M10 A scientific approach to initiating, implementing and sustaining improvement

1. M10A scientific approach to initiating, implementing and sustaining improvement Helen Crisp, the Health Foundation Sharon Williams, Cardiff University

2. Workshop objectives • Appreciate the difference between making improvements and studying improvement • Understand theories of change management to strengthen improvement efforts • Appreciate the mix of technical, educational/learning and social-behavioral skills that are necessary for sustained improvement • Gain the tools to understand not onlyif a change is an improvement, but why it works and the likelihood of sustainability and spread

3. Overview of the course • Introduction - The improvement problem • Foundations of change management • The triple skill-set: technical, learning and social behavioural skills • Measuring the change, understanding why it works and whether it can spread • Wrap up

4. Overview of the course • Introduction - The improvement problem • Foundations of change management • The triple skill-set: technical, learning and social behavioural skills • Measuring the change, understanding why it works and whether it can spread • Wrap up

5. Problems with quality improvement • Improvement in healthcare has not lived up to its promise • Some brilliant projects but improvement is patchy, and often does not ‘stick’ • Improvements seem resistant to scale up beyond clinical teams or departments • ‘Spread’ - wide scale implementation beyond the original setting - is rarely achieved How might improvement efforts get beyond these limitations?

6. Assumptions behind improvement efforts • Healthcare involves medical science and social science operating across simple, complicated and complex situations • Improving healthcare is a social process, theories and methods from social science can help improvement work • Improving one’s own work is the hallmark of a professional • Successful scientific improvement contributes to advancing the theories of the science and methods for implementation

7. Working definition of improvement science: The application of a range of basic and applied sciences in order to improve the effectiveness and efficiency of efforts to improve health care for patients and populations

8. Common problem in improvement work:Magical thinking

9. Magical thinking EMPOWER PATIENTS TO ASK DOCTORS TO WASH THEIR HANDS INFECTION GOES DOWN A MIRACLE OCCURS!

10. Improvement work in healthcare • Optimism that a bright idea is enough • Lack of cumulative theory building • Promising interventions rolled out without understanding: • how it works (mechanisms) • the interaction with the context where developed • the necessary ‘dose’ to sustain beyond pilot/ project phase

11. Two types of activity • Making and Studying an improvement are different activities and both are necessary to develop the science of improvement

12. Scientific thinking involves Studyingthe improvement • Developing a theory for the change • Testing whether the theory holds up in practice • Developing measures of the change • Evaluation of the methods for implementing change • Studying implementation in different settings to ensure that there is a generalisable approach

13. Different questions driveMakingandStudyingimprovement • How did you improve what you improved?(e.g. methods of planning, assumptions, observations, adaptations) • How did you study the improvement process, outcomes? (e.g. methods of inquiry, measurement, inference, reflection)

14. Overview of the course • Introduction - The improvement problem • Foundations of change management • The triple skill-set: technical, learning and social behavioural skills • Measuring the change, understanding why it works and whether it can spread • Wrap up

15. Discussion point • On your tables consider some of the possible reasons: • Why do change initiatives fail?

16. Why change initiatives fail • Allowing too much complacency • Failing to create a sufficiently powerful guiding coalition • Underestimating the power of vision • Under-communicating the vision by a factor of 10 or more • Permitting obstacles to block the new vision • Failing to create short-term wins • Declaring victory too soon • Neglecting to anchor changes firmly in the corporate culture Source: Kotter (1996)

17. Barriers to continuous quality improvement in healthcare • Lack of consistent driver for continuous improvement • Inadequate information systems • Lack of physician involvement • Insufficient senior management leadership and support • Problems in adapting the principles & practices of industry-based CQI to healthcare • Ferlie & Shortell (2001)

18. Theoretical foundations of change management • Individual perspective: • Behaviourists believe human actions are conditions by expected consequences. Behaviour rewarded tends to be repeated. To change behaviour need to change conditions that cause it (Skinner, 1974) • Gestalt–Field perspective helps individuals to understand themselves and the situation in question, which leads to changes in behaviour • Some theorists believe it’s a combination of external and internal motivators that influences human behaviour

19. Theoretical foundations of change management • Group Dynamics: • Long history - Bring about change via teams and groups • Rationale – as people work in groups/teams, individual behaviour can be modified or changed in light of groups’ prevailing practices and norms e.g. peer pressure • Open Systems School: • Sees the organisation as a combination of connected sub-systems which operates as one system. • Any change on one part of the system will impact on other parts • The organisation is an open system based on the interaction with the external environment and internal interaction between the subsystems • Concerned with aligning activities to achieve the organisational goals and objectives

20. Four levels of Change for Improving Quality in Healthcare Ferlie & Shortell (2001)

21. Change continuum Large scale Small scale Incremental Transformational Source: Burnes (2009)

22. Discussion point Thinking about improvement projects you are familiar with – where would they fit on the ‘Change continuum’? Small scale Large scale Transformational Incremental

23. Speed and force of change Rapid Change/ Transformation Slow Change/ Transformation Structures and Processes Behaviour and Culture Source: Burnes (2009)

24. Force field analysis Driving Forces Restraining Forces The Status quo Current Behaviour

25. Exercise: • Each table has one of two case studies, consider for this improvement project : • Where does it sit on the change continuum? • Does the outline project plan look appropriate with regard to Speed and force of change? • Using the force field analysis: • What are the drivers for change? • What are the restraining forces?

26. Feedback from groups

27. Planned and Emergent change Environment Stable Turbulent Planned Emergent Approaches to change Source: Burnes (2009)

28. Planned and Emergent Change • Planned approaches to change dominated much of the early work – view change as “moving from one fixed state to another through a series of predictable and pre-defined steps” (Burnes, 2009) • Emergent approaches to change became popular in 1980s assumes changes is continuous, open-ended and unpredictable (Burnes, 2009).

29. Planned approaches to change Effective Change • Action research model • Three-step model (Lewin, 1958) Unfreeze Change (Re)freeze Time

30. Planned approaches to change Four phase model of planned change (Bullock and Batten (1985) • Exploration Phase • Assessing the need for change • Planning Phase • Understanding the problem, collecting data, diagnosis of problem, setting change goals and designing actions • Action Phase • Moving from current state to desired future state, evaluating the implementation and feedback the results • Integration Phase • This phase starts once the changes have been implemented successfully. Concerned with disseminating and sustaining changes and reinforcing new behaviours

31. Bold strokes and Long marches Kanter et al., (1992)

32. Emergent approach to change • Processual research (main strand of emergent change) • Define process as “a sequence of individualand collective events, actions and activities unfolding over time and in context” (Pettigrew, 1997) • “The process of change is a complex and untidy cocktail” (Huczynski and Buchanan, 2001) • Recognise the importance of planning and the processes of continuity • Power and politics play an important role in initiating and managing change (Pettigrew, 1997)

33. Five guiding principles of processual research • Studying processes across a number of levels of analysis • Studying processes in past, present and future time • Role in explaining for context and action • Search for holistic rather than linear explanations of process • Need to link process analysis to the location and explanation of outcomes Source: Adapted from Pettigrew (1997:340)

34. Five central factors for managing change • Environmental assessment • Collect & analyse information about external and internal environment • Leading change • Create positive climate for change; link action of people at all levels of the organisation • Linking strategic and operational change • Linking intentional strategic decisions to operational changes and emergent changes influence strategic decisions • Human resources as assets and liabilities • Knowledge, skills and attitudes need to be combined for successful outcomes • Coherence of purpose • Decisions and actions need to flow from the above and complement and reinforce each other. Source: Pettigrew & Whipp (1993)

35. Role of managers in change • Decision-making: • Intuition and vision • Gather, analyse and use data • Understand political consequences of decisions • Synthesis conflicting views • Empathise with different groups • Coalition building • Gain the support and resources to implement decisions • Check the feasibility of ideas • Gaining supporters • Bargaining with other stakeholders • Presenting new ideas Source: Carnall, (2003)

36. Role of managers in change • Achieving action • Handling opposition • Motivating people • Providing support • Building self-esteem • Maintaining momentum and efforts • Team-building • Generating ownership • Sharing information and problems • Providing feedback • Trusting people and energising staff Source: Carnall (2003)

37. Discussion point • What do you think are some of the key criteria for successful change implementation?

38. Ten commandments for executing change • Analyse the organisation and its need for change • Create a shared vision and a common direction • Separate from the past • Create a sense of urgency • Support a strong leader role • Line up political sponsorship • Craft an implementation plan • Develop enabling structures • Communicate, involve people and be honest • Reinforce and institutionalise change Source: Kanter et al., (1992: 382-3)

39. Models of Change Agents • Leadership models: change agents are senior managers responsible for strategic change • Management models:change agents are middle managers responsible specific elements of strategic change programme/ projects • Consultancy models: change agents are external or internal consultants who can operate at any level • Team models:Dedicated team of change agents that operate at various levels and consist of the requisite manager, employees or consultants needed to complete the change project. Source: Caldwell (2003)

40. Refreshment break

41. Overview of the course • Introduction - The improvement problem • Foundations of change management • The triple skill-set: technical, learning and social behavioural skills • Measuring the change, understanding why it works and whether it can spread • Wrap up

42. Skills for quality improvement • Quality improvement is a collective effort that is dependent on a supportive context • So too is the development and application of leadership and other skills • QI leaders need broad skills & knowledge: • - Not just technical QI knowledge; also • - Soft relationship skills, and • - Collective learning skills. • Central support is vital for QI skill development

43. Technical skills for quality improvement • Some examples: • Project management • PDSA cycle (plan-do-study-act) • Statistical process control charts • Process mapping and flow charts • Care bundles • Breakthrough collaborative methodology • Failure mode and effect analysis • SBAR (situation-background- assessment –recommendation) ... and many more ...

44. Capability and capacity building in technical skills Professional in QI Months/ years: Fellowship programme, Masters etc Intensive training 1 -2 week course, conferences, seminars 1 day workshop, team project training

45. But technical skills are not enough! • Unless other skills sets are in place: • Staff slow to recognise how the technical skills help them to deal with the many demands for service changes and improvement • Don’t use the resources available from people like IHI, Health Foundation etc • Unable to build on the momentum that a QI project can generate – doesn’t last beyond the ‘pilot’ Different skills are needed for improvement in an adverse organisational context

46. Discussion point • What do you think are some of the ‘soft skills’ needed for QI work in healthcare?

47. Soft skills for quality improvement • Our top 10: • Communication • Team leadership • Followership • Influencing skills • Negotiation • Assertiveness • ‘Political’ (organisational) awareness • Time management and prioritisation • Knowledge management • Stress management

48. Learning skills for quality improvement • Important to facilitate the ‘social’ aspect of improvement work • Teams have to learn and work together to implement the changes required for improvement • Learning skills comprise a mixture of structures/ approaches: • Communities of practice/ clinical communities • Networks; managed/ semi-structured/virtual • Action learning sets • Learning exchange routes seminars/ regular meetings/ e-mail networks

49. Learning skills for quality improvement • Methods of learning e.g.: • Critical reflection • Observation • Story swapping Attributes for learning skills to be effective • Willingness to learn • Encouraging participation • Externalising tacit knowledge

50. The Improvement Pyramid Leadership development Source: Gabbay et al (2014)