Energy of vitality, passion, the future and sense of possibility. Brings hope and optimism and helps people feel more ready and confident to build the future Physical Energy of action, making things happen and getting them done. Key part of vitality, maintaining concentration and commitment Source: adapted from Steve Radcliffe

Conclusions about energies for quality and cost improvement in healthcare Tendency to focus on intellectual energy connecting intellect to intellect keeps us in our comfort zone it isn’t transformational We will achieve greater results if we link physical energy to emotional and spiritual energy

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

“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

“Turn your face to the sun and the shadows fall behind you” Māori whakatauki

“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

Discretionary effort is contractual is personal

Harm free care: our higher purpose http://harmfreecare.org/harm-free-care/videos/

Key questions Is 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?

Spreading innovation

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. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi cationsPolicyAndGuidance/DH_131299

Types of innovation Process innovation Service innovation Strategy innovation Source: Kathryn Baker http://www.au.af.mil/au/awc/awcgate/doe/benchmark/ch14.pdf

Think about some examples of each from your own experience Task What are the differences between process, service and strategy innovations? Think about some examples of each from your own experience

Examples of process innovation Redesigning the appointment process in the GP surgery Reinventing the triage process in Accident and Emergency Making it easier for patients to order repeat prescriptions Redesigning the job application process within recruitment and selection Introducing a rapid turnaround “one stop shop” for outpatient testing

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

Examples of strategy innovation Transforming the paradigm of urgent and emergency care across the community Designing radical new integrated models of health and social care for people with long term conditions Shifting power: patients, families and communities as co-creators and producers of health Building new approaches to large scale change based on mobilising principles from social movements and community organising

Examples of service innovation Creating new specialist services in the community, eg, intravenous therapy, deep vein thrombosis, complex wound clinics Introducing hyperacute stroke services across the city Creating a “virtual” induction for all newly appointed clinical staff Radical redesign of the clinical pathway for people who break their hips Introducing “virtual wards” for intensive support outside of hospital

Kinds of service innovation Integration Simplification Substitution Segmentation Parker H Making the shift: a review of NHS experience. Health Services Management Centre and NHS Institute for Innovation and Improvement http://www.bhamlive3.bham.ac.uk/Documents/college-social-sciences/social-policy/HSMC/publications/2006/Making-the-Shift.pdf

Substitution: providing higher value, lower cost care for patients/service users through location substitution: substituting high tech clinical environments for community based settings skills 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 doctors technological substitution: maximising the use of new technologies in the service. A specific type of technological substitution is channel shift clinical substitution: moving from a medical care model to community care or family or self care model organisational 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.

Current prevalence in quality and cost efforts Risk Type of innovation Current prevalence in quality and cost efforts Risk Contribution to large scale change How to spread Process Service Strategy

What are the implications for the ways I need to spread them? Key questions What 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?

The NHS Change Model

Engagement to mobilise and leadership of change

Communicating versus mobilising SPECTRUM OF APPROACH/ACTIVITY aims to generate understanding and share information communicates a message awareness is success Segments and targets different audiences media and tools are typically centrally designed and managed strong promotion of service (NHS) values aims to generate commitment to action creates a cause action is success Often unites disparate audiences focused on connecting media and tools are locally co-designed/ implemented service values with personal values, leading to committed action

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

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

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

Framing Is 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 action Snow D A and Benford R D (1992)

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 action Research 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 make Shortly 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. action Source: Marshall Ganz

But not all emotions are equal......... Action motivators Action inhibitors inertia urgency Overcome anger apathy hope fear solidarity isolation So 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 action Emotions tell us what we value in the world. INERTIA , (being in autopilot, stagnation, no progress ) and to overcome this creation of a sense of URGENCY APATHY (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 action ISOLATION 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 others Self-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 difference Self-doubt Source: Marshall Ganz

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 do Make a connection with emotions through values Call people to action Watch both films from a “show don’t tell” perspective

Leadership styles matter Primary objective Directive Immediate compliance Visionary Providing long-term direction and vision for employees Affiliative Creating harmony among employees and between the leader and employees Participative Building commitment among employees and generating new ideas Pacesetting Accomplishing tasks to high standards of excellence Coaching Long-term professional development of employees

Leadership styles used: the dominance of pacesetting

Climate dimensions What it feels like when the climate is good Flexibility There are no unnecessary rules, procedures or practices; new ideas are easily accepted Responsibility Employees are given the authority to accomplish tasks without having to constantly check for approval Standards Challenging but attainable goals are set for the organisation and its employees Rewards Employees are recognised and rewarded for good performance Clarity Everyone within the organisation knows what is expected of them Team commitment People are proud to belong to the organisation

Transformational leadership: why do large scale change efforts fail? They get designed using the same mindset, beliefs and rules as have been used before they get designed as top down, often structural, solutions rather than transformation of complex adaptive systems lack of a holistic model or perspective which links components together A “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 change operational and financial reality gets in the way of re-inventing the system

Transformational leadership: why do large scale change efforts fail? They fail to mobilise clinical and managerial leaders Lack of emotional engagement and alignment of incentives with core values Scale and pace: it typically takes far longer than the planning horizons of leaders diffusion approach does not go to plan - we are able to generate change (“pilots”), but unable to generalise it

Transformational leadership: why do large scale change efforts fail? They fail to mobilise clinical and managerial leaders Lack of emotional engagement and alignment of incentives with core values Scale and pace: it typically takes far longer than the planning horizons of leaders diffusion approach does not go to plan - we are able to generate change (“pilots”), but unable to generalise it In 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

Anatomy of change Physiology of change Definition The 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. Focus Processes and structures to deliver health and healthcare. Energy/fuel for change. Leadership activities measurement and evidence improving clinical systems reducing waste and variation in healthcare processes redesigning pathways creating a higher purpose and deeper meaning for the change process building commitment to change connecting with values creating hope and optimism about the future calling to action

Leading large scale change: ten key principles Moving towards a new vision that is better and fundamentally different from the status quo Identifying and communicating key themes that people can relate to and that will make a big difference Multiples 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 stakeholders Mutually reinforcing change across multiple processes/subsystems

Leading large scale change: ten key principles Continually refreshing the story and attracting new, active supporters Emergent planning and design, based on monitoring progress and adapting as you go Enabling many people to contribute to the leadership of change, beyond organisational boundaries Transforming mindsets, leading to inherently sustainable change Maintaining and refreshing the leaders’ energy over the long haul

Key questions What 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?

The NHS Change Model

National CQUIN (pay for quality performance) NHS Safety Thermometer CQUIN – Incentive 2012-13 National CQUIN (pay for quality performance) NHS Safety Thermometer

The NHS Safety Thermometer …. 4 The NHS Safety Thermometer …. Operational definitions Getting started Using data for improvement Best in class Measuring baselines and improvement over time has been a crucial part of the programme 80,000 patients surveyed to date (January 2012)

Key questions To 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?

Utilise an evidence-based quality improvement methodology

Are you utilising an evidence based quality improvement methodology? What’s the difference/ relationship between an improvement methodology and a change model?

Are you utilising an evidence based quality improvement methodology? This might include one or more elements of the following: Lean Six Sigma The EFQM Excellence Model NHS Institute approach to Large Scale Change Institute for Healthcare Improvement (USA) Model for Improvement We 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 others You should build on what you are already using (strength or asset based) all the methodologies enjoy some common features each has particular strengths for different problems they may be used in combination, particularly where change is required at different scales simultaneously You may want to create your own approach that combines a number of the methodologies

Key questions To 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?

The NHS Change Model

Safety Express improvement goals Activity 300 3000 Goals 95% HFC Dec 2012

Improvement goals Activity 300 3000 Goals 95% HFC Dec 2012 Yesterday it was announced that South Tees Hospitals had become the first site to record 95% harm free care

What next? 500,000 people 82% 88% 95% Pilot Baseline Pilot End Goal

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