1. Implementing Solutions
Patients need Proof the NHS can be trusted to stop this happening again.

2. The RCA Process Getting Started
Gathering Information & Mapping the Incident
Identifying Care & Service Delivery Problems
Analysing Problems & Identifying CFs and RCs
Generating Solutions & Recommendations
Implementing Solutions
Writing the Report

3. Successful implementation is a process not an event
Communication
Diffusion
Dissemination
Adoption
Spread and sustainability
Terms
Diffusion and dissemination are the processes by which the guidance or safer practice is communicated
Adoption is the decision by others to adopt the guidance
Implement is to carry out an action or put into effect a plan or procedure
Implementer is someone who carries out that action
Implementation is when new ways of working are acted upon and changes are made to behaviour and or practice
Embedding is when the new ideas or practice are spread within organisations or between organisations to enable sustainable change i.e. the new ways of working and improved outcomes become the norm, and part of everyday practice
Guidance is something that guides
Safer practice is the habitual practice, habit or custom which makes things safer
Director is a person that directs, the person who is responsible for the interpretive aspects of a procedure, who then supervises the integration of all the elements

4. Implementation = Making change a part of the day-to-day
operation of the system
To test whether it has been achieved -
Ask yourself…
would the change persist even if its champion were to leave the organisation?

5. Set achievable goals
WWW
What by When by Who

6. Make the Important Measurable
Measure, Measure, Measure
Some is not a number
Soon is not a time
IHI Orlando NPSF conference
Make the Important Measurable
Then make the Measurable Important
How do we know we have improved...
Need to measure stuff e.g.
Some = 100,00 lives
Soon = am

7. Action Planning www.npsa.nhs.uk/rca Incident No: Action 1 ê Action 2 ê
Root CAUSE / Lesson learned
EFFECT on patient/service
Recommendation(s) to address root cause (or rationale, if no action or recommendation is set).
Action(s) to achieve recommendations
Level for action
(organisation, directorate, team etc)
Implementation by whom:-
Implementation by when:-
Resource required (time)
Resource required (money)
Resource required (other)
Evidence of completion
Monitoring & evaluation arrangements
Sign-off by:-

8. Common mistakes in Action Planning...
Using change already underway for others reason.
(May appear handy but often not relevant or robust)
Listing consideration or reviews as solutions
(Activity ≠ Change)
Assuming Change = Improvement

9. Consider... How will the action plan be - drawn up? - monitored?
....Busy people who need to prioritise often
ensure they cover what is measured/monitored

10. What It Takes To Improve
Will to change the current system
Strong positive leadership and a realistic appraisal of resources and barriers
Ideas about changes that will improve the system
And a theory that links changes to outcomes
Execution of the ideas
And a way to distinguish successful from unsuccessful changes

11. Application of Science
Plan – What we are going to try out
Do – (or JDI)
Study – Just enough results for learning
Act – Adopt, Adapt, Abandon

12. Plan Sustainability & Spread
When new ways of working and improved outcomes become the
norm. (Thinking and attitudes have shifted)
Spread
The extent to which learning and change has been adopted in other
areas that could benefit from them

13. Implementing change Apostles – Lead. +ve even when things are bad
Friends – Biggest group
Cynics – Need to win their hearts
The dead – Not for or against! (Apathy)
Hostages – Saboteurs (Dangerous)

14. Cascade training Role models
Make use of role models +champions
Paint run - likened to cascade training
- Cascade training is limited/hard/slow technique ?

15. Key Points – Implementation
Take a simple approach and start small
Get people on board
Never assume we are doing what we think we are doing
... Measure, Measure, Measure