Bringing together members of the Q community from across the West of England to connect, network and start collaborating to shape the way in which we can work together to accelerate improvement in the NHS
5. Your Q community
• A connected community working
together to improve health and care
quality across the UK
• Supports people in their existing
improvement work: making it easier
to share ideas, enhance skills and
make changes that benefit patients
29.03.2017 Welcome to Q in the West of England
7. Designed by you, for you
• Designed with 231 founding members – diverse
cross section of improvers from across the UK
• Members continue to help shape the community
29.03.2017 Welcome to Q in the West of England
15. What’s next for you?
29.03.2017 Welcome to Q in the West of England
16. Opportunities to help lead
Convener
Apply to help shape how Q develops
locally; facilitating local networks and
feeding in centrally
Connectors
Volunteer to help members make
connections online and face to face
29.03.2017 Welcome to Q in the West of England
17. What might the future look like?
29.03.2017 Welcome to Q in the West of England
18.
19. Thank you
Visit us online: http://q.health.org.uk
Email us: QMembers@health.org.uk
Follow us on Twitter: @theQCommunity #Qcommunity
21. Our
• A chance to meet and collaborate with other like-minded
improvers
• Share best practices for improving your local healthcare
services
• All teach and all learn philosophy
• A place to grow and shape to meet our local needs
22. Your Journey
• A chance to apply for an improvement coaching course
that will enable you to, guide, motivate and support
colleagues involved in improvement work
• Co-produce 5 specially designed CPD learning events
• Access to our online QI toolkit
• Apply to join a ‘Commons Stewardship Group’ which will
lead and facilitate initiatives across the West of
England
23. Q National Commons Stewardship group
Made up of 15 national convenors
West of England
Commons Stewardship
Group
1 convenor with
5 additional members
Gloucestershire
STP Chapter
BNSSG
STP Chapter
BSW STP
Chapter
Expressions of
interest to
Dave Evans
28. Joint & Equal, and how?
Co-production = "professionals supporting change,
not delivering it“
“Co-production is an equal relationship between
people who use services and the people responsible
for services. They work together, from design to
delivery, sharing strategic decision-making about
policies as well as decisions about the best way to
deliver services.” Think Local Act Personal 2016
29. September 2015
Patient Volunteers have
many skills, some of
them in short supply for
the NHS.
Personally I have for 25 yrs
worked in the field of
Quality, and how to design
systems that deliver it.
30. 3 x Measurement Paradigms
A RI
Accountability Improvement Research
Who?
Audience
(Customers)
Purchasers
Payers
Patients/members
Medical groups
Medical group
Quality Improvement team
Providers and staff
Administrators
Science community
General public
Users (clinicians)
Why?
Purpose Comparison
Basis for choice
Reassurance
Spur for change
Understanding of
(a) Process
(b) Customers
Motivation and focus
Baseline
Evaluation of changes
New knowledge
without regard for its
applicability
31. Sunnyside PPG
(Patient Participation Group)
The PPG is a Partnership of patients, doctors, healthcare professionals,
and surgery staff.
Our mission is to:
1. Help patients to take more responsibility for their health.
2. Contribute to the continual improvement of services and quality of care.
3. Provide practical support for the practice and help implement change.
4. Foster improved communication between the practice and its patients.
Clevedon Sunnyside
32. Sunnyside GP practice already applies Improvement
Science (IS) in a number of ways, for example ..
1. Reducing DNA Rates over time – an initiative that now impacts 1/3 of
practices in North Somerset.
2. Working with patients who want to learn to Self-Manage using their own
data, as well as the data collected (over time) on their behalf by clinicians
3. FFT over time patient-by-patient/ signal-from-noise
4. Establishing a “systems approach” to our STP – specifically via Sign Posting
& Social Prescribing
5. Establishing a “systems approach” to Involuntary Loneliness e.g. Leg Club
But some HCPs don’t get the paradigm that
Quality ≡ IS ≡ over time Systemics
44. Shaping our approach: what can we do?
100 people
1000 ideas?
……where is there variation?
……what can we improve together?
45. Shaping our approach: what can we do?
We have a history of delivery!
NHS South West Quality and Patient Safety
Improvement Programme 2009
WEAHSN
– NEWS and sepsis
– ED safety checklist
– mortality reviews
46. GWH approach:
- Structured sustainable projects:
– SU2S
– ELC
– PQUIP
– Point of Care (cardiology)
– HIPQIP Scaling Up
– ‘Saving Babies Lives’ care bundle
• Delirium (Scotland) • Sepsis (Wales)
Shaping our approach: what can we do?
52. Cultures are…
“the way we do
things around
here”
“There needs to be a more consistent
approach across the NHS, and a
coordinated drive to create the right
culture”
Freedom to Speak Up Report, February 2015
52
53. Clear evidence base
53
“Every interaction by every leader at every level shapes
the emerging culture of an organisation”
(West et al, 2014)
54. 54
– Specification and planning
– Infrastructure design
– Measurement and oversight
– Self-study
55. Lessons from high performers?
55
– Leverage operational excellence
– Swarm problems in real time
– Discipline of knowledge share
– Create opportunities for learning
– But…the hard part is the leadership model
Leaders should:
– Find ignorance
– Convert to knowledge
– Teach others to do the same
56. What is the typical approach to change in
the NHS?
Deficit based
• what is wrong?
• solve problems
• identify what we
need to improve
• fill gaps and
deficiencies
Strength based
• what is strong?
• work with our
existing assets and
resources
• amplify what works
• “positive deviants”
56
59. An adaptive framework – local, regional
and national
59
Create and
sustain the
necessary
conditions for
continuous
improvement
13 initial
actions
Develop
capability
64. Our commitment to change – 3 pledges
16
• We will model in all our dealings with people and in our own
organisations the inclusive, compassionate leadership and
attention to people development that establish continuous
improvement cultures.
• We will support local decision-makers through collectively
reshaping the regulatory and oversight environment. In
particular, we owe local organisations and systems time and
space to establish continuous improvement cultures
• We will use the framework as a guide when we do anything
at a national level concerning leadership, improvement and
talent management so we engage across the sector with one
voice.
70. How do we avoid the echo chamber?
22
Enthusiasts Visionaries Pragmatists Conservatives Laggards
The typical effect sizes of spread activities
are perhaps 10-20% at best (Grimshaw)
Source: Geoffrey Moore, building on the work of Everett Rodgers
73. ‘Shaping our approach’
• Healthcare Q’mmunity connects and activates
improvement
• Q network helps to save lives
• Q network welcomes 1000th member
• In control of my health through Q
• Q fever hots up healthcare
• Using Q to end the queues
Putting Quality First is a strategy that many other industries pursued decades ago. It has for example turned the UK Car Industry from a basket case into a world beater – and they are by no means alone in this.
From the late 80s engineers the world over started to network to share their discoveries and to evolve their expertise – assisted of course by a burgeoning communications technology. Don Berwick’s IHI has attempted to mirror this – but (I would say) with less of an impact.
Prioritising Quality is an evolved and new way of thinking – a paradigm shift is needed because most people just don’t get it – and actually (25 years after I had my first shift, I now know that) a series of paradigm shifts is needed. Don Berwick now admits that he didn’t get it – he walked out half way through Deming’s 4 day seminar!
I don’t yet know if Network Q will become the grand facilitator of the needed shifts – of something which leads to a paradigm shift for the NHS – but by being part of it I’m personally committed to finding out.
There are two main ways of folding your hands – neither is better than the other – but sometime in childhood each of us chooses just one of these ways and then sticks to it. Doing it the other way is, metaphorically at least, a new way of thinking – a different paradigm, mind set, a new world view even.
First you have to change your theory, and then test it to see what happens.
Then you can study the outcomes and decide whether it’s worth making the new way a standard part of every day life.
Most of you are probably thinking – I didn’t even know there is a second way, but now I do know and I’ve tried it, the pain is not worth the gain?
Incidentally, this is how the NHS Model for Improvement is meant to work.
Deciding whether something new we are trying is actually beneficial requires data and evidence – over time.
This is the new paradigm of Quality – and it changed the world – and still does.
The notion is that if you always Put Quality First, everything else eventually comes right –
but to achieve this there has to be strong Managerial Leadership and Constancy of Purpose, and everything has to be subsumed to the system – its design and its maintenance, then its continual improvement – and even (if there’s no other option) its transformation.
The NHS Constitution says that as Patients we can expect a Quality Environment, and a System that delivers Quality Outcomes.
Deming would have asked “how can we know if a promise is being kept?”
and “by what method?” He died in 1993, but if here today he would ask why there is so much costly inspection, and why so many arbitrary targets which attempt to motivate people and hold them to account, but which sadly do the opposite – actually causing poorer Quality!
A new paradigm is needed – and that is what he prescribed – and was emulated in the Berwick Report (2013). If you want a concise introduction to Deming just read this report.
Co-production video- https://www.youtube.com/watch?v=vugLEaEcBR0&app=desktop
http:// www.thinklocalactpersonal.org.uk/_assets/Resources/Coproduction/LadderOfParticipation.pdf
I am a “co-producing” patient – a self-empowered one. I’m not the only one in this room, and there is a growing number of us. We are trying to work to a different paradigm.
Actually being intrinsically motivated and self-empowered is the only kind of empowerment that works. This is another new paradigm. Here is a model which seeks to explain this – taken from a forthcoming paper seeking to define what good health for an individual looks like.
Here is another new Paradigm. It’s been around in the NHS for many years, yet if Deming were still here he would have said it is far from being core to the culture. Here are some of the reasons: http://www.improvementscience.net/jois/jois_view_abstract.php?volume=33
Don Berwick’s Report in 2013 advocated that this model should become core to a new Quality-based learning culture https://www.gov.uk/government/publications/berwick-review-into-patient-safety
Incidentally here are some of things to bear in mind when using the Improvement Model:
Visiting and continually re-visiting the Purpose brings clarity for everyone involved
Establishing assumptions and then hypotheses -- so that they can be tested -- connects everyone to the reality of what is actually happening – you only have to read the Nobel-prize winning Daniel Kahneman to realise just how easy it is to separate ourselves from what’s really happening https://en.wikipedia.org/wiki/Thinking,_Fast_and_Slow
Achieving maximal Learning at minimal Cost requires some smart experimental design
Avoiding the scaling-up of an intervention too quickly – better to go slow to go fast, whilst en route drawing-out wider and deeper learning
Monitoring data over time, and in real time, enables the creation of systemic knowledge: BaseLine® http://www.saasoft.com/baseline/baseline.php
Prioritising Outcome data before Activity data – connects everyone to the purpose
Redesigning systems to avoid wasted resources is a skillset not commonly available in Healthcare – but I can be learned
Being continuously aware of what Deming called “Tampering” – how common sense destroys quality https://en.wikipedia.org/wiki/Tampering_(quality_control)
Here are three more important paradigms. Understanding the difference will help you understand how to successfully work both with the existing culture AND the newly emerging one that’s properly rooted in improvement science, innovation and learning.
The A-I-R Measurement Model really can help sort out your measurement dilemmas.
http://www.improvementscience.net/blog/?p=4178
This paper also describes the 7 philosophical foundations of Improvement Science.
The way that numbers get used in the NHS is driven by the Accountability paradigm – sometimes professional researchers are brought-in, often a long time after an intervention – using Research methods that are often quite alien and impractical to the everyday life of the NHS, and these methods are usually used in a way that is oblivious to the (very practical) possibilities that stem from Improvement.
The main reason I wanted, as a patient/carer, to join Network Q was that to me it demonstrates that I am taking my role as Patient Leader seriously. One of my formal roles for example is as PPG Chair in the surgery where I’m a patient: Sunnyside in Clevedon.
Our mission statement (on the slide) is very similar to the one recommended by NAPP (the National Association of Patient Participation) so is not peculiar to our practice. It however does not occur to most PPG members that in order to assist the achievement of this mission they should learn some new skills, nor do I think this ought to be a requirement for volunteering, but to an as yet small (but growing number) we believe it ought in time to be such a requirement.
Being able to say we’re part of the Network Q Community I predict will also be a distinct help when validating our work: with other practices – and with our CCG – for whom Improvement Science is still tends to be seen as a “nice to have” rather than as an essential core activity.
In the past year we have also set-up a patient-led group that from July will precis the BNSSG performance reports so that patients can understand them and see how the system is currently running – via PPGs.
Very happily (!) the person who has the job of representing the 3 CCGs and interfacing with us (Marie Davies) is also now also a Network Q member, so she immediately gets that we’re on the same page and level – and can work jointly with us.
To Deming, being able to view variation (change) over time is a vital first step to being able to maintain stability – which can then be a solid platform for the testing of improvement ideas.
This can also be the key to real engagement
Julian Simcox: Patient Leader: for most of my adult life I’ve been a Professional 1st/ Patient 2nd like I guess most people here. Nowadays I have a switched paradigm – it’s Patient 1st and carer 1st too – but does this mean leaving everything to the professionals to sort out? My answer to this is NOT On YOUR LIFE and so this is why as a patient I have become a Network Q member? It’s a no brainer because Co-producing decisions means being able to share a common language.
Speaking of paradigms – a paradigm is a way of seeing things, a way of thinking – it’s a way of helping you make sense of (and adapt to) – your environment. And if a particular paradigm seems to work alright it quickly becomes a HABIT – though not necessarily the BEST WAY of seeing: (Stand-up : Praying hands metaphor). To change your habit/ behaviour, first you have to change your paradigm. This rarely comes naturally; in 1986 Don Berwick attended W. Edwards Deming’s 4 day seminar and flew home after 2 days believing it to be a waste of time! Then he woke up and went back for the other 2 days – without this paradigm shift the IHI would not now exist.
In 1950 W. Edwards Deming taught Japanese industrialists a new paradigm – one that over the next 30 years changed the world: Subordinate everything to Quality and design your organisational systems to consistently deliver it. Up until then everyone thought to only way to get quality was to pay for it. More resources = more quality. Deming’s new paradigm not only changed the world, it led to us being here today – but TO GET IT, FIRST you have to SEE it. What you see is what you do is what you get is what you see. He called the Q paradigm a Chain Reaction, but it starts with paradigm-shift because FIRST you have to be able to see it.
Here are a number of (as I see things, NEEDED) paradigms:
the NHS Constitution says Patients have rights, but how would we (and i) know they’re being delivered upon?
I’m not the only patient leader in this room – we’re largely unseen. We’re waiting to be Co-producers, but as yet we are not usually “designed-in-to” the NHS system. Network Q membership should help this?
The NHS Model for Improvement is Deming’s way of making science and learning something that’s methodically sustaining in the life of an organisation – it is elegantly simple to do – but only if FIRST you get it/ see it. Then it culturally impacts everything.
Knowing, and hence Measurement, is vital for understanding and improving your system – but there are 3 distinct paradigms and the one we need most (improvement) gets squeezed out – yet it could be a bridge (if enough individuals can just see it, do it, get it).
+ (6) (7) Here is what a group of patients is leading for themselves in N. Somerset. If you want to know more come talk to me later? To finish: (Stand-up: Folded Arms metaphor)
Numerous national reports have made recommendations for change in culture and style of leadership. Berwick report said: the most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.”
What do I mean by culture?
There is a very strong evidence base for why should focus on developing enabling cultures – you all play such a critical role as senior leaders to ‘oxygenate’ your organisation and work with partners across your local system to do the same
Following Smith review, national board formed specifically to oversee developing capability in improvement and leadership development. Board reports into the 5YFV CEO group
The framework is deliberately designed to be adaptive – we want to work with people across the system to test and learn what works, this is a long journey over the next 15-20 years
Model, support and be guided by the framework
Ed wanted to finish with ‘it’s all about the people………..’