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 ………. ………… ……… ……….. ………. ………. ………. …………. 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!