Innovating Care & Services through Co-design & Co...
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Innovating Care & Services through Co-design & Co-production Gothenburg April 2016
Transcript of Innovating Care & Services through Co-design & Co...
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
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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.
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'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
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What & how…?
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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 [email protected]
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
