1.6 practical tools for transformational change - bradbury and mc naney (453)
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Practical Tools for Transformational Change
ICIC16 Barcelona
Elizabeth Bradbury, Director AQuA
Nicki McNaney, AQuA Affiliate
Objectives
• Explore approaches to behavioural and technical change
• Discuss use and alignment of improvement tools and techniques
• Explore building improvement capability across systems
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Established in 2010 as a NHS health and care quality
improvement organisation. Based in North West England
Members: 73 commissioner and provider organisations
Hosted by Salford Royal Foundation Trust and
accountable to:
- AQuA’s Board
- AQuA members through membership agreements
Extensive work on integration and transformation
www.AQuAnw.nhs.uk
About AQuA
AQuA’s Integrated Care and Transformation Story
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Leading System-Level
Integrated Care
Integrated Care International
Exchange Programme
Integrated Care Fellowship Programme
2014-152012-14
Integration
Discovery
Communities
Transformat-
ional Change
Programme
Integrated
Care & Frailty
Networks
Bespoke
locality
support
Masterclass
series
2015-16
System Development
2016-17
Bespoke place
based facilitation
and expert
coaching
Masterclass series
AQuA’s System Integration Framework
© AQuA Action 2012
Integration to Improve
• Safety
• Experience
• Effectiveness
• Population health
• Use of resources
Service and
Care Model
Design
Service User
and Carer
Engagement
Leadership
Workforce• Role design
• Skills
• Capacity
Information
and
Information
Technology
Financial and
Contractual
MechanismsCulture
Healthcare
value
Governance
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Integrated Teams
Integrated Services
IntegratedSystems
Focus on population outcomes and system
enablers
Focus on redesigning integrated clinical and
support services
Focus on redesigning direct care for
patients and carers in all settings
Understanding Integrated Systems
Developing Theoretical Model
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Complexity Science
Large Scale Change
Improvement Science
System Leadership
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What are the integration challenges that you are trying to solve?
What tools and techniques are you currently using?
How are you building capability for transformational change?
Behavioural
Technical
Improvement and change management skills
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Integrated Teams
Integrated Services
IntegratedSystems
Focus on population outcomes and system
enablers
System development
Emerging Model of Large Scale Change
Source: Paul Plsek (2008) on behalf of the Academy for Large Scale Change
Identifying
need for
change
Framing/
reframing
the issues
Engaging/
connecting
others
Making
pragmatic
change in
multiple
processesAttracting
further interest
After some
timeSettling in
Possible outcomes
1. sustainable norm
2. plateau
3. run out of energy
Living with
results and
consequences
Maybe later
Repeats
many
times in
hard to
predict
ways
Time delay
Leading in complexity
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A good enough plan
13Source: Integrated Care for Older People in Salford
Salford’s Integrated Care Model and Operational Plan, June 2011
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Measures
Integrated Care for Older People in Salford Salford’s Integrated Care Model and Operational Plan, June 2011
Simple rules or minimum specifications
Making better decisions:
• Boundary rules (inclusion/exclusion)
• Prioritising rules (consider alternatives)
• Stopping rules (investments and innovations)
Doing things better:
• How to rules
• Co-ordination rules (flocking)
• Timing rules
Source: Eisenhardt, K. and Ascherman, S.W. (2015)
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In pairs:
Agree 3 simple rules for designing a new model of integrated care
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Integrated Teams
Integrated Services
IntegratedSystems
Focus on redesigning integrated clinical and
support services
Service development
Understanding the patient journey
No one is responsible for the end to end processes (Value stream)
30 – 70% does not add value to the patient
Up to 50% of process steps involve a handoff leading to duplication, waste and error
Job roles can be narrow and fragmented
Flow analysis
What are the value adding steps for patients and how
can time in-between be reduced?
Is the information flow a problem? Is it generating Information for Action?
Who has end to end process responsibility for
high volume elective / non elective flows?
Who has clinical process responsibility and how
often does this change?
Understanding value in the eyes of the customer
Kano
Model
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Integrated Teams
Integrated Services
IntegratedSystems
Focus on redesigning direct care for
patients and carers in all settings
Microsystems improvement
• First step - Reduce defects
• Second Step – Reduce waste (cost)
- doing the right thing, first time and every time
• Third Step – Enhancements or new features
Adapted from Noriaki Kano
Steps for improvement
Testing rapid small scale cycles of change:
Small Steps to Big Leaps
“The secret of getting ahead is getting started. The secret of getting started is breaking complex overwhelming tasks into small
manageable tasks, and then starting on the first one”
Mark Twain
What are we trying toaccomplish?
How will we know that achange is an improvement?
What changes can we make that will result in the improvements
that we seek ?
Model for improvement
Act Plan
Study Do
aims
Copyright IHI 2000
testing ideas before implementing changes
measures
change principles & ideas
Bright
idea!
Lots of small scale changes – test to find out what works
Improvement
Improvement
Improvement
Improvement
?
Multiple PDSA Cycles
Hunches
theories
ideas
Changes that
result in
improvement
A P
S D
A P
S D
APS
D
APS
D
A P
S D
A P
S DD S
P A
D SP A
DATA
Need to start small!!
Source: Bromford, P (2015)
Building system capability
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Concept of two jobs
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Leadership and culture
Patient flow and pathways
Clinical Microsystems improvement
Source: Bojestig, Jonkoping CC Sweden
Improvement approach
Organisation –‘big dot’
Programme
Project
Source: Bojestig, Jonkoping CC Sweden
Planning and execution
Tracking through PMO
Mesosystem
Macrosystem
Microsystem
Source: Bojestig, Jonkoping CC Sweden
Strategic aims and measures
Mesosystem
Macrosystem
Microsystem
Source: Bojestig, Jonkoping CC Sweden
Improvement capability
Leader
Advanced Practitioner
or expert (0.5%)
Practitioner (5%)
Foundation (Everyone)
How are you building system capability?
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Further Information
www.AQuAnw.nhs.uk
Twitter: @AQuA_Inform