Innovating Care & Services through

Co-design &Co-production

Gothenburg April 2016

Objectives for today Understand the principles of solution focused conversations.

How these principles could be used to influence whole system change.

How this approach could help co-create outcome-basedcommissioning.

An East London example in Newham… 'FUTURE GENERATIONS'.

My starting point…

Clarifying/remembering purpose: helping people to achieve their full potential.

What limits our capacity to achieve this?

o Getting fixated on or stuck in problems.

o Using excuses (reasons), & attributing blame.

o Disillusionment: it will never change, not in my control, not my problem.

o Too big a change, too quickly.

o Trying to go it alone - ego.

o Emphasis on need (demand), want (desire) vs. what works & what makes a difference.

So, do we HAVE to innovate…?

"Innovation is crucial to the continuing success of any organisation"

'Change is constant. Change is inevitable' Benjamin Disraeli

At its best, innovation is:

Transformational

Revolutionary

Organic

Innovation comes with a health warning… !!!!!

Upheaval

Reorganisation

Restructuring

Rearrangement

So what are 'co-production' & 'co-design'?

Will they produce sufficient transformation and revolution?

Will this lead to big enough system change?

Will they contribute to making a real difference to people achieving their full

potential?

Co-production

• Approach to decision-making process, rather than a specific method.

• Service users contribute to provision: those affected are best placed to help design it.

• Service users lead mechanisms to problem solve & agree outcomes.

• Decision makers or service providers work with citizens or service users to make decisions or design services that work, as 'equal partners'.

• Values driven & built around people, not systems.

And Co-design

In-depth staff/patient interviewing

Focus on experience and emotions

-Significant positive & negative feelings (USER)

-Get feedback (INFORMANT)

Define the problem (TESTER)

Share & co-create improvement (DESIGN PARTNER)

''Radical reconceptualisation of patient role with structured processes for involving them throughout all stages of quality improvement''

Research limited: Ongoing debates about how it is best interpreted, applied, & evaluated in practice.

Move from patients that just 'take it' -> client-defined goals. Treating people as averages -> individuals. Involving people in decisions about their destiny.

BUTWhose right about what is wrong?

Whose solution is the right one?

Are we asking the right questions?

What difference will any of this make to the WHOLE system?

Big State vs. Big Societypatients vs. people service users vs. community

De-medicalisation and self determination

Solution Focused Conversations:

The principles

Solution focused brief therapy - SFBT

o Late 70s: Steve de Shazer & Insoo Kim Berg

o Solution building rather than problem solving

o Not necessary to know much about the problem,

cause or function in order to resolve it.

'Future-focused, goal-directed questions designed to identify exceptions, solutions & scales.

These are used to measure progress towards solutions & to reveal behaviours needed to achieve & maintain progress'

1988 De Shazer 'miracle question'…

Imagining a future where problems are solved…

''Suppose one night, whilst you're asleep, there is a miracle & the problem that brought you here is solved. However, because you are asleep, you don't know the miracle has happened. When you wake up in the morning, what will be different that will tell you a miracle has taken place? What else?''

.

'Strengths perspective' 1989 Weick, Rapp, Sulliman & Kishardlt

Five assumptions: Saleebey 1992

1. Strengths always exist

2. Strengths need to be self determined to motivate.

3. Joint exploration aids discovery of strengths.

4. Prominence of strengths counteracts the urge to blame.

5. All environments have utilisable resources for recovery.

Philosophy

o If it's not broken, don't fix it.

o Do more of what works: presence of positives, not absence of negatives.

o Bypass what isn't working - exceptions. Problems maintained by doing more of the same, expecting no change.

o Solutions don't necessarily connect with the problem, but solution focused conversations may help resolve it.

o Clients are the expert & they define goals. Ask questions (take a 'not knowing' stance), be curious.

o Future is conceptualised, negotiated & created. Knowing where you wish to be makes getting there easier.

o Focus on what is possible & changeable - doing something that makes a difference.Small changes lead to bigger changes.

Types of questions:

Goal setting - What are your goals? What would be different? What will you notice? What would others notice?

Miracle question - If you woke up & the problem was solved…

Exceptions- When the problem's not there: what's different about these times? How do you achieve that? What do you do differently?

Coping- How do to cope? How do you stop it getting worse? What keeps you going? What is your greatest support?

Scaling

NB. Always amplify… What else? What else?

Scaling questions

Where are you now?

Where do you need to be?

What would help you move up one point & stay there?

A solution focused approach:

How could it influence a whole system change?

What do people need for whole system change to happen?

Need to feel connected, have imagination captured.

Social beings evolve towards images that are affirming.

Effective communication to facilitate change.

Avoid assumptions about problem.

Contribution respected & energised in the change process.

WHOLE SYSTEM perspective – CONSENSUS.

System-wide strength-based conversations.

Appreciative enquiry, revealing what is working & description of the future.

Re affirming joint goals & aspirations.

Networks of relationships and communication.

Ownership and buy-in to the future.

Focusing on what enables people to fulfil their potential.

Re-branding 'patient engagement'-> people & communities building consensus.

Fostering a cultural change in multiple parts of the system at the same time.Sharing learning, experience, vision & resources.

Imagine…

Patient satisfaction.

Patient feedback.

Questions to uncover issues, problems & gaps.

Taking a 'I know best' stance... 'You said, we did'.

Assumptions of solutions based on problems & gaps.

Multiple individual perspectives-> lack of consensus.

Moving from…

Building system-wide consensus of:• What is working• Vision of the future • What it would take

Consensus = powerful decision-making tool-> trust and synergy-> develops shared responsibility for the

decision & its successful implementation

Building a community that wants to collaborate - discover, build on & co-create solutions.

Focusing on making a difference with all those that have a stake in improving children's outcomes.

To…

How this approach could help co-create outcome-based commissioning.

The Newham way…

What are we trying to accomplish together?

• Making a difference: Outcomes-driven - focus on impact.

• Whole system integration.

How will we know that things are getting better?

• Partnerships & relationships : cross boundary ownership of design & delivery.

• Valued & responsible workforce, using people's skills & expertise efficiently & flexibly.

• Seamless collaborative approach utilising inherent resources & minimising duplication.

• Alignment of priorities.

• Sustainable projects & activities : utilising community resources. Eg. schools in locality/community working.

• Growing demand & complexity balanced with doing what makes a difference.

• Quick wins, cultural changes & major re-commissioning exercises.

What change is needed that will result in an improvement?

• Joined up clinical & care pathways (health, social care & education).

• A system that share success, risk & accountability.

• Collaborative approach that involves EVERYONE in the vision & development. Co-constructive process 'weaving of the story'.

• Secure buy in at every level.

• The way we measure 'outcomes' & and incentivise.

An East London example in Newham… We have a dream…

Children's Academy

'FUTURE GENERATIONS'

N E W H A M

What we know about Newham

- Youngest population in England 0-19 yr olds 90,800 (28%)

- Highest birth rate in England 2014 6,023 births

- Third deprived in England 24.6% under 16 in poverty

- 70% born to Mums who come from outside UK

- 93.9% school children BME

Newham Profile. ChiMat 2016 March

29

Our challenges…

Low birth weight

Obesity

Dental decayHomelessness

Poverty

Entry to youth justice system

Emergency attendances

Asthma admissions

What we know

What we discovered in Newham• No commissioning focus on children or

maternity.

• Overlapping commissioning responsibilities & separate funding streams.

• Different drivers & perspectives.

• Multiple, often disparate priorities, strategies & policies.

• Patchy, unsatisfactory service specifications.

• Poor-quality data.

• Activity & output focus in contracts.

• Undeveloped relationships/links.

33

'Future Generations'A vehicle using whole system, solution

focused conversations to catalyse the commissioning of

co-created approaches for improving outcomes for children & young people in

Newham, East London.

Hypothesis. If Future Generations is working at its best:

1. Stronger system-wide relationships & collaboration:

Strength-based conversations, asking the best questions that reveal the solution & how we would know things were getting better.

Equal & effective whole system partnership/leadership - sum of its parts.

Workforce & community that feels respected, valued, integrated & equally accountable.

2. Quality:

Improves patient experience & clarifies expectation.

Unifies perspectives and joint outcomes.

Fully accountable, integrated system

Focus on doing what works & makes a difference-> quality improvement, improvement in health and wellbeing outcomes, narrowing the gap.

3. Efficiency:

Reduce waste and manage demand.

Utilises and focuses resources.

4. Finance:

Contains cost

37

What & how…?

38

Individual workshops

Getting on the same page

What people said….

• There would be no real or artificial lines between social care, health care & education.

• Services would be embedded in the community close to people's homes & resources.

• More personalised response and service offer

• What matters is to feel safe, & be active: 'more cycle lanes, shutting streets at weekends'.

• Willingness to share good practice and what works well.

• “Telling our story once” - more joint assessments, care planning & information sharing.

• In any change process, consider & support workforce.

• Mobilising and using the skills and innovation of the voluntary and community sector.

Second joint workshop

C&YP families, professionals, third sector, schools, children services, commissioners, etc.

Consensus: sharing views & strengths from the individual workshops.

Future orientated vision for the vehicle 'Future Generations'.

Community services for children

- What works? What could we do more of? Building on strengths/resources.

- Describing the vision of the future if things were transformed… Miracle question.Patient journey examples.What would be a sign children where getting healthier? What would we notice, what would each individual part notice? What would

be different?

- What difference would it make to children's health and wellbeing?

--->joint outcomes framework for children of newham

First joint workshop

Health & Wellbeing Learning & Achievement

Safety & Stability

OUR VISIONOver 85,000 children and young people live in Newham. We are committed to ensuring each one of them grows up happy, healthy, and with an excellent education which prepares them for the next stage in their lives.

At the heart of our vision is the simple premise that the best way to help families is to support them to identify strengths and build on what works. We believe children, young people and families will do better if we focus together on developing strong relationships which enable us to build networks and resilience, building on the power of connections between families, neighbours, learning, jobs and communities.

OUR PRINCIPLES

Early Help & Safeguarding

Right support, right level, right timeChildren and young people are safe from harm

Integrated Working Seamless services from the point of view of families Strong partnerships and integrated leadership building on our strengths

Making a difference

A solution-focused approach Getting the most from every £ that we spend Doing what works, based on the evidence

Continuous improvement

Listening to children, young people and their familiesValuing and developing the children’s workforce

Children have the best start in life

Children and young people are successful learners and confident

individuals

Children and young people

are responsible citizens

Children and young people in need, or with a disability,

have improved life chances

Resilience & Responsibility

Children and young people reach appropriate developmental and social milestones

Children and young people develop resilience and

achieve independence

Young people reach adulthood with the skills and aptitude for work

Children and young people access positive community activities and social networks

Children and young people are safe from harm Children and young people do not

harm others

Children and young people make positive life choices

Children and young people are physically and emotionally healthy

Children and young people access positive community activities and

social networks

What we've achieved…

- Integrated way of working between commissioning teams.

- Commitment to pool resources for community children's services.

- Building whole system collaboration & vision through 'Future Generation' vehicle.

- System-wide health & wellbeing outcome measures: health, education & social care.

- Integrated design & delivery of services.

- More efficient & collaborative handling of commissioning, procurement & contracts.

- Joint performance monitoring.

- Strategic information sharing agreements.

- Efficiencies through deleting duplication in current commissioned services.

Which has resulted in…

Next – process

- Stabilise Children’s Health Integrated Commissioning Team (health & social care).

- Greater stakeholder involvement through 'Future Generations'… building consensus & owning a stake in the future.

- Continue to build a sustainable model with prevention and partnership working at its core.

- 'Future Generation' approach to Long Term Conditions for children, & obesity challenge.

- Implement ‘community’ model – whole system localities/neighbourhoods with Health Visitors, School Nurses, GPs, Paediatricians, Mental Health Services.

-

Next – improved outcomes• Promoting normality & safety, ensuring more children born in non-obstetric-led units where

appropriate.

• Developing collaborative community care - reducing attendance at hospital & emergency admissions.

• Increased immunisation rates.

• More children 'school ready'.

• Improved dental health.

• A focus on lifestyle choices, thus reducing levels of obesity.

• Improved Infant Mortality.

Dr Lizi Goodyearelizabeth.goodyear@nhs.net

Innovating through Co-design: Introduction to Always Events®

Pat Rutherford, Vice President Institute for Healthcare Improvement, USA

Session B3International Forum on Quality

and Safety in Healthcare

April 13, 2016

Gothenburg, Sweden

Session Description

In this session you will learn about the Always Events

framework for the co-design of care processes to improve

patient experience, making reliable what matters to

patients.

After this session participants will be able to:

Describe the key elements of the Always Events

framework

Initiate an action plan to co-design an Always Event in

your clinical setting

Through the Patients’ Eyes

“Patient-centered care focuses on the

patient’s needs and concerns as the

patient define them.”

Picker/CommonwealthPatient-Centered Care Program

Always Events®

Always Events are defined as “those

aspects of the patient [individual] and family

experience that should always occur when

patients [individuals] interact with healthcare

professionals and the delivery system.”

Picker Institute (US), 2011

Criteria for Always Events®

1. Important – Patients (or service-users) and family

members have identified the event as fundamental to

improving their experience of care, and they predict that

the event will have a meaningful impact when

successfully implemented.

2. Evidence-based – The event is known to contribute to

the optimal care of and respect for patients and family

members (either through research or quality

improvement measurement over time)

Criteria for Always Events®

3. Measurable – The event is specific enough that it is possible

to determine whether or not the process or behaviors occur

reliably. This requirement is necessary to ensure that Always

Events are not merely aspirational, but also quantifiable.

4. Affordable and Sustainable --The event should be

achievable and sustainable without substantial renovations,

capital expenditures, or the purchase of new equipment or

technology. This specification encourages organizations to

focus on leveraging opportunities to improve the care

experience through improvements in relationship-based care

and in care processes.

Always Events are… Always Events are not…

Reliable processes or behaviors that

ensure optimal patient and family

member experiences of care

Evidence-based practices (e.g.

hand-washing) or professional

standards of practice (e.g. patients

are treated with dignity and respect)

that should “always” occur to ensure

safe, high-quality care

Co-designed with patients and family

members (done “with”)

Improvement in processes that are

done “for” patients and family

members

Integrated into overall person- and

family-centered care strategies

An isolated organizational QI

initiative or local improvement

Understand “What Matters to Patients?”

in the Pilot Unit or Program

Co-Design an Always Event®

Create a Vision for the AE and Develop an

Aim Statement

Specify Details of Successful Changes

for The Always Event

Reliably Implement Standard Work Over Time

Communicate Standard Work Processes

Use Process Measures to Assess Progress

PLAN

Implement Standard Work

DO

Observe & Redesign Standard Work as

Needed to Increase Reliability

STUDY/ACT

Even

tA

lwaysGenerate and Test

Specific Change Ideas to Address What

Matters

Co-Designing an Always Event

Understand what matters to patients in the pilot unit or program

Engage patients/individuals and family members and a clinical team >> convene a launch meeting

Decide upon a specific focus for improvement (partnership between the clinical team and patients and family members)

If successful, what will have a big impact on patient experiences of care?

Create an aim statement (how good, by when?)

Generate change ideas for an Always Event

Test specific change ideas – adopt, adapt, abandon

Specify details of successful changes for the Always Event

“We will always support you in

moving on in care” – Lancashire

Care

“I always know what to do when I get home

or, if not, I know who to contact.” –

Blackpool Teaching Hospital

“We always understand what matters

to you.” – Sutter Care at Home

Visions for the Always Event

and Aim Statements

Always Event (in the voice of the patients or service-users)

Sample Aim Statement

The care team always understand what matters to me.

By 31 December 2016, 90% of patients in Ward A will be asked “what matters” and have a plan of care that integrates patient needs, values, preferences to address “what matters.”

I always understand what to do when I go home and, if not, who to contact.

By 31 March 2016, 75% of patients or carers discharges from the dementia unit will indicate they were confident or very confident in their ability to care for themselves at home and they knew who to contact during a phone call 2 weeks after discharge.

I have access to loved ones to support my healing during my hospitalization.

General Hospital will have four units with extended visiting hours by July 2016.

Sequential Testing, Implementation and Spread

Sustaining the

improvement and

spreading the change

to other locations

Developing

changes

Implementing

changes

Testing

changes

Theory and

Prediction

Test under

a variety of

conditions

Make part of

routine

operations

Study

Act

Do

Act Plan

DoStudy

Evaluating Outcomes and Spreading

Weekly or Monthly Data

OutcomeData

Target

Pilot #1

Pilot #2

All Units or Programs

Change 1

Change 2

Change 3

Change 2

Change 1

Change 1

Example #1:

Always Ask…. What matters to you?

The Need and Opportunity

Nurses, doctors, health care staff, and community

health providers seek to understand the

comprehensive needs and goals of the

patients/individuals they serve. Yet, in the busy

world of clinical care, there are innumerable

situations where what really matters to

patients/individuals and their family members is

not understood or addressed.

Example of an Always Event®:

What Matters to You?

n engl j med 366;9 nejm.org march 1, 2012

Enhancing conversations between

patients and clinicians from -- “What’s

the matter?” to also including “What

matters to you?”

Themes from Storytelling about

Patient Experiences when Vulnerable

Ask – Don’t Assume

What Matters in Every Encounter

Matrix of Change Ideas

Difficult to Implement

Easy to Implement

High Impact Low Impact

Jennifer

Rodgers RN

Yorkhill, NHS

Scotland

Mother’s Care Map for her Child with

Special Needs

Example of a

Bedside

White Board

Any concerns

or worries about

going home (or

to next care

setting)?

Diabetes Visit Cards

The patient sorts the cards to select issues that form the

agenda for the visit

Satisfaction is improved and patients report more control of

their disease

Developed in England by the Design Council to improve the effectiveness

of chronic care visits at physicians’ offices

LAST FIVE MINUTES

• Review the goal of the visit.

• Develop a personal

connection.

• Is there anything else you’d

like to discuss?

• Uncover any unresolved

issues.

• Let parent know who to

contact.

• Confirm next appointment.

“What matters to

you today?” (1st and last 5 Minutes)

© 2014 Sutter Health

Discussions in hospital and continued in the home

What are you most concerned about at this time?

What would you like to have happen as a result of our care?

How would you like to feel?

What is one thing that is most important to you that you want to be able to do again?

Open-Ended QuestionsFeeling lonely as I live alone.

Next steps: Continue to “tell the story”75

ALWAYS EVENT Infographic for Sutter Health

•Featured at the 2015 Sutter Health Management Symposium

• In plain language describes how to engage patients with every encounter

•Applies to all staff in all settings

Example #2:

“We will always support you in moving on in care”

www.england.nhs.uk

Always Events Programme in

NHS England

• NHS England, in collaboration with Picker Institute Europe and the Institute for Healthcare Improvement (IHI) have developed a programme to pilot and test the Always Events framework and create guidelines and a toolkit for implementing Always Events within the NHS in England.

• The programme will run until April 2016 and will comprise 10 provider pilot sites in England. The purpose of the programme is to evaluate Always Events in these locations and assess the impact on improvement of quality in healthcare settings.

www.england.nhs.uk

Always Events®: National Programme

Participating Trusts

Aintree University Hospitals

Ashford and St. Peters

Blackpool Teaching Hospital (Phase I)

Calderdale and Huddersfield

Kent Community Trust

Lancashire Care (Phase I)

Royal Marsden

Southampton

Taunton and Somerset

University Hospitals of Morecambe Bay

Nursing & Quality Directorate

Tell us about your experience when you have stopped seeing your community nurse or therapist?

o I was really sad

o It was OK because someone else form the team came to see me

o It made me unhappy – she was my friend

o I had a telephone number of someone to contact

o I can’t think about them not coming to see me – I will always need

help

o I was a bit worried but I started to see someone else

Nursing & Quality Directorate

How can we make ending your support from Learning Disability Services better for you?

oA place or person to contact if we need help oA fridge magnet telling me who to contact (I lose

pieces of paper and business cards)oA photograph of the new person coming to see meoWarning in advance that my support will be ending and

the person is leaving or being replacedoBeing told who you are going to see if the person you

normally see is not available oKeeping in touch with the service. Coffee mornings,

catch up eventsoThe person leaving introducing me to another worker I

can contact

Nursing & Quality Directorate

How would we like our treatment to end?

oFace to face

oWith notice it is going to happen to give me time to think

oPhotograph of the person on our letters so we know who

you are talking about

oContact number of a person we can speak to if we are

worried (on a fridge magnet or key fob)

oLetters that are easy read with symbols and no difficult

language

Nursing & Quality Directorate

Co-DesignAlways event wording

We will always support you in transitions of

care

We will always support you in moving on in

care

Were you given enough notice

about when you were going to be

discharged?

Were you told in enough time that you were ready

to move on?

Nursing & Quality Directorate

Letter

Nursing & Quality Directorate

Chair: Mr Derek Brown Chief Executive: Professor Heather Tierney-Moore OBE

Adult Community

Lancashire Care NHS Foundation Trust

Learning Disability Service

Bridge House

Whalley Banks

King Street

Blackburn

BB2 1NT

Telephone: 01254 283300

Fax: 01254 283330

Dear

Following your recent discharge from the Community Learning Disability Health Team,

we are offering you the opportunity to join the next meeting of the Pop In and Chat

group which will be held at:

Yours sincerely

Andy Clift

Integrated Service Leader

Adult Health – Learning Disability Service

Ref: AC / AmC

Date

PRIVATE AND CONFIDENTIAL

Name

Address

Date: Friday 30th October 2015

Time: 1.30pm (13:30) till 2.30pm (14:30)

The Stansfeld Centre

Stansfeld Street

Blackburn

BB2 2NG

Pop-in and

chat invitation

Nursing & Quality Directorate

Nursing & Quality Directorate

Nursing & Quality Directorate