Blog: Outlearning the Competition: The Building Blocks for Improvement - Dr Peter Chamberlain

What do highly performing organisations have in common? From Team Sky to Salford Royal, growing evidence suggests that it’s organisations’ ability to run a slick and effective ‘learning system’, providing the mechanism to sustain continual improvement. As put by Professor Steve Spear of MIT, “today’s leading organisations outrace their competition by outlearning them.”

Dr Peter Chamberlain, GP &
Commissioner at NHS South
Sefton CCG

But before we rush to think that having a super learning system guarantees success, the system itself is only one of three factors needed to maximize improvement. Also needed is the right cultural and infrastructure ingredients, such as compassionate leadership and the integration of clinical work with informatics. Organisations then need to base these essentials on the right principles, most notably in healthcare that their work is firmly person-centred.

​How organisations develop across all three areas is what’s fascinated me across my career. It’s what I’ve learnt from my time as a GP and clinical commissioner on Merseyside, as well as my time studying 15 high performing organisations as part of a fellowship at the Institute for Healthcare Improvement in Boston, Massachusetts.

What I've seen time and again is how hard it can be for organisations not at the leading edge to translate what can be quite abstract concepts into reality. What specific, pragmatic initiatives can and should an organisation be doing to bring these ideas to life?

To try and help, I devised the Quality Improvement Building Blocks Framework, shown below. The aim being simply to support organisations to think through how they need to develop in order to improve. Underpinning the 3 layers and 12 building blocks are 60 specific pragmatic development areas (not shown) which organisations can focus on.

The framework draws on interviews and iterative presentations to quality experts around the globe, as well as a range of other frameworks and training programmes in quality improvement. It’s now been tested with a range of organisations in the North West, working with the Advancing Quality Alliance (AQuA).

It’s not a silver bullet: it focusses on organisational development to facilitate continuous quality improvement and can’t negate the need for adequate funding, staffing, clinical training and due diligence procedures.

However, it’s striking how often struggling organisations will not have the middle layer of the framework (cultural and infrastructure essentials) in place. In such circumstances, regardless of best intentions, quality assurance processes (such as performance management and regulation) simply don’t achieve the intended results. As a consequence, commissioners, provider leads and staff at the point of care get increasingly frustrated and desperate.

​It’s in situations like that where the framework can be helpful to steer an organisation’s development. Through trial and error, we’ve found three different ways for organisations to use the framework, ranging from the (relatively) quick, to the long-term:

1. ‘Dialogic’ / jigsaw – framing the conversation in helping everyone understand what key concepts exist and how they fit together.
2. ‘Directive’ / explanatory guidance document – unpacking core concepts of each building block with evidence and examples of application to deepen awareness of those in responsibility eager to progress.
3. ‘Diagnostic’/ full framework – pragmatic longitudinal organisational development tool to complement coaching and a quality strategy in contributing to achieving high performing status. 

In true quality improvement fashion, the framework is still undergoing testing and support information is building. Our learning is that a number of prerequisites are required for the framework to gain full impact. These include valuing of quality improvement methodology, executive support, senior leadership capacity to address development areas, and the mechanisms throughout with the organisation to facilitate readiness for change.

Many of the concepts in the framework will be new to NHS clinicians and managers for whom such aspects never made it to part of their core training. As a result we have found quality expertise and coaching helpful and in some cases essential to guide those new to the respective concepts. However, the framework also takes organisations from where they are at and can flexibly work and walk alongside the improvement journey.

We believe the framework is fit for real world organisations that experience real world pressure and hope that with further collaboration alongside regional and national bodies that it will be scalable for use across the NHS.

Interested in knowing more? Get in touch with either myself - I'm on twitter at @drpjchamberlain, or my colleague at AQuA Liz Twelves on liz.twelves@srft.nhs.uk or @Lizzie12s.

Please feel free to send us your comments. We'd love to know if this rings true for your organisations' experience. We need to learn as much as anyone else!

This blog was originally published by the UK Improvement Alliance (UKIA). To find out more about their work please visit their website, or follow them on Twitter @theUKIA.

Blog: Enhanced Recovery in the United States - Wendy Lewis

Earlier this year I was invited to cross the Atlantic for an exciting trip to Philadelphia, USA to take part in the first annual Transatlantic Enhanced Recovery Leadership Forum.

Wendy Lewis

Alongside a team of 5 other UK healthcare professionals, including surgeons and anesthetists, we were there singing the praises of Enhanced Recovery work within the UK; with my role being to represent this from a nursing and improvement perspective.

For those who aren’t familiar with Enhanced Recovery (ER), it’s an evidence and person-centred approach to care that started in elective colorectal surgery, but has since been widely adopted for many surgical specialties, including urgent or unplanned procedures.

The four main principles of ER ensure that patients:

• Are partners in their own care 
• Are in the best possible condition before surgery 
• Have the best management during and after their operation 
• Experience the best care to enable them to return to their normal level of activity as soon as possible 

Since the national programme ended in 2012, the NHS has gone from strength to strength with ER; seeing improved clinical outcomes, experience of care and productivity for patients, their family and staff. Internationally recognised, we’re now at a stage where countries from across the globe are looking to the UK to learn how they can begin their own journeys in implementing ER.

Recognising the potential for the UK to support ER in other health care markets, the trip was also supported by UK Trade & Investment, as well as Evidenced Based Perioperative Medicine (EPBOM).

Over the two days, we met with a number of senior leaders and clinicians from across the US, who were keen to hear our views on how ER could be designed, delivered and led within their healthcare system for maximum benefit to patients. Each member of the UK team also had the chance to present to the forum, and discuss their particular area of expertise.

It was really interesting to explore how the US health system might adopt our own work on ER, and reengineer it to meet their very different structures. Throughout the discussions we had a number of themes being considered:

• How do we create the case for implementing ER in the US? 
• What are the essential clinical components of ER that create maximum benefit to the patient, staff and productivity? 
• What data is important to capture in order to support sustainable improvement? 
• How do we create person-centred, value-added care within care pathways under difficult economic conditions? 

One of the highlights of the visit was a fascinating lecture from Professor Mike Grocott, of the Xtreme Everest research group. Describing their research on the effects of hypoxia (low oxygen levels in the blood) at high altitudes, this work has since been used to improve care in intensive care facilities, and in particular around diseases of the heart and lungs and severe infections. It really was amazing to hear how lessons learnt from the summit of Mount Everest have made their way to the bedsides of intensive care units.

Interest for ER in the US is now growing rapidly. With a strong body of clinical leaders now networking and beginning to work together more and more, it’s really inspiring to see this work progressing. I’ve also had the pleasure to help support this by co-writing an ER implementation guide for the American Society for Enhanced Recovery (ASER).

Whilst they’re keen to learn from the UK’s success, it’s also interesting to see that they face many of the same challenges in implementing ER as we did in England. Difficulties in creating clinical change and stakeholder engagement are nothing new, so looks like the reaction to change are the same on both sides of the pond!

Having spent a number of years working on ER within hospitals, the Department of of Health, and NHS Improving Quality, it was amazing to take part in this trip and learn about ER from a whole new perspective.

It gives me huge pride what clinical teams in the UK are now achieving for patients, and I’m sure my colleagues in the US will see those achievements too!

Wendy Lewis is AQuA’s Portfolio Lead for Experience & Engagement and Whole System Flow. You can contact her on wendy.lewis@srft.nhs.uk or follow her on Twitter @ERPwend.

AQuA Welcomes Delegates to First Event on Whole System Flow

Last week we welcomed over 80 delegates for an exciting first look into Whole System Flow, as part a new programme of work between AQuA and The Health Foundation.

Delegates join us at the Samlesbury Hotel, Preston for our first event on Whole System Flow.

Colleagues from both AQuA member organisations and wider afield joined us at the Samlesbury Hotel, Preston to learn about our latest developments around this work.

At the event, our Chief Executive David Fillingham discussed the need and context behind developing this new offer, and how we hope to take it forward over the coming year.

Speaking after the event, he said “As this new piece of work begins to gather pace, it was fantastic to see so many of our members and colleagues from across health and social care join us to hear how we hope to take this forward.

We know that solving the complex issues behind Whole System Flow will require a joined-up approach across different organisations, services and staff, and we’re really grateful such a positive input from delegates to help shape our next phase of work over the coming months.”

Whole System Flow describes the coordination of all resources across a locality to deliver effective, efficient, person-centred care, in the right setting, at the right time.

Also referred to as Patient Flow, it is considered a priority for the NHS if we are to understand and solve the complex issues behind delays in services, and make efficient use of staff, services, equipment and information.

Throughout the day Wendy Lewis, our Programme Lead for Whole System Flow, also led a number of workshops and activities with delegates; reflecting on the benefits behind system thinking and exploring how organisations might better work together to understand systems of care and design innovative solutions.

We were also joined by Christine Owen from the Improvement Hub at Healthcare Improvement Scotland, who gave an overview of their work on Flow in Scotland, as well as Bryan Jones of The Health Foundation.

In September, The Health Foundation will be publishing a paper on David’s initial findings on Whole System Flow. We will also be discussing this further at a second event to be held in October, with further details to follow in the comings weeks.

Below you can find a collection of tweets throughout the day:

UKIA members visit the North East Transformation System

UKIA members visit the North East for the
latest on Lean methodologies.

A team of staff from the Advancing Quality Alliance (AQuA) as well as other members of the UK Improvement Alliance (UKIA) recently travelled to Gateshead for an exciting visit hosted by the North East Transformation System (NETS), to share work on their latest improvement projects.

The UKIA, of which AQuA is a founding member, aims to bring together organisations from across the UK's four countries, to share best practice on quality improvement and learn from each other.

Over the two days the group explored Lean tools and methodologies for improvement in healthcare, alongside colleagues from Haelo, Healthcare Improvement Scotland, 1000 Lives Improvement NHS Wales and Yorkshire & Humber AHSN.

In his first network meeting as UKIA Director, Richard Taunt explored the following questions with members:

• How members continue to foster successful improvement relationships
• How members facilitate new and joint improvement projects
• How UKIA can work as the 'front door' to improvement work across UK healthcare

Members also welcomed Jim Mackey, Chief Executive of recently established NHS Improvement, who discussed the latest developments to drive improvement across the whole of the NHS, and how to balance competing demands between quality, finance, innovation and performance.

Lesley Massey, Director at AQuA, said: "As the work of the UKIA gathers pace, this was a great opportunity to come together with members to look at the latest thinking and shining examples behind Lean methodologies.

"Everyone really enjoyed the opportunity to see Lean in action, with visits to the Surgical Care Centre, Pathology hub, and Urgent Care Centre at Queen Elizabeth Hospital in Gateshead.

"We were also very grateful to Jim Mackey for joining us from NHS Improvement, and hope we can continue to support the drive for quality improvement at a national level."

Richard Taunt, UKIA Director added, "The visit to Gateshead was super for a number of reasons: the honesty of Jim Mackey, the expertise of the Trust, but above all the commitment of UKIA members to working together to improve health and care really shone through.

“As we move into our next phase of development as an Alliance, we're starting from great foundations."

For more information on the UKIA, please visit their website or follow them on Twitter @TheUKIA. You can also follow Richard via @RichardTaunt.

Blog: Magic in the Mundane - The Chemical Solution

Emma Walker - Portfolio Lead, - Academy, Safety
& Mortality and Shared Decision Making

Writing in 1988, Avedis Donabedian suggested that the key markers of high-quality care are outcomes. The likelihood of achieving these outcomes is increased if organisations have the necessary structures and processes of care in place to meet quality standards.

In other words, to deliver a high quality outwards-facing ‘product’ requires continually improving internal structures and processes.

This was reinforced for me when a team from AQuA made the short trip to Ellesmere Port in Cheshire to visit Innospec, a specialist chemicals company, traditionally specialising in octane additives used in making motor fuel. With demand for lead in petrol decreasing, in 2006 the entire existence of the business was under threat. They were faced with two choices: innovate or disband.

Ten years on, not only have Innospec survived, but are thriving, adding whole new lines of business such as 'performance chemicals' (that’s ingredients for shampoo to you and me). What’s been behind their success? Five factors became apparent.

1. Focusing on leadership
   Innospec have demonstrated strong, stable and decisive senior leadership from the very outset of their improvement journey. They have clearly set the strategic vision, established acceptable standards, and followed through on promises to drive the business forward. This ability to look ahead and make long term plans about how to transform a business to meet the changing demand of customers is something that has perennially challenged NHS organisations all too often caught in management flux.
   
   
2. Pre-empting failure
   All members of Innospec staff to speak up and articulate "What might go wrong here?" By identifying which mistakes could lead to a major incident, they are confidently able to predict the consequences of each error (e.g. would it lead to major harm?). By developing systems to mitigate human error they have made it easy to do the right thing and hard to do the wrong thing. This proactive approach to anticipate and be prepared for problems chimes with the Health Foundation and Professor Charles Vincent’s framework for measuring and monitoring safety.
   
   
3. Learning from errors
   Innospec were keen to demonstrate how they learn from incidents, errors and near-misses, with a culture focused on learning not blame. They design processes with the customer at the centre, proactively ensuring there are sufficient measures in place to catch errors before they lead to harm. Initiatives such as ‘Near Miss of the Month’ awards help make safety everyone’s responsibility.
   
   
4. Behavioural safety
   Innospec have developed a specific ‘behavioural safety’ training programme in order to embed a strong safety culture in all their staff. They utilise the risk elements of processes to drive safety improvements rather than as a ‘box ticking’ exercise. Impressively, all members of staff we spoke to felt able to detail potential hazards without hesitation or fear of reprisal – a real testament to their open and transparent culture. This approach links with AQuA’s approach to psychological safety, with programmes including resilience, appreciative inquiry and human factors.
   
   
5. Culture
   The culture of Innospec is supported by leadership, but encourages a “bottom-up” approach to improvements. Their focus was on utilising the appropriate tool or technique in the right situation, rather than being hung-up on a specific methodology. The primary focus is on making incremental changes and process improvements using whichever technique fits the need of the business within a particular situation. This approach has the benefit of having the flexibility to vary depending on what they are trying to improve.

At this point you may well be thinking that this is nothing new, that there’s nothing here you haven’t heard before.

If so, you’re absolutely right.

Innospec didn’t go from the brink of failure to market-leading because of a magic bullet – the creation of an 'accountable fuel additive care organisation' if you will – but rather because they focused on the basics, and didn’t let their attention waiver for year after year. Mundane? Maybe. Effective? Certainly.

In our work at AQuA we have seen many times that such a focus on the basic components of improvement delivers results in healthcare (a point also made by Nigel Edwards in his recent blog on the Vanguards). Our work programme has been designed to help our members innovate, improve and develop – all while building a culture now which will sustain improvements into the future. To find out more, visit the AQuA website.

You can follow Emma on Twitter at @EmmaCherub or follow AQuA @AQuA_NHS.

This blog was originally published by the UK Improvement Alliance (UKIA). To find out more about their work please visit their website, or follow them on Twitter @theUKIA.

Exploring Whole System Flow event - 5 July

As part of an exciting new programme with The Health Foundation, we'll be hosting our very first event exploring Whole System Flow, 9:00am - 3:30pm on  5 July at the Samlesbury Hotel, near Preston.

Whole System Flow describes the coordination of all resources across a locality to deliver effective, efficient, person-centred care, in the right setting, at the right time.

Also referred to as Patient Flow, solving complex issues behind bottlenecks and delays in services is seen as a national priority for the NHS, if we are are to make efficient use of staff, services, equipment and information.

At the event, we'll be sharing our latest learning and developments on our work so far, and exploring some of the benefits of improved system thinking on safety, outcomes, productivity and experience as part of a whole system community.

We'll also be working with members to better understand the complexities behind their different systems of care, as well as looking at some of the key issues affecting flow and how we might work together on innovative solutions to these.

This event ideal for system leaders, senior decision makers, finance directors and informatics leads.

Please download the event flyer for further information, or book your place here.

If you have any queries about the event or would like to find out more, please email AQuA@srft.nhs.uk, or call 0161 206 8938.

Join us at NHS Confederation 2016

This week we'll be attending the annual NHS Confederation 2016 conference and exhibition in Manchester.

As the voice of NHS leadership and employers across the country, Confed brings together and speaks on behalf of the whole health and care system.

With a range of leading figures from healthcare, NHS staff and partners in attendance, the conference is always an exciting chance to explore latest developments and share learning alongside colleagues from across the country.

This year's conference will be focusing heavily on efforts to transform health and care for patients, and looking at new and emerging models of care, redesigning health and care systems, and better integration and efficiency of services.

We're delighted to be attending this year's conference, and look forward to meeting AQuA members and colleagues from across the NHS to share our work, and learn how other organisations are improving care for patients.

Come and visit our team at Stand 129 inside the exhibition hall, which you can find on the exhibition floor plan. We'll also be tweeting updates throughout the day from @AQuA_NHS with the hashtag #Confed2016.

You can also find a full programme of events and activities, as well as a list of speakers on the conference website, or follow @NHSconfed on Twitter for updates.