QI Essentials: More than a set of tools…

There’s no doubt that quality improvement employs a large set of tools – driver diagrams, statistical process control charts, Pareto charts, force field diagrams, cause and effect diagrams, PDSA cycles, affinity diagrams, flow charts… The list could go on and on. Indeed, one of the comforts that quality improvement brings is the chance to build experience with a repertoire of tools that can help us as a team view systems and processes, gather information, organise information, understand variation and relationships between factors. Knowing that there is a tool to use in a given situation helps build belief that there is value in applying a systematic approach to solve a complex problem. As an organisation or system builds improvement capability, there is additional comfort from the increased fluency that builds across a community of improvers with these tools, which provide practical and helpful structure when working through complex problems, much as a structured risk assessment tool helps frame a clinical team discussion and decision-making. Most of these improvement tools are more powerful when applied by a team of staff and service users working together, and so utilising tools together as a team can help create and reinforce the cultural aspects of quality improvement such as a flattened hierarchy, equal voice, inclusivity, shared purpose.

A summary of core quality improvement tools from the Improvement Handbook (Associates in Process Improvement)

The extensive use of tools within quality improvement has led some to ask if quality improvement is simply a toolbox – a set of tools that one applies within a broader approach to change. Are we applying and embedding quality improvement if we are just utilising tools at appropriate times? There appears to be an increasing narrative that using process mapping to understand a system, creating a driver diagram to help visualize our theory of change, or using statistical process control charts to view variation demonstrates that we are applying quality improvement.

It’s fantastic that teams are seeing the value of using QI tools as part of their daily work, helping them view the system, organize information or understand variation. In my view though, this isn’t sufficient to truly build a culture of continuous quality improvement. At ELFT, we encourage the use of QI tools – something we describe as daily improvement. However, we need to also recognise that using tools in our daily work misses the opportunity of applying rigour and a burst of energy within formal quality improvement projects to achieve breakthrough levels of performance.

Quality improvement projects also employ tools, but in pursuit of solving a complex quality issue and achieving an aim that really matters to service users and the team. Without the use of structured projects applying the quality improvement method for 6-9 months on a complex issue, we run the risk of getting better at the daily operational challenges, without really tackling the complex, more strategic, longer-term challenges that require us to think differently and discover new ways. Of course, the quality improvement project requires us to create temporary project teams and dedicate resource to work on the issue, which creates a healthy tension with the demands of delivering the day job. Perhaps this might be one reason for people preferring to see quality improvement as a set of tools for teams to apply when they see the benefit, rather than an approach to applied problem solving for both daily challenges and the more strategic long-term challenges.

Continuous quality improvement also requires a change in leadership mindset – devolving problem-solving to the point where the problem is experienced, actively supporting broad involvement in experimentation and improvement activity, encouraging those we lead to take a systematic approach to problem-solving, creating an environment where people feel safe to speak up and contribute to improvement.

In the Toyota production system, the word ‘kata’ describes the set of behaviours and habits that enable the organisation to continually improve. The word kata comes from the choreographed movements practised in martial arts.

Within the management system developed at Toyota, there are two forms of kata – the improvement kata, and the coaching kata. The improvement kata involves four steps:

1. Understand the direction or challenge (clarifying the long term goal or vision)
2. Grasp the current condition (understand the current system and issues)
3. Define a target condition (set an improvement aim)
4. Experiment towards the target condition (test new ideas using a structured Plan-Do-Study-Act process)

Most improvement practitioners would recognise the improvement kata as the core steps for any improvement method, and fundamental to the design and delivery of QI projects.

The coaching kata redefines the role of leaders as guiding learning and application of the PDSA cycle to navigate uncertainty in order to achieve the target condition. This involves asking questions instead of providing solutions, and transmitting confidence. It is believed that one can only teach something and convey confidence if they themselves have tried it and mastered it. So leaders can only become good coaches if they themselves have been a learner, and have adopted the improvement kata to solve problems.

I think this is helpful in showing us that using QI tools as part of daily work can support embedding of improvement into the way our team works together and tackles challenges on a day-to-day basis. To truly adopt the improvement kata, we need to also apply quality improvement to identify our biggest challenges, and discover our way to new levels of performance through structured experimentation. All of this relies on leadership that has first-hand experience and expertise in quality improvement, and adopts the coaching kata in guiding and supporting teams through the complex challenges they are working through.

@DrAmarShah

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QI Essentials: Shaping our future

The last few weeks has demonstrated how incredibly dedicated and adaptable we can be, as citizens, service users and workers within the healthcare system. In responding to the enormity of the covid-19 challenge, the speed with which services and staff have changed and prepared has been quite breathtaking. Of course, the urgency of the situation meant that this immediate response to the pandemic led to quick decisions and implementation, often in a command-and-control structure without consultation and co-design with staff and service users to the extent that we would normally wish.

Every single service at East London NHS FT has changed in the way it operates, from clinical services to corporate services to the executive team. Over the last few weeks, as the pace of changes settled a little, we began to start the process of capturing the changes that had taken place and to systematically consider the impact of these changes.

To help with this, a simple one-page quality impact assessment was developed – asking simple questions about the changes that had taken place (what had stopped, what had increased, what had changed) what potential impact these changes may have had (both positive and negative), and what data might help us recognise this impact.  [click here to download the ELFT quality impact assessment tool]

This first step of simply capturing and logging the immense scale of change and potential impact has been important, and taken several weeks to fully complete. However, this is still largely a paper exercise that needs to inform a much broader and more open conversation. As we move beyond this initial phase, we have an opportunity to truly rethink the nature and model of services in order to better meet the need of our local communities.

There have been some lightning fast innovations during the last six weeks that we would want to hold onto, using a proper mechanism to implement and sustain these changes into routine operations. There are also some old practices that we’ve stopped, and wouldn’t want to go back to, either because they never added much value or we have found better ways to meet the need. There have probably been some interventions we put in place temporarily due to the crisis that we can think about stopping, and we can all think of some aspects of previous service delivery that we’re not able to provide now, but would want to bring back because they provide immense value from the perspective of the service user.

Using a simple 2 x 2 grid, like the one below developed by the RSA, is part of our second stage of ‘shaping our future’ – helping our teams sense-make from all the recent changes and decide what actions to take next to determine our future.

The profound impact on healthcare and society from the pandemic is likely to impact us in multiple ways. Restrictions on movement and service provision during the outbreak are likely to lead to increased demand as the restrictions ease and services begin operating again. Continuing social distancing will mean having to rethink how we operate services – both in terms of patient proximity in waiting rooms and clinical spaces, but also staffing rotas and working arrangements. Interruptions to chronic disease management are likely to lead to effects on morbidity and mortality in the medium term. And the longer term effects on society, through loss of income, housing and increase in mental illness, will likely lead to increased demand on health and social care over time.

Credit to Victor Tseng @VectorSting for the diagram of waves of impact

Proactively planning for these scenarios at service-level will be key to enabling us to prepare and remain adaptable over the coming months in a highly unpredictable situation. We have developed a simple scenario planning tool to support our services with this [click here]:

But the greatest opportunity, perhaps a once-in-a-generation opportunity, is to really rethink our models of service provision and redesign these almost from scratch, wrapping around what really matters to our service users and the population we serve. We are trying to apply our core principles of improvement and people participation to this critical work, co-designing what our future service needs to look like with staff and service users across all areas of our organisation. We are also trying to apply our learning about the triple aim – starting by understanding our population and the inequalities that exist, and in some ways have been exacerbated by the pandemic, in thinking about what our services need to provide, and integrating quality, performance, and value alongside population health in an approach to redesign [click here to download the ELFT framework for shaping our future]. Through virtual workshops, we aim to facilitate an open, honest discussion between staff and service users to see if we can truly rethink how our services need to look in the future, building on the innovation from the last few weeks, but trying to really challenge traditional thinking and focus on how we can support people with what matters most to them.

Amidst all the loss, grief, isolation and difficulties that we’re experiencing right now, this represents a glimmer of excitement and hope that we can turn unprecedented adversity into true opportunity to improve quality of life for those we serve.

@DrAmarShah

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QI Essentials: Opportunity in adversity

Moments of crisis and adversity have given rise to innovation and creativity at so many times in history and for so many organisations.

Serious creativity, as Edward de Bono described it. De Bono is a physician and psychologist who originated the term ‘lateral thinking’. De Bono has developed many of the provocation techniques designed to help us move from passive judgement and decision-making, which is the way our brains usually process information and make decisions, to active creativity enabling us to think differently about a particular context. There are many potential ways to introduce provocation to our thought pattern, some of which we are working through now as we try to prepare and manage the coronavirus pandemic.

How would we support people with chronic, complex needs without being able to travel? How could we run a service without actually physically being together? How can we maintain quality of service with only half the current levels of staffing? All of these questions provoke us to think differently about what really adds value, and what we can do differently. Tough questions, particularly when the scenarios are becoming real, rather than imagined. But it also enables us to confront opportunities that we’ve always been aware of, but possibly haven’t quite had the will to tackle.

So, as we are forced to challenge our normal patterns of work and behavior, to meet the threat of the global pandemic, let’s try to seize the opportunity in this adversity to innovate and design a better system for tomorrow. As we do this, there will be merit in holding onto what we know and practice in our daily application of improvement, in creating cultures of experimentation in our teams and organisations. Here’s a few things that might be helpful for us all:

• Stay curious. It’s too easy, with the need for swift decisions and managing the here-and-now, to lose our curiosity. Try to hold onto regular time to reflect. Notice what’s happening, and ask questions so that we can capture our learning and build theories.

• Test. There’s almost always value in testing before implementing, even when we think we have the perfect plan that will solve the problem. Stay true to the principles of good experimentation – take a moment to be clear what we’re trying to learn from the test, describe our theory behind the change we’re testing and what we predict will happen, prescribe the start and end of the test and who needs to do what to make it happen, and then set aside time to regroup and reflect on what we learnt from the test. Use this to inform your next steps – either to adapt the idea, or if you’re ready, to implement.

• Framing. For leaders especially, helping frame the context in which we’re experimenting is critical. If we support the view that we’re just putting in place temporary measures to meet the current crisis, and that we’ll go back to the status quo afterwards, we’re missing a massive opportunity to learn. Instead, let’s frame this as an opportunity for us to really think about how to best serve the need, and what we can do differently to maximise our effectiveness and efficiency, with the aim of holding onto the things that work for the longer term.

• Build a rhythm. As with improvement, having a regular rhythm helps set the pace. With more and more of us working apart from each other, find ways to connect and be together, replicating the aspects of co-location that add so much value to team working. This is likely to need some testing and adapting, but I’m pretty sure the rhythm of connecting will be much, much more frequent than the previous – with shorter, but more frequent and virtual connection than our usual rhythm of weekly meetings.

@DrAmarShah

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QI Essentials: Improvement as a specialism

Quality improvement has come of age.

It’s wonderful to see the increasing belief in the systematic approach of quality improvement, within the NHS and also further afield. The evidence base is growing that we can solve our most complex issues in health and healthcare by deeply involving those closest to the issue in a process of discovery and learning.

For those of us who are practicing and studying the science and art of improvement, this brings great opportunity – to shepherd and guide large scale improvement, to help nurture cultures of continuous improvement, to develop career pathways for those who wish to develop expertise in quality improvement.

I’ve been thinking recently about what we, as a community of improvers, can do to strengthen improvement as a specialism. A specialism is an activity or study that one becomes expert in and devotes oneself to. How can we strengthen the expertise and aggregation of learning within the field of quality improvement, but without making it exclusive? Ultimately, if our goal is to develop cultures of continuous improvement, we need to democratise improvement and enable everyone to believe they can improve the system, and have the knowledge and skills to do so. So, how best to do this whilst also developing expertise and rigour in the application and discipline of quality improvement? Here are two areas where I feel we can make collective impact…

There’s been a proliferation in recent years of the use of the words ‘quality improvement’. I see job descriptions now with the title including the words ‘quality improvement’, and often wonder whether the job is actually different, or whether the title has just changed? More and more organisations seem to be developing quality improvement teams and plans. I wonder how much is really based on belief in the method, and how much is simply because we feel we have to follow this path? Many of those charged with leading quality improvement within organisations feel disconnected from leadership and strategy, and quality improvement can so easily be viewed and set up as an end in itself, rather than be the way that we deliver our organisational plans and achieve our collective goals. Alongside the proliferation of QI in job titles, I see and hear people talking about improvement collaboratives, often without any obvious resemblance to the principles of good improvement design. Any programme of work these days seems to be able to be labelled an ‘improvement collaborative’. I’m not sure what the theory is behind this – do people feel that it will engage others better? Does it seem like a more attractive way of framing our work? Surely we’re all trying to improve things, so what harm can it do?

I’m sure all of this is done with the very best of intent, with the aspiration to help us improve. However, if we, as committed scholar-practitioners of improvement, don’t call out the inappropriate use of the words and language of quality improvement, we risk undermining the rigour and specialism. Pretty soon, we can expect people to start stating that ‘quality improvement doesn’t work’. But is it really quality improvement that doesn’t work, or the way in which we are executing it? Quality improvement gets diluted to an aspiration, rather than a discipline. We need to help people understand how to apply quality improvement properly, using the discipline and scientific thinking, and integrating it into the way we work rather than becoming a shiny standalone programme.

When I look to the literature to learn from examples of excellent quality improvement work, there’s far less than we ought to find. A tiny proportion compared to the research literature. So the second way that we as improvers can build our field into a genuine specialism, is to share our learning and outcomes. We need to describe the robust methods and design that we use, and help others recognise the principles of good improvement when they see it. We need to celebrate the learning and results we generate, so that we can continue to help build belief that quality improvement, when applied properly, can genuinely achieve transformational change. But only when applied properly, with skillful guidance and rigour.

If this call for improvement to become a specialism has resonated with you, then join me… I’d love to hear from you.

@DrAmarShah

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QI Essentials: For those leading large-scale improvement…

With the new year well underway this latest blog is dedicated to those who are leading improvement in large systems, wherever they may be in the world …Have a read of Amar’s latest QI Essentials Blog..

The New Year is, for many, a time for reflection, appreciation and goal-setting. In this spirit, I’m dedicating this January blog to my peers who are leading improvement in large systems, wherever you may be in the world. Leading large-scale improvement can be an exhilarating place to be, but it can also be frustrating and lonely at times. I want to recognise and thank you for all you do in service of improving the lives of those we serve, and for carrying the torch of quality improvement – inspiring those around you, and supporting people to influence and improve the systems they work in and receive care in.
From my own learning over the last seven years, through testing and failing, many many times, here’s a few things to keep in mind if you’re in the privileged position of shepherding and guiding your organisation or system’s large-scale improvement effort …

Apply the principles of good improvement to leading improvement

This may seem obvious, but treat large-scale improvement in the same way that we support teams to improve. Develop a theory, come up with some ideas, test these, measure and adapt rapidly. And co-produce as deeply and authentically as you can. There’s often a tension between the system’s desire for governance and assurance of improvement (which can result in a sluggish, bureaucratic decision-making process and overly simplified linear approach to improvement), and applying good improvement to the way we approach large-scale change (which is messier, requires rapid adaptation and needs to be led much closer to where the real work happens).

Go where the energy is

Within any system, there will be variation in will for change. I’ve learnt that it’s far more effective for us to wrap close support around teams with energy, rather than to persist in injecting energy into a team or service in the hope that this will create will and urgency for change. The most influential way to generate energy for change is really through peer-to-peer conversation and story-telling. It’s unlikely that we can be as effective when working through traditional hierarchies. So, I’d urge us to have more conversations about where the energy is, make sure we’re close to the work to be able to spot this, and then flexible enough in our approach that we can focus our support where the will already exists.

Stay agile and organise for impact

I’ve been guilty in the past of sticking with a plan for too long, in the hope that things will suddenly change, when a slightly more objective view would have helped me see that the core ingredients for improvement are often lacking. Part of the art of leading large-scale improvement is in recognising that we’ll need to be agile and adapt as we go. Our initial structure and plans only represent our initial theory. And the complex systems that we’re supporting change rapidly. Our learning systems need to be designed to give us real-time feedback on readiness for improvement and progress. We need to talk often about how we can adapt to what we’re seeing – communicating with leaders and sponsors, adapting our focus to create the biggest impact. This means we need to support our improvement team to be nimble and flexible – supporting teams closely, but with an objectivity that allows us to observe, interpret and shift our attention and support if circumstances aren’t conducive for improvement.

Think about language and framing

Quality improvement can easily feel like extra work, and something that’s a bit alien. We bring with us a strange new language, and ask teams to improve their system when we’re often struggling just to complete the day job. Our only chance of success is in helping people see the relevance for their own experience and for those they serve. If we’re to reach such a vast number of people and connect with them emotionally, we need to use language that’s simple and that resonates. I think back to the first project I coached, when we hadn’t yet even begun our QI programme. We spent time connecting with the ‘why’, and encouraging everyone to contribute ideas. We used no jargon in the way we worked together, and there was a beautiful simplicity and raw connection to purpose that wasn’t disrupted by paperwork, formal meetings or strange language.

In creating a movement for change, we need to develop a proposition that’s memorable and easily adoptable, but also allowing local adaptation. The ability for a team to make QI feel locally owned, by adding their own stamp – whether in the form of language, creative arts or through the freedom of choosing what they work on – is critical in enabling rapid spread.

Celebrate frequently, and encourage story-telling

There’s nothing quite so powerful at influencing human beliefs and behaviour as connecting deeply with another person’s lived experience. If there’s one area that all of us can probably spend more time and attention on, it’s story-telling – identifying the great stories that emerge within our improvement efforts, supporting those closest to the work to tell their story, and finding multiple channels, media and fora to reach our audience. I now think about, and talk about stories, on a daily basis in the way I lead. I find myself often asking “where is the story?” or “how can we support this team to tell their story?” Increasingly, I think the way to organise ourselves for large-scale improvement should be to maximise storytelling. Our team ought to include expertise in capturing, packaging and conveying stories. The way we organise our infrastructure for improvement ought to be agile enough to maximise the potential of stories. The relentless drumbeat from leaders to create constancy of purpose is so critical to marshalling everyone behind our improvement efforts, but even more influential is the peer to peer storytelling that can inspire, share ideas and help people gradually shift their fundamental beliefs towards true commitment to continuous improvement.

Balance

Play the long game. Guiding a system to adopt a continuous improvement mindset takes many many years. There will be lots of moments of exhilaration, as well as moments when you’ll want to tear your hair out and give up. Try to keep your eye on the long-term goal, and not get too influenced by the ups and downs along the journey. But – grab each short-term win and celebrate! Each little win can influence many others to join you on this journey.

Above all, be kind to yourself. Leading large-scale change is hard work. Akin to a marathon, it takes dedication and stamina. It can take a toll personally, and can become almost a crusade in its all-consuming intensity. Take time to reflect regularly, identify what brings you joy and ensure you find time for this – both in work, and out of work. I’ve found this to be so important in helping me maintain my energy and optimism over many years.

My deepest gratitude and respect to those who are in the position of leading large-scale improvement. I hope the responsibility is bringing to you the same sense of deep meaning and purpose that I have found…

@DrAmarShah

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QI Essentials: Beyond Projects

Improvement is now becoming a way of life and a way of being. How do we hold onto and strengthen our approach to QI projects?…Have a read of Amar’s latest QI Essentials Blog..

Since we began our quality improvement journey in 2013-14, QI projects have been the mechanism through which we have achieved breakthrough performance. Wrapped around the single question of “what matters most?”, QI projects have brought together a diverse group of stakeholders close to the issue to discover solutions to complex problems, achieving improvements that were previously inconceivable. Our QI approach across the organization has never focused solely on projects, as even our very first driver diagram from 2014 below shows.

We placed just as much emphasis on building will, building improvement capability and creating alignment and support for QI work. Yet the basic structure of a QI project has served us well over the last 5 years. It brings focus, it enables permission, it creates a space to think and imagine, it supports rapid cycle testing…

Over time, we have built belief in the utility of applying quality improvement to solve complex problems, through the systematic method, testing and learning, measuring over time, and deeply involving those closest to the issue. We have also supported 3000 people to learn improvement skills and tools, enabling us to speak a common language and be more effective in the way we understand and solve problems. It’s probably no surprise then that people are now starting to see improvement as a way of life, and a way of being – constantly searching for ways to improve, never being completely satisfied with the status quo, and applying their improvement knowledge to the everyday challenges that we face at work, whether or not these are part of a QI project.

Over the last few weeks, helped by our partners at the Institute for Healthcare Improvement, we have been talking about how we move beyond QI projects. It seems obvious that if improvement thinking and tools are only applied within QI projects, we will fail to harness the true opportunity of quality improvement. So, how do we hold onto and strengthen our approach to QI projects, whilst also enabling and supporting people to utilise their improvement knowledge and skills in everyday work?

Quality management

For me, there are two parts to this answer. Firstly, we need to utilise our quality management system as our approach to helping us manage and improve quality of all that we do. We can’t apply quality improvement continuously – anyone who has been part of a quality improvement effort will realise that this would be exhausting! Quality improvement should be a burst of effort to achieve a step-change in performance. Alongside QI, we need to recognise when we need good quality control, quality assurance or quality planning. As we become more adept at recognizing and deploying a particular aspect of our quality management system to an issue, we will be able to apply our ‘quality’ thinking to all that we do.

Depending on our role, we spend our time in different parts of the quality management system. Most of us spend the majority of our time doing the day job, with perhaps a few hours a week devoted to a quality improvement effort. We would benefit from a robust quality control system that allows us to understand quality and performance in a rounded sense, as close to real-time as possible, identify issues and solve them rapidly as a team. Our improvement mindset and tools are completely applicable to managing our service on a day-to-day basis as part of quality control.

Those of us in team leadership roles will spend some of our time in quality control, but more time focused on quality improvement and perhaps some time in quality planning. And those of us in senior leader roles spend much more time in quality planning – developing and executing strategy, with some time authorizing and sponsoring improvement efforts, and much less time in quality control. Whichever part of the quality management system we find ourselves in, our improvement mindset of being solution-focused and trying to influence the system we work within is an asset. The tools we have learnt through quality improvement may be of help to us, even when we find ourselves in quality assurance mode, or quality control or quality planning. Simple examples of this are the driver diagram, which has helped us visualise our strategy as a Trust (quality planning), or statistical process control charts, which help us understand how our system is performing (quality control).

When do we not need a QI project?

The second part of the answer lies in understanding when a QI project is the best approach, and when it isn’t. We have learnt, mostly through our failures, when to apply formal quality improvement projects to solve a problem – when the problem is a complex adaptive one, when it will likely require testing and learning to discover the solution, when we need a diverse team of stakeholders to understand the system from multiple perspectives, when the support of an improvement coach and sponsor will be helpful in guiding and supporting the work… But many of the challenges we face in our daily work don’t fit this description. Does that mean we can’t use quality improvement?

When I’m trying to improve the way my outpatient clinic functions to try to make sure I don’t keep running late, many of the factors are within my direct control. Do I need to set up a formal QI project, and get approval from a sponsor, in order to work on improving the flow of the clinic? Probably not. But I can apply my improvement learning to understand the problem through a fishbone diagram, create a driver diagram to better understand the factors related to a smooth-flowing clinic, develop ideas and test these out in my daily practice, keep track of key data to understand whether we are improving over time. I may not even need a formal team to work on this, or meet regularly, in order to improve the functioning of the clinic. But the discipline of improvement, with a systematic method and approach, will likely be helpful to me in tackling this problem.

There are lots of little things that we identify in our day-to-day work experience that could be improved. Not all of these are complex problems. We might feel that we understand the problem, and can even identify a solution that could fix it. Do these things need a project? Again, most probably not. We can just go ahead and try to solve the problem, without even always needing approval or permission. This is the ‘just-do-it’ approach. It might also be useful to apply the PDSA discipline of having a clear theory and prediction before we ‘just-do-it’, planning the test of change and having a way to understand whether it had the effect we were predicting. Of course, we may find that our solution doesn’t work, or needs broader engagement with the team. Then we may need to rethink whether this really is a simple ‘technical’ problem.

So there are potentially lots of ways in which we can apply our improvement mindset, but also our improvement tools, to solve problems outside of QI projects. It’s natural to conflate quality improvement with quality improvement projects, as that has been the typical way in which we have applied our quality improvement tools and knowledge to solve problems. But there is huge utility for quality improvement outside of projects. Tools such as flowcharting, or fishbone diagrams can help us understand the system better. The principles of PDSA can be applied for simple changes we want to make on an everyday basis, without having to sit within a QI project. We will continue to need QI projects for those big, complex quality and safety issues for which we need to bring together a diverse group of stakeholders, discovering solutions through testing and learning with close support. But lots of other opportunities for improvement don’t necessarily need a QI project. Our challenge is to retain the situational awareness to recognise these opportunities, hold onto our mindset that we can influence the system to make things better, determine whether the opportunity would benefit from a formal QI project structure or not, and then apply our improvement tools to make a difference.

QI Essentials: Top down AND bottom up

Deciding between a top-down approach to improvement and a bottom-up approach to improvement is a false – and meaningless – choice. We need to support both. It’s about top-down AND bottom-up, at the same time… Have a read of Amar’s latest QI Essentials Blog…

Should our quality improvement activity be directed at strategic areas of priority? Should we define, from the top of an organisation, what every team’s QI work should be aimed at?

But how does that fit with focusing on what matters most to those we serve, our patients and service users, and also what matters most to those in our point-of-care teams? How can we engage our teams in quality improvement without giving them the autonomy and power to define what they choose to work on?

Herein lies one of the big dilemmas in applying quality improvement work within a large complex organization. What I hope to describe in this blog is that deciding between a top-down approach to improvement, and a bottom-up approach to improvement, is a false, and meaningless, choice. We need to support both. It’s about top-down AND bottom-up, at the same time…

At East London NHS Foundation Trust, many people have described our quality improvement design as being largely bottom-up, akin to letting ‘a thousand flowers bloom’. And it’s true, to an extent. In the first year of our QI programme in 2014, we did support those who we were keen to be our early adopters to choose their own projects. But even in those early days, we had two high-level aims (reducing harm, and right care, right place, right time) to which all projects had to be aligned. They were loose aims, but there was some alignment to Trust strategy, even in those very early days.

We chose, though, to intentionally design our quality improvement to be as inclusive as possible. We didn’t want to just identify two or three big complex topics or areas for our improvement activity to focus on. We wanted everyone to feel that they could be part of this movement, and so we allowed a lot of scope for any and all projects to join. We valued engagement and interest above all else at this stage, realising that if we achieved enough energy in the first year this would become a real driving force for the future.

Within a year though, we had started to form some light-touch governance structures around our QI work so that projects now had to go through a locally-led approval process to ensure that teams were tackling topics that were meaningful. We also started to get much clearer about our high-level strategic improvement priorities.

Ultimately, if all our teams work on disparate topics, without any alignment around strategic priorities, all this improvement activity doesn’t really serve to move us in a common direction towards our mission as an organisation. For me, that’s akin to waste. So we do need to find a way to ensure that our improvement activity is aligned to high-level goals, but in a way that is shaped by what matters to those closest to where care is delivered.

When we started to identify our high-level priorities, we realised pretty quickly that the assumption that what matters at Board-level and what matters at team-level are different is not necessarily true. Our data and conversations at the Board showed us that our number one safety issue was inpatient physical violence. But it also turned out that, given the opportunity, plenty of our inpatient wards chose to work on inpatient physical violence because it really mattered to them too. Access to services was a major issue for a lot of our service users, and it also turned out to be a big topic of interest for our Board and commissioners. So there’s perhaps an unrecognised level of synergy in priorities at both ends of an organisation. Priorities identified at the point of care often align naturally with priorities aligned at the most senior levels of the organisation.

The clearer we can make our strategic improvement priorities, and the better able we are to communicate why these are important, the more likely we are to engage our teams and service users to see how their work can align to these. Our leadership team spent a lot of time talking about our two ‘big dots’ of harm reduction and right care, right place, right time back in 2014. And we similarly reinforce our current four strategic priorities through lots of our formal and informal communications today at ELFT.

For me, the top-down / bottom-up debate is really about balance. We of course have to make sure that our improvement work is aligned to the strategic priorities for the organisation. If we don’t achieve this, then our quality improvement work will remain on the periphery – a ‘nice-to-do’ but not integral to the way the organisation functions and delivers for those it serves.

As with so much of our improvement work, it’s largely a question of how you do this in a careful, sensitive and thoughtful way. Having an open dialogue is a way into creating this fine balance between strategic priorities and point-of-care priorities. Given the opportunity to converse and discuss what really truly matters, and involving a range of people from all levels of an organisation, we often find that there isn’t as much divergence as we originally thought.

Now, all our quality improvement work begins with a very simple question: What matters most?  This question can be asked of everyone, no matter whether you’re at the Board, working in a clinical or corporate team, or receiving care as a service user. This helps bring clarity to both our strategic priorities, and our improvement priorities at team level. Around two-thirds of our quality improvement work at ELFT is now directly aligned to our four strategic objectives. But that still leaves a third that isn’t. For me, that’s a great asset and a real virtue in our approach to improvement at ELFT.

Given the choice, I will always err on the side of giving teams of staff and service users the latitude to work on whatever they feel is the most important issue to tackle. Ultimately, without the will and ideas of those closest to the point of care, how would we improve at all?

You can read all past QI Essentials posts here.

QI Essentials: Developing Improvement Capability

Developing improvement capability has the potential to deliver a step-change in organisational performance, but only if done in the right way. Have a read of Amar’s latest QI Essentials Blog…

The landscape of healthcare improvement in England is massively different to 2013 when we were planning the start of our improvement journey at ELFT, feeling our way into a fairly uncertain world. Almost all NHS providers are now using quality improvement, although it’s probably fair to say, with some variation in application and belief. One commonality across all our organisations is the need to build improvement capability.

Why is this the case? It remains a rarity for training curricula in any healthcare professions to incorporate learning about how to improve complex systems. Seems strange, as that’s what many of us spend our working lives pursuing. A few training institutions are now embedding quality improvement into undergraduate and postgraduate training, such as Sterling University, Salford University and City University, but most providers still recruit a workforce that is largely naïve to healthcare improvement, and so we have to develop these skills on the job. This makes developing improvement capability a key task for organisations that intent on pursuing continuous improvement, but also runs the risk of quality improvement being viewed as training or a set of skills that can be learnt in a classroom.

Having focused on building improvement capability for over five years at ELFT, here are some of my key learnings. Developing improvement capability has the potential to deliver a step-change in organisational performance, but only if done in the right way. Viewing this key enabler of continuous improvement as ‘training’ is a classic error. Building capability is about developing skills, but also about activating people with these new skills and providing support to help them apply these to real-life problems. The theory of quality improvement is pretty straightforward. It’s the application that is difficult. Improvement capability needs to focus on practising the theory and tools of improvement to solve issues in the workplace.

So, my first learning has been to avoid training people in quality improvement without having a mechanism to apply these skills to solving real quality problems. Our key vehicle for quality improvement capability building at ELFT has a requirement for all participants to bring a quality issue that the team has agreed they will work on, and to apply the learning to this project over the course of the programme.

It follows that capability building ought to then be structured around the life cycle of a project, and provide an opportunity to learn from the design stage all the way through to implementation. A minimum time scale for this should be six months, to really enable people to learn about good improvement design, planning, testing, measurement and implementation.

My second learning is about modelling an improvement mindset in the way that we develop improvement capability. We improve in partnership – whole multidisciplinary teams together with patients, service users and families. So, our capability building programmes ought to model this, and bring together a diverse group of people to learn and practise together. All our improvement capability programmes at ELFT are open to all, and we avoid separate disciplines learning about quality improvement in isolation of others. We want quality improvement work to feel energizing and fun, so we bring these elements into our capability building too, with plenty of exercises, games and creative activities.

Lastly, improvement is all about trying something, reflecting and adapting. So we ought to apply this to our capability building too. Capture data, in real-time, to understand the experience of those involved, and make adaptations to keep iterating your programme. This kind of real-time evaluation is key to ensure that your capability building efforts adapt to the changing needs of your attendees. Over 5 years at ELFT, we’ve moved beyond the innovators and early adopters, and with this comes the need to adapt the way in which we engage and support people to learn and apply quality improvement. We revise our capability building plan every year, to take stock of where we are, where the gaps are, and how we plan to meet these. Here’s some images to show how our capability building plan has evolved from 2015 through to 2019:

My third key learning about improvement capability is to approach this topic in a way that gives the actual projects the best possible chance of success. If we view capability building as a path to improving organisational performance, we realise that we also need to ensure that projects have a robust and close support structure, with skilled improvers available to guide and senior sponsors showing curiosity and attention to the work. This necessitates building skills at different levels within our workforce at the same time, so that those at the Board are learning the skills and applying them to their role in quality improvement, at the same time as sponsors, improvement coaches and teams of staff and service users. This helps with one of the key challenges with quality improvement that I hear so often – that people have developed the skills, but don’t have the time to apply them. If we’re working at multiple levels, we have a better chance of team leaders and senior leaders seeing the value of quality improvement, and helping ensure that their teams of staff and service users have protected time to work together in solving our most complex quality issues.

You can read all past QI Essentials posts here.

QI Essentials: Quality, Cost and Value

For the first time in our improvement journey, this year we are directly targeting value as a primary goal in our portfolio of improvement efforts. We are starting to move from one approach to quality and another to cost, to an integrated approach to quality, cost and value. Have a read of Amar’s latest QI Essentials Blog…

When we embarked upon our quality improvement journey at ELFT back in 2013, we thought quite hard about how we could frame this new direction for the organisation in a way that would resonate with people and inspire, but without undermining our previous approaches and efforts to improve quality. We didn’t get it right, in many ways, and we’ve been continually adapting and improving our approach to improvement over the last six years.

One aspect of our QI approach that we all seemed to agree on was that it had to be purely focused on quality. We believed that a focus on quality would lead to better cost management, but supportive literature from the mental health and community health setting was non-existent. We were concerned that if we even mentioned cost when we explained why we were embarking on a quality improvement journey, we might ignite anxieties that this was really all about cuts and cost savings wrapped up in new jargon. In England, this is a heightened anxiety in the context of recent QIPP (quality, innovation, productivity and prevention) programmes which were largely focused on cost, and CQUIN (commissioning for quality and innovation) which is again largely perceived as the threat of losing income if we don’t achieve certain targets. So, we framed our first organisational mission, back in 2013, around quality – providing the highest quality mental health and community care in England by 2020. And we supported and encouraged all our quality improvement projects to focus purely and simply on quality of care.

Our early QI work was aimed at reducing harm from community acquired pressure ulcers and reducing inpatient physical violence, as well as improving access to community-based services. As people started to see that we could discover solutions to some of our most complex quality issues by involving those closest to the issue in a deep process of discovery, innovation and iteration, we have slowly but surely built belief across the organisation in the systematic and inclusive approach of quality improvement.

Two years into the work, having achieved step changes in many of our big organisational quality goals, we began to ask the question about whether we could measure the cost impact of the work. If we reduced inpatient physical violence, this meant that we were avoiding the costs of extra staffing, extra medication, extra days in an inpatient bed, the costs of repairs to the ward, the cost of days lost due to staff sickness, and on and on… We brought our entire finance team together with an expert in economic evaluation to learn the approach of predictive cost modelling. Our finance team began to work alongside our clinical teams to understand the cost of harm, and to predict the costs avoided by preventing harm. We’ve now been able to publish much of this work, for others to use.[i]^,[ii]

Although we only partially realised this at the time, our quality improvement approach as an organisation was impacting on far more than just the quality of care we were providing. We have since developed a framework to describe the return on investment that we have seen through quality improvement,[iii] as shown in the image below:

We’ve recognized that, first and foremost, the return from quality improvement is about improvements in patient, service user, carer and family experience and outcomes. This might seem obvious, but it’s directly related to the core purpose of the organisation so is absolutely critical to the business case for QI. There is increasing literature supporting the case that adopting quality improvement, genuinely ceding power to those closest to care to be able to improve the system they work in, and providing them with the skills and support to do so, leads to a better experience at work. Makes intuitive sense, and is increasingly borne out in the evidence.

We’ve also seen large numbers of teams demonstrate that they can improve productivity through quality improvement, even if their quality improvement work was driven by a quality goal rather than by efficiency needs. For example, our community based psychology teams who are now able to see more patients more rapidly, with fewer non-attendances, with no extra resource. Our teams working on harm reduction have been able to quantify the costs avoided by preventing harm, such as physical violence or through improving the disciplinary process so that fewer staff are suspended.[iv] And a small number of teams have been able to demonstrate recurrent cost savings through removing cost from the system entirely, such as our older adult mental health wards which have redesigned the way they work to support people to stay in their homes for longer, instead of coming into a hospital bed, enabling us to close a ward and realise about £1m recurrent savings.

The key to all these other types of return from quality improvement are that they were first and foremost about tackling an aspect of quality that really mattered to those who use the service and those who work in the service. They weren’t driven by the need to avoid cost, remove cost or improve efficiency. They were by-products, but what an incredible effect when aggregated across an organization.

As we’ve been able to quantify these additional aspects of value, and tell the story back to our teams, there is increasing belief that quality improvement impacts on value beyond just quality. This has given us the courage to let go of our old language of cash releasing efficiency savings, and start adopting the language of improvement more consistently – talking about waste, variation and value instead, and recognising the opportunity of engaging our entire organization in this conversation and search for improved value, rather than allowing the burden of finding our 4% of annual efficiency savings to sit heavily on the shoulders of a small proportion of our most senior staff.

For the first time in our improvement journey, this year we are directly targeting value as a primary goal in our portfolio of improvement efforts. And every one of our QI projects will be supported to predict and measure the impact of their work on other aspects of value, beyond their primary quality goal – this might be impact on staff, or productivity, or costs avoided. We are starting to move from one approach to quality and another to cost, to an integrated approach to quality, cost and value.

Two weeks ago, I visited a ward in our forensic service and met with a team of staff and service users who talked passionately about their plans for the next ward QI project. The idea was sparked by our conversations about waste and value in the organisation, and has inspired service users and staff on the ward to identify areas of ward spend that they believe are waste and could be better utilised. Some of this is driven by a desire to be more environmentally friendly, and some is driven by a desire to refocus our limited resource on activities that really help improve quality of life for those we serve. It was genuinely humbling to see the energy and passion amongst service users and staff to ensure that we, and they, get maximum value for every pound of public money. This, in a single story, epitomises how far we’ve come and what we are aspiring to…

[i] Brown, J., Fawzi, W., McCarthy, C., Stevenson, C., Kwesi, S., Joyce, M., Dusoye, J., Mohamudbucus, Y. & Shah, A. Safer Wards: reducing violence on older people’s mental health wards. BMJ Qual Improv Report 2015;4: doi:10.1136/bmjquality.u207447.w2977

[ii] Taylor-Watt, J., Cruickshank, A., Innes, J., Brome, B. & Shah, A. Reducing physical violence and developing a safety culture across wards in East London. British Journal of Mental Health Nursing 2017;6(1):35-43

[iii] Shah, A. & Course, S. (2018) Building the business case for quality improvement: a framework for evaluating return on investment. Future Healthcare Journal 2018;5(2):132-7

[iv] Shah A., Aurelio, M. & Fitzgerald, M. (2017) Quality improvement for non-clinical teams. NEJM Catalyst

You can read all past QI Essentials posts here.

QI Essentials: Thinking of holding a meeting for QI? Read this first…

Sometimes a 15-minutes huddle is more efficient than a 1-hour meeting… Have a read of Amar’s latest QI Essentials blog for tips on how to run effective Quality Improvement meetings.

For most of us, when we think about how to bring people together to work on something, our first thought is often to hold a meeting. So when we’re working on a quality improvement project, we might naturally default to organising our work by holding meetings. I’m hoping this blog might change the way we think about how to bring people together to work on quality improvement…

Over the 15 years that I’ve been working in the NHS, for a variety of organisations, I can’t even fathom how many hours of my life have been spent in meetings. And this just seems to keep increasing, the more senior one’s role. However, I’m fairly confident that the vast majority of meetings that I’ve sat in, or chaired, haven’t been as effective as they could be. I’m sometimes left wondering why I’ve actually been in the room, what value I’ve added, or what we’ve achieved in the time together. Leaving a meeting more energised than when I entered hasn’t usually been the norm.

With quality improvement, our task is to bring together a diverse group of people representing different aspects of the system we want to influence, in order to generate and test out new ideas aimed at achieving a shared purpose. Is the best way to do this through a series of meetings? Perhaps, but maybe not in the way we traditionally run meetings…

Quality improvement is an almost completely practical activity. The value comes from applying ideas in practice, with a little bit of planning and thinking around how we might learn and adapt. Once you’ve got going with a project, the only real reason for coming together as a team is to ask three simple questions:

• What is the data telling us?
• What did we learn from our last test of change (the study part of the PDSA cycle)?
• How should we plan our next test – what’s our theory and prediction, how might we design a test to see if this holds true, and what data would we need in order to evaluate this?

I’d suggest that a 15 minute huddle might easily be enough to work through these three questions together, as long as we’ve planned how we want to use the time. A meeting is a process, and so needs careful design. Turning up to a meeting with just an agenda and list of attendees is really only scratching the surface of how to run an effective meeting.

As with any process, we need to be clear about what objective we want to achieve, and how we’ll design the process to involve everyone in achieving this. So having a project lead or meeting facilitator is critical, in order to make sure we make most efficient use of the time we have. Whoever takes on this role will need to put in a little time before each catch-up to design how best to use the time. This might involve thinking about the room layout or seating arrangements, the equipment available, any exercises that will be needed, and other roles within the meeting (such as recording actions, or time-keeper) which will help the team be as effective as it can be.

If our tests of change are long, the pace at which we are able to learn and bring about change will be slow. So our ambition is to run tests at a quicker pace, enabling us to be more agile and nimble. It makes sense then to try to meet more frequently, but for less time. Coming together for 15 minutes a week, which helps us run a test that lasts no longer than a week, is much more effective than a one hour meeting once a month. My only caveat to this would be that in the early days of a project, when we’re trying to bring the project team together around a shared purpose, and then attempting to understand the system, we might need slightly longer sessions which allow deeper connection and more involved exercises. An hour spent as a group creating a really detailed cause-and-effect diagram or generating ideas and developing a driver diagram might be hugely valuable time well-spent.

We have an opportunity in the way that we go about quality improvement to model a better way of working that involves people more deeply, connects people to shared purpose and makes more efficient use of our most scarce resource: our time. We want to pull people towards quality improvement work, to feel energised by it, and so the way in which we go about the work needs to generate energy and excitement. A well-designed, short huddle that helps us build a rhythm around frequent tests of change is more likely to help us learn faster, solve our quality issue quicker and generate more energy within the team around the work.

Our focus and energy needs to be spent on changing the system, not administering the process – so I’d encourage us to think about how we can remove waste in the way we go about the work. Do we really need minutes for quality improvement meetings? Can we capture and distribute actions in the meeting itself, rather than leave this as a task after the meeting? Could we use a whiteboard or flipchart to capture actions as we go, take a photo and circulate, so we’re all set to work on our actions and test of change from the minute we go our separate ways? What could we do instead to create energy, involve people more deeply, tell stories to connect back to the shared purpose…?

You can read all past QI Essentials posts here.

QI Essentials: The daily practice of improvement

What does it take to make quality improvement a part of our every day habits and behaviours? Have a read of Amar’s latest QI Essentials blog…

In “Outliers – the story of success”, Malcolm Gladwell challenges the notion that success is based on innate skill, hard work or focused ambition. Or that we can ascribe the success of an individual purely down to factors related to that individual. Gladwell writes about the role of family, culture and friendship in an individual’s success, stating that “what we do as a community, as a society, for each other, matters as much as what we do for ourselves.” In studying the success of individuals across a range of disciplines, Gladwell suggests that 10,000 hours of practice are needed in order to develop world-class expertise in a particular skill, since dubbed the” 10,000-hour rule”.

Quality improvement is definitely a skill that needs to be practised in order to refine and improve one’s technique, much like my piano playing. QI isn’t simply knowledge, or a method. We know from many evaluations and studies that most people and organisations, despite knowing the theory of quality improvement, struggle to actually apply it on a consistent and regular basis in daily work. And what does it really mean, to make quality improvement part of everyday work? I hear frequently the phrase “making quality improvement business as usual”, but what does this actually mean?

For many organisations, quality improvement consists of structured projects aimed to specific improvement opportunities with multidisciplinary teams coming together to work on a goal of shared interest, using improvement tools and a systematic method. But does a programme of multiple projects equate to making quality improvement part of daily work? Organisations that have truly embraced a continuous improvement philosophy and demonstrated fidelity to this for a decade or more have found that it involves more than just projects. Of course, that’s not to say that projects aren’t important. QI projects are an absolutely vital mechanism for delivering tangible improvement on specific complex issues, bringing together a group of stakeholders to discover solutions and test them out over a period of several months. The accumulation of projects across the breadth of an organisation and over time helps transform organisational performance to new levels.

However, the downside of viewing the adoption of continuous improvement in an organisation as simply a programme with multiple projects is the risk that quality improvement becomes limited to only being practised within projects and by the small groups of people coming together around projects. The true opportunity of quality improvement lies in both tackling strategic improvement opportunities through robust project structure AND using our quality improvement skills on a daily basis to help us identify challenges and improve processes every single day, by every single person.

So, what does it take to be able to move beyond training people in QI skills and deploying these to QI projects, to using quality improvement in our every day work, no matter what our role? And will simply practising be enough to become world-class in quality improvement? Certainly, we’ve seen in our work at East London NHS Foundation Trust that it’s important to be able to try out the skills of improvement, see the effects, learn about the method through actually trying it out on real-life improvement opportunities – and that this helps build not only confidence in the approach, but also the skill in being able to use it effectively. Some of the recent evaluations of the use of Plan-Do-Study-Act cycles by Julie Reed and colleagues at North West London CLAHRC are highlighting the importance of properly learning and applying the method, practising in the real-world with skilled support to guide. So, could we consider that deliberate practise will help us become great improvers and how many of us could realistically hope to achieve this, given that it would need 20 hours of practise a week for 10 years in order to achieve Gladwell’s 10,000-hour rule?

Well, firstly, there’s increasing evidence that deliberate practise by itself may not be as important as we originally thought in improving performance within a particular domain. A meta-analysis from Princeton University in 2014 looking at practise and performance across domains such as music, sports and games have found that practice explained 26% of the variance in performance for games, 21% for music and 18% for sports, but only explained 4% of the variance in performance in education and less than 1% for professions. The theory is that deliberate practice is only a predictor of success in fields that have very stable structures. For example, in chess, tennis and classical music, the rules never change – so studying more and practicing more has a much greater effect on performance. I’d argue that the world of healthcare is much less stable – our systems our complex and ever-evolving, the use of improvement needs to be highly adaptable and dynamic. So although deliberate practise is likely to be important in becoming proficient in using quality improvement skills, it’s not going to be enough for us to become truly world-class improvers.

So, if practise isn’t enough, what else does it take? Perhaps the place where I’ve found most learning about this is from Mike Rother’s six years of research in Toyota and their management thinking and practice, that have enabled it to embed continuous improvement and adaptation into and across the organization in a way that few other organisations have been able.

Perhaps it isn’t surprising to some, but the key is… behaviour. Specific behaviours, habits and patterns of thinking and conducting oneself, that are practiced over and over, every day at Toyota. In Japan, these routine habits and behaviours are called kata. It’s a way of practising scientific thinking – moving towards a mindset of seeing our environment and work as a system, identifying opportunities, developing theories, and seeing the value of testing, learning and adapting. Avoiding jumping to conclusions, but practicing a systematic approach to understanding the world around us, comparing what we think (our theory) with what we see (evidence) and adjusting based on the difference between these two.

Kata is applicable to all, including leaders – perhaps particularly for leaders, where it is easy to feel the need and pressure to find solutions to challenges, and to believe that we have the best solutions by virtue of our expertise, experience or skill. At Toyota there are two types of kata that are key: the improvement kata, and the coaching kata. The improvement kata describes a systematic approach to being curious about the status quo, seeing the work around us as a system, bringing people together and opening our minds to different theories that would improve the system, testing these and adapting based on what we see. The coaching kata is key to the role of managers and leaders, in teaching the improvement kata and bringing it into the organization. The primary role of Toyota’s managers and leaders is about increasing the improvement capability of people, developing people who in turn improve processes and systems through the improvement kata. This involves a set of practices which have their roots in the Buddhist master/apprentice teaching method – guiding, teaching, encouraging, showing, developing, enabling the person to discover things for themselves through using the improvement kata.

In our learning at ELFT about embedding quality improvement into daily work, it’s clear that QI projects and training are absolutely key – to help us learn and practise the skills, build belief, create step-changes in performance on complex quality and safety issues. But we’ve also learnt that the real value comes in applying what we’ve learnt into our daily habits and rituals as ‘improvement kata’ –  bringing our scientific thinking into the way we understand our work and challenges on a daily basis, using our simple QI tools where and when they make sense, involving people in a more meaningful way in developing theories, using the discipline of test-learn-adapt to continually improve ourselves and the world around us. And the role of leaders and managers is key to this – in inviting ideas from a diverse range of people, in stopping us from jumping to conclusions, in encouraging the testing of creative ideas, in helping us find time to think together…

You can read all past QI Essentials posts here.

QI Essentials: What does a Chief Quality Officer do?

What is the role of a CQO?  There are still very few chief quality officers in the UK, although it’s a common role in the US. In this blog, Dr Amar Shah reflects on the role and responsibilities of a Chief Quality Officer…

I figured it was probably about time to tackle this topic, given that we’re six blogs into the series! So, what is a Chief Quality Officer (CQO), and what does one do?

It’s probably useful to start by mentioning that CQOs are very common in the US and some other parts of the world, but still pretty rare in the UK. I think I am perhaps the only CQO of a provider Trust in England (although I’ve just seen that University Hospitals Coventry & Warwickshire may be appointing their first CQO, which would be exciting!) We have the excellent Simon Watson at NHS Lothian in Scotland, but there may otherwise be no CQOs yet in any provider Trust in the UK.

But back in 2013, the Keogh review, which looked into the fourteen English hospitals with higher than expected mortality rates, recommended that healthcare organisations have people with the breadth of skills and expertise to know what data to look at, how to scrutinise it, and use it to drive tangible improvements. The review referenced the prevalence of Chief Quality Officers in the US, but stated that this may not necessarily require a new Board role. Professor Nick Black endorsed the need for a new Board role, writing that “we need Chief Quality Officers with vision to lead, inspire staff and facilitate rigorous assessment and improvement of quality throughout their trust.”

The basic argument is that as the core purpose of a healthcare provider is about quality of care, it ought to have Board-level expertise in quality, just as it does for finance in a Chief Finance Officer. That there even is such a thing as ‘expertise in quality’ remains questionable for many, who argue that simply being a clinical leader such as a doctor or nurse on the Board, remains sufficient expertise and knowledge on the topic of quality of care. Increasingly though, there is recognition of a body of scientific knowledge on continuous improvement, quality management, complex systems, human behaviour and change, that can be a major asset for organisations that are aspiring to provide the highest possible quality and moving from ‘good to great’.

Another common question that I’ve been frequently asked is ‘who is responsible for quality?’ when you have a nurse leader, medical leader and quality leader on the Board. My view is that this is a healthy tension, as when quality becomes one person’s responsibility, we’re heading in the wrong direction! Quality is so core to our mission as an organisation that it absolutely has to be a shared, collective responsibility, for us to have any chance of meeting the needs of those we serve. At ELFT, I work closely with the Chief Nurse and Chief Medical Officer on all aspects of quality, and our understanding of the best way to manage this will continue to evolve.

OK, enough about the need for CQOs. What does one actually do? Partly, I’m in the enviable position of being able to make it up as I go, as there’s such little precedent in the NHS. But I also feel the weight of having to demonstrate the value of the role, in order to encourage other leaders that they would genuinely benefit and see a return from an investment in Board-level expertise on quality.

The role of a Chief Quality Officer is about influencing the culture of an organisation to engage and activate people, leading breakthrough improvement work, building an infrastructure to support improvement at scale, and developing a holistic quality management system that incorporates rigorous planning, meaningful assurance and reliable quality control. What kind of activities do these translate to? Well, let’s take the example of planning. Usual NHS planning is fairly dull, mostly to satisfy external agencies and usually centred around paper plans. I’ve tried to influence a new approach to planning at ELFT, with one example being our new Trust strategy which we launched in 2018. The strategy itself is a simple one-pager, visualised using an improvement tool called a driver diagram.

The process of creating the strategy involved over 30 workshops and 1000 people (both staff, service users and stakeholders) over a period of four months, with the qualitative data collated and analysed systematically to build the strategy from the ground up. This took longer than the old approach might have, but it allowed people to be part of the conversation, come to terms with it over the course of a few months and feel that they really own our new promise to our population. It will give us a much better chance of delivering, I think.

Let’s take another example related to influencing culture. For six years now, I’ve met with all new starters at ELFT through a one-hour session at induction, as a very simple but effective way to influence the culture of the organisation. I had a huge amount of fun leading our Breaking the Rules campaign in 2017, which enabled all staff and service users to voice rules that they perceived were getting in the way of us doing the right thing. As a campaign, it reinforced the principles that we’re trying to encourage through our improvement philosophy of flipping the power, giving all a voice, and stopping doing things that add little value.

The CQO role has a breadth that means I have to influence across all executive portfolios, all parts of the organisation and at all levels. It also includes being the executive director for the corporate quality function, which supports the organisation through expertise in quality improvement and quality assurance.

The executive and Board role means having to tread the fine line of being an internal guide to the team, whilst being in the team. It can be a difficult place to be, as I know I’d be less effective if I didn’t retain enough objectivity to be able to guide and act as a critical friend, but also need to be an effective team player within the executive and take on collective responsibility and lead on my share of areas.

The executive team often has to grapple with meeting internally- and externally-driven aspirations or requirements, and balance the need for assurance, control and improvement. This is an entirely healthy tension for a well-functioning executive team, and surfaces precisely the kind of conversations that a maturing improvement-focused organisation ought to be engaging in. The Chief Quality Officer role helps provide guidance on these questions, internal challenge and also offers solutions.

An average week for me usually includes a mix of Executive team or Board meetings; time with our quality teams, leading on design and delivery of our Trustwide workstreams for strategic improvement priorities or quality assurance activities; leadership on Trustwide programmes of work such as staff engagement or analytics; a smattering of corporate meetings (that I do my best to only attend if I’m adding value); and visits to clinical or corporate teams as executive walkrounds or to celebrate their improvement work.

Every week always also includes clinical work, as a Chief Quality Officer is one of perhaps only a couple of people in the executive team with ongoing regular clinical responsibilities. I find this aspect of the job rewarding, as it allows me to switch attention rapidly from the individual to the whole system. Being able to continually flip between perspectives and learn from both helps me be a better leader I think.

So, that’s my best guess at what I do, or should be doing, now that I’m a year into the role. I’d love to hear your thoughts on whether you see an ongoing need for chief quality officers in healthcare. And wouldn’t it be nice if this blog inspired a chair or chief exec to consider what a CQO might bring to their organisation??

You can read all past QI Essentials posts here.

QI Essentials: Learning systems for improvement

Achieving change in behaviour and culture in complex organisations requires intentional design. In this blog, Dr Amar Shah shares some learning on key components of the design of learning systems for improvement.

The pursuit of continuous improvement helps us create a learning organisation, described by Peter Senge as “where people continually expand their capacity to create the result they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together”.

Achieving this change in behaviour and culture in complex organisations requires intentional design. Those of us leading continuous improvement will likely have toyed with a number of different ways of supporting large numbers of teams, working in different contexts, to apply quality improvement and align this towards a common goal. In this blog, I share my learning about the seven components that I’ve found are key to the design of learning systems for improvement, shown in the image below.

Bear in mind that as we look to create a learning organisation, we will be trying to build systems of learning at multiple levels – at the level of the macrosystem (whole organisation), at the level of mesosystems (divisions or directorates), at the level of microsystems (individual teams) and even at the level of the individual. Yes, even we as individuals ought to shift towards a learning mindset, and the seven components above are just as applicable at the individual or team level, as they are at the whole-system level.

1. Shared purpose

Probably the most important of all. Having a clear purpose or goal, aligned to what really matters. Creating a deep visceral connection to emotion, rather than a set of words on the wall, is what we mean here. As a team, would everyone be able to talk passionately, and consistently, about what the purpose of the team is? As an organisation, is it clear what the mission is, and can people describe this in their own words and feel a connection to it?

2. Shared language

For us to learn and play together, we need a common way to communicate. The language of improvement can be a wonderful bridge across different professions and power hierarchies. The use of improvement tools can allow all to have an equal voice and power in determining how we improve. Improvement can bring teams together from different contexts but facing similar challenges, learning together through the common language of improvement, and building networks across the organisation that otherwise might not exist.

3. Autonomy

The application of quality improvement, in itself, shifts power outside of formal hierarchy to enable people to develop their own theories about what may make a difference, and the ability to try new ideas without fear of failure. In large-scale improvement, there’s a delicate balance between bringing teams together that are all working towards a common purpose with a shared theory of change (such as flow, or joy in work), whilst still devolving power and autonomy to each team to understand what matters most in their context, and make the changes that they believe will make a difference.

4. Collective leadership

Collective leadership is described by Professor Michael West as “the purposeful, visible distribution of leadership responsibility onto the shoulders of every person in the organisation”. The design of large-scale improvement can support this by involving a diverse range of people in the work, including patients, service users and family members. We can also intentionally redistribute power within improvement work by allocating leadership roles to those who hold no formal hierarchical role. One of the beautiful aspects of supporting quality improvement work is that it witnesses the emergence of new leaders from unexpected places, given the opportunity and permission to improve the system for those we serve.

5. Connections and relationships

Bringing people together and creating safe spaces to share with each other helps build relationships within teams and across teams. This is critical to allow the surfacing of difficult issues, the ability to explore and make sense through emotional connection, and to ensure people feel free to fail and learn in the pursuit of a common goal. Any learning system needs to develop ways for people to truly connect with each other as humans, not just as professionals. Story-telling can be a wonderful way in to this deeper connection.

6. Data and measures to understand variation

Learning systems need to support teams to understand the variation that exists within their own microsystem, and also learn from the variation across teams. Key to this is the use of data over time, shared transparently, in order to support learning and adaptation. As with all quality improvement work, no single measure can help understand how a complex system behaves, so we need a range of measures (outcome, process and balancing). For large collaborative learning systems with multiple teams working towards a common purpose, there needs to be a way to learn across teams and from the variation, so standardising the outcome measure is really important.

7. Infrastructure to support the learning system

Learning systems for quality improvement are usually built to tackle complex challenges that haven’t been solved before. Inevitably, this is going to be difficult work. Teams need close support through this journey, which will include access to improvement expertise and knowledge, leadership support to make changes that challenge the status quo and access to content knowledge about ideas and evidence that has been shown to be effective in solving the challenge. Any learning system design needs to give consideration to how teams will access this support as easily as possible, in order to accelerate the improvement work.

You can read all past QI Essentials posts here.

What it takes…

What does it take within a team to run a quality improvement project through to completion? Is it about brilliant ideas or the energy of a charismatic leader? Perhaps it’s about everyone having skills in quality improvement, or finding time to do the work?

With so many organisations now recognising the potential opportunity of applying quality improvement to solve complex issues, and increasing support for this approach from regulators and national bodies, it’s going to be pretty important to understand the key components that enable teams to own and integrate QI into their day-to-day work, particularly given the level of strain that the healthcare system is under. Everyone I talk to is already working hard, giving their best, trying to do all they can to improve the lives of those we serve. So how then to fit in quality improvement, without it becoming an additional burden?

Earlier this week, I was fortunate to hear the story told by a team of their successful quality improvement project, which was then discussed by a group of improvers from four different healthcare providers. Here’s what we heard and learnt…

First and foremost, we felt the passion from everyone involved to solve the issue. The team chose the topic for their improvement work themselves, through a conversation with staff and service users. What emerged was a general dissatisfaction that service users on the secure forensic mental health ward weren’t able to fully utilise the leave off the ward that they had been granted, for a variety of reasons. The service users were frustrated that leave often had to be cancelled or couldn’t be facilitated by staff, which often led to conflict on the ward. Staff felt as if they were letting down their service users when leave couldn’t be facilitated due to staff availability, and that the service users’ recovery was often being impaired by not utilising opportunities to connect back with the community.

This initial open dialogue between staff and service users helped create a consensus and unity across the whole ward community around a complex challenge, with multiple factors contributing to the problem, that they all had an incentive to help solve. It was a topic that mattered to all stakeholders, and surfaced from within, rather than from higher up in the organisation. It seems startlingly clear to me that successful quality improvement work often starts from a single question: “What matters most?” to those who will be directly impacted by the work.

Second, we heard a tale of genuine persistence. The team, made up of a diverse group of staff and service users, met every fortnight for a year. Every fortnight for an entire year… That takes commitment and dedication, whilst working on a busy and dynamic ward. Staff changes, increased acuity on the ward, incidents – none of these impacted on the regular rhythm of the fortnightly meetings. They became part of the routine habits within the team. But the work also needed structure.

As the team described their work, the clarity of roles shone through. The project had a clear leader, who incidentally wasn’t the formal leader of the ward team. But those with formal leadership roles within the team, the ward manager and Consultant, were fully involved in the work – attending the fortnightly meetings, ensuring the team found time for the work and supporting the integration of the work within existing spaces on the ward, such as the ward round and community meeting. This seems important to me. Both that those with formal power on the ward were actively involved, but also that the work was led by someone without a formal leadership responsibility, so she had a little more space and time to focus on the project.

Third, we heard how the team included service users at every stage of the project – from the very first conversation about what they should improve, through to understanding the problem, to considering how they might solve it. Here’s an example that left us all in awe. The team used a common quality improvement tool called a Fishbone diagram, or cause-and-effect diagram, first developed by Dr Kaoru Ishikawa, a Japanese quality expert. The tool helps identify the root causes contributing to a problem. Many of us have probably used this tool before, but we were surprised by the way in which the team created theirs.

They used one of their weekly community meetings on the ward with around 10-12 service users to understand the factors that caused leave to be unmet. The cause and effect diagram below was created by this group of service users. Pretty phenomenal – while many of us improvers use this tool routinely, I’m not sure I’ve ever seen one created by a group of patients or service users before.

At East London NHS Foundation Trust, we have recently evaluated all our completed QI projects (several hundred at this point) and compared those that have involved full partnership with service users (which we call the Big I of involvement) against others. We found that those with Big I involvement were 2.8 times more likely to have successfully completed than those that had no involvement of service users, or just occasional involvement. Even more evidence to suggest that involving service users doesn’t just help us develop better ideas, or support their recovery, or accelerate the work – it also gives the project a much better chance of actually achieving its aim.

The team spoke proudly about the ideas they had tested, which had helped them improve from an average of 3.5 unmet leaves each week a year ago, to 0.4 unmet leaves each week at present. I came away energised and inspired by their story, and with three lessons that I think we can all incorporate into the way we use quality improvement in our teams: ensure we focus on what matters most to the staff and service users involved, be persistent and develop a regular rhythm for the work, and involve our patients and service users from the very beginning through to the very end as full partners in the improvement effort.

You can read all past QI Essentials posts here.

Activating agency

Over the last few weeks I have been reminded that, at its heart, quality improvement work is really all about connections, relationships and purpose. We may need the technical skills of quality improvement and the systematic method to navigate and learn our way through some really complex problems. But the true opportunity in quality improvement lies in bringing people together and unleashing their potential around a common purpose.

The word ‘agency’ isn’t yet in common healthcare parlance, even if we see the word ‘improvement’ frequently overused for all manner of activities. And yet, agency is really what we seek most of all. Agency refers to the ability of an individual or group to choose to act with purpose.

As our health and care systems in England and across the globe face the significant challenge of having to provide high quality care year on year whilst seeing demand increase and resource remain the same, or often reduce, it can be easy to feel powerless in this struggle, or to tighten control from the centre of organisations. There are no easy solutions, and it can feel like a huge weight to bear for leaders. However, our opportunity comes from recognising the true value of our greatest asset – our people, including staff, service users, carers and citizens – in helping us find the path to better healthcare and health of the population.

A team of people with agency can achieve quite remarkable things – whether this be the #Hellomynameis campaign for more compassionate care, the global What Matters to You movement in healthcare, or even the non-violence civil disobedience led by Mahatma Gandhi in India ninety years ago. Agency can help bring positive change of previously unimaginable scale at an incredible pace, but it needs both power and courage.

For organisations that are truly on a continuous improvement journey, the use of quality improvement is fundamentally about devolving power – inviting those closest to the point of care to help us find solutions to our most complex challenges, providing them with the skills and support to change the system for the better. The unrelenting drumbeat of quality improvement, the story-telling by teams that are seeing results and the constancy of purpose that is needed from leadership may sometimes feel almost cult-like, but is so important for creating the conditions to give people courage to try something different in what can often be difficult circumstances.

Based on our last five years of work at East London NHS Foundation Trust (ELFT), I am increasingly convinced that all quality improvement needs to be designed around one simple question: “What matters to you?” If we genuinely start each improvement effort with this simple question, asked with both service users and staff together, and use this to ignite a dialogue about what truly matters, we can start to connect people and create a community with common purpose. We begin then to move away from ‘us’ and ‘them’, to simply ‘us’. Quality improvement offers a way to help us break out of our silos and start to come together, united by a shared goal and bringing the best that each of us have to offer to help us get there.

Some of my most memorable moments over the last five years have been through observing individuals, who might ordinarily have felt powerless in the system, start to feel a sense of power within themselves. Administrative staff identifying and testing change ideas to reduce waiting times and distress for young people who need access to mental health expertise; domestic staff bringing their knowledge of the ward environment to help discover ways to reduce incidents of aggression and violence; service users voicing ideas and influencing the team about what would aid their recovery and journey through the service. The flattening of the traditional hierarchy that quality improvement can bring, and the effect on an individual’s sense of agency can be startling.

There is also a collective agency that is palpable. An energy and sense of optimism as people encounter positive experiences of other people exercising power and courage. Quality improvement nurtures this through bringing people together in learning systems to share their experiences and ideas, through our focus on story-telling, which can inspire so many others to gain the courage to act, and through our intentional and frequent celebration of the amazing things we see taking place every day.

And there is agency at the level of the system. We are certainly feeling the effects of this at ELFT, where people increasingly sense that the structures and culture within which they operate are giving them permission, licence and freedom to exercise their power and courage. This needs authentic and positive reinforcement by leaders over a long period of time, to build a sense of psychological safety. It also needs tangible changes and signals to demonstrate that things can actually change in response to need, and that the power resides in all of us to bring change. Campaigns like “Breaking the Rules” can really help give people an outlet to voice their ideas, and demonstrate that leadership are intent on creating agency at the system-level.

So, if you’ve seen quality improvement so far as simply projects that help improve quality of care, I urge you to look beyond this. See the true potential of quality improvement in helping us connect more deeply to what really matters (to us and those around us), to strengthen our relationships within our teams and with those we serve, to bring people together around common purpose and discover ways to change the system for the better. And most of all, to activate agency… in individuals, in groups and in the whole system.

You can read all past QI Essentials posts here.

Top tips for starting a quality improvement project

Thinking of starting a quality improvement project? Identified something that needs improving? Here’s my three top tips on setting up your project for success…

1. Start with the end in mind.

Often, the spark for improvement comes from an idea, a realisation that things would be better if we tried this new way of doing things. This is completely natural. And yet it’s the wrong place to start for quality improvement work. QI isn’t about implementing an idea, it’s about solving a complex issue where we’ll need multiple ideas and theories about what a better system might look like. So, although our minds are curious and imaginative, and often trained to consider alternative solutions, we need to work backwards when we start a quality improvement project. What is that idea aimed at achieving? What’s the outcome that this might improve? Make this the aim of the quality improvement project, not the initial idea that might have sparked the curiosity. You’ll open up the possibilities, invite more creative thinking, engage a wider group and have a better chance of improving outcomes.

2. Focus on what really matters.

Our healthcare systems are straining to meet today’s demands, and workload for our staff is going up. To give your quality improvement project the best chance of success, forget the ‘nice to have’, and focus on the critical. Wrap your quality improvement project around what truly matters. But to whom? To senior managers? To the team? To your patients, service users and families? I’d suggest starting any quality improvement project with a conversation involving all of the above. All will be absolutely key to the work, and all should be involved from the very beginning in choosing what to focus your quality improvement effort on. It’ll help ensure your project is tackling what people care most about, and it’ll build engagement and will for the work ahead. And my guess is that you won’t find too much disparity between what your patients really care about, what the team really cares about, and what senior managers really care about.

3. Improvement is a team sport

All care is delivered in teams, and so all improvement should be done as teams. There’s something powerful about a whole multidisciplinary team coming together with their patients and service users to identify their biggest improvement opportunity, and working on this together. It helps strengthen team working, it brings people together around a shared purpose, it helps connect the staff to what really matters to those they serve, and it starts to break down some of the power imbalances – both within staff, but also between staff and service users and patients.

Successful teams come together often for short huddles, find time to reflect together, and develop habits around their work. Similarly, think about how you can bring together a small project team, with representatives from all parts of the service and service users, to meet regularly about the project. Find ways to build this into the existing spaces and rhythm within the team, rather than creating a new meeting or additional ask. Role model quality improvement in the way that the team works – keep the meetings short and efficient; try standing meetings; avoid excessive note-taking. The only real purpose of coming together as a team to discuss a quality improvement project is to reflect on how the last test of change went, and plan the next test of change. So, could you start finding new and creative ways of achieving this that don’t involve meetings?

QI Essentials blog with Dr Amar Shah comes out every month. Here you can read all previous posts.

Improving Quality ≠ Quality Improvement

In this new blog series, Dr Amar Shah – Consultant forensic psychiatrist & Chief Quality Officer at ELFT – will explore all things QI, sharing tips and tricks, demystifying QI and sharing stories to inspire everyone to improve the system in which they work. Enjoy!

Over the last few years we have seen a proliferation in the interest and use of quality improvement in health and healthcare. This represents a really promising shift in our mental models about how to solve some of our most complex quality issues. Alongside the increasing use of the word ‘improvement’ in our everyday language within healthcare, I’ve observed some difference in understanding of what exactly we mean by the term “quality improvement”.

So, what is quality improvement? And is it any different from what we’ve always done? Surely we’ve always been trying to improve quality?

In helping people try to work through these questions, I often start with the provocation that improving quality is not the same as quality improvement. This often evokes some puzzled expressions. A simple reversal in words, but two very different concepts.

For any product or service, there are many ways we can improve quality. In healthcare, we’ve used many different mechanisms and methods to improve quality for decades. One approach is planning or redesign, which involves deeply understanding the needs of the population/customer/service user, looking at the evidence and best practice across the industry in order to ascertain what structures and processes we need to put in place. This is something we might do once a year. Another way to improve quality is through assurance: occasionally checking that we are meeting a particular standard or threshold. A third way to improve quality is through quality control, which incorporates really good operational management, monitoring performance in real-time within the team, taking action when needed to bring the system back into control, and escalating rapidly when we can’t solve a problem. The fourth way to improve quality is through quality improvement: a systematic method to solve complex problems through testing and learning, involving those closest to the issue deeply in discovering new solutions.

So, quality improvement is a particular, and very specific, approach to complex problem solving that relies on testing and learning (and failing many times). Quality improvement empowers those closest to the improvement opportunity to discover a better way, and should deeply involve both staff, patients, service users and carers in understanding the issue, identifying new ideas and testing these out to see which work within the given context. As we are looking to learn whether a particular service or issue has improved, we also look at data quite differently, in order to see whether something has changed over time.

This leaves us with an exciting opportunity. The emergence of quality improvement can build on all our efforts to date, rather than replace them. The real questions are whether we are able to identify the right kind of challenges and opportunities for which quality improvement is perfectly suited, and whether we can create the appropriate conditions in which quality improvement can thrive…