leadership and culture for sustaining and spreading improvement jean penny
TRANSCRIPT
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
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!