Clinical leadership in improvement

1. Clinical leadership in improvement Professor Matthew Cripps @matthew_cripps1

2. What will we cover? • What is leadership in improvement? • The journey to improvement leadership • Role and foundations of leadership in improvement • Tools and techniques • How do our minds work? • What are the basics of optimal improvement? • Bits and pieces – e.g. saboteurs, planning fallacy, knowledge transfer

3. What is leadership in improvement? • Helping people choose to do difficult things that make things better, and showing them how • Key elements • Processing Knowledge transfer • Prototyping “Failure is the opportunity to try again more intelligently” • Persuasion Behavioural science • Persistence If you know you’re right, never give up – but make sure you are right!

4. How did we find ourselves here? Does anyone set out to be an improvement leader? E.g. I ended up here out of frustration, laziness and ego… “Why do I always have to be the one to say No?” “What would we be doing differently if I lived in a world where I got to say Yes?” And so began the accidental invention of the RightCare approach…

5. Evolution of NHS RightCare • Atlases of Variation & Health Improvement Packs • Clinical and Financial Engagement • Improvement processing • Clinical leadership • The “Way in” – indicative data and “Where to Look” • Intelligence packs – “What to Change” • Knowledge transfer and shared learning – “How to Change” • Prototyping – “what’s wrong with this?”

6. Role and foundations • What’s the Point? • Is the primary purpose of improvement – 1. To improve the health system Or; 2. To keep the NHS financially viable

7. What’s the point? • In reality it’s both – • Deciding where to improve should focus on population health need AND account for the need to stay afloat • This leads to the first algorithm for healthcare leaders (Where to Look)… • Where are we letting our population down the most in terms of their healthcare? And; • Where are we wasting the most money doing the letting down? • And how does the leader lead this?

8. The role of the leader • Ensure and guide through EASE – • Evidence-based positioning, choices and decision-making • Awareness – the first step to improvement • Simplicity – embrace reductionism • Enablers – inputs, processes, outputs & outcomes • Push vs Pull “It is said of a good leader that when the work is done, the aim fulfilled, the people will say “we did this ourselves”” – Lao Tzu

9. Evidence-based positioning Knowing you’re right before you’re belligerent… If we ensure we take evidence-based positions, then we know we’re doing the right thing. How many of us do this now? For most of us – not as much as we could…

10. Intuitive and considered thinking:‘Thinking Fast and Slow’ Intuitive Considered • Daniel Kahneman, Nobel science prize winner, psychoanalyst and behavioural economist - “we all think fast and slow” • His research shows beyond statistical doubt that • If we give a predominance to either fast (intuitive) or slow (considered) thinking… • This makes us are more often wrong than if we balance the two • Where are you on the scale?

11. How do you get nearer the middle? Seek further evidence Ante/ Pre-mortem planning - Imagine failure – assume you follow your first thought and it goes horribly wrong – what might have happened? Why? Argue with yourself…

12. Clinical leadership in improvement –evidence you’ll like… There is a statistically significant correlation between higher quality, outcomes and patient satisfaction and more clinicians on the boards of NHS organisations Clinical Leadership and the Changing Governance of Public Hospitals, Public Administration 2015. Veronesi, G., I. Kirkpatrick and F. Vallascas Clinicians on the Board: What Difference Does It Make?’, Social Science & Medicine, 77, 147–55. (2013) Veronesi, G., I. Kirkpatrick and F. Vallascas

13. But… The same study found that, in the absence of extensive financial involvement, more clinical leadership leads to less efficiency Add in extensive financial engagement and this goes away A role of leadership is to make sure everyone is involved, as much as possible - “I never achieved any significant improvement without a manager and an accountant standing next to me” – Professor Sir Bruce Keogh

14. Awareness – the first step • We have to know where we aren’t very good in order to know where we can get better • This leads to a key concept of leadership – • Embrace negatives to create positives, e.g. • Where aren’t we very good? Leads to “how do we become good?” • (In planning) What could go wrong and how do we mitigate?

15. A key principle of population healthcare improvement • If we aren’t aware of clinical and financial variation, then we can’t head off in the right improvement direction “What good is running if you’re on the wrong road?” – German proverb • Variation allows us to discuss and conclude • Where we are different • Where those differences aren’t warranted (and therefore where we should focus our improvement effort) • What we would look like if we didn’t have those differences • How to change ourselves so we eliminate those differences

16. Simplicity “Great things are done by a series of small things brought together” Vincent Van Gogh “The simple answer is always the best” William of Ockham “If you can’t solve a problem, then there is an easier problem you can solve: find it” George Polya

17. What can ancient Greece and medieval England teach NHS improvement? • System Vs Pathway - do people design complexity or simplicity better? • Thales’ principle of reductionism and Ockham’s Razor • Components (steps in pathways) are simpler to understand than whole systems (e.g. FE, UC) • Break down to simple components, design optimal and build back • up into complex systems • Mild heart conditions treatment – change lifestyle first, before prescribed drugs. Learnt this via reductionist research on body chemistry and physiology.

18. The simple answer is always the best • Already simplified the “way in” to improvement (where we should focus) – • Where are we letting down our population the most, in terms of their healthcare, and where are we wasting the most money doing the letting down? • Leaders need to help teams and systems to simplify – • The causes of the problems healthcare improvement leaders need to tackle • How to identify the solution • The process of improvement

19. Simplifying the problem • Overuse and Underuse • Overuse – leading to • Waste • Patient harm (even when the quality of care is high) • Underuse – leading to • Failure to prevent disease • Inequity

20. Simplify how to identify the solution Get everyone to agree what we would look like if we were as good as we could be

21. Simplifying the improvement process Where to Look (Diagnose) What to Change (Design) How to Change (Deliver)

22. Why won’t everyone just do what I think? “What we wish, we readily believe, and what we think, we imagine others think also” – Julius Caesar It might be that what you think is wrong. But, often its because how we convey what we’re thinking doesn’t tick other people’s boxes So, do we seek to change the boxes they want ticked (huge cultural and behavioural shift) or is it simpler just to… Tick their boxes?

23. The decision-making table Nurse AHP Consensus Medic PH officer General Manager CFO LA CEO Provider

24. Is that all? No…. Meeting the needs of differing perspectives/ objectives/ mandates are part of the equation But that alone won’t tackle everything…. …behaviours and how our minds work matter at least as much… An understanding of behavioural science can help all leaders and their teams

25. What is behavioural science? According to LSE: Behavioural science is the cross-disciplinary, open-minded science of understanding how people behave. It cross-fertilises and brings closer together insights and methods from a variety of fields and disciplines, from experimental and behavioural economics to social and cognitive psychology, from judgement and decision-making to marketing and consumer behaviour, from health and biology to neuroscience, from philosophy to happiness and wellbeing.

26. Meet Linda • Linda is in her mid-30s • At university she studied political science and her dissertation was on women’s rights in the post-industrial political landscape • In her teens and early 20’s she was politically active regularly attended feminist events and political marches • Which of the following do you think most likely describes Linda now? • 1. Linda is a healthcare manager in a CCG • 2. Linda is a healthcare manager in a CCG and member of the CCG’s equality and diversity working group • 3. Linda is a healthcare manager in a CCG, member of the E&D group and a politically active feminist

27. Linda’s probabilities Healthcare manager Healthcare manager / member of E&D group Healthcare Manager / E&D Group / active feminist

28. Broken rules This is representativeness trumping statistical fact - a rule of probability is that the more detail you add the less likely a thing becomes But our minds over-ride this because Options 2 and 3 represent the type of person we feel Linda is and our minds latch on to this: Our intuitive thinking has latched on to available evidence and given it more weighting than it deserves Even if I had said that Linda is a healthcare manager and chair of the E&D group. I haven’t made option 2. more likely than 1, just as likely

29. Principles of the human mind • By and large, humans believe they are rational creatures. But… • Our minds are highly susceptible to making systematic errors and then covering up the fact that this has occurred. • Our minds also make it easy for us not even to wonder whether a systematic error might have occurred.

30. Behavioural science – influencing us all A poorly chosen font makes us pay less attention to the message in a document, and to be more inclined to disagree with it. If you nod whilst seeking to persuade someone, they’re more likely to be persuaded People in good moods relax, their considered thinking switches off and they are more likely to make errors of logic. If you frown while you think, you’re less likely to be tricked by your intuition

31. Pick out the most important words in this NHS RightCare narrative… CCGs and practices can use this pack to target population healthcare improvement and work together to bring quality and value up to that achieved by similar practices, working closely with NHS RightCare and its Delivery Partners. Welcome to your practice level data pack on cardiovascular disease (CVD). This pack helps to identify variation and opportunities between demographically similar general practices on key indicators along CVD pathways. The focus on practice-level variation is to help CCGs to target their improvement support to the member GP practices that will most benefit. To this end, GP practices have been compared with their own demographic cluster group and not with the CCG’s.

32. Switch it off!

33. Switch it off!

34. Lazy brains As a result, intuition overrides consideration by our very nature Human minds are inherently lazy

35. Lazy brains – answer this question… A bat and ball cost £1.10 The bat costs one pound more than the ball How much does the ball cost?

36. Lazy Brains

37. Lazy Brains

38. So how does intuition work? • Intuition relies on recognition (pulling things from our minds that were already there) – clinical education and training uses this fact extensively • But where there is no recognition to be had, e.g. with an innovative improvement opportunity, our intuition does not consider this and switch itself off, leaving the stage clear for our considered thinking to take over… • Instead, it tries to override our considered thinking, fill in gaps it can not fill in and flood us with confidence that we know what we can not possibly know • “Our excessive confidence in what we believe we know, and our apparent inability to acknowledge the full extent of our ignorance” – Daniel Kahneman

39. How should a leader account for this? Intuitive Considered “All I know is that I know nothing” – Socrates • Always consider that you might be wrong • Make sure your team feel comfortable saying what they think, including when they think you’re wrong (they’re very good at knowing!) • Always consider that others might be wrong too! • Especially if they make quick decisions and don’t change their minds very often

40. Break

41. Decisions, decisions Understanding behavioural science is all about enhancing decision-making NOT manipulation (unless the individual using it is being manipulative). Behavioural Science IS • Understanding how the mind works and the strengths and weaknesses inherent in this • Why do people make the decisions that they do? How do they make them? • Using this knowledge to lead, build cases and help decision-makers increase proportion of correct decisions and successful delivery If we understand how the mind works when it considers information and makes decisions, we can account for it and increase the rate of good vs bad decisions (our own and those of others)

42. An unambiguous statement Ann approaches the bank

43. Ambiguity With balaclava on head and gun in hand, Ann approaches the bank

44. Ambiguity Seeing the ducks on the river, With balaclava on head and gun in hand, Ann approaches the bank

45. Inputs vs processes vs outputs • Which is most important? Two minutes in pairs… • You can have the best inputs in the world but if there’s no (consistent) process, what are you going to do with them? • Your process can be optimal but if the “way in” isn’t you’ll use it on the wrong things • Dangerous as means you’re good at delivering the wrong stuff • If you don’t have well articulated outputs, how will you deliver what is needed and know you’ve done the job? And how will you enthuse stakeholders to join in at the beginning?

46. Ambiguity – our issue • We believe the most important parts of any process are the ‘way in’ and ‘way out’

47. Our experience of ambiguity In local health economies, we found that when decisions were made on which programmes to prioritise and deliver – there was no clear process on ‘the way in’ or ‘ the way out’ for Executive, Clinical and programme leads Ambiguity and inequality were rife Projects which were sub-optimal were getting through the decision making process as a result, colleagues with innovative ideas were disenfranchised and the population wasn’t getting the improvement it needed

48. Algorithms & decision-making Over 200 studies into decision-making via algorithms vs decision-making without them 60% found that algorithms led to significantly better decision-making 40% found that there was no difference This is essentially a 100% victory for decision-making via algorithms – they never lead to lower value decisions and most often lead to higher value ones. How does this manifest in healthcare? E.g. without algorithms, experienced radiologists contradict themselves 20% of the time when they see the same image on different occasions.

49. Use decision trees • The use of clearly defined decision criteria reduces ambiguity and increases the quality of projects selected • Worked with the frontline to enhance CCG 2018/19 improvement plans • You all have these in place… But are you using them? Leaders can ensure that they are used…

50. Blackpool CCG Decision Tree for prioritising reform proposals Set Timetable for completion of case outline* Ideas & Cases High Priority RoI* >£250k Are there any health benefits? Rate of Return <12 months Medium Priority RoI* >£100k Do not proceed No Yes Low Priority RoI* <£100k Is it a must do? Yes High Priority RoI* >£500k No Does it save money? Rate of Return >12 months No Medium Priority RoI* >£250k No Does it increase value*? Yes Prioritise Low Priority RoI* <£250k Yes Can it be delivered? Yes Can it be made deliverable? No Yes Do not proceed No