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Transcript of Transforming the system to improve quality and reduce costs 18 th May 2012 Helen Bevan @helenbevan ...
Transforming the system to improve quality and reduce costs
18th May 2012
Helen Bevan
@helenbevan http://twitter.com/helenbevan
Jim Easton
Programme9.00 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
Jim Easton
10.40 Aligning intrinsic motivation for changes with drivers of extrinsic motivation and connecting with shared purpose
Helen Bevan
11.45 Innovation for quality and cost improvement at scale Helen Bevan
12.15 Lunch
1.00 Engagement to mobilise and leadership of change Helen Bevan
1.45 System drivers, rigorous delivery and transparent measurement
Jim Easton
2.30 Improvement methodology Helen Bevan
3.00 Building alignment: why the sum is so much greater than the parts
Jim EastonHelen Bevan
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
200,000
patients
£430
million
Pressure ulcers Falls
Urinary infections(in patients with
catheters)
VTE
Harmfreecare
Absence of harm from
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
Pressure Ulcer
Fall(with harm)
Urine Infection (catheters)
VTE Harm free
care?
Patient 1 no yes yes yes No
Patient 2 no no yes yes No
Patient 3 yes yes yes yes Yes
Patient 4 yes yes yes No No
Patient 5 yes yes no yes No
Protected from all four harms?
Pressure Ulcer
Fall(with harm)
Urine Infection (catheters)
VTE Harm free
care?
Patient 1 no yes yes yes No
Patient 2 no no yes yes No
Patient 3 yes yes yes yes Yes
Patient 4 yes yes yes No No
Patient 5 yes yes no yes No
One in five
Protected from all four harms?
Pr Ulcer
Risk Assessment
Risk Management
Nutrition & Hydration
Medication
Equipment
Continence
One plan – four harms
www.harmfreecare.org
Guide
Measure
Stories
E learning
2
Four key messages underpinningthe NHS Change Model
1. To achieve large scale change, we need the intrinsic motivation of connection to shared purpose, engaging to mobilise, transformational leadership skills
2. 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
3. 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
4. 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
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 controlCommitment to a common purpose creates energy for delivery
Managing duality
Source: Helen Bevan
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.
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
Source: Stanton Marris
• Which of these four Cs generates the most energy for the healthcare workforce?
• Which C is the most energy sapping?
Four sources of energy
Energy DescriptionIntellectual 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/PublicationsPolicyAndGuidance/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
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
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
Integration
Segmentation
Simplification
Substitution
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.
Type of innovation
Current prevalence in
quality and cost efforts
Risk Contribution to
large scale change
How to spread
Process
Service
Strategy
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
© NHS Institute for Innovation and Improvement, 2011
Communicating versus mobilising
• 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
SPECTRUM OF APPROACH/ACTIVITY
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)
© NHS Institute for Innovation and Improvement, 2011
If we want people to take action, we have to connect with their emotions through
values
action
values
emotion
Source: Marshall Ganz
But not all emotions are equal.........
inertiaurgency
anger apathy
solidarity isolation
you can make a difference
Self-doubt
hope fear
Ove
rco
me
Action motivatorsAction inhibitors
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
Style 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
• 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
Transformational leadership: why do large scale change efforts fail?
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
1. Moving towards a new vision that is better and fundamentally different from the status quo
2. Identifying and communicating key themes that people can relate to and that will make a big difference
3. Multiples of things (‘lots of lots’)
4. Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders
5. Mutually reinforcing change across multiple processes/subsystems
6. Continually refreshing the story and attracting new, active supporters
7. Emergent planning and design, based on monitoring progress and adapting as you go
8. Enabling many people to contribute to the leadership of change, beyond organisational boundaries
9. Transforming mindsets, leading to inherently sustainable change
10. Maintaining and refreshing the leaders’ energy over the long haul
Leading large scale change: ten key principles
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
© NHS Institute for Innovation and Improvement, 2011
CQUIN – Incentive 2012-13
National CQUIN (pay for quality performance)
NHS Safety Thermometer
The NHS Safety Thermometer ….
Operational definitions
Getting started
Using data for improvement
Best in class
80,000 patients surveyed to date (January 2012)
4
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
What’s the difference/
relationship between an
improvement methodology and a
change model?
Are you utilising an evidence based quality improvement methodology?
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 simultaneouslyYou 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
Improvement goals
Activity
300
3000
Yest
erday
it w
as
annou
nced th
at S
outh
Tees
Hos
pitals
had
becom
e th
e fir
st si
te to
reco
rd 9
5% h
arm
free
care
82% 88%
95%
Pilot Baseline
Pilot End
Goal
500,000
people
What next?
@helenbevan http://twitter.com/helenbevan