shcr review 2015 - appendix 5 case studies

1 | S H C R i m p a c t r e v i e w – A p p e n d i x 5

The School for Health and Care Radicals: what impact has it had?

Appendix 5: in-depth case studies

Stella Martorana

Jonny Gifford

CIPD


Contents Note......................................................................................................................................................... 2

Introduction ............................................................................................................................................ 3

Kirsty, Healthcare Assistant ..................................................................................................................... 4

Rebecca, Deputy Sister ............................................................................................................................ 6

Ekta, Quality Improvement Fellow .......................................................................................................... 8

Adrian, Communications Director ......................................................................................................... 10

Gemma, Head of Quality ....................................................................................................................... 12

Liz, Quality Improvement Advisor and Collaborative Coach .................................................................. 14

Paula, Colorectal and Stoma Care Nurse Specialist ............................................................................... 16

Trevor, Patient Online Volunteer .......................................................................................................... 18

Karen, Scottish Patient Safety Programme Mental Health Coordinator ................................................ 20

Pamela, Senior Economic Advisor ......................................................................................................... 22

Lois, Head of Practice Support .............................................................................................................. 24

Dominic, Service Delivery Manager ....................................................................................................... 26

Jane, Clinical Audit Facilitator ................................................................................................................ 28

David, Public Governor (Volunteer) ....................................................................................................... 29

Note This appendix forms part of the review of the 2015 School for Health and Care Radicals run by NHS Improving Quality. The review was conducted by the research arm of the CIPD between November 2014 and September 2015. The main report, which presents an overview of the findings, is also available.


Introduction This appendix presents findings, from in-depth interviews with participants in the SHCR. These aimed to shed light on the process of becoming a more effective change agent and on what change agents do differently that distinguishes them, as well as gain further insights into the impacts of the school on participants’ work, their organisations and the wider healthcare community.

The interviews were conducted in April and May 2015. The recruitment strategy involved an email being sent to all SHCR participants by the NHS IQ to invite them to take part in the interviews. Twenty-five participants responded that they were willing to be interviewed. From these, 15 interviewees were selected to include mainly NHS employees, two UK based non-NHS employees and two participants based outside the UK. Thus, we used an initial convenience sample, inviting participants to volunteer as interviewees, followed by a purposive sample to broadly reflect the international nature of SHCR participants (Trochim, 2006).

Once informed consent had been obtained, the interviews were conducted and digitally recorded. The critical incident technique was used in the interviews to drill down into participants’ stories of how they have developed as a consequence of being part of the school. The interview recordings were transcribed using a confidential service and the transcriptions thematically analysed by the research team using the qualitative data analysis software NVIVO.

Summary case studies were produced and shared with the respective interviewees for their amendments and approval. One interviewee declined for their case study to be published for reasons of organisational sensitivity. The remaining 14 case studies are presented in anonymised form below.


Interviewee 1, ‘Kirsty’, Healthcare Assistant Working with stakeholders to improve staff & patient safety

‘Kirsty’ is a final year student working for NHS Trusts as a flexible healthcare assistant. She carries out various clinical and non-clinical tasks and her role involves working effectively in a variety of settings, wards and departments as part of a multi-disciplinary team.

She applied her learning from the SHCR to develop a risk management system for adults with history of offending and/or acute psychosis.

What was the situation? In February 2015, a multidisciplinary team at ‘Midtown’ Hospital Trust discussed the case of a vulnerable adult with history of offending that had been recently admitted to hospital. In this instance, Kirsty, who was doing a placement as LD Nurse, realised that an assessment or safeguarding form was missing, as well as clarity around legal requirements and information sharing between professionals.

Regarding the form, she explained that its implementation is needed to ensure safety of the staff, the other patients and the adult with history of offending. It also enables effective patients care.

“It helps to have a risk management in place. It informs the level of supervision a patient might need. For instance if somebody is under section 3 or they have legal restrictions, both staff and security have to know what these legal requirements mean. So if you have a proper framework in place it just makes the staff life easier and protects everybody”

How did Kirsty approach the situation? She decided to bring the issue to light and initiate the discussion with her colleagues and other professionals such as police officers and nurses in order to deal more effectively with similar cases in the future.

“Basically I just started asking if certain things were in place [...] After the meeting I sat down first with the safeguarding lead and learning disability liaison to discuss my observations [...] I asked the police officer to have a bit of a chat with me. I asked the different professionals to spend time with me and discuss my observations.”

The school provided guidance on the practicalities of the change process, as outlined below.

I tried to follow certain things I learnt from the course, like how I should approach people, how I should find adults to support this process, how I should ask for feedback in this kind of case. At the end we ended up with a form that is going through now the whole process to be implemented within the Trust.

The project is now in its final stage and awaiting final approval.

What difference did the SHCR make? Kirsty stated that before the SHCR she did not have enough confidence and knowledge of change methods to successfully challenge the status quo and promote new ways of working.

“Obviously there is a bit of resistance or criticism, but I think I’m more proactive and confident at least to share the observations and ideas and see what other


people think [...] The SHCR definitely has had an impact on my confidence, but also the practical things as well, how you’re supposed to do this and how you can do it in a positive way [..] I think storytelling is something I tried to practice and more consciously use”

Contrary to last year, she has networked more extensively with her colleagues. In fact, she looked for their feedback and incorporated suggestions from different experts in the form.

“When it comes to change I listen or aim to listen better, which means that I will take into consideration everybody’s perspective, the differences to understand why people may resist change. So when I try to initiate a bit of a change recently it was key to consider finding people who can join and support the case”

What’s the benefit been? Kirsty stated that the SHCR has helped her lead the change, because she has developed confidence, resilience and an understanding of the importance of information sharing, storytelling techniques and networking. The school increased also her empathy and openness to other people’s viewpoints.

Finally, the SHCR provided a compelling sense of belonging that sustained her actions during her journey to change.

“You really felt like you were part of a community [...] it was great to create a community and learn from each other”


Interviewee 2, ‘Kate’, Deputy Sister Gathering feedback from colleagues to identify service quality barriers

‘Kate’ is a Deputy Sister working in healthcare service for older people at a University Hospital.

She applied her learning from the SHCR to the identification of barriers to service quality within her ward, composed of twenty eight staff members.

What was the situation? Kate’s ward had many challenges ahead, due to the large number of in-ward patients and the lack of permanent staff. Since the ward was created, in October 2014, they had three different ward managers.

“I’m working on a ward, which is very new and we’ve got lots and lots of challenges at the moment with a large percentage of patients, so we haven’t got a complete permanent team at the moment, so that is a challenge when you are trying to bring about change. I’ve acknowledged the fact that staff were not happy on the ward. We’ve got staff who were leaving and not necessarily for the right reasons.”

How did Kate approach the situation? Kate decided to set up a ‘Friday Hubble’ with the multi-disciplinary team, to facilitate team building and draw together a plan for the nurses working over the weekend. The idea came from the ‘NHS Change Day’, which took place on March 11th, when the SHCR was running.

“We try and take it in turns to bring cake in for the Friday Huddle, we get together with the MDT and we create a really good solid plan that the nurses can use over the weekend”.

Prior to the SHCR, the weekend staff used to receive a plan for each patient. Now, they have two lists: one list of patients who require a senior review and another list of patients that can be allocated to other areas. The introduction of this system improved access to information and service quality.

In addition, Kate set up a two-week intensive incident reporting, in order to gather anonymous feedback from her colleagues on what needed to change.

I could see there were lots of changes that needed to be happening on the ward and I wanted to use it as a way of seeing what the staff’s opinion about what changes we needed to make first.

On a daily basis, her colleagues reported what went wrong during their shift (e.g., things not stocked up properly) and placed the anonymous stickers inside a box at the reception desk.

I emailed everybody, because obviously, I’m not there all the time. There are three other deputy sisters on my ward, I tried to get them involved with making sure they promoted it and gave the stickers out. I particularly homed in on people like the receptionists, who sit at the main desk and often hear people saying, ‘Oh, this isn’t going right’ or, you know, moaning.

Kate analysed feedback from the staff, identified opportunities for improvement and wrote an action plan tackling barriers to service quality. The plan has been recently discussed with her line-manager and she is awaiting a final feedback. In the meantime, she set up an online forum to share the project outcomes with her sisters.


What difference did the SHCR make?

“I think the school has definitely given me confidence. Before, I was thinking of lots of ideas where we could change things, just in small ways, on the ward, to provide safer or more quality care and since doing this course, it’s given me the confidence to move with those ideas, accept that fact that people are going to say, ‘No’ or be a bit resistant and I’m not going to be put off, I’m just going to keep going”.

Before implementing the project, she informed the consultant for the ward, the manager, and she also involved other three sisters in the promotion of the programme.

“People have said it was a really good idea [they] are really keen to find out what’s going to be happening, so definitely, definitely, I’ve got people […] they are quite engaged with it”

What’s the benefit been? The SHCR increased Kate’s confidence and resilience. She has fostered support for change, consulted with others to identify barriers to high-quality patient care and actively sought solutions to short and long-term problems.

I’m still quite passionate about the things that I’ve learnt there and how it will improve my patient care and leadership skills in the future. I really hope that I can inspire other people that I work with to do it as well. [..] I’m working with a different group of people now, so I don’t know if it’s a coincidence, but I’m in a different place to where I was this time last year


Interviewee 3, ‘Sarah’, Quality Improvement Fellow Introducing a new clinical practice for new-born babies under antibiotics

‘Sarah’ is a Quality Improvement Fellow in Paediatrics at ‘Charles’ Hospital.

She applied her learning form the SHCR to introduce a new clinical practice improving patient safety: the use of C-reactive protein (CRP) to exclude infections in new-born babies under antibiotics.

What was the situation? Sarah came across scientific articles explaining the importance of using CRP when babies are under antibiotics.

“And I came across this article, I read it, and said: Why don’t we implement this practice? [..] But as people don’t like changes and certain people are like, ‘Because this solution is coming from this person, I don’t want to buy it.’ [..] This is the working culture and you can’t change it in a day”.

In addition to the cultural challenge described above, Sarah enlisted the organisational structure among the barriers to change.

“There is only a two-tier system, consultant or SHO level. So there is no middle grade doctors in paediatrics. So I work on the junior level because I wanted to work as a QI fellow. So when you work on a junior level, it’s really, really hard to make any changes happen or get your voice heard”.

How did Sarah approach the situation? Despite her initial failures during the promotion of the clinical practice, Sarah decided to be persistent, and capitalised on the SHCR teaching.

Firstly, she gained the support of the Lead, who was attending the SHCR as well.

So initially, I met her for some quality-improvement work but then I came to know she also completed the School of Health and Care Radicals this year. So then we kind of found a common ground [...] we both think that we have a common, shared purpose

On a Friday morning they organised a ground round to present the latest-evidence medicine proving that repeated CRP makes the difference in neonatal care. Still they had some resistance, therefore Sarah decided to involve the Clinical Lead from a tertiary neonatal unit where the practice had been implemented. His reputation was undiscussed as people would rely on him for specialist neonatal advice.

“It has become a very established practice now. I would say most of our babies are now getting a repeat test done within 24 hours of starting antibiotics. So now we don’t see resistance about it”.

What difference did the SHCR make? Sarah built an important connection with the Lead thanks to the SHCR, but also learned that she cannot rely on one person only to make change happen.

“After the School, I know that to have a change in practice and to sustain it, you need the engagement from your other team members […] So I got other people involved who can influence the team, if they were not getting influenced by me and


my clinical lead. So that was the visiting consultant from the tertiary neonatal unit.”

Sarah changed her approach in other situations as well. For instance, recently she wanted to publish advice leaflets for children in order to explain the process in a child-friendly language and improve the patient experience. At first she failed, as there was no money to fund the project. Shortly after the hospital refused the funding, she contacted a charity and won its support through persuasive talks delivered by other people involved in the project such as the designer of the leaflet and a mother of a child. In this instance, the application of storytelling techniques learned during the SHCR was crucial to secure funding for the project.

What’s the benefit been? Sarah stated that the SHCR helped her understand that change can start from the bottom. In addition, she understood that involving other people is crucial for the success of a Change Agent.

“I think this is the key point I learned from there that, no, I shouldn’t consider myself as a troublemaker. I am a rebel and I should be proud of it. I am a radical. It doesn’t matter at what level I work, if I have the right qualities and right intention I can make change happen”.

The SHCR connected her with likeminded individuals and this sense of belonging enhanced her resilience skills.

“I have listened to so many stories during the modules from the School of Health and Care Radicals and I’ve come to know that nobody’s life as a change agent was easy or is easy. That you will have hurdles. You just have to sustain yourself there with the right intention and just be there and try to build up a team. You will achieve your goals but it’s not going to be easy [...] so it is a lesson of resilience in a way”


Interviewee 4, ‘Mark’, Communications Director Implementing new communication channels to discuss high-quality care for patients

‘Mark’ is Communications Director at The Park Hospital NHS Trust.

He applied his learning from the SHCR to the implementation of new internal communication channels facilitating information sharing and discussion on the best ways to deliver care.

What was the situation? Mark realised that the hospital was holding onto traditional communication channels and that needed to change.

“Within our health system, we're using the approach developed by ECIST for breaking the cycle. Locally, we're calling it Safer Care, Shropshire, Telford & Wrekin #safercareSTW. We were just going round houses in terms of whether or not we should have a Twitter account”.

He wanted to implement more innovative communication channels and structures to engage staff and indirectly improve patient care and service quality.

“The change was not so much about outcome, but about process, and saying, ‘Actually, what I first and foremost want is to have a clear channel through which people can engage on this issue and develop their own ideas”

How did Mark approach the situation? Mark fostered the involvement of his colleagues and leveraged the power of informal networks.

“Using the tools in the School for Health and Care Radicals, it didn't feel like I'd made the decision on my own, because I used informal networks to send out an idea, ask for views, check for sensitivity. So what I felt I'd done at the end was make a decision that there was enough support around that I would be able to take forward”.

He showed resilience, courage to challenge the status quo and willingness to challenge even his traditional thinking.

“So particularly through some of those things around working on my informal ties, and thinking, Actually, I've got enough support for this and secondly, I'm not so scared of going for no; I've developed a very much thicker skin. Then I was able to just say, Right, I'm just going to establish this Twitter account,"

Finally, Mark set up an account that developed over 70 followers within two days.

“I'm starting to use this as a platform for encouraging conversations across organisational boundaries around the best ways to deliver care [...] I tried to make it interactive, so the way that the tweets started was by saying to people, How about saying to the world ‘Hello, my name is Anna and this is mypledge for the week?”

What difference did the SHCR make? In the past, bureaucracy and Mark’s strive for unanimous consensus used to prevent any change, resulting in the adoption of traditional communication channels.


“[Last year] it would have been tortuous. We'd have had to go through a committee, and it would have been deferred, and we'd have had to - oh, God knows what”

Attending the SHCR has been the turning point in his management of innovation processes as it empowered Mark to take the risk and bring about change.

“So yes, that was the important thing. I see it as a quite powerful role within the organisation, and one of the realisation elements was that it's sometimes easy to forget the power that one has inherited in one's role, because you just think, Oh, I'm just me. I'm a board representative for this organisation, and the people around me are not just relating to me as a peer. Let's try this, let’s do this”

What’s the benefit been? The SHCR enhanced Mark’s networking skills; he created new informal networks and strengthen ties both within and outside the organisation.

It was an empowering experience that boosted his energy and motivation.

“I guess I'm the kind of person where I need regular injects of creativity, like participating in the SHCR. It's very easy to get tied down with the bureaucracy and the false assurance, particularly as a director in a large organisation, and too busy reacting to what's happening. Taking part in it was a really useful kick-start for me in 2015, to remind me what I'm here for”.


Interviewee 5, ‘Pauline’, Head of Quality Building a shared sense of purpose to facilitate cultural change

‘Pauline’ is Head of Quality at Community partnerships, a social enterprise. . When she took part in the SHCR, her role was Quality Manager. However, her learning from the course played a large part in informing her application for the Head of Quality post.

She applied her learning from the SHCR to the promotion of cultural change within her organisation, in the context of her new role.

What was the situation? Pauline used to run into obstacles in her journey to change, striving for quality improvement and high quality care. She outlined her sense of “feeling different” and the need for validation characterising her routine at work.

“When I started the course I did think there was just me who felt differently and thought differently. Then actually what the course tells you is that there are more people like you, not just on the SHCR but in the organisation in which you work. Finding these people and getting them on board is vital for cultural change to occur and be sustained.”

How did Pauline approach the situation? Pauline has recognised the importance of finding likeminded individuals and networking extensively with her colleagues. For instance, she recently found out about a course on Quality Improvement through the SHCR and, being conscious of getting more people on board to drive the quality agenda, invited her colleagues to participate.

“I blogged on our organisation’s intranet about my vision for quality within the organisation, and to hear other people’s ideas; those who want to change quality at a service level be they clinicians, administrative colleagues etc. So l wanted to spark that interest and look at how we might do that. I promoted the course and asked who was interested, encouraged them to enrol so we could start a mini quality improvement movement.”

A number of colleagues enrolled on the course.

Pauline explained that she has challenged the status quo frequently to identify new and better ways of working.

“I am the kind of person that will put that challenge in and ask, why? Are we doing the right thing? Is there a different way to do this but equally, is quality going to be maintained? People don’t necessarily like being challenged do they? But if you can refer back to the course and explain why that change is needed or where you are coming from, try to understand where they are coming from. That’s really important, especially for those people who aren’t as receptive. The SHCR re-enforced that it’s not just OK to challenge, it’s often necessary.”



“In the past I would have gone off and done things on my own and to try and change the world. I now understand the importance of getting people on board. One person can’t do everything. There really is strength in numbers”

As outlined above, the SHCR was crucial to develop networking skills and understand the importance of building alliances and an effective community of colleagues sharing the same purpose.

Furthermore, she embedded these principles into her thinking and behaviour, adopting a transformational leadership style.

As Head of Quality, she has not changed just one, single aspect of practice, but has begun to contribute to a cultural change of the organisation with regards to quality improvement.

“It [the SHCR] made me think about how in the role I would engage others, try to get others onside. How we could encourage colleagues to challenge from the bottom up, not just the top down. […] The organisation I work for is really keen on this approach. The SHCR has provided me with the tools required to really embed this way of thinking and to ensure quality improvement is led by those who understand where change, for the better, needs to happen.

What’s the benefit been? The school enhanced Pauline’s networking skills, shifting the focus from compliance promotion to the adoption of a relationship building approach, moving from a “must do” culture to a “want to do” culture. It complemented her knowledge of change methods and provided a social identity to grasp on during tough times. In fact, the school resolved her sense of being “different”. As a result, her level of confidence increased significantly and gave her the “permission” to continue to challenge.

She now sees the importance of selling an idea and getting likeminded people on board so that quality can be improved via a culture of co-ownership.


Interviewee 6, ‘Caroline’, Quality Improvement Advisor and Collaborative Coach Using social media to inspire and encourage colleagues to change

‘Caroline’ is a Quality Improvement Advisor and Collaborative Coach at a not-for-profit organisation based in Canada. Her organisation provides coaching and collaboration with health care partners related to quality improvement, and public and patient engagement.

She applied her learning from the SHCR to foster involvement and support in change initiatives aimed at improving service quality and patient care.

What was the situation? In February, Caroline learnt of the local event ‘Change Day’ that was aimed at celebrating pledges and actions to improve healthcare. Caroline was participating at the SHCR at that time and was willing to promote change and encourage people to sign up and make pledges.

How did Caroline approach the situation?

“I spoke about the need for me personally, so my values first, the change starts with me. I wasn’t connected and I wasn’t keeping up to date, and that since using twitter I felt that I was more part of a community. Since I was part of The School for Radicals, I felt I had some of the tools and the support that I needed”

Caroline decided to be more active on Twitter and on the Facebook group for Change day. She also signed up to be a Change Day Ambassador. Over the last few months she took a leading role, presenting at staff meetings and fostering involvement within the team, composed of 37 colleagues.

“Every time someone does a pledge, I’m trying to make it more personal and trying to bring it back to the story, so reframe into storytelling rather than a random pledge. So I’m trying to really get connected to people on their values and create the shared purpose for us all”

An example of a time when she fostered involvement on social media is outlined below.

“I did a sketch note. I put it out on Twitter. I put it out on the Facebook group and it was eight ways to get pledges for Change Day. There was a webinar around Change Day BC and I presented the ways that I had been promoting Change Day by webinar. Next week I’m attending another education day, if you like, to meet more people in the province to see how we can really take those pledges up to the next level”

Caroline has kept herself updated with innovative projects taking place in other countries, such as the SHCR, and wanted her organisation to learn of new initiatives going on across the world. For this purpose, they have introduced monthly meetings where she can share her learning and provide feedback to the rest of the group.

In addition, Caroline has formed a team looking at human centred design, specifically at new ways to approach change and collaboration.



“Last year in general, I felt very isolated. I found I was using the same kind of advice in about how to promote change. It was things like what are your top down goals of your organisation. It was very technical and compliant.

Caroline stated that her approach to change has stretched to include values and motivation of her colleagues, in order to build a community of people sharing the same goal: high-quality care for patients.

“I’ve shifted over the last year to much more of a commitment model rather than a compliance model, so what actually motivates people to change. [..] It would be things like telling stories and trying to motivate internally […] Whereas a year ago, I think I would have gone more for the metrics and push the methodology a little bit more.’

The school influenced her decision to apply for the internal post of Collaborative Coach. So far, she has coached Local Action teams, that tackle child youth mental health and substance abuse, about building relationships with key stakeholders.

“It is how these teams are going to build the relationships with each other as the foundation for transforming healthcare for child youth mental health in the province”.

What’s the benefit been? Caroline stated that she developed networking skills and confidence, moreover she discovered the power of transformative storytelling for social change. She is grateful to the SHCR because it helped her identify new levers for change and it created a supportive community of people.

“The big piece for me was in my work I feel quite isolated. I was really looking for connections, support and to be kind of a part of a community […] I feel still fairly isolated in my work, but I think that’s just the way our organisation is. I now have people inside my organisation who I connect strongly with, and I have many, many more outside of my organisation that I connect very strongly with.”


Interviewee 7, ‘Holly’, Colorectal and Stoma Care Nurse Specialist Challenging the status quo to introduce new ways of working and improve patient care

‘Holly’ is Colorectal and Stoma Care Nurse Specialist at a NHS Hospital.

She applied her learning from the SHCR to the introduction of new ways of working.

What was the situation? Holly explained that she wanted to bring about change within the nurse specialist team because poor ways of working were undermining staff wellbeing, and service quality was negatively impacted as a result.

“I was struggling to find a way to do that, because I am not the team leader, I am not a Manager, I am just one of the team [...] Some members of the team were working 12 hours a day, five days a week. They were exhausted, they were unhappy and this was coming out in how they communicated with each other and functioned within the organisation”

How did Holly approach the situation? In February, during a meeting with the Colorectal Nurse Specialist team, Holly raised her concerns. She triggered a discussion on their situation, initiating a conversation on what needed to change. Challenging the status quo “opened this can of worms of how burnt out everybody felt and how completely bogged down with the amount of work we were trying to do”.

Then, she supported the introduction of the Colorectal Nurses Change Day, as outlined below.

“We spent a whole day [colorectal nurses day] looking at our service and trying to develop it and change the way we work”

As a result, they set up fortnightly meetings where each person developed a plan outlining actions for the following two weeks, including information on what they needed to find out and feedback to the rest of the team.

In addition, they started scrutinising their usual processes and procedures to enable a more efficient allocation of resources.

“We are managing the pathway of cancer patients through the organisation and doing a lot of things that could be done by administrative staff. Because they are not doing it, we have, over the years, picked up these various roles that really shouldn’t be us doing it but we do. We need to push back some of those now, hand them back to the multi-disciplinary team [...] to give us more time to spend with the patients who need our support.”

Holly initiated the change successfully, as she gained the engagement of her colleagues, and together they changed some ways of working, but the process is still at an early stage.

“We haven’t actually got all the answers yet but we are working on them and that is huge progress from where we were”.

What difference did the SHCR make? The SHCR enhanced Holly’s resilience skills and boosted her confidence and energy to finally challenge the status quo and promote new ways of working.


“I think the main thing is realising that change starts with me [...] Although it is uncomfortable, you have to go for it really […] I think what worked well was not being worried about people saying no and the resistance to change. It was recognising that you are going to have no’s and actually that is the reason for discussing it further and helping to bring people along with you”

During week 1 of the SHCR, Holly’s energy and motivation increased to the extent that her colleagues asked her to lead them through the initial part of the change process.

“I hadn’t told them at this point that I was doing the school so I think they did wonder what my motivations were and where I was getting my energy from”

The SHCR impacted also on her self-awareness and approach to change, as described below.

“I think previously I had been very much get my head down and get through the work day to day. What I have realised is that I need to raise my head up a little bit within the organisation, make connections with other people in other teams and use them for support”.

What’s the benefit been? The SHCR was an empowering experience that helped Holly to develop confidence, resilience and networking skills.

She built also an important connection through the SHCR. In fact, she contacted a Quality Improvement Executive after learning of his participation to the school. He was impressed by the impact that the SHCR had on Holly to the extent that he decided to re-run the school within the Trust to inspire and motivate other colleagues. So far, a group of 40 people enrolled to their internal SHCR.


Interviewee 8, ‘Richard’, Patient Online Volunteer Understanding the NHS culture to promote patients’ access to health record

‘Richard’ is a volunteer involved in Patient Online, an NHS England programme designed to support GP practices to offer and promote online services to patients, including access to records, online appointment booking and online repeat prescriptions. Richard is a member of Patients Working Together group, which is made up of patients and patient representatives supporting Patient Online to adopt a patient-centric approach.

What was the situation? Richard wanted to promote patients’ access to health records but knew that this was not common practice. He was seeking ideas and solutions to bring about change within the NHS.

“I think patients themselves are a substantial wasted and underused resource of the NHS. They should be more, if you like, brought ‘into the boat’ to help manage the resources more effectively.”

How did Richard approach the situation? As part of the NHS Expert Patients Programme, Richard created and shared presentations with some regional teams in UK. In April, he decided to participate to the Electronic Patient Records conference where he spoke of the importance of online services such as medical records access. In this instance, he applied storytelling techniques learned during the SHCR such as sharing his story and values with the audience.

“My presentation explained what the programme was, and then went on to show how I had personally benefited from online access to my own record. I then emphasised that online access had not only helped my well-being, but also that it had enhanced my relationship with my GP. I did emphasise this aspect because I know many GPs value the partnership they've got, particularly with patients with long-term conditions, and so that was emphasised to achieve a more effective engagement of the audience.”

What difference did the SHCR make? Richard stated that the SHCR was a door into the NHS culture: “The SHCR suggested that the course would help delegates to make changes by ‘rocking the boat’ – but I recognised that having never worked within the NHS in any capacity, I wasn’t even in the NHS boat! First of all, I had to find a way of climbing into the boat so I could start making changes”.

Another learning point for Richard was the realisation that the impacts he was striving for could be easily not considered or disregarded within an NHS culture.

“The mere fact that changes proposed and implemented didn’t generally involve the patient made me realise, via the School, that people just forget about patient-led suggestions and initiatives [...] I didn’t initially fully understand where the health service was coming from, and how inbred the culture is that it's not important to patients to have online access to their own health records”

The school helped him understand resistance within the organisation, in fact empathy and openness to other people’s viewpoints improved significantly since he took part to the school. As a result,


Richard stated that he can understand the issues from a NHS quality and culture perspective, and can talk to GPs on level playing field.

The SHCR also reminded him that he needed to create a powerful vision for change enlisting others in in a shared view of the future.

“I recognised progress to the vision could be in small steps - you don't have to change all the world in a day! You've got a vision of what you want to help achieve and working in the direction of that vision -towards the meeting the expectations of patients and citizens - it was important to recognise small changes that were made along that path.”

In particular, Richard developed storytelling skills for engaging presentations, as outlined below.

“Yes, it [the school] suggested that storytelling should be recognised as helping to try and make people see it from my own eyes as a patient. Secondly it helped me realise that I needed to acknowledge where clinicians and others working in the NHS were coming from, you know, their starting point when I'm trying to affect the change and get it accepted. Their reasons for accepting, and ‘buying into’ a change might not necessarily be mine, and they might not even recognise my reasons.”

What’s the benefit been? Richard has developed an understanding of the NHS culture, which enabled him to create plans to ensure that the desired changes become a reality. He has developed openness to the viewpoints of people resistant to change, as the school increased his empathy. In addition, the SHCR enhanced his storytelling techniques.


Interviewee 9, ‘Ruth’, Scottish Patient Safety Programme Mental Health Coordinator Building relationships to engage her colleagues in surveys and learning events

‘Ruth’ is Patient Safety Programme Mental Health Coordinator at a NHS board.

She used her learning from the SHCR to engage the staff in surveys and training courses.

What was the situation? Ruth enrolled to the SHCR to have in-depth understanding of change theories, process and tools in order to lead change in her organisation.

“So they will listen to me and engage in what I want them to do because I am asking them to do something that is extra to their job”.

Some examples of desired outcomes are participation to staff survey and attendance to learning events.

How did Ruth approach the situation? Ruth set aside some time for informal talking and conversation with her colleagues working in the ward.

“When I work on the wards with clinicians who work in the patient safety programme, I make time to see them and try and get to know them so then they are more likely to engage in the programme when I listen their concerns.”

Since the school started, she has had regular meetings with the staff in order to build effective relationships and encourage and support her colleagues. Essentially, she has adopted a relationship building approach.

“If I’m at the hospital […] I will try, even if I am just seeing one appointment for one ward, I will try and pop into the other wards and […] and say, Hello, how are you doing, how's it going? […] I think it's important to make time to build that relationship before trying to ask them to do different thing’.

An example of a time when she encouraged and supported a colleague is outlined below.

“For example, one of the nurses, wasn't getting support from his ward manager and he kind of lacked confidence in some of the work so I tried to encourage him in what he was doing and listen to his concerns and suggest ways that he might get round that.”

As a result, there have been more people engaged and willing to participate to staff surveys, collect outcomes data or attend learning events.


“I might have, in the past, thought people weren't doing something. I would have maybe labelled them in my head as laggards or resistors to change but now I think of them, to try and understand their viewpoint and think maybe they just don't know as much about what we are doing.”


The SHCR increased her empathy, as outlined above, and enhanced her communication skills. In the past, Ruth used to rely solely on traditional communication pathways, exemplified by email requests to participate to staff surveys. She has now adopted an interactive communication style.

Moreover, she has consulted people on what needed to change and has valued her colleagues’ ideas and concerns.

“Prior to that I might have thought, It will be okay […] but now you think, No, these are genuine concerns and we need to listen to them and make something that's more fit to be used across different wards, rather than just thinking, They'll just go with it […] because it probably wouldn't work. If we get as much feedback as we can then you are more likely to get something that will work when it's used across a wide area.”

What’s the benefit been? The school boosted Ruth’s confidence and resilience. It also enhanced her networking skills and empathic abilities, resulting in openness to other people’s viewpoints and better listening skills.

“Even in the face of resistance, you just have to keep going and remain upbeat and encouraging.”

Finally, she would like her colleagues to participate to the School for Health and Change Radicals in 2016, with a view to building an effective team sharing the same purpose.

“I'd hope to get more people to do the course next year, to get a group of people from here and I've been getting staff to do the fundamentals, quality improvement staff, for some of the wards that I work with. Three of the nursing staff have signed up for that.”


Interviewee 10, ‘Helen’, Senior Economic Advisor Embracing radiologists’ resistance to change to promote new working practices

‘Helen’ is a Senior Economic Advisor at an overseas Radiology College. The College is a professional medical society dedicated to serving patients and society by empowering radiology professionals to advance the practice, science and professions of radiological care.

Helen applied her learning from the SHCR to change management, in order to facilitate the transition of radiologists to new ways of working.

What was the situation? The College of Radiology and another Association of Radiology have been following the trend of physicians transitioning to new payment models with the goal of helping their members to make these changes for radiology.

“It will change the way that radiologists get paid, and it also changes the way that they work.”

When Helen enrolled to the school, the College had just received the results of two surveys showing that most radiologists have not transitioned to the new models yet.

How did Helen approach the situation? The disappointing results of the survey led Helen’s team to focus on the little progress made.

“Leaders in the Radiology Practice Management Group including their chair of this committee, the executive director of their organisation and I reviewed their survey results. Then my physicians who are chairs of our network and I reviewed our survey results as well. All of them decided that there was nothing we could do with the data that we had, and there was no message.”

Helen’s thinking was different. She thought that the radiologists’ resistance to change was unavoidable and it should have been embraced.

“I wrote an article recently that said basically to our membership, ‘If you haven’t changed, don’t worry you are not alone.’ […] So one of the worries with the radiology practices is they hear about how our government wants to push the change quickly, and they are not changing fast enough and have been left behind.”

The article, published in a healthcare professional journal, reassured radiologists that there was still time and resources available for them to engage in the transformation process.

Helen participated to the development of training courses for radiologists running in June and fall 2015. Moreover, she searched for case studies to add to the ACR online resources. The case studies illustrate exemplary stories of colleagues that changed their practices and ways of working.

“We point them to the stories to say, here are different ways, small and large, where radiologists have tried to change, it has improved in team based care, the quality of patient care and has changed how they work.”


What difference did the SHCR make? The SHCR increased Helen’s confidence and enhanced her resilience skills, in fact she decided to stick with her dissenting opinion against the majority of her colleagues. She also stated that last year she would have not sent an empathic message to the community of radiologists.

“I think the biggest thing I got out of that [the SHCR], that I hadn’t thought of before was, instead of saying, ‘You must change’. Was to try to get them to say, ‘We want to change.”

Furthermore, the school unveiled the power of storytelling to engage with people on an emotional level and facilitate their learning. Consequently, Helen applied storytelling principles to the development of online resources such as case studies.

What’s the benefit been? Helen stated that the SHCR enhanced her empathy, energy and positivity in face of resistance, along with storytelling skills. It boosted her confidence to challenge the status quo and dig deeper in the change experience from the radiologists’ viewpoint.

“I thought that it was inspiring to know that there are other people in the world in healthcare that are trying to effect the change and that there was reinforcement that it can be done at the grass roots level or not from the hierarchy but from the bottom-up. Once I started listening to the modules I really got drawn in. I think you are all doing a great thing empowering people that they can make a change.”


Interviewee 11, ‘Lindsey’, Head of Practice Support Soliciting and valuing GPs’ negative feedback to improve service quality

‘Lindsey’ is Head of Practice Support at a Clinical Commissioning Group.

She applied her learning from the SHCR to the engagement of member practices in initiatives such as staff surveys and to the identification of barriers to service quality.

What was the situation? Lindsey’s role involves relationship management with twenty-five member practices counting about 160 GPs in total. She makes sure that they are informed of plans and actions outlined by the Clinical Commissioning Group (CCG).

Lindsey wanted to increase the practices’ level of engagement in surveys and other initiatives led by the CCG, as outlined below.

“We have a poll every year administrated by MORI, which came out on Friday. The GPs and other stakeholders mark us as to how well or otherwise we’ve done and this year we’ve done pretty well. But there are seven of the practices that didn’t participate at all.”

How did Lindsey approach the situation? Lindsey decided to focus her attention on the practices that decided not to participate.

“Some of it will be because they didn’t feel it was worthy of their time. That’s fine but I need to change that relationship over the next year so that they believe that 20 minutes is worth investing.”

Firstly, she has tried to identify the GPs who refused to participate to the poll.

“I’m now going to […] dig much deeper to work out what it was that they were thinking and how in fact we could improve the relationship […] So, the first thing I did this morning was send them individually an email with the actual result and saying that […] there were some areas where GP colleagues felt that things could be better and would they be prepared to discuss it with me?”

Lindsey encouraged GPs to come forward and express their concerns with a view to resolving issues and improving their processes.

“I generally meet the GP practices every month. So, during those meetings I’ll try and tease out any issues that they might have flagged, anonymously on this poll. Try and tackle it, one issue at a time”

What difference did the SHCR make? The SHCR revolutionised the way Lindsey reacted to practices’ refusal to participate, in fact last year her attention was drawn solely by the positive outcomes.

“Going back to the Mori poll on last years I was happy to get 70% and didn’t or haven’t spent as much time as I will be doing this year on the 30%. […] I am interested in the ‘power of no’ perspective to understand the lack of engagement by the 7 as well as dissect the information supplied by the participating GPs, that indicated they were not entirely satisfied with the way we communicate


Lindsey added that she wanted to harness the power of rejection and negative feedback, as taught by the SHCR.

“So, today I’ve gone through and identified all the negatives, as I see them, and now using this information, as positive feedback that alerts us to potential issues”

The school influenced her coping strategies, boosting her confidence to initiate change. It empowered her to assume the initiative and take some steps forward in her journey to change.

“Being a health care radical change starts with me […] the NHS world is governed very much top down and you feel that your span of control is quite small...”

In addition, Lindsey shared study materials with colleagues working on various projects. Essentially, the school has provided a library of content to support conversations with her colleagues.

What’s the benefit been? Lindsey has developed resilience and networking skills, her openness to others’ viewpoints has increased as well as her confidence to face resistance. It also enhanced her communication skills.

“I think one of the abiding lessons that I learnt from the school was you can’t just keep hammering at the door using the same size hammer. You know, you have to keep changing the message or using a different tack or trying a different approach.”

Finally, the school provided a sense of belonging to a community of likeminded individuals which reassured her on a personal level and served as a pervasive driver for change.

“If you’re way of working seems to be often in swimming against the tide of the way that other people work, eventually you sit back and think, ‘Oh, who’s right and who’s wrong here?”


Interviewee 12, ‘Alan’, Service Delivery Manager Changing leadership style to lead the team through an organisational restructure

‘Alan’ is Service Delivery Manager at the NHS.

He applied his learning from the SHCR to build better relationships with his team to ensure he could lead them successfully through an organisational restructure.

What was the situation? When Alan enrolled to the school, an internal restructure was taking place. He was eager to understand how to engage his staff in the change transformation process.

“I need to engage all of the team members on the fact that the job that they’re doing, on a day to day basis, is potentially going to change in the next two to three years. That’s the kind of role that they’ve done for the entire time this service has existed.”

How did Alan approach the situation? Alan changed the way he would liaise with his team. As an example, he described a performance review conducted recently with the Internal Communications Lead.

“So instead of me just saying, you need to go out and engage people on a different future, I’ve tried to get the manager thinking, and help him understand what that means for the people involved”

Alan has encouraged him to adopt a more participative and less directive leadership style, taking into account the viewpoints of the members of his division, which counts 450 people. He highlighted aspects and factors that the manager should consider prior to choosing the communication topic and channel.

“The review earlier on was more talking about the impact on the team member. Is that going to work for them? Without having a connection with them, how would you even know what you’re going to communicate out is what they want to know, what they’re interested in, where their emotion lies?”

Alan has been the first one to adopt the new approach and inspired his team to do the same. He also shared study materials with his colleagues. In fact, the SHCR provided a library of content to support the conversations with his team; the study materials served as icebreakers to start meaningful conversations.

Alan explained that his division is at the early stages of service transformation through digitisation. He has motivated people to take ownership of the change process, as outlined in the quotes below.

“With a strategic objective for the organisation of digitising 80% of our transactions it’s important that we take the staff with us as we work to achieve that goal. The new vision for the service has only been in place really for a couple of weeks now, but the main improvement has been employee engagement.”

Alan wanted to build a community of people sharing the same goal: high-quality service.

“The argument that we’re trying to make is if we’re all in it together and we take an emerging approach, we could find numerous other ways of adding value, saving


the NHS money, reducing wastage, or using information that we’ve got at our fingertips in a much more effective way.”

What difference did the SHCR make? The SHCR helped him develop self-awareness to acknowledge his communication and leadership style. This formed the basis for change, as he understood the value of others’ viewpoints.

“The approach that I would have taken, prior to getting involved in the school, would be to just sit at the head of the table and explain what needs to change. Whereas the difference that I try to implement now is to try and get people to be part of it, and understand that it’s the right thing to do. What that means for them and have them come with me, rather than me tell them anything.”

Alan recognised that before the school his leadership style was hierarchical.

“The feel that they [the meetings] originally had was me giving an update, and then instructing the team managers what they needed to do. Now it’s a very different feel. We talk a lot more about the journey that the service is on, rather than me just giving them a list of instructions to follow […] I think there’s more of an understanding of the shared purpose between me and the managers that I oversee.”

As a result of participating in the SHCR, Alan has embedded storytelling into his communications.

“I think one of the things that I’ve taken from the school was the element of telling a story and to inspire people, and how to frame things.”

What’s the benefit been? Alan stated that the SHCR increased his self-awareness, empathy, and confidence. It also enhanced his networking and storytelling skills. Moreover, Alan has changed and improved his approach to relationship buildings as a result of the school participation.


Interviewee 13, ‘Barbara’, Clinical Audit Facilitator Promoting information sharing and collaborative working with a clinical team

‘Barbara’ is a Clinical Audit Facilitator and TARN* Coordinator at a NHS Hospital.

She applied her learning from the SHCR to the relationship with a clinical team and the development of new ways of working.

What was the situation? Barbara’s working relationship with the clinical team was challenging, as outlined in the quote below.

“A few years ago when I was handed that team to work with, nobody would venture through the door to their meeting. Initially someone came with me, two of us used to go.”

Barbara wanted to change the way their educational half-days were organised to encourage collaborative working.

“We only used to hear about the projects when they had finished them, and were ready to present the results.”

How did Barbara approach the situation? Barbara started meeting the clinical team regularly and encouraged other colleagues to do so. She took the habit of meeting the Chair before any monthly meeting to discuss the content and overall purpose of the event. She also invited a few people to do presentations.

“Rather than them coming along after they’ve completed a project, we’re trying to develop a sense of ownership and get everybody on board before any work actually goes ahead. There are a lot of years of experience in the meeting, so we try to draw on that and give everyone a chance to comment, and to discuss the methodology, aims and objectives. Sometimes the team will revise what they intend to do based on the outcome of the discussion. So it’s a development process.”

The small-scale changes introduced by Barbara led to other initiatives impacting significantly on their ways of working. The number of people willing to present their proposed projects grew in number over the last few months.

“It’s a very small change but it’s starting to snowball in that within a few months they’ve begun to embrace it. So I’m trying to expand on that now and roll it out to other meetings, and also to expand the scope of what we do with the team and with their projects, so that everybody’s on board. It sounds quite a small thing but actually it’s quite a big change for us, from a meeting that we never used to even walk into.”

What difference did the SHCR make? The SHCR boosted Barbara’s confidence and energy, to the extent that she has attended meetings with the clinical team regularly and actively participated to those.


“[Last year] I wouldn’t have spoken up like I do now. I felt quite intimidated in those meetings but generally I think, over time, they’ve begun to develop some respect for the work that I do with them”

Barbara stated that the SHCR improved her networking skills, in fact she has connected with people that she wouldn’t naturally network with.

“I’ve tried to make an effort at every meeting, to talk to at least one person that I wouldn’t have otherwise talked to, because there are always alliances to build. So I’m very much aware of that now.”

She defined the SHCR ‘an empowering experience’, as outlined below.

“There’s been a huge empowerment and a change in my attitude in that, rather than being afraid to do anything or feeling as though I don’t have permission to do something, this has given me the permission to actually say, yes go ahead and do it.”

What’s the benefit been? The school boosted Barbara’s confidence and motivation, and it improved her networking skills. Barbara specified that the SHCR provided meaning to her daily struggles, creating a purpose shared by a community of likeminded individuals.

“I did feel quite isolated until I attended the school but now I think, well I’m not really isolated, I’m just working in a different place, I’m working on the edge. The school has also made me realise how many other people there are out there who are pretty much the same as me and that gives a sense of belonging which outweighs any isolation.

*Trauma Audit & Research Network

Interviewee 14, ‘Mike’, Public Governor (Volunteer) Supporting carers in hospital settings: Re-igniting a dormant strategy for change

‘Mike’ is a Public Governor at a Hospitals NHS Foundation Trust who applied what he’d learned from the SHCR to reignite the Trust’s commitment to supporting unpaid carers.

What was the situation? Three years ago, Mike was asked by the Director of Nursing if he would lead a project to create a Trust-wide carers’ strategy to improve support for unpaid carers. With the help of a multi-agency steering group, Mike produced a detailed carers’ strategy and action plan which was then handed over to the Trust to take forward.

“There are lots of wins from this project. It is a win for the patient because they will be looked after better and outcomes will be improved. It is a win for the carer because they will get support to help them continue in their role and stay well. It is a win for the staff as it makes their job just a little easier, and finally, it is a win for the trust as it can help reduce length of stay and reduce readmissions.”

When several months went by with only some of the recommended actions being carried out, it was clear that the existence of a carers strategy and action plan would not, in itself, bring about the


necessary changes, especially with so many other competing demands on staff’s time. As a former practitioner of change management at a multinational corporation, where there was an expectation that change would automatically follow strategy, Mike was unsure of how to proceed, particularly since his role as governor wasn’t operational. Fortunately, the answers he needed came to light after enrolling with the SHCR.

How did Mike approach the situation? To reignite a sense of urgency that change was needed, Mike first task was to approach the Deputy Director of Nursing with a story of a carer who was very unhappy about being excluded from discussions about the care of his mother, a former patient on the hospital’s dementia ward. As Mike pointed out, by putting the carers’ strategy into practice, the Trust could help ensure that no other carers would go through the same experience in future. The Deputy Director shared his sense of urgency and, using her organisational knowledge and influence, recruited 18 members of staff from a wide variety of roles to form an alliance for change.

“We have a fantastic dementia ward at the hospital, but the story that I got from one of the carers centres was a really powerful one about poor experience that had resulted from the carer not being properly involved. It really struck a chord. It was very emotive.”

The alliance came together at a workshop in July 2015. A representative from the Carers Trust and a fellow SHCR radical helped to design and deliver the programme. Powerful stories were used to engage the attendees and encourage ideas on not only what needs to be done but how.

“The content of the workshop was very much driven by the training we did [the SHCR]. For example we started the workshop with a story that really got across the problems of not supporting carers so that people could really empathise, and then followed it with a positive story to reinforce the discussions from the first story.”

What difference did the SHCR make? Mike said that the GE approach had been effective in the past, but the learnings from the SHCR had been particularly valuable within the culture and context of the NHS. The School had subsequently altered his approach to leading change because it had highlighted the importance of the emotional engagement of stakeholders. Mike also harnessed the power of storytelling along with networks and relationships as crucial levers for change.

“At the moment, we are still at an early stage but I have found storytelling and effective framing extremely useful. We had an instant impact with the stories we used. After recounting the first story to our Deputy Director of Nursing, she said, ‘We have got to sort this out. We’ve got to do it. At the workshop, one member of nursing staff said: “When I came today, I didn’t think I would learn anything new, but the workshop was very powerful. I will go away today, determined to drive change”

What has the benefit been? The SHCR really reinvigorated Mike’s motivation and provided learning to give the project real momentum and impact.

“We have some way to go yet but I know we’ve taken the right path this time and I don’t think we’d be where we are now without the SHCR.”


Reference Trochim, W. (2006) Nonprobability sampling. Research Methods Knowledge Base. Available at: http://www.socialresearchmethods.net/kb/sampnon.php

http://www.socialresearchmethods.net/kb/sampnon.php

shcr review 2015 - appendix 5 case studies

Health & Medicine