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Achieving continuous and maintained improvement requires an orchestrated balance of top-down and bottom-up involvement. Engaging staff in healthcare quality improvement is imperative – and sits at the heart of what we do at ImproveWell. Here, we provide a round-up of must-read resources for facilitating transformation from the roots. 

1. The psychology of change

The Institute for Healthcare Improvement (IHI) recognises that there’s a large gap between what we know and what we actually do. There are many reasons that people resist change. The key is to unleash individuals’ intrinsic motivation, co-design people-driven change, co-produce within authentic relationships, distribute power and adapt as you go. Psychology of Change Framework to Advance and Sustain Improvement reveals how.

The white paper states that, ‘to reach a higher level of performance and reliability, healthcare quality improvement teams and health care organisations will need to create the conditions for people to advance and sustain improvement.’ This means recognising ‘the inherent value in each person, regardless of identity or position.’  

Figure 1: IHI’s Psychology of Change Framework

2. Lessons for leaders

Q, the long-term initiative funded by the NHS and the Health Foundation, held its Positive service shifts accelerated by COVID-19 webinar in September as part of the NHS Reset campaign. The webinar explored ways in which COVID-19 has resulted in a positive breakdown of old systems and structures – providing an opportunity for sustained change in healthcare quality improvement and beyond. The panel noted the following changes:

  • Health promotion and disease prevention was boosted by community cohesion
  • Primary and community care benefitted from digital triage and community NHS trusts took on leadership roles
  • Diagnosis and treatment by hospital specialists also shifted online and patients were encouraged to consult with GPs before heading for hospitals
  • Admin staff moved to remote working, waiting lists were shared across local health and social care economies areas to manage elective care more efficiently, collaboration between GPs increased through supra-practice organisations and hospitals began to concentrate specialisms

The changes have been enabled by ‘top-down clarity and bottom-up agency’, which trounced ‘organisational inertia’ and allowed a ‘can-do’ attitude to blossom. The regulatory hard line was softened, the need for box ticking was lessened and bureaucracy decreased. But is this sustainable? The report highlighted several issues, including:

  • Digital exclusion
  • Regulatory bureaucracy is likely to return
  • Limits to system-wide collaboration
  • Blank cheque approach will end
  • A waning of community solidarity.

Figure 3: Model for sustainable change

What is needed is a change in mindset from everyone from clinician right through to patient. ‘Other organisational incentives matter too, such as formal targets, performance management regimes and informal measures, such as what is celebrated or leads to career advancement.’ The report concludes that advancements achieved during the pandemic need to be honed and protected. To read the full report, click here.

3. Skills for collaborative change

Q’s second contribution comes from its Improvement Lab with the help of NESTA. They have singled out the skills needed for collaborative change, which include:

  • Co-creation
  • Relationship building
  • Facilitating creativity
  • Building momentum
  • Articulating benefits
  • Tolerating uncertainty
  • Considering the wider system
  • Seeking alternatives
  • Testing and improving new ideas

plus some key attitudes, too. This resource was developed before COVID-19 but has been revisited subsequently. Q has developed a skills map to help encourage and implement these changes and offer tips on how to best use it. Access the toolkit here.

4. Building a resilient system

Commissioned recently, Building a resilient system: reflections and insights from health and care leaders by management consultants Carnall Farrar went back to the start of our response to COVID-19, to ask key questions about health systems in the face of a pandemic. What has changed? And why? One key learning is that rapid changes are possible even in the most testing of times. The NHS has undergone transformational change through necessity. However, the inevitable delay in elective and regular testing and treatment has created a worrying backlog. The report’s conclusion is that leaders should develop a system focused on person-centred, place-based care.

Figure 4: Person-centered, place-based care; Evolving leadership; Empowered & engaged workforce. Healthcare quality improvement.

It calls for increases in:

  • collaboration
  • empowerment
  • flexibility and innovation
  • data-driven decision making. 

Crucially, the report also suggests patients are viewed more holistically, with a consideration of their communities and ways of living being as important to bear in mind as symptoms and illnesses. This, in turn, could lead to the pooling of resources for a more efficient and effective response. The huge community effort driven by COVID-19 was one of the positives arising from the pandemic and one the report believes the NHS should capitalise on. Work undertaken in Wigan is given as a prime example.

‘The pandemic enhanced collaboration and relationships as people and organisations came together to focus on a single goal.’

The importance of local government and social care in strengthening the health service overall has been underestimated. Aligning incentives and building partnerships can create positive outcomes. Lastly, and perhaps most importantly, the report encourages:

  • the support of staff well-being (especially for BAME personnel)
  • empowering and valuing of all staff
  • creating an agile and flexible workforce.

In terms of leadership, the report recommends concentrating on five key areas:

  1. Focus and shared purpose 
  2. Collaborative relationships 
  3. Empowering approach 
  4. Flexible, innovative outlook 
  5. Data-led decision-making 

5. Speaking truth to power

In this BMJ opinion piece, authors Megan Reitz and John Higgins explore the imperative for staff at all levels of healthcare organisations to speak up, as well as the reasons for silence, perceptions of speaking and listening up in the NHS and the inevitable blind spots that leaders have – and what can be done about them. They draw on the results of a five-year global, cross-sector study, including a study of some 1,539 UK-based healthcare employees. 

“[One] imperative to speak up, especially important during this pandemic, relates to sharing the ideas needed for teams to respond with agility to quickly changing circumstances. Nearly three-quarters of respondents claim they have, or may have, ideas or suggestions that could assist their organisation’s performance. Over one-third of those, however, have not spoken up with their ideas formally.”

Reitz and Higgins note that there is a perceived ‘hierarchy of speaking up’: “those who are junior are less likely to speak up than those who are more senior. Unsurprising perhaps, but this has consequences. It is often the junior employees who, because of the nature of their jobs, see issues and opportunities most immediately, who are most in touch with the actual rather than reported reality.”

They offer the following advice to leaders: 

  • Assume you are scarier than you think
  • Question your ‘little list’ of whose opinion counts
  • Send ‘speak up’ rather than ‘shut up’ signals and responses

“Leaders must, therefore, as an imperative, develop the capacity to encourage a broader range of voices to speak up, challenge the taken-for-granted and offer ideas. One could argue this is the imperative for leaders.”  Read the full article here

Photo by Jungwoo Hong on Unsplash