Get safety, improvement, transformation out of their boxes: inter-dependent not independent approaches

Get safety, improvement,
transformation
out of their boxes:
inter-dependent not
independent approaches
to change
#Quality2020 @HorizonsNHS @HelenBevan @Karas01 @DianeKetley @LeighAKendall

Hello and welcome
Please say hello
Type in ‘conversations’ box what
3 words describe your best
insights from the forum.
@HorizonsNHS #Quality2020

Helen Bevan
Sasha Karakusevic
Leigh Kendall
Diane Ketley
NHS Horizons is a small team within
NHS England and NHS Improvement that
provides design and delivery support on
practical approaches to large-scale change

Does this really matter
to patients
and
clinical teams

What is it like to be
a patient on a
complex pathway?

So how many questions
would you be asked on
your patient journey?
Poll
0-100
100-500
500-1000
1000+

Leigh and Hugo's Story
• I had HELLP syndrome at 24 weeks'
pregnant.
• (A rare, life-threatening pregnancy
complication)
• Blue-lighted to a hospital two hours
away from home
• My baby son – Hugo - born while I
was under general anaesthetic
• I was in the adult intensive care, and Hugo was in neonatal intensive care – literally at opposite ends of
the hospital.
• Being 16 weeks premature, Hugo was critically ill – staff in either unit would not facilitate us meeting.

Can we improve on these scenarios?
How would you use safety, improvement and
transformation approaches to improve these
scenarios?
We will put you in to breakout rooms to discuss your
thoughts for around 10 minutes
At the end of your discussion consider
How much did you agree?
How certain were you about what to do next?

How much agreement was there between you?
1- 5
How certain were you about the next steps to
take?
1-5
(1 = Low 5 = High)
High does not mean good and low does not
mean bad

Our approach needs to fit our context
Adapted from Ralph Stacey@HorizonsNHS #Quality2020
5 1
1

The answer isn't behind you
Wasgij “ Cone-gestion”

Perhaps the biggest challenge is to
change how we see the world

Focus our
effort on high-
impact issues

4.6m shortage 40m shortage Talent wasted

 what you learn with agency
[the power to make a
difference, individually and
collectively] is different from
what you learn without
agency even if it is the same
information 
Etienne Wenger
Lankelly Chase workshop, October 2019

“Complexity thinking adds a real-world, multi-
dimensional appreciation of the system…but it
does not make it easier to effect change; in fact
the opposite is true.
Even though this makes our ambitions to
improve healthcare infuriatingly more difficult,
we must grapple with the world we actually
inhabit, not the one we wish we did”
Braithwaite, Churruca, Long et al BMC Medicine 2018
Choosing Complexity
#Quality2020 @HorizonsNHS

What do we need to focus on to
embrace complexity?

What if we apply the principles of spread and adoption
to safety, improvement and transformation?
…dynamic, reciprocal
interacting, iterative and
evolving activity...not linear
and mechanistic
…developmental,
contextualised, adaptive,
learning and social process
More information at http://horizonsnhs.com/programmes-of-work/spread-and-innovation/

How do we connect
with others to
work better together?

to make
Taking the
Power is the ability to produce intended effects
Bertrand Russell
change happen

Find the 3% “super-connectors”!
Source: Organisational Network Analysis by Innovisor
Just 3% of
people in the
organisation or
system typically
influence 85% of
the other people
.Influencers

Don’t underestimate the power of social as a
source of information to drive change

What does this mean for me?
- Build your connections
and relationships
- Be a model of trust and
positive behaviours
- Always, always follow up
Be a
superconnector
- Get their insights
- Engage them in
change
- Stay connected for the
long haul
Find your
superconnectors

Leigh and Hugo’s Story – What Happened Next?
• Hugo and I finally met 36 hours after he was born. NICU, maternity,
and ICU were simply unable to communicate effectively with one
another.
• The clinical care we both received was exemplary – they saved my
life, and gave us 35 precious days with Hugo.
• After Hugo died, I submitted a
formal complaint to the hospital
about my experience in ICU.
• The response I received was
dismissive – so I set to work.

#HugosLegacy was created – requesting meetings with health care professionals, connecting with
people on social media, writing a blog, writing articles for national publications.
Campaigning, speaking at the Houses of Parliament and House of Lords

Nobody’s Patient project

Nobody’s Patient workshop at St George’s Hospital, September 2016

• I used my power to make things
happen;
• I utilised social media as a force
for change; to have conversations,
find the superconnectors, spread
good practice
• Interdependent approaches,
taking things out of their boxes
included NICU, OBGYN,
anaesthetists, theatre staff, and
others. Moving from “well this is how
we’ve always worked” to realising
talking to one another and
collaborating
How I made this happen

Breakout
How can we build on people's
desire to get more things right?
When you come back please
share your ideas in the
conversation space
5 minutes

Sharing power

Launch Event
Project P
Falls assessment service
Film making

People own what they help to create..
Bottom up not top down
• Frontline engagement
• Co-creation
• Going where the energy is
• Flexible and emergent…….
• Virtual / Social media
AndConnecting the system to itself
• AACE – Chief Executives Support
• NHSE (Ambulance improvement programme)
• Other groups where we can (learn and share)
• People with an interest and/or passion
Approach based on Myron’s Maxims
Find your
allies……

Basis of national falls guidance for ambulance services,
details Association of Ambulance Chief Executives
Falls Initiative and WAST Falls Pathway

• WAST falls framework development is driven by patient safety
and patient experience
• Using QI methods
• Transforming how parts of the system work and interrelate
• Complexity – working with emergence
https://nhshorizons.passle.net/post/102ghnd/complexity-and-system-convening-a-lightbulb-moment
https://youtu.be/XpJauiWQYkw?t=1
Safety, improvement and transformation working together
@ClaireRoche19 @ihbaines

• Designs a plan
• Accountability within a
governance system
• Ensures that delivery
milestones are met
• Deals with risk and
ensures that barriers
are overcome
• Works with emergence
• Builds commitment to a
collective goal
• Builds relationships
• Seeks win/wins
• Makes sense of things for
adopters: the why?
• Enables spread across a
whole system
Independent
Complicated
Interdependent
Complex
PROGRAMME
MANAGEMENT
SYSTEM
CONVENING
Working with complexity needs an enabling
leadership style
More information at http://horizonsnhs.com/programmes-of-work/spread-and-innovation/

Creating time and space for transformation

Which is the odd one out?
1 2
3 4

Structures are often
designed to deliver
current processes
efficiently
They cannot be
guaranteed to
deliver major
transformation
programmes
Changing the whole
structure is a big
task (that might not
produce the
expected result)
Think about where
the boundaries are
Break the task down
to contain the it and
manage anxiety
Build alliances
Make sure you have
a process to build
connections
between the
elements
Act to create time to
probe, sense
and respond
Key Points

Creating the right kind of
spaces to work together

The era of the unconference
We are witnessing the collapse of expertise and
rise of collaborative sensemaking
David Holzmer
Source of image: ACCA

for an Accelerated
Design Event (ADE)
•Co-designed
•Facilitated
•Dynamic
•Adaptive
•Connective
•Playful
Source: The Value Web/ MG Taylor
• Iterative
• Integrative
• Collaborative
• Self-organising
• Emergent

Our vaccination
coverage is not
high enough.
We need to
redesign the
system…

49 |
We used Future Backwards to build a shared understanding
• Become more aware of other
perspectives and to become
more aware of our own
perspective
• Reveal historical perceptions
of the past
• Enable more diverse thinking
• Navigate in an uncertain
world
• Understand hopes and
aspirations as well as fears
and concerns
Where
we
came
from

50 |
What your room will create in 5 stages
Where
we
came
from
https://wiki.sensemaker-suite.com/index.php/Future_backwards

• Flexible offer and access for
vulnerable groups
• Education and training to
support communication
• Stakeholder input into design
• Designing delivery and
commissioning for optimum
access/uptake
The themes that emerged

Work as imagined
Work as done

Creating space for creativity
Source of data: Nick Milton
http://www.nickmilton.com/2014/10/why-
knowledge-transfer-through.html
Social connection/discussion is
14 times more effective
than
written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com

There are
10540 children
who aren’t
vaccinated
Let’s start our
work here.

Breakout
What creative methods are you using to
bring people together?
5 minutes
When you come back, please summarise
your thoughts ready for the conversation
space.
Please do not press return/send
until we ask you to....

Creating a positive environment for change

Where is the power for
change in the system?
Here
And here
Where are expert functions
roles like safety, improvement
and transformation based?
Here
The places in the system to focus if we want change
to happen quickly and at scale
Support change to happen (without having the
power to make change happen directly)
Source: Mintzberg’s five components of an organisation

Beneficial changes arising from Covid that
people in the NHS would like to amplify:
Source: #OurNHSPeople tweet chat, August 2020
Key themes
• There are leaders everywhere in the
system
• Distributed leadership – people being able
to take on tasks based on what people
needed, rather than banding or status
• Bringing people together - out of silos
• Making new connections with people
across their organisations, and across
the system

Thursday 15 March

Your reflections
What 3 words describe
our jobs to be done?

Whatever we do, we do it together

Our film on crowdsourcing
https://www.youtube.com/watch?v=YKWIfMrV92c

Get safety, improvement, transformation out of their boxes: inter-dependent not independent approaches

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