Embedding Improvement
Science in Training
Programmes:
Why Bother?
Professor Jean Penny,
University of Derby
jean.penny@btinternet.com
All working life in and with NHS
Diagnostic Radiographer and teacher
National improvement roles 1994 – 2008
Improvement educator and advisor 2008 – present
Awarded OBE for services to NHS 2003
Visiting professor University of Derby 2008
Jean.penny@btinternet.com
Improvement:
19 years and still learning
Healthcare will not realise its full
potential unless change
(improvement) making becomes an
intrinsic part of everyone’s job, every
day, in all parts of the system.
Batalden, P. B et al.
Quality and Safety in Health Care 2007;16:2-3
◦ What is Improvement Science?
◦ Why bother embedding it into
training programmes?
 Who
likes change?

Any improvement is a change
◦ not every change is an improvement
◦ but we cannot improve something unless
we change it
Eliyahu Goldratt
Goldratt E (1990) Theory of Constraints, North River
Press, Massachusetts
Any improvement is a change
 any change is a perceived threat to
security

◦ there will always be someone who will
look at the suggested change as a threat
Eliyahu Goldratt
Any improvement is a change
 any change is a perceived threat to
security
 any threat to security gives rise to
emotional resistance

◦ you can rarely overcome emotional resistance with
logic alone

Eliyahu Goldratt
“Anyone who thinks
you can overcome
emotional resistance
with logic was
probably never
married”




Any improvement is a change
any change is a perceived threat to
security
any threat to security gives rise to
emotional resistance
emotional resistance can only be
overcome by a stronger emotion
Eliyahu Goldratt

What to change?
◦ Pin point the core problems

What to change to?
◦ Construct (simple) practical solutions

How to cause the change?
◦ Induce the appropriate people to invent such solutions
◦ they must own the problem
Eliyahu Goldratt
Goldratt E (1990) Theory of Constraints, North River
Press, Massachusetts
4 equally important parts of
improvement
People
What
User and public
involvement
Change
management
How
Diagnostic tools
and techniques
Process
Project and
programme
management
Discipline of improvement
in health and social care (Penny 2003)
 If
I had one hour to save the
world, I would spend 59
minutes defining the problem
and one minute finding a
solution
A Einstein
Challenge the
paradigms
The Model for
Improvement
Understanding the problem.
Defining what you’re trying to do
What are you trying to accomplish?
How will you know that a change
is an improvement?
What changes can you make that will
result in the improvements that you
seek ?
Act
Plan
Study
Do
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The
improvement guide: a practical approach to enhancing organizational
performance 2nd ed, Jossey Bass Publishers, San Francisco
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
3.5
Average length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
9.0
3
8.0
2.5
7.0
2
6.0
5.0
1.5
4.0
1
3.0
0.5
2.0
31
29
27
25
23
21
19
0.0
15
17
Months
7
13
6
11
5
9
4
7
3
5
2
3
1
1
1.0
0
Weeks
Patient length of pre-ward stay
Stroke Ward
from 01/2007 to 07/2007
35.0
30.0
Mike Davidge NHS Institute
for Innovation and
Improvement
25.0
20.0
15.0
10.0
5.0
0.0
Patients
The Model for
Improvement
What are you trying to accomplish?
How will you know that a change
is an improvement?
What changes can you make that will
result in the improvements that you
seek ?
Act
Plan
Study
Do
What have others done? What does
the evidence say? What hunches do
we have? What can we learn as we
go along?
Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L, (2009), The
improvement guide: a practical approach to enhancing organizational
performance 2nd ed, Jossey Bass Publishers, San Francisco
Change principle
Change principle
Solution /
change in team
/ organisation A
Solution /
change in team
/ organisation B
PDSA cycle for learning and
improvement
Act
What we plan
to do next is
…. (state
next plan)
• what changes
are to be made?
• next cycle?
Study
Looking at what
happened, what
we learned from
this was…..
(lessons learned)
Plan
•objective
• questions and
predictions (why)
• plan to carry out
the cycle (who,
what, where, when)
We planned
to.......( state
the basic plan)
In order to …..
(tie it back to
the aim)
Do
•complete the
• carry out the plan
analysis of the data • document problems
• compare data to
and unexpected
predictions
observations
• summarise what • begin analysis
was learned
of the data
What we did
was….. (brief
description of
actions)



The Model for Improvement breaks things
down into small steps and works on the ‘little
dots’ – at the frontline
These small steps should be part of the
answer to the question of how to move the
‘big dots’
Align all improvement projects to strategy
The
strategic
aim (and
big
problem)
Primary Drivers:
Contribute
directly to the
strategic aim
Secondary Drivers:
Contribute directly to
primary drivers
The interventions / change ideas that
contribute directly to secondary drivers
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
?
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
Intervention 1
Intervention 2
Intervention 3
◦ What is Improvement Science?
◦ Why bother embedding it into
training programmes?
Improvement in pre-registration
education: aim – to raise awareness to
improvement for better safer care
To develop health and social care
students who are curious about how
they could improve their service, and
who are receptive to different ideas
and able to bring about the necessary
changes by applying a variety of tools
and techniques in their own context
2006





‘my duty, part of my professional role, I
should get involved’
‘be prepared to extend role and take on new
responsibilities’
‘small problems have a big impact on
patients’
‘anyone can take part – we’re all responsible’
‘I have the skills’
Tribal consulting, External evaluation 08/09
It is making a difference......
‘…..I have interviewed over 100 applicants of newly qualified staff …..One
of the questions asked was " Service development is everyone's
responsibility, …have you been involved in any changes happening while
you have been on a placement?
It was obvious …that one particular University's candidates had all identified
an area for improvement in practice .. and had tested and evaluated them
during their stay there. Some of their ideas were still in use and others were
not. Some of the ideas were interesting and made us think about looking at
those areas for improvement ourselves.
…..it was very clear that the candidates from other local universities had not
been involved in any changes
……we employed those that could clearly discuss how to introduce and
evaluate a change in practice or improvement to patient care’.
Nurse Manager, Neonatal Unit, North of England, March 2011

Engagement of key
stakeholders

◦ University structures i.e.
plan everything in advance
◦ Difficult time as currently
revalidating
◦ Difficulty getting
everybody in the same
room at the same time
◦ Barriers in engaging
with practice
◦ Engaging Faculty and
colleagues

Resources
◦ Time
◦ Funding
◦ Human Resources
and Extra work
◦ Rooms
Timescale / Timing

Attitudes
◦ Student Attitude and
receptiveness
◦ Staff Attitude and
receptiveness
Tribal Consulting, External evaluation of 08/09

The main challenge to sustainability is
ensuring that key faculty and senior
academics truly understand and value
improvement as a concept. When this
happens improvement is prioritised and
sustained in an ever pressurised curriculum.
Replies from 33 universities (69%) of the
48 universities on the NHSI contact list

Work with your team /colleagues: value differences
Really understand the problem
Develop aims and measures: What are you trying to

Measure for improvement: How will you know a






achieve?
change is an improvement?
Gather change ideas: What changes can you make that
will result in the improvement you want?
Test change ideas (PDSA cycles) before implementing
Learn from things that do not work
Link frontline changes to strategic objectives
Healthcare will not realise its full
potential unless change
(improvement) making becomes an
intrinsic part of everyone’s job, every
day, in all parts of the system.
Batalden, P. B et al.
Quality and Safety in Health Care 2007;16:2-3
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
Embedding
Improvement
Science in
Training
Programmes:
Why Bother?
Professor Jean Penny,
University of Derby
jean.penny@btinternet.com



‘Competence: what individuals know or are able to
do in terms of knowledge and skill
Capability: extent to which individuals can adapt to
change .... and continue to improve their
performance’
‘These days there is so much knowledge available
that we risk drowning in it.......Learning about how
things are interconnected is often more useful than
learning about the pieces’
Fraser Greenhalgh (2001) Coping with complexity: educating for capability