As I reflect on the last 10 years of working in healthcare improvement it is clear that the challenges we face are common, predictable and location agnostic. I have travelled the globe as the CEO of Haelo, listening to talented people describe how they are improving the healthcare systems they work in. Similarly, I have worked very closely and intensively with teams in Salford and Greater Manchester. Somewhat surprisingly there appears to be common threads that bind all teams and these come from the challenges they receive from one another. I’m going to fondly call them ‘improvement show stoppers!’ We all experience them and they are often the things that ‘take us aback’. For example I am always surprised when people challenge the evidence or the data, but, after years in improvement I should have an expectation that this will happen and that it’s a normal part of the process. My skill as an improvement leader is to have a sufficiently deep understanding of the science that will help me explain this in a way that acknowledges the core challenge but offers a credible alternative. It’s my belief that to succeed in improvement we need to surface and address these issues head on.
So… what are they? I’ve picked five of my favourites to explore in this blog and will pick up five more in my next one. I would love to hear your thoughts and experiences on whether these resonate with you?
1. The ‘special place’ phenomena – it’s now part of my internal checklist to wait for teams to tell me how ‘you need to understand it’s different here‘ whether this is a team in Salford or San Diego they believe themselves to be unique with a ‘special’ set of circumstances and team dynamics. The challenge for us as improvers is to acknowledge their uniqueness whilst, at the same time, encouraging them to accept that there are systems and processes which can, and indeed should, be standardised so that they are exactly the same wherever they happen. The airline industry has addressed this with their mandatory safety briefing, whilst service options vary according to route or company every flight starts with a briefing. No one says ‘we are different here, we don’t need a safety briefing’. Imagine if we could achieve this in healthcare? Imagine if every patient entering hospital had a safety briefing before they were admitted? In Haelo we have been working on exactly that … a global patient safety briefing. It’s been one of the most exciting programmes that we have engaged with and continues to flourish with over 80 thousand views and briefings in English, Spanish and in a regional accent for New Zealand.
The special place phenomenon also gives rise to other challenges such as ‘that will never work here’ and ‘the data are wrong’
2. The ‘this is bigger than me’ phenomenon- sometimes articulated as ‘what difference can I make?’. Improvement can seem overwhelming. People who work in healthcare see the complexity in the systems of care for each patient on a day to day basis. Our ability to feel like we can make a difference to a complex system is central to empowered leaders. In his work on social movements, Marshall Ganz refers to this as YCMAD (you can make a difference). This was an essential tenant of the Obama electoral campaign which achieved highly improbable success, namely the election of an African American president. Ganz is part of a generation of social scientists who have taught us that we need to harness the talent of every person in the system. How do we do this? My experience suggests that there is power in simplifying the challenge and using collaboration to fight of isolation. In 2007, I led the stroke 90:10 collaborative, a North West programme which aimed to get 24 hospitals to improve their national sentinel audit scores from an average of 65 to 90 in two years. One of our biggest challenges was to ensure that every patient who had an ischaemic stroke had access to an antiplatelet agent (aspirin or equivalent) within 24 hours, this was aligned with the evidence base and NICE guidance. We had known for 10 years that we would save 1 life for every 100 patients treated if we were successful yet the performance varied from 3 to 5 out of 10 patients successfully treated in the participant hospitals. A baseline that had remained unchanged for 10 years. The solution to the problem lay in not one, but multiple changes to the system: earlier identification by the public of stroke symptoms; rapid assessment by the ambulance service; advance warning to the A&E department; rapid brain imaging; prescription of the medicine and the ability of the patient to take the medicine. We learned in our improvement collaborative that between the 24 hospitals someone had ‘cracked’ each part of the improvement required but no one had cracked all of it. Communications between teams was virtually non existent with each team thinking they had to start from scratch. The improvement collaborative helped to quickly exchange ideas between teams, build trust that they were more similar than different and accelerated all the teams, successfully achieving the goal by 2010. A great achievement for the North of the country and one which we were able to share through publications in implementation science.
The ‘this is bigger than me’ phenomenon also gives rise to other challenges such as ‘this isn’t my job’ and ‘I don’t have permission to do that’.
3. The ‘time bandit’ challenge. As the conversation with improvement teams matures and people gain confidence the inevitable ‘elephant in the room’ emerges. We really want to make these changes, but how are we going to find time to do it? As healthcare becomes more and more pressured this challenge is real and isn’t going away. It’s my belief that the improvement community have to help with reframing improvement. The current belief is that improvement needs to be done ‘outside’ the daily work as a special project or meeting. If we turn to the origins of our science we can see that this is a misnomer. For several hundred years, action research or action learning has been used to improve all aspects of our lives. Medicine is particularly adept at using it in the treatment of illness. If I go to my doctor with back pain they will advise treatment with anti-inflammatory agents, rest and icing. If I go back after two weeks and this hasn’t worked I may get a referral to physiotherapy, if a course of PT doesn’t work I will get a referral for imaging and a referral for a specialist opinion. This iterative treatment is based on treatment observations and a plan made once the options have been tested. This is the essence of our toolkit in improvement. Plan something, do it, study what happened and make a new plan. In industry this happens as part of the daily work. In his book ‘Chasing the Rabbit‘ Steve Spear describes production engineering workers undertaking 60-70 tests of change in an 8 hour shift. Compare this with the average improvement team in health who are often documenting 1-2 PDSA’s per month? Our job is to make improvement part of ‘the job’! The best improvement teams do this by integrating testing into the workflows of the day. As part of the routine of the work. For example a team who does a daily ward round will also discuss who is testing the new medications rounding protocol and then review the findings of the test at the shift handover to plan the next tests. The cycle of learning is continuous and not dependent on a single inspired individual or ‘special time’ being set aside.
4. We’ve done all this before – every time I work with clinical teams I make it a habit to ask what they have already achieved. Usually I ask ‘ what are you proud of?’ I’m always staggered by the humility of healthcare professionals who modestly describe their significant contributions to patient experience and the care systems that they work in. Most importantly, I have come to appreciate that we are hardly ever starting from a blank sheet of paper. Someone, somewhere will have previously tried to tackle the problem in question and will have a wealth of knowledge and ideas about what has previously worked and not worked in the context. One of my important bits of learning is that these people, far from being cynics, are often frustrated by their inability to influence the current regime. In the national ‘harmfreecare’ programme we worked with healthcare professionals from across the system to reduce harm from four harms (pressure ulcers, falls, urinary catheters and venous thromboembolism). So many experts surfaced with a passion for their work but often their energy was directed into challenge rather than cooperation. It took many hours of listening and explanation to get a small number onside and they achieved significant impact together demonstrating a reduction of over 20% in pressure ulcers within three years. Many of those who believed the work to be done and succumbed to their feelings of futility were brought into the fold by the energy and success of the participant groups, eventually finding a place where their past experience could support new leaders. This coalition of the willing became a powerful force yet the voice of the naysayer persists to this day. My advice, listen, learn but don’t let them win!
5. The wall of silence…. Just when you think you’ve got a plan for improvement someone throws a proverbial spanner in the works. It comes from left field and you can’t explain it: Where has it come from? Why have they waited so long? Why haven’t they input to the process before now? In planning our improvement work we often give people many opportunities to make a contribution. We have stakeholder meetings, we ask for oversight groups, we involve people with expertise BUT we have a challenge. The same people (great people) turn up every time, whilst their colleagues sit back and let them. What is this about? I have come to learn that silence is one of the enemies of the improver. Just because people are silent it does not mean they are happy or consenting. An esteemed medical director I used to work with called this ‘kicking it into the long grass’, apparently this is a tactic for delay which has worked well in the NHS with one initiative after the next launched but not completed. For some, a mind set of ‘if we wait long enough this will go away’ is the line of least resistance. The big question is… how can we overcome this? Over the years I have tried to address this issue, inviting people who wouldn’t ‘traditionally’ be in the improvement team to join. Its amazing how well a personal interaction works with these folk, especially when accompanied by a personal narrative about why I am called to this work. There is always common ground which binds our purpose, we just need to find it. The granades also lessen if we anticipate how the programme might be challenged and by whom and factor in a realism that whilst we love change not everyone is wired that way. Our strength lies in believing that together a small motivated few can change the world.
I don’t want anyone to read this blog and think that I’m being negative about improvement. I love the work, I love the people doing the work but I am driven by the results it produces for patients. My belief is that we need to be given the right tools to work with and that one of these is understanding the likely resistance in the system and sharing strategies for overcoming barriers to improvement. What are your ideas? Can you share them with us?
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