Transforming the system to improve quality and reduce costs 18 th May 2012 Helen Bevan @helenbevan http://twitter.com/

1. Transforming the system to improve quality and reduce costs 18th May 2012 Helen Bevan @helenbevan http://twitter.com/helenbevan Jim Easton

2. Programme

3. Introductions: finish the sentence Introduce yourself to others on your table by finishing these three sentences: • The change initiative that I am currently working on that I would like to reflect on today is ... • The problem we are addressing is ... • The strengths we are building on are... Your answer to each question should literally be one sentence

4. The NHS Change Model

5. Our case study

7. Harmfreecare Absence of harm from

8. Why we selected these harms • common harms • important to patients and their carers • significant improvements can be made to deliver reductions in all four • patients who have one of these harms may be at higher risk of one (or more) of the other harms • Where we have focussed our efforts in reducing one, we may have had a negative impact on the others e.g. We may deliver a successful intervention to reduce VTE or pressure ulcers but in doing so increase falls • Delivering harm free care involves one plan to deliver against four common harms across a whole community

9. Protected from all four harms?

10. Protected from all four harms?

11. One plan – four harms

12. 2 www.harmfreecare.org

13. Four key messages underpinningthe NHS Change Model • To achieve large scale change, we need the intrinsic motivation of connection to shared purpose, engaging to mobilise, transformational leadership skills • However, we also need drivers of extrinsic motivation; transparent measurement and holding to account, incentivising payment systems, performance management systems if we are going to create change across the system • What happens if we don’t align intrinsic and extrinsic factors is that the extrinsic factors kill off the energy and creativity that is necessary for delivery • We need an aligned approach

15. Managing duality Source: Helen Bevan

16. Approaches to change • Deficit based • what is wrong? • solving problems • identifying development and improvement needs • gaps and deficiencies to be filled • Asset based • what is right that we can build on? • exploiting existing assets and resources • “positive deviance” • amplifying what works

17. Our shared purpose

19. “Paradoxically, the most important first task in creating a successful quality and cost improvement strategy is not to identify the size of the challenge or to work out which areas of service delivery offer the greatest opportunity for change. Rather, it is to create a deeper meaning in the challenge that lies ahead, to link the cost improvement programme to the higher purpose of the organisation or NHS system. The framing for quality and cost improvement isn’t just about cost and quality improvement. We want to think deeply about the meaning of what we are asking people to do in an era of quality and cost improvement. Fundamentally, it is about the higher purpose of the NHS and the calling that each of us has to serve that purpose.

21. Energy generators Connection How far someone sees and feels a connection between what matters to them and what matters to the organisation Content How far the actual role, job, task that someone does is enjoyable to them and challenges them Context How far the way that the organisation operates and the physical conditions within which someone works makes them feel supported Climate How far “the way we do things around here” encourages individuals and teams to give of their best Source: Stanton Marris

22. Energy generators Connection How far someone sees and feels a connection between what matters to them and what matters to the organisation Content How far the actual role, job, task that someone does is enjoyable to them and challenges them Context How far the way that the organisation operates and the physical conditions within which someone works makes them feel supported Climate How far “the way we do things around here” encourages individuals and teams to give of their best • Which of these four Cs generates the most energy for the healthcare workforce? • Which C is the most energy sapping? Source: Stanton Marris

23. Four sources of energy Source: adapted from Steve Radcliffe

24. Conclusions about energies for quality and cost improvement in healthcare • Tendency to focus on intellectual energy • connecting intellect to intellect keeps us in our comfort zone • it isn’t transformational • We will achieve greater results if we link physical energy to emotional and spiritual energy

25. Guess who understood the importance of spiritual energy? “Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.” Aneurin Bevan, founder of the NHS

26. “Large scale change is fuelled by the passion that comes from the fundamental belief that there is something very different and better that is worth striving for” Leading Large Scale Change (2011) NHS Institute for Innovation and Improvement

27. “Turn your face to the sun and the shadows fall behind you”Māori whakatauki

28. “Money incentives do not create energy for change; the energy comes from connection to meaningful goals” Ann-Charlott Norman, Talking about improvements: discursive patterns and their conditions for learning, March 2012

29. Discretionary effort is contractual is personal

30. Harm free care: our higher purpose http://harmfreecare.org/harm-free-care/videos/

31. Key questions • Is the ‘higher purpose’ for my change initiative clear and recognised by our leaders,workforce and partners? • Are our quality and cost improvement proposals explicitly framed as a connection to the higher purpose?

32. Spreading innovation

33. Innovation Review by Chief Executive of the NHS “It is widely accepted that more of the same will not do. More radical changes in the way services are delivered and how people work will be required. We need to plot a sustainable course for the future of the NHS. Innovation can help provide the route-map, improving quality at the same time as driving productivity and efficiency in a difficult financial environment” Department of Health (2011). Innovation, health and wealth: accelerating adoption and diffusion in the NHS. Page 4. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_131299

34. Types of innovation • Process innovation • Service innovation • Strategy innovation Source: Kathryn Baker http://www.au.af.mil/au/awc/awcgate/doe/benchmark/ch14.pdf

35. Task • What are the differences between process, service and strategy innovations? • Think about some examples of each from your own experience

36. Examples of process innovation • Redesigning the appointment process in the GP surgery • Reinventing the triage process in Accident and Emergency • Making it easier for patients to order repeat prescriptions • Redesigning the job application process within recruitment and selection • Introducing a rapid turnaround “one stop shop” for outpatient testing

37. Strategy innovation “the question today is not whether you can reengineer your processes; the question is whether you can reinvent the entire industry model” Gary Hamel

38. Examples of strategy innovation • Transforming the paradigm of urgent and emergency care across the community • Designing radical new integrated models of health and social care for people with long term conditions • Shifting power: patients, families and communities as co-creators and producers of health • Building new approaches to large scale change based on mobilising principles from social movements and community organising

39. Examples of service innovation • Creating new specialist services in the community, eg, intravenous therapy, deep vein thrombosis, complex wound clinics • Introducing hyperacute stroke services across the city • Creating a “virtual” induction for all newly appointed clinical staff • Radical redesign of the clinical pathway for people who break their hips • Introducing “virtual wards” for intensive support outside of hospital

40. Kinds of service innovation Integration Simplification Substitution Segmentation Parker H Making the shift: a review of NHS experience. Health Services Management Centre and NHS Institute for Innovation and Improvement http://www.bhamlive3.bham.ac.uk/Documents/college-social-sciences/social-policy/HSMC/publications/2006/Making-the-Shift.pdf

41. Substitution: providing higher value, lower cost care for patients/service users through • location substitution: substituting high tech clinical environments for community based settings • skills substitution: enhancing the skills of specific groups of staff to undertake roles previously undertaken by those with a higher skill level, for instance enabling nurses to prescribe drugs, a role that was previously only carried out by doctors • technological substitution: maximising the use of new technologies in the service. A specific type of technological substitution is channel shift • clinical substitution: moving from a medical care model to community care or family or self care model • organisational substitution: looking at a wider range of providers to those who have traditionally delivered NHS care, for instance voluntary and community groups and social enterprises.

43. Key questions • What combination of process, service and strategy innovations do my improvement plans require? • What are the implications for the ways I need to spread them? • What levers are available to me to spread innovation in my current context? • How do I use them? • How am I linking spread of innovation to other components of the change model?

44. The NHS Change Model

45. Engagement to mobilise and leadership of change

46. Communicating versus mobilising SPECTRUM OF APPROACH/ACTIVITY • aims to generate understanding and share information • communicates a message • awareness is success • Segments and targets different audiences • media and tools are typically centrally designed and managed • strong promotion of service (NHS) values • aims to generate commitment to action • creates a cause • action is success • Often unites disparate audiences focused on connecting • media and tools are locally co-designed/ implemented • service values with personal values, leading to committed action

47. Leaders ask their staff to be ready for change, but do not engage enough in sensemaking........ Sensemaking is not done via marketing...or slogans but by emotional connection with employees Ron Weil

48. A challenge “What the leader cares about (and typically bases at least 80% of his or her message to others on) does not tap into roughly 80% of the workforce’s primary motivators for putting extra energy into the change programme” Scott Keller and Carolyn Aiken (2009) The Inconvenient Truth about Change Management

49. Leaders as “signal generators” “As a leader, think of yourself as a “signal generator” whose words and actions are constantly being scrutinised and interpreted, especially by those below you [in the hierarchy]” “Signal generators reduce uncertainty and ambiguity about what is important and how to act” Charles O’Reilly, Leaders in Difficult Times, 2009

50. Framing Is the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to action Snow D A and Benford R D (1992)