Professor Jean Penny, University of Derby jean.penny@btinternet

1. Embedding Improvement Science in Training Programmes: Why Bother? Professor Jean Penny, University of Derby jean.penny@btinternet.com

2. Jean Penny All working life in and with NHS • Diagnostic Radiographer and teacher • National improvement roles 1994 – 2008 • Improvement educator and advisor 2008 – present • Awarded OBE for services to NHS 2003 • Visiting professor University of Derby 2008 Jean.penny@btinternet.com Improvement: 19 years and still learning

3. Embedding Improvement Science in Training Programmes: Why Bother? Healthcare will not realise its full potential unless change (improvement) making becomes an intrinsic part of everyone’s job, everyday, in all parts of the system. Batalden, P. B et al. Quality and Safety in Health Care 2007;16:2-3

4. Embedding Improvement Science in Training Programmes: Why Bother? What is Improvement Science? Why bother embedding it into training programmes?

5. Question • Who likes change?

6. What is Improvement Science? • Any improvement is a change • not every change is an improvement • but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

7. What is Improvement Science? • Any improvement is a change • any change is a perceived threat to security • there will always be someone who will look at the suggested change as a threat Eliyahu Goldratt

8. What is Improvement Science? • Any improvement is a change • any change is a perceived threat to security • any threat to security gives rise to emotional resistance • you can rarely overcome emotional resistance with logic alone • Eliyahu Goldratt

9. “Anyone who thinks you can overcome emotional resistance with logic was probably never married”

10. What is Improvement Science? • Any improvement is a change • any change is a perceived threat to security • any threat to security gives rise to emotional resistance • emotional resistance can only be overcome by a stronger emotion Eliyahu Goldratt

11. Share the problem not the solution • What to change? • Pin point the core problems • What to change to? • Construct (simple) practical solutions • How to cause the change? • Induce the appropriate people to invent such solutions • they must own the problem Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts

12. Discipline of improvement 4 equally important parts of improvement People Process User and public involvement Diagnostic tools and techniques What Change management Project and programme management How Discipline of improvement in health and social care (Penny 2003)

13. If I had one hour to save the world, I would spend 59 minutes defining the problem and one minute finding a solution A Einstein

14. Challenge the paradigms

15. Act Plan Study Do The Model for Improvement What are you trying to accomplish? Understanding the problem. Defining what you’re trying to do How will you know that a change is an improvement? What changes can you make that will result in the improvements that you seek ? Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The improvement guide: a practical approach to enhancing organizational performance 2nded, Jossey Bass Publishers, San Francisco

16. Charts vs. Tables

17. How often you measure can also have an effect on how you look at the results Average length of pre-ward stay Average length of pre-ward stay Stroke Ward Stroke Ward Patient length of pre-ward stay from 01/2007 to 07/2007 from 01/2007 to 07/2007 Stroke Ward 3.5 9.0 from 01/2007 to 07/2007 8.0 3 35.0 7.0 30.0 2.5 6.0 2 25.0 5.0 4.0 1.5 20.0 3.0 1 15.0 2.0 0.5 10.0 1.0 0 5.0 0.0 1 3 5 7 9 15 17 19 21 23 25 27 29 31 11 13 1 2 3 4 5 6 7 0.0 Months Weeks Patients Mike Davidge NHS Institute for Innovation and Improvement

18. Act Plan Study Do The Model for Improvement 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 the improvements that you seek ? What have others done? What does the evidence say? 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 2nded, Jossey Bass Publishers, San Francisco

19. Transferring solutions is rarely effective. Transfer change principles… Change principle Change principle Solution / change in team / organisation A Solution / change in team / organisation B

20. PDSA cycle for learning and improvement Act Plan • objective • questions and predictions (why) • plan to carry out the cycle (who, what, where, when) We planned to.......( state the basic plan) In order to ….. (tie it back to the aim) What we plan to do next is …. (state next plan) • what changes are to be made? • next cycle? Study Do • complete the analysis of the data • compare data to predictions • summarise what was learned • carry out the plan • document problems and unexpected observations • begin analysis of the data What we did was….. (brief description of actions) Looking at what happened, what we learned from this was….. (lessons learned)

21. Measurement: Big dots and little dots The Model for Improvement breaks things down into small steps and works on the ‘little dots’ – at the frontline These small steps should be part of the answer to the question of how to move the ‘big dots’ Align all improvement projects to strategy

22. The interventions / change ideas that contribute directly to secondary drivers The strategic aim (and big problem) Primary Drivers: Contribute directly to the strategic aim Secondary Drivers: Contribute directly to primary drivers Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 ? Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3 Intervention 1 Intervention 2 Intervention 3

23. Embedding Improvement Science in Training Programmes: Why Bother? What is Improvement Science? Why bother embedding it into training programmes?

24. Improvement in pre-registration education: aim – to raise awareness to improvement for better safer care To develop health and social care students who are curiousabout how they could improve their service, and who are receptive to different ideas and able to bring about the necessary changes by applying a variety of tools and techniques in their own context 2006

25. Some key lessons Tribal consulting, External evaluation 08/09 ‘my duty, part of my professional role, I should get involved’ ‘be prepared to extend role and take on new responsibilities’ ‘small problems have a big impact on patients’ ‘anyone can take part – we’re all responsible’ ‘I have the skills’

26. It is making a difference...... ‘…..I have interviewed over 100 applicants of newly qualified staff …..One of the questions asked was " Service development is everyone's responsibility, …have you been involved in any changes happening while you have been on a placement? It was obvious …that one particular University's candidates had all identified an area for improvement in practice .. and had tested and evaluated them during their stay there. Some of their ideas were still in use and others were not. Some of the ideas were interesting and made us think about looking at those areas for improvement ourselves. …..it was very clear that the candidates from other local universities had not been involved in any changes ……we employed those that could clearly discuss how to introduce and evaluate a change in practice or improvement to patient care’.  Nurse Manager, Neonatal Unit, North of England, March 2011

27. Barriers and challenges • Timescale / Timing • University structures i.e. plan everything in advance • Difficult time as currently revalidating • Difficulty getting everybody in the same room at the same time • Attitudes • Student Attitude and receptiveness • Staff Attitude and receptiveness Tribal Consulting, External evaluation of 08/09 • Engagement of key stakeholders • Barriers in engaging with practice • Engaging Faculty and colleagues • Resources • Time • Funding • Human Resources and Extra work • Rooms

28. 2012 review: Engaging Faculty and colleagues Replies from 33 universities (69%) of the 48 universities on the NHSI contact list The main challenge to sustainability is ensuring that key faculty and senior academics truly understand and value improvement as a concept. When this happens improvement is prioritised and sustained in an ever pressurised curriculum.

29. Final messages about improvement 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 Learn from things that do not work Link frontline changes to strategic objectives

30. Embedding Improvement Science in Training Programmes: Why Bother? Healthcare will not realise its full potential unless change (improvement) making becomes an intrinsic part of everyone’s job, everyday, in all parts of the system. Batalden, P. B et al. Quality and Safety in Health Care 2007;16:2-3

31. Act Plan Study Do Model for Improvement Embedding Improvement Science in Training Programmes: Why Bother? What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Professor Jean Penny, University of Derby jean.penny@btinternet.com

33. Educating for capability Fraser Greenhalgh (2001) Coping with complexity: educating for capability ‘Competence: what individuals know or are able to do in terms of knowledge and skill Capability: extent to which individuals can adapt to change .... and continue to improve their performance’ ‘These days there is so much knowledge available that we risk drowning in it.......Learning about how things are interconnected is often more useful than learning about the pieces’