Making a
difference
NHS Improvement
Stroke Programme
Making a
difference
Key principles behind
making a difference
The human dimensions
of change
How to put it all into
practice
Run charts &
control charts
Ladder of
inference
PDSA cycles
Generative
relationships
Variable
40
35
Ounces
30
Flow charts &
deployment
charts
25
20
15
10
5
0
S
R
T
A
Date
Workforce
Development
Data & measures
F
C
MODELS FOR
IMPROVEMENT
S
£
Clinical value
compass
Global Aim
Template
Small groups
Task
Force
Meeting
skills & disciplines

Team
Crew
Left-hand
column
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Fishbone
diagrams
Making a difference is about
Knowing
what to
do
What to change for the biggest
impact
Doing it
Making the change in the most
efficient and effective way
Checking
it worked
Has all the effort made any
difference?
Keeping
it going
Sustaining the benefits of the
changes
Leadership
Knowing what to do
Ask those who
experience the
service
Establish how
the service
aligns with…
Patients
Families
Staff
Clinical and quality standards
National and organisational
objectives
Measure it!
Stroke services are data rich
Knowing what to do
Poole Hospital asked stroke patients to develop an
aspirational pathway for transfer of care
In changing the process they improved both patient
experience and stroke unit access
Making a difference is about
Knowing
what to do
What to change for the biggest impact
Doing it
Making the change in the most efficient
way
Checking
it worked
Has all the effort made any difference?
Keeping it
going
Sustaining the benefits of the changes
Doing it!
Designate
the project
lead
Create a
project plan
together
• The driver not
the one who
does
everything
• Not necessarily
the most senior
role in the team
• Share it
• Base it on
credible
evidence
• Make
objectives
• SMART
• Aligned
Test first
• Start small and
check impact
(PDSA)
• Pilots make
people less
nervous
Take people
with you
• Service users
• Senior leaders
• Team
Making a difference is about
Knowing
what to do
What to change for the biggest impact
Doing it
Making the change in the most efficient
way
Checking
it worked
Has all the effort made any
difference?
Keeping it
going
Sustaining the benefits of the changes
• Obtain clear measures of progress
against initial objectives from data
and patient feedback
Don’t depend on anecdote/gut
feeling
• If the service is improved tell
everyone!
Apply for an award!
Checking it
worked
Making a difference is about
Knowing
what to do
What to change for the biggest
impact
Doing it
Making the change in the most
efficient way
Checking
it worked
Has all the effort made any
difference?
Keeping
it going
Sustaining the benefits of the
changes
• Consider sustainability
before you finish
• NHS sustainability
toolkit
• Modify if needed
• Extend if possible
Keeping it going
The NHS Sustainability Model
Maher, Gustafson, Evans 2003
©NHS Institute for Innovation and Improvement 2006
Monitoring progress
Training
and involvement
Adaptability
Staff
Process
Credibility
of evidence
Attitudes
Senior leaders
Organisation
Clinical leaders
Benefits
Infrastructure
For the web based version go to
www.institute.nhs.uk/sustainability
Fit with goals
and culture
Applying the sustainability model
Dorset Community Health
Overall score 60.5
Sustainability - Improvement Gains
(all sections)
Least to gain from improvement
Benefits
Credibility of the evidence
Adaptability
Monitoring Progress
Involvement and Training
Behaviours
Senior Leaders
Clinical Leaders
Fit with goals and culture
Infrastructure
www.institute.nhs.uk/sustainability
Most to gain from improvement
Managing the Human
Dimensions
of Change
Common elements:
Measurement
Activity
Communication
Improvement ‘tools’
Organisational support
Review
Any changes involve taking
people with you
Attitudes to change differ…
Annoying
evangelism
Proportionate
enthusiasm
Irrational
obstructionism
Moderate
interest
Healthy
scepticism
What are YOU like?
Attitudes to change
Calming down
Keeping in real world
Perspective
Focussing
?
Annoying
evangelism
Irrational
obstructionism
Proportionate
enthusiasm
Support
Direction
Feedback
Moderate
interest
Healthy
scepticism
Motivating
“Unpacking”
Exploring
Debate (argument)
Evidence of benefit
Selling
Maintaining Momentum
• Managing transition
– Know yourself and
value others
• Sustaining
Improvement
– 70% of organisational
change is unsuccessful
Know yourself and value
others
Working with others – some guiding principles
Changes happen to us all
whether we like them or not
Opportunity or
threat
•
•
•
•
•
New role
New responsibilities
New experiences
New relationships
new career
opportunities
• Exposure of
inadequacies
• Stress
• Pressure to achieve
• Lost profession
• Lack of belonging
What’s in it for them?
CONTROL
SAFETY
HAPPINESS
POWER
PRODUCTIVITY
PROFIT
PRESTIGE
MOTIVATION
OUTPUT
CHOICE
COMMITMENT
RESULTS
FLEXIBILITY
LEISURE
STATUS
VALUE
SENSE OF
ACHIEVEMENT
RESPONSIBILITY
FUN
IMAGE
SECURITY
FRIENDS
INTEREST
HASSLE-FREE LIFE
Value the differences: even when
they don’t see things as you do!
“What do you mean ‘It’s a bit muddy’? ”
Change is different from
transition
Change is situational: new site, new
boss, new team roles, new policy
Transition is the psychological process
people go through to come to terms with
new situations
Change is external, transition is internal.
Bridges, W. (2003) Managing transitions: Making the most of
.
change, 2nd ed London, Nicholas Brearley
Morale
Fun?
Anger
Continuous
improvement
Lost
Denial
Despair
Clues
Learning
Understanding
Unless transition occurs, change will not work
•
•
•
Transition starts with an ending
The neutral zone is the no-man’s-land between old
reality and new
Transitions end with a new beginning
ENDING
NEUTRAL
ZONE
BEGINNING
Three phases of transition:
Neutral zone
ENDING
NEUTRAL ZONE
BEGINNING
Three phases of transition:
Neutral zone
ENDING
NEUTRAL ZONE
BEGINNING
Process of transition
It’s nothing new
1747 James Lind
discovers that fresh
oranges and lemons
prevent scurvy
1795 before the British
navy adopted lemons
or limes as standard
issue at sea
Take them with you….
Making a difference:
Working with
Stroke Improvement :
Our experience (so far)
Rhoda Allison
Our service:
Torbay & Southern Devon Health & Care Trust
Local population
250,000
Mix of urban and rural areas
2 Local councils
Inpatient
15 bedded stroke rehabilitation unit
Two community teams
ESD and stroke
Community neurology
Impetus for change
• Ever increasing workload and expectations
• NICE quality marker: access to 45 minutes of each
therapy at least 5 times each week
• Ensuring that people with stroke leaving hospital who are
not considered ESD can still access timely input at the
right level
• Ensuring that people with other neurological conditions
are not disadvantaged by the focus on ESD
What did SIP help us with?
Data collection
•
Macro level
– Total number of referrals and people on treatment, waiting times etc
– Total number of staff available
•
Micro level
– How staff spend their time (every 15 minutes)?
– What exactly does each person having treatment need each week and
what do they receive?
Process mapping, sharing ideas, change agent
It’s the P word?
PROPERLY!
Example: What you might do with macro data
• What are the total numbers of referrals received each week?
• How does this compare with staffing available?
• How do we know what is an expected workload?
(Cochrane review and Collaborative statement suggests that 1.0 PT;
1.0 OT & 0.4 SLT are core therapy professions to take 100 referrals for
ESD per year)
No guidance available for 45 minutes, or other conditions? What about
skill mix?
Example: some of our micro data
Band 3 staff supporting PTs
Clinical meeting
3%
Clinical administration
20%
Direct patient contact
46%
Telephone
3%
Transport
14%
General administration
3%
CPD
10%
Time spent on direct patient contact in IP units by
PT staff (Putman et al, 2006)
100
90
80
70
60
50
40
30
20
10
0
GB 46%
CH 54%
DE 66%
BE 62%
What next for us?
• We recognise that we need to establish what is an
expected workload in a field of practice where every patient
is an individual!
– Share data with other services
– Set a standard and test it out
• Staff are developing a plan to further increase productivity
& reduce waste
– Protocol for delegation to Band 3s
– Consider basing staff in geographical areas
Making a difference?
• Would recommend SIP resources, support & publications
• Share ideas across the region?
• If you intend to collect data, you may not need to collect at
all levels at once!
Thank you to all the staff in our trust!