National Leading Health and Wellbeing Programme

2nd July 2014

Leadership and culture for sustaining and spreading

improvement Jean Penny

Jean PennyAll working life in NHSDiagnostic Radiographer and teacherImprovement roles since 1994

BPR Leicester Royal Infirmary 1994 - 1999National Patients ‘Access Team 1999 - 2002NHS Modernisation Agency 2002 – 2005NHS Institute for Innovation and Improvement 2005 -2008

Awarded OBE for services to NHS 2003Visiting professor University of Derby 2008

Jean.penny@btinternet.com

Improvement: 19 years and still learning

“All models are wrong but some are useful”

W Deming

“A promise to learnA commitment to act”

D Berwick

Agenda

Recap Culture Sustainability Spread, adoption and social movements

Messages about improvement from improvement session 1

Work with your team /colleagues: value differences Really understand the problem Develop aims and measures: What are you trying to

achieve? Measure for improvement: How will you know a change

is an improvement? Gather change ideas: What changes can you make that

will result in the improvement you want? Test change ideas (PDSA cycles) before implementing

and learn from things that do not work Link frontline changes to strategic objectives Share achievements and learning with others

Culture for improvement

is how things are done in the workplace is heavily influenced by shared unwritten

rules Often reflects what has worked well in the

past

Think about the questions on culture

Culture

Unwritten rules are one of the most powerful parts ofculture. They are described as 'unwritten' because theyare: not often openly discussed rarely questioned or challenged because they are not

frequently discussed usually shared by most, if not all, the people who work

within the team / organisation provide a common way for people to make sense of what

is going on around them often influence people without them necessarily realising

it have a powerful influence on how people behave at work

Unwritten rules and behaviours

The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007)

NHS Institute for Innovation and Improvement

Senior clinicians / managers know best Knowledge is power Everyone understands the jargon Only someone in my profession / role

understand the problem Meetings constitute activity Filling in a form makes it happen It is wrong to be wrong ....and wrong to

admit to being wrong

Some unwritten rules

The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007)

NHS Institute for Innovation and Improvement

Senior clinicians / managers know best

Knowledge is power Everyone understands the

jargon Only someone in my

profession / role understand the problem

Meetings constitute activity Filling in a form makes it

happen It is wrong to be

wrong ....and wrong to admit to being wrong

Behaviours = culture

Discussion: What are the resulting behaviours as a result of these unwritten rules(behaviours are what you see, hear and feel)

Senior clinicians / managers know best

Knowledge is power Everyone understands the

jargon Only someone in my

profession / role understand the problem

Meetings constitute activity Filling in a form makes it

happen It is wrong to be

wrong ....and wrong to admit to being wrong

Behaviours = culture

Discussion: •What other unwritten rules does your team / organisation have?•What are the resulting behaviours?

Find out about the values held Identify as many behaviours as you can. Look and listen dress codes: uniforms, identity symbols level of formality: in relationships and social events working hours: balance between work and family meetings: how often, how they are run, how long they last decision-making: how is this done? communication: jargon, how do you get to know about things? rites rituals and traditions what always happens and what never happens? disagreements and conflicts: how are they handled?

Compare the stated values and behavioursSearch for the unwritten rules that might account for the apparentdiscrepancy between the stated values and the behavioursDecide which unwritten rules matterUnderstand the background to the unwritten rules: how did they comeinto being and why do they persist

Gain a deeper understanding

The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007)

NHS Institute for Innovation and Improvement

Patient centeredness Belief in human potential Improvement and innovation encouraged Recognition in the value of learning Effective team working Communication Honesty and trust

An improvement culture is....

The Improvement Leaders' Guide to Building and Nurturing an Improvement Culture (2007)

NHS Institute for Innovation and Improvement

Sustaining improvement

The improvement itself and any changes in practice

OR

Continuous improvement and a commitment to finding a better way of working – a culture change

What do you want to sustain?

Complexity of sustaining healthcare improvements: what have we learned so far (2004) NHS

Modernisation Agency, Research into Practice report 13

Sustainability is the ability to withstand variation and evolve alongside other changes

Sustainability is when new ways of working and improved outcomes become the normnot only have the process and outcome changed but the thinking and attitudes behind them are fundamentally altered and the systems surrounding them are transformed in support.

What is meant by sustainability?

The ten factors of sustainability

Process:◦ Benefits beyond helping patients – making job easier◦ Credibility of evidence – obvious, evidence based, believed◦ Adaptability of improved process – continuous improvement ◦ Effectiveness of system to monitor process – communication of results

Staff◦ Staff involvement and training to sustain process◦ Staff attitudes towards sustaining change - involvement and empowerment ◦ Senior leadership engagement – responsibility and advice ◦ Clinical leadership engagement – responsibility and advice

Organisation◦ Fit with organisation’s strategic aims and culture – history of improvement,

consistency of improvement goals with strategic aims ◦ Infrastructure for sustainability – staff, facilities, equipment

Lynne Maher, David Gustafson, Alyson Evans ©NHS Institute for Innovation and Improvement 2006

Scores: maximum score 100• A score of 55 or over offers reasons for

optimism

• Scores below this suggest you need to take some action and to work on improving the two factors that have the biggest potential for improvement. Re score in about 6-8 weeks

©NHS Institute for Innovation and Improvement 2006

Think about your improvement work and consider the factors of sustainability

Where are your strengths? What areas do you need to work on?

Activity: Discussion on sustainability

Spread, adoption and social movements

The goal is to spread sustainable improvement: The factors are similar!

Leadership People who influence (at all levels) Support at senior level Ownership of initiative Effective relationships (multi-professional) Staff engagement Incentives Readiness of improvement Local context Nature of initiative Evidence of improvements Process of implementation Integration into practice Dedicates resources

Note:

•No rank order

•Relative importance of each factor varies from one initiative to another

The New Improvement Wheel (2005) NHS Modernisation Agency Research into Practice report 14

Spread verses adoptionSpread means that the learning that takes place in

one area is actively shared and acted upon others i.e. that others have adopted

Spread indicates ‘push’

Adoption indicates ‘pull’

Seek to spread a change principle and enable others to work out the specifics for their context (assisted wheel re-invention)

Solution / change in

organisation A

Change principle Change principle

Solution / change in

organisation B

Creating attraction for change The concept of resistance to change is

negative and emotionally draining We all change naturally; at our own pace

with our own rationale Don’t speak of ‘us’ and ‘them’

◦ consider the ‘What’s in it for me’ factor Spread can be better understood

through ‘attractors’ How can I make my change more naturally

attractive to others?

Adopter categorisation

Innovators

EarlyAdopters

EarlyMajority

LateMajority Laggards

Rogers E (2003) Diffusion of Innovations 5th ed New York: Free Press

2.5% 13.5% 34% 34% 16%

Roger’s adopter categories are based on studies of when an individual adopted a specific innovation

Nearly everyone is a “laggard” at some time; with a very rational reason!

Factors to describe an idea Relative advantage

◦ How clear and how much is this new idea/practice better then current situation?

Compatibility◦ How closely does new idea/practice reflect beliefs and values of potential

adopter(s)? Complexity

◦ How easy is it to understand the new practice/idea? Communicability

◦ How easily can it be shared with others? Observability

◦ How visible is the new practice or idea and its results? Trailability

◦ How easy is it to test the new idea? Reversibility

◦ How easily can the potential adopter revert to the old ways? Uncertainty

◦ How certain can an potential adopter be of positive results from the change?Fraser S (2002) Accelerating the spread of good

practice, Kingsham Press UK

Social movements

Core Characteristics Energy Mass Passion Commitment Pace & momentum Spread Longevity

Social movements

NHSI The power of one the power of manyhttp://www.institute.nhs.uk/index.php?option=com_joomcart&Itemid=194&main_page=document_product_info&products_id=580

A social movement is a voluntary collective of individuals committed to promoting or resisting change through a co-ordinated activity to produce a lasting and self –generating effect and creating as they do a shared sense of identity

1. Frame to connect with hearts and minds To connect with ideals, needs, values and aspirations

2. Energise and mobilise Engagement to commitment to mobilisation

3. Organise for impact To translate energy and passion into purposeful effective

action

4. Change as a personal mission Need every member to believe that their contribution no

matter how big or small will make a difference

5. Keep forward momentum Momentum = unstoppable = sustainability

5 principles of Social Movements

Martin Luther King said ‘I have a dream’ He did not say ‘I have a strategic plan’

Traditional programmatic approach

A planned programme of change with goals and milestones

Centrally led Talks about motivating

people Change done to people or

with them – leaders and followers

Driven by formal systems

How is it different?Movement approach Change is about releasing

energy Largely self directing and

bottom up Talks about moving people

People change themselves and each other – peer to peer

Driven by informal social networks systems

Need both according to the objective and context

What are the three key messages you have got from this session?

One action as a result

Think quietly by your self for a few minutes Then find two others and share

Recap of improvement

methodologies

What are you trying to accomplish?

How will you know that a change is an

improvement What changes can you make that will result in an

improvement?

Model for Improvement

Act Plan

Study Do

Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives

Measuring processes and outcomes

What have others done? What hunches do we have? What can we learn as we go along?Langley G, Moen R, Nolan K, Nolan

T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nd ed, Jossey Bass Publishers, San Francisco

Leadership framework for improvement

34

1. Set Direction: Mission, Vision and Strategy

Make the status quo uncomfortable

Make the future attractive

3. Build Will• Plan for improvement• Set aims/allocate resources• Measure system

performance• Provide encouragement• Make financial linkages• Learn subject matter

5. Execute Change• Use Model for Improvement for

design and redesign• Review and guide key initiatives• Spread ideas• Communicate results• Sustain improved levels of performance

4. Generate Ideas• Understand organisation as a

system• Read and scan widely, learning

from other industries and disciplines

• Benchmark to find ideas• Listen to patients• Invest in research and

development• Manage knowledge

2. Establish the Foundation• Prepare personally• Choose and align the senior

team

• Build relationships• Develop future leaders

• Reframe operating values• Build improvement capability

Source: Robert LloydExecutive Director Performance Improvement

Institute for Healthcare Improvement January 16, 2007

Goodbye, thanksAnd good luck!