Helen Bevan

@helenbevan #HQSCNZ

What we will cover this afternoon

• Principles for scaling up

• Principles for scaling down

• A new role for scale and spread: the convenor

3

How do we both scale up and scale down?

Personalised care (“what matters to

me?”) for each individual AND at a

scale that impacts on hundreds of

thousands of people

For personalised services at scale, we have to take a view from both the balcony and the dancefloor

From the balcony:• See the big picture of care across the whole

system and identify the biggest opportunities• Create standardised care pathways that deliver

high quality, safe care to our population

From the dancefloor:• Step into the shoes of individuals• Understand health and healthcare from the

perspective of their lives• Co-produce with consumers, families and staff at

the point of care• Make sure this addresses “what matters to me”

Balcony and dancefloor framework from Ronald Heifetz

Across the globe, people are questioning the conventional “spread” model

Pilot project Rolling out

“If we opened our eyes we would see the wonderful irony. Trying to manage human change through pilot and roll-out has actually

grown something. A proliferation of project managers”.John Atkinson

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Because the reality is often different

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The reality of spreading up

…A dynamic, reciprocal

interacting, iterative and

evolving activity...not

linear and mechanistic

…developmental,

contextualised, adaptive,

learning and social

process

@helenbevan #HQSCNZ

The key thing to remember about spread in health and care

In health and care improvement, we often try to design spread complex care processes as if

they were complicated & it doesn't work. Complex isn't higher-order complicatedness. It

is a fundamentally different kind of system!

See: morebeyond.co.za/7-differences-between-complex-and-complicated-systems/

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Seven differences between complicated and complexComplicated Complex

Causality Linear cause-and-effect pathways allow us to identify individual causes for observed effects

There are no clearly distinguishable cause-and-effect pathways

Linearity Every output of the system has a proportionate input i.e. Newtonian physics

apply.

Outputs are not proportional or linearly related to inputs; small changes in one part of the system can cause sudden/unexpected outputs in other parts of

the system

Reducibility We can decompose the system into its structural parts and understand the functional

relationships between these parts in a piecemeal way.

The structural parts of the system are multifunctional i.e. the same function can be performed by different

structural parts

Controllability & solvability

Systemic contexts and interactions can be controlled, and the problems they present can be diagnosed and permanently solved

These systems are prone to high levels of surprise, uncertainty and interventions causing unexpected

changes and even new or worse challenges.

Constraint (openness)

Environments are delimited i.e. governing constraints are in place that allows the system

to interact only with selected or approved types of systems.

Complex systems are open systems, to the extent that it is often difficult to determine where the

system ends and another start.

Knowability These systems, because they are closed and can be deconstructed can be fully known or

modelled

We cannot transform complex systems into complicated ones by spending more time and

resources on collecting more data or developing better theories

Creativity & adaptability

Complicated systems need an external force to act on them in order to introduce change

These systems are able to observe themselves, learn and adapt. They are creative.

Source: Sonja Blignaut @sonjabl

7 interconnected principles

Complexity

Spread in health and care is a complex activity occurring across a complex system

• Complexity around innovation, the process of spread, the context of spread

• Health and care is a complex adaptive system

• Match complexity of the approach to spread with complexity of the situation

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Complex systems are driven by the quality

of the interactions between the parts, not the

quality of the parts. Working on discrete parts

or processes can properly bugger up the

performance at a system level. Never fiddle

with a part unless it also improves the system@ComplexWales

Source of image: Eclipse

An independent initiative

Supported by specific tools & information

Within a clear

boundary

Improve smoking cessation rates amongst people living with asthma and COPD

An independent initiative An inter-dependent initiative

Improve the response to

someone presenting to primary care in a mental health crisis

Primary care

Emergency Department

Mental health service

Supported by specific tools & information

• Social and collaborative

• Built on shared purpose

• Multiple methods

Within a clear

boundary

Improve smoking cessation rates amongst people living with asthma and COPD

Innovation development and spread are inter-dependent

• How an innovation is developed influences spread

• Early involvement increases commitment and ownership

• Increased focus on role of adopters in adaptation and spread

#nhsspread @ExpoNHS #Expo19NHS

7 interconnected principles

2. Development of innovation

Source: adapted from Mary Uhl-Bien

7 interconnected principles

1. Complexity

Source: adapted from Mary Uhl-Bien

7 interconnected principles

1. Complexity

'How to master the art of creating the ‘adaptive spaces’ that enable

innovations to spread' – with Prof Mary Uhl-Bien (4pm UK time, 4 Dec,

Zoom meeting): https://q.health.org.uk/event/how-to-

master-the-art-of-creating-the-adaptive-spaces-that-enable-

innovations-to-spread-with-prof-mary-uhl-bien/

NHS and Virginia Mason Institute partnership

Multiple levels of “adaptive space”:

1. “Best day of the month” – a formal space for cross-organisational dialogue

2. Driving improvement – a formal space for strategic level dialogue

3. Rapid Process Improvement Workshop – a space for building connections across rank and status

4. A daily huddle – a space for cross-professional dialogue

Most CEOs would not relish six hours in a windowless room with their regulator but these CEOs each declare the meeting ‘the best day of the month!’ Why?

Because the meeting resembles a protected relational space, where individuals are all working towards the same shared goal of service transformation.

Nicola Burgess, Warwick Business School

https://www.health.org.uk/news-and-comment/blogs/making-time-to-talk-the-challenge-of-spreading-knowledge

Focus on the value rather than the innovation

• It’s about what others will value rather than what you want to spread

• What problem of local priority will it solve?

• What benefit will it offer?

7 interconnected principles

3. Value

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The perspective of the individual is pivotal

• Changing behaviours is hard

• The more work routines affected, the greater the spread challenge

• Generate energy for change, skills and confidence by building motivation

7 interconnected principles

4. The Individual

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In communicating for change, we tend to communicate our own values and goals, rather than connect to the values and goals of the audiences we want to engage

Four questions to help us move beyond this:

1. What do we want to change? What do we want to be true that isn’t true right now?

2. Whose behaviour change is necessary to making that happen? Who has to do something (or stop doing something) they’re not doing now for us to achieve that goal?

3. What would that individual or group believe if they took that action? In other words, what does that audience care about most, and how can we include that in our messages?

4. How will we get that message in front of them? Where are their eyes?

Lauren Parater, Ann Christiano, Annie Neimand & Hans Park: https://ssir.org/articles/entry/communicating_complexity_in_the_humanitarian_sector

From an inward to an

outward mindset

7 interconnected principles

5. Leadership

Post conventional leaders

Current global trends call for leaders who can

demonstrate a high level of maturity in dealing

creatively with increasing complexity, uncertainty,

diversity, and numbers of paradoxes

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Post conventional leaders

“Tomorrow’s management systems will need to value

diversity, dissent and divergence as highly as

conformance, consensus and cohesion.”

Gary Hamel

Networks build communities, energising and connecting individuals• Spread will happen more through relationships

than any other factor• Create a “pull” for innovation by building

communities to energise individuals and maintain momentum

• Support networks and encourage connections with other networks

• Support use of network building mechanisms; eg platforms like WhatsApp, Slack, Facebook groups and other social media

7 interconnected principles

6. Networks

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Spread happens more through relationships than any other factor

• [To be published] evaluation of NHS hospital systems [trusts] that undertook comparable Lean initiatives with vastly different outcomes.

• The difference? The level of social connections between those working to lead improvement

Source: Nicola Burgess, Warwick Business School, evaluation of the partnership between

the NHS and Virginia Mason Institute

If you take the kind of human side stuff and all the things we think about – relationships and all those sort of things – we think that we come to work every day and we pass people in the corridor and we know each other and all this. Well, we

don’t. We work in our own microcosms, right, and what this [NHS-VMI partnership] has done – it’s got the consultants and the doctors talking and getting on first name terms with the physiotherapists and the porters and the pathologists and

people that they wouldn’t come into contact with, you know, and I think that that is extraordinary in how then people start

to develop the way in which they work together to continuously improve.’

A CEO participating in the Virginia Mason institute project quoted by Nicola Burgess

https://www.health.org.uk/news-and-comment/blogs/making-time-to-talk-the-challenge-of-

spreading-knowledge

Knowledge flows generate learning to enable spread

• Collate and share local feedback and evaluation of innovation adoption and impact

• Share knowledge through networks

• Build a culture of learning and transparency, sharing and seeking knowledge from others

7 interconnected principles

Learning

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Sharing knowledge and learning for spread at multiple levels

Source: Harold Jarche

Social Networks

1. Our healthcare systems need to act like Complex Adaptive Systems in order to evolve and thrive – and for innovations to move from the margins into the operational core. But the system doesn’t typically act as a CAS currently.

2. To act like a CAS, health and care leaders must regularly create temporary cross-silo ‘adaptive spaces’ (eg hackathons, Labs, virtual communities, tweetchats) where new ideas can find allies, get prototyped and improve enough to embed in the core and spread.

3. Adaptive spaces are the location where the system needs/benefits focus [pull] of a new idea becomes strengthened – beyond merely supporting an innovation focus [push].

4. Currently the day-to-day efficiency drive in healthcare too often smothers the creative innovation and learning drive (embodied in adaptive spaces)

5. The approach is underpinned by inter-dependent relationships, connections and trust

6. An emerging post-conventional form of leadership supports the creation of these spaces, but is not yet widely recognised or supported in the healthcare system

7. Significant implications for how we support improvement: programmes vs. platforms

(Thanks to Matthew Mezey)7 conclusions about scaling up

Questions from JaneWe are planning our next three to five years, with a focus on scale and spread.

The three key priorities are:

• Consumer engagement

• Equity

• Integration

We want to keep within the spirit of Whakakoahi

What advice would you give?

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A growing interest globally in the concept of “mass customisation” for

health and care

Combining the personalisation and flexibility of individualised services and

taking it to a level of scale to cover a mass population

People don’t want more choice; they want what they want, where, when and

how they want it (Irma Jason)

“A practical alternative, widely used in

other industries, is to stratify the customer

population into groups that are sufficiently

homogenous to enable arranging a set of

commonly needed supports and services to

meet their expected needs.”

- Joanne Lynn

36

How? (more basically) Consumer Segmentation

Source: Lynn J et al. (2007). Using population segmentation to provide better health care for all: the “Bridges to Health” model. Milbank Q.

https://www.ncbi.nlm.nih.gov/pubmed/17517112

Source: IHI

We already segment based on patients’ clinical characteristics; population health starts with segmentation

1. More holistic segmentation delves into not only the 2-dimensional view of patients (clinical), but rather the 3-dimensional view (who these patients are, not just what problems they present with)

2. How do we get this more holistic view? Psychograhics

37

We need holistic segmentation (not just clinical)

Source: The IHI

Is about someone’s values, attitudes, personalities, and lifestyles, and are the key to understanding their priorities and motivations.

B. Walker. “Two cutting-edge ways to use psychographic

segmentation in healthcare.” Patientbond 2016.

38

Psychographics

Source: the IHI

Depending on the situation and the need - we make the decicion together on what suits me and the situation best!

Segmenting by psychographic charactertistics

Independent

and committed

Worried and

committed

Traditional and

unscathed

Vulnerable

and worried

Before During After

Make an

appointment

virtually

Consulting

Waiting

list

Called up

Self check

Reception

Your own

contact person

Waiting

room host

Reading a

journal

Video

meeting

Letter

Calls

Source:Swedish Association of Local Authorities and Regions

Scaling down

For personalised services at scale, we have to take a view from both the balcony and the dancefloor

From the balcony:• See the big picture of care across the whole

system and identify the biggest opportunities• Create standardised care pathways that deliver

high quality, safe care to our population

From the dancefloor:• Step into the shoes of individuals• Understand health and healthcare from the

perspective of their lives• Co-produce with consumers, families and staff at

the point of care• Make sure this addresses “what matters to me”

Balcony and dancefloor framework from Ronald Heifetz

Working with personas: the example of Esther

Esther is not a real person, but her story has led to impressive improvements in how people flow through the complex network of providers and care settings in

SwedenEsther is a person who needs care and attention from more

than one health and care provider. To support Esther in good health there is a need for all health and social care providers

to collaborate seamlessly across organisational borders.

Esther came from Jönköping in Sweden. She has inspired thousands of people to improve the health and care system all

over the world

Esther is a persona

A persona is a characterisation that helps focus problem solving and design.

The best persona incorporate real experience that identifies key themes based on qualitative user research, quantitative data and discussion.

The result should be someone people feel they can identify with.

Archetype versus stereotype

• An archetype refers to a generic version of a person and is neutral

• A stereotype refers to the attributes that people think characterise a group

• A stereotype has little to do with the individual, and so mostly tries to characterise them based on group affiliation or association. In other words, inferred characteristics.

• With a persona, you're describing relevant attributes of some typical people, not inferring attributes based on some group affiliation or prejudice. Hence, a persona is better described as an archetype

Core Offer:

the “big five”

Health and wellbeing

Getting the basics right

Positive and inclusive

work environment

Support to first time people

managers & supervisors

Flexible working

The NHS People Plan Core Offer: What we have heard so far

Personas for the Core Offer• We have created personas to help us understand the

needs, experiences, behaviours and goals of NHS people who will be impacted by the Core Offer

• The personas help us recognise that different people have different needs and expectations and that there is no “one size fits all” with our NHS people

• The personas are not meant to be representative but reflective, based on relevant attributes of typical people

• The personas are not a final product; they should continue to evolve as more people discuss them and the Core Offer design process progresses

How the personas were developed

• A group of NHS equality and diversity champions, HR leaders, union representative and clinical leaders developed the first drafts of the personas

• The NHS Horizons team reviewed the draft personas, undertook further telephone research, amended the personas to reflect a range of demographic characteristics and added stock photographs

Step one: create your persona

For the category of person your team has chosen:

• Make them real: fill in the details of their life

• Base your persona on evidence, experience and wisdom

• Create an archetype not a stereotype

Who are our NHS people we might not be reaching through existing channels?

People with protected characteristics

• Age: Older people, middle years, early years, children/ young people

• Disability: NHS people with physical sensory, and learning impairment, mental health conditions, long term conditions

• Trans: People undergoing gender reassignment and/or people who identify as Trans

• People who are married or in a civil partnership

• Women before and after childbirth and who are breastfeeding

• Race and ethnicity: People from a BAME background and non English speakers

• People with different religions/faiths or beliefs or none

• Gender: men and women

• Sexual orientation: lesbian, gay, bisexual and heterosexual

People impacted by inequalities• Carers as staff members

• Looked after and accommodated children and young people

• Carers: unpaid family members

• Homeless people: people on the street; staying temporarily with friends/family; in hostels/B&Bs.

• People involved in the criminal justice system: offenders in prison/on probation, ex-offenders.

• People with addictions and substance misuse

• People who are non-binary

• People on low incomes

• People who have poor literacy

• People living in deprived areas

• People living in remote, rural and island locations

• People in other groups who face health inequalities

People in particular contexts and roles• Teams in primary care• General Practitioners• Staff grade, associate specialist and specialty doctors

• Locums and agency staff• Staff who are contracted out• Staff at lowest grades – AfC bands 2 and 3• Students and trainees

My name:My age: My role:

My current working life:

My career history:

What matters to me:

My goals and dreams:

My fears:

Other important information:

Persona

How will the Core Offer support and help this person?

How can we make sure the Core Offer reaches this person?

What must be done additionally to meet the needs of this person?

What is missing from the Core Offer for this person?

RAEMAI am 37 and a doctor in training (Upper GI surgery) in a hospital

My current working life: Work 5 days a week variable clinical

workday length; on procedure days I start at 7.00am and

end at 6:30pm. On call once a week and every third

weekend. Required to teach and have a leadership role.

My career history: Entered my specialty training directly

after qualification at 25.

What matters to me: Working with an excellent, supportive

team who enable me to deliver high quality clinical care.

Having time and energy to care for and be with my family.

My goals and dreams: Become a consultant. Create & value

a diverse inclusive workforce. Shorter work week (PT) & still

be valued as a professional.

My fears: Burnout. Never becoming a consultant. Missing

my children’s childhood.

Other important information: Married with 2 young children

under 5 & no family nearby to help. Continuously pulled

between work and family.

How will the Core Offer help and support me? Provide personalised

mentorship and coaching for medics at my career stage. Enable a ‘just

culture’ so I feel comfortable seeking help, personally and professionally,

from within my team. Accessible mental health support which is relevant

to people like me.

What is missing from the Core Offer for me? Tangible examples that my

hard work will be valued and respected and that my concerns and ideas

will be heard and considered.

Alternative career pacing, such that I can choose whether to teach, have

leadership and do research while my children are young rather in addition

to my clinical work; I can assume these responsibilities and accelerate my

career progression later.

What must be done additionally to meet my needs? Clarity about how

diversity and inclusion would be valued in the NHS. Appoint more women

to leadership positions; give me role models who ‘look like me’.

How can you make sure the Core Offer reaches me? To me at work (I do

not have the bandwidth to work once I am at home). Clear, concise and

meaningful to me. Should not interrupt my already booked clinical day.

Photo by Ahmad Zohnii on Unsplash

SARAI am 23 and a newly registered Staff Nurse working on a children’s ward

My current working life: I work 12 hour shifts, 3 days or

nights one week and four the second week. I work with

children and young people who are admitted to

hospital for their cancer care.

My career history: After three years training, this is my

first ward as a registered nurse.

What matters to me: I have always wanted to be a

nurse and I was so excited to get my dream job on a

ward I worked on during my training.

My goals and dreams: To complete my preceptorship

and … and in the future become the first BAME Chief

Nursing Officer for England!!

My fears: Letting my patients down and not being able

to do everything that I want to for them. Experiencing

unfair treatment for being BAME.

Other important information: I live in a big city a

distance from my family, in a flat share. There isn’t

much money left after rent and bills so it’s difficult for

me to do things that let my hair down.

How the Core Offer will help and support me?

A clear career progression with mentoring and support to

be the best that I can be. Provision for health and wellbeing

options, eg gym membership that means that I can keep

myself well without having to worry about paying for it.

What is missing from the Core Offer for me?

Flexibility to work across community and acute care to

follow the patient journey

What must be done additionally to meet my needs?

A commitment to maintain energy, passion and a desire to

stay in the NHS for a life long career through networks and

community opportunities.

How can you make sure the Core Offer reaches me?

Make sure that the offers that are relevant and meaningful

to me and my career are part of my PDP and mandatory

training.

Photo by Frank Busch on Unsplash

My name:My age:

My current life:

My health history:

What matters to me:

Who is in my network:

My goals and dreams:

My fears:

Other important information:

Consumer

My name:My age: My role:

My current working life:

My career history:

What matters to me:

My goals and dreams:

My fears:

Other important information:

Employee

Crossing the chasm!

Source of image: @voinonen

Everret Roger’s diffusion of innovation curve

Innovators

Everret Roger’s diffusion of innovation curve

Innovators

Adopters

The key role of the “convenor” for enabling spread:

• Acting as interface between innovation and ‘usual business’

• Creating an adaptive environment for spread

• Lessening ambiguity for adopters in complex change situations

• Strategically coordinating spread across a whole system

• Mobilising networks, crowds and influencers

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Programme manager vs. convenor

• Designs a plan

• Accountability within a governance system

• Ensures that delivery milestones are met

• Deals with risk and ensures that barriers

are overcome

• Works with emergence

• Builds commitment to a collective goal

• Builds relationships

• Seeks win/wins

• Makes sense of things for adopters: the why?

• Enables spread across a whole system

IndependentComplicated

InterdependentComplex

PROGRAMMEMANAGER

CONVENOR

• Find out “what matters to me?”

• Start from people’s interests, strengths and abilities

• See people in their wider context - not just their healthcare symptoms

• Build on assets - don’t just minimise deficits

• Spread happens one person at a time

• Cultivate a co-design mindset, not just an expert one

• Start with shared purpose

• Design for a complex system (CAS), not a complicated one

• Create adaptive spaces where people can learn and share

• Build an outward mindset

• Involve potential adoptees right from the start

• Evaluate, reflect and learn as you go

Scaling down Scaling up

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A role description for a convenor1. Convenor: creating spaces where people can come together to learn and

share and influencing people to take part

2. Choreographer: bringing diverse people together, building bridges between their different worlds and creating the “dance”

3. Co-producer: ensuring that consumers, families and staff at the point of care are true partners in making and spreading change

4. Connector: helping people make links with each other, within the system and beyond

5. Capability-builder: supporting people to use proven methods and tools for making and spreading change

6. Clarifier: helping people make sense of the changes from their own perspective and reducing ambiguity

7. Coach: providing support and mentoring to help guide and steer change

8. Community-builder: building a shared purpose and a sense of “us”

Source: adapted by Helen Bevan from the work of John Bessant

1. What were the main things you learnt from this session?

2. How could this be useful to you?

3. What might you do differently as a result?

Adapted from Bennet‐Levy & Padesky, 2014@helenbevan #HQSCNZ

“A practical alternative, widely used in

other industries, is to stratify the

customer population into groups that

are sufficiently homogenous to enable

arranging a set of commonly needed

supports and services to meet their

expected needs.”

- Joanne Lynn

64

How? (more basically) Patient Segmentation

Source: Lynn J et al. (2007). Using population segmentation to provide better health care for all: the “Bridges to Health” model. Milbank Q.

https://www.ncbi.nlm.nih.gov/pubmed/17517112