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