m10 a scientific approach to initiating, implementing and sustaining improvement helen crisp, the...

M10A scientific approach to initiating, implementing and sustaining improvement

Helen Crisp, the Health FoundationSharon Williams, Cardiff University

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 only if a change is an

improvement, but why it works and the likelihood of

sustainability and spread

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Overview of the course

1. Introduction - The improvement problem

2. Foundations of change management

3. The triple skill-set: technical, learning and social behavioural skills

4. Measuring the change, understanding why it works and whether it can spread

5. Wrap up

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5. Wrap up

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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?

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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

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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

Common problem in improvement work:

Magical thinking

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Magical thinking

EMPOWER PATIENTS

TO ASK DOCTORS TO WASH

THEIR HANDS

INFECTION GOES DOWN

A MIRACLE OCCURS!

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

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Two types of activity

Making and Studying an improvement are different activities and both are necessary to develop the science of improvement

Scientific thinking involves Studying the 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

Different questions drive Making and Studying improvement

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)

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5. Wrap up

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Discussion point

On your tables consider some of the possible reasons:

Why do change initiatives fail?

Why change initiatives fail1. Allowing too much complacency

2. Failing to create a sufficiently powerful guiding coalition

3. Underestimating the power of vision

4. Under-communicating the vision by a factor of 10 or more

5. Permitting obstacles to block the new vision

6. Failing to create short-term wins

7. Declaring victory too soon

8. Neglecting to anchor changes firmly in the corporate culture

Source: Kotter (1996)

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Barriers to continuous quality improvement in healthcare

1. Lack of consistent driver for continuous improvement

2. Inadequate information systems3. Lack of physician involvement4. Insufficient senior management leadership and

support5. Problems in adapting the principles & practices

of industry-based CQI to healthcare

Ferlie & Shortell (2001)

Theoretical foundations of change managementIndividual 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

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

Four levels of Change for Improving Quality in Healthcare

Levels Examples

Individual Education, Data feedback, Benchmarking, Guideline, Leadership development

Groups/Team Team development, Task redesign, Clinical audits, Breakthrough collaborative, Guideline

Organisation Quality Assurance, CQI/TQM, Organisation development, Organisation culture, Organisation learning, Knowledge management/transfer

Larger system/environment

National bodies (NICE), Public disclosure, Accrediting agencies etc.

Ferlie & Shortell (2001)

Change continuum

Small scale Large scale

Incremental Transformational

Source: Burnes (2009)

Discussion point

Small scale Large scale

Incremental Transformational

Thinking about improvement projects you are familiar with – where would they fit on the ‘Change continuum’?

Speed and force of change

SlowChange/ Transformation

RapidChange/

Transformation

Behaviour and Culture

Structures and Processes


Force field analysisDriving Forces Restraining Forces

The Status quoCurrent Behaviour

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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?

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Feedback from groups

Planned and Emergent change

Environment

Approaches to change

Stable Turbulent

Planned Emergent


Planned and Emergent ChangePlanned 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).

Planned approaches to change

Action research model

Three-step model (Lewin, 1958)

Unfreeze Change (Re)freeze

Time

ACTION

EVALUATION

RESEARCHEffectiveChange

Planned approaches to changeFour 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

Bold strokes and Long marches

Bold strokes Long Marches

Objective Major strategic or economic change

Behavioural/cultural change

Timescale Rapid, short-term change Slow, long-term change

Involvement Senior Manager The whole organisation

Kanter et al., (1992)

Emergent approach to change• Processual research (main strand of

emergent change)

• Define process as

“a sequence of individual and 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)

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 outcomesSource: Adapted from Pettigrew (1997:340)

Five central factors for managing changeEnvironmental assessmentCollect & analyse information about external and internal environmentLeading changeCreate positive climate for change; link action of people at all levels of the organisationLinking strategic and operational changeLinking intentional strategic decisions to operational changes and emergent changes influence strategic decisionsHuman resources as assets and liabilitiesKnowledge, skills and attitudes need to be combined for successful outcomesCoherence of purposeDecisions and actions need to flow from the above and complement and reinforce each other. Source: Pettigrew & Whipp (1993)

Role of managers in changeDecision-making: • Intuition and vision• Gather, analyse and use data• Understand political consequences of decisions• Synthesis conflicting views• Empathise with different groupsCoalition 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)

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)

Discussion point

What do you think are some of the key criteria for successful change implementation?

Ten commandments for executing change1. Analyse the organisation and its need for change

2. Create a shared vision and a common direction

3. Separate from the past

4. Create a sense of urgency

5. Support a strong leader role

6. Line up political sponsorship

7. Craft an implementation plan

8. Develop enabling structures

9. Communicate, involve people and be honest

10. Reinforce and institutionalise change

Source: Kanter et al., (1992: 382-3)

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)

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Refreshment break

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5. Wrap up

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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

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Technical skills for quality improvementSome 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 ...

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Capability and capacity building in technical skills

QI

Lead

Organisation

Advanced practitionerQI project

/programme leads

Basic skills all / most staff

Professional in QI Months/ years: Fellowship programme, Masters etc

Intensive training1 -2 week course, conferences, seminars

1 day workshop, team project training

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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

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Discussion point

What do you think are some of the ‘soft skills’ needed for QI work in healthcare?

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Soft skills for quality improvementOur top 10:

• Communication• Team leadership• Followership• Influencing skills• Negotiation• Assertiveness• ‘Political’ (organisational) awareness• Time management and prioritisation• Knowledge management • Stress management

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Learning skills for quality improvementImportant 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

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Learning skills for quality improvementMethods of learning e.g.:• Critical reflection• Observation• Story swapping

Attributes for learning skills to be effective• Willingness to learn• Encouraging participation• Externalising tacit knowledge

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Leadership developmentThe Improvement Pyramid

Source: Gabbay et al (2014)

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2. Doing improvement and studying improvement




6. Wrap up

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Importance of measurement

• Without measurement cannot be sure that anything has changed

• Enables monitoring of changes and whether improvement is sustained

• Builds the case for resources for the improved service

• The right measures will enable understanding of how the intervention works

The Health Foundation’sLining Up Research projectAn ethnographic study of interventions to reduce central line infections

What happens when organisations are asked to interpret data definitions, collect data and report on CVC-BSIs?

Link between measurement and improvementMeasures showing high rates of CSU infection could motivate action – but only if credibleLow rates sometimes induced unjustified complacency

Credible data is a must

If I’m honest right before we started, we didn’t think we were that bad. […] We thought, you know, [we] don’t really have a problem with central line infections. But I think what it was, nobody ever looked to see whether we were any good […] and when we compared our infection rates, actually they were far worse than any of us ever realised. (Senior nurse, participant 43)

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Measurement for improvementSome examples:

• Statistical process control charts

• Patient experience surveys

• Staff awareness/atttitude surveys

• Repeat analysis of survey results

• Clinical indicator data

• Clinical audit – patient record data

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Exercise: Measuring the change to demonstrate improvementIn your groups, consider the case study you have been given:

• What measures would demonstrate if the project has achieved a change?

• What measures are key as improvement measures?

• What barriers might there be to the collection of the necessary data?

• What concerns would you have about validity and comparability of the data?

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Feedback from groups

“Consideration of context goes hand in hand with the problem of establishing causality.”

So,

“Context” is fundamental to both making and studying improvement... and to the development of the science of improving health care.

Mary Dixon-Woods

Importance of context in spread of improvement interventions• The improvement intervention is not an inert

medicine

• It is never applied in isolation

• Each organisation, service, department has to adapt the intervention

• BUT

• It’s essential to know what are the core components

• Implement with veracity to the underlying concept

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Discussion point:Context considerations What aspects of context are important when aiming to implement improvement interventions?

In original setting?

When you try to replicate in a new setting?

Some we thought of earlier:• Fit with current processes, systems

• Fit with national, regional, local policy drivers

• Attitude of organisation to improvement

• Level of coverage of staff with technical QI skills

• Stability of organisation and system

• Leadership of professional groups

• Teamwork, inter-disciplinary and cross-system working

• Who has the power?

• Other?

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2. Doing improvement and studying improvement




6. Wrap up

A framework for change

Slow TransformationSlow Change


Level: The OrganisationFocus: CultureApproach: Emergent change

Level: The OrganisationFocus: Structures & ProcessesApproach: Bold Stroke

Level: Individual/GroupFocus: Attitudes/BehaviourApproach: Planned change

Level: Individual/GroupFocus: Tasks & ProceduresApproach: Kaizen events

Rapid TransformationRapid Change

Turbulent EnvironmentLarge Scale Transformation

Stable EnvironmentSmall Scale Transformation

What does this mean for Improvement Science?

Combination of approaches: planned and emergent change?

Linkages between top-down and bottom-up approaches to change

Context-dependent (see Perspectives on context – Health Foundation)

Change agents do not necessarily occupy senior roles

Power and politics!

Responsibility for change is devolved

A range of skills. including learning skills are needed (see Gabbay et al., 2014 , Skilled for improvement? – Health Foundation)

Sustainability and spread

• Allowing both discovery and assessment of what is effective;

• Fostering good system design and redesign; and

• Supporting rigorous scholarly work crossing disciplinary and professional boundaries

Improvement science concerns the models, methods and metrics that create the underlying knowledge ...

Eight steps to successful change

1. Establishing a sense of urgency

2. Creating a guiding coalition

3. Developing a vision and strategy

4. Communicating the change vision

5. Empowering broad-based action

6. Generating short-term wins

7. Consolidating gains and producing more change

8. Anchoring new approaches in the culture

Source: Kotter (1996)

References and further readingBate et al., (2014) Perspectives on context, The Health Foundation http:/www.health.org.uk/publications/perspectives-on-context/

Bullock, R & Batten, D (1985) It’s just a phase we’re going through: a review and synthesis of OD phase analysis, Group & Organisation Studies, 10 (Dec) 383-412.

Burnes, B (2009) Managing Change (5th Edition) Prentice Hall: Harlow, UK

Caldwell, R (2003) Models of Change agency: A fourfold classification, British Journal of Management, 14(2) 131-142

Carnall, C (2003) Managing Change in Organisations (4 th ed) Prentice Hall.

Dixon-Woods M et al (2012) Overcoming challenges to improving quality. The Health Foundation http:/www.health.org.uk/publications/overcoming-challenges-to-improve-quality/

Dixon-Woods M et al (2013) Lining up: How is harm measured? The Health Foundation http:/www.health.org.uk/publications/lining-up-how-is-harm-measured/

Ferlie, E. & Shortell, S. (2001), Improving the quality of health care in the United Kingdom and the United States: a framework for change, Milbank Quarterly, 79 (2,) 281-315.

Gabbay, J. et al (2014) Skilled for improvement? The Health Foundation

Kanter et al., (1992) The Challenge of Organisational Change, Free Press

Kotter, JP (1995) Leading change: why transformation efforts fail, Harvard Business Review, March-April.

Lewin, K. (1958) Group Decisions and Social Change. In Readings in Social Psychology. Maccobby et al. (eds.), Holt, Rinehart & Winston 330-344 .

Martin G. et al (2013) Frameworks for change in healthcare organisations: A formative evaluation of the NHS Change Model, Health Services Management Research, 26(2-3) 65-75.

Pettigrew, A. & Whipp, R (1993) Understanding the environment. In C Mabey &B Mayon-White (eds) Managing Change, The Open University.

McWilliam, C. & Ward-Griffin, C (2006), Implementing organizational change in health and social services, Journal of Organizational Change Management, 19 (2) 119-35.

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For more information on the Health Foundation and improvement science see:

w.w.w.health.org.uk

sign-up for our newsletterwww.health.org.uk/account/newsletter-registration/

follow us on Twitter @HealthFDN(http://twitter.com/HealthFDN)

Thank you for your participation

Contact details: Helen Crisp: [email protected] Williams: [email protected]

m10 a scientific approach to initiating, implementing and sustaining improvement helen crisp, the...

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