Wednesday, March 21, 2018

Buurtzorg Diaries - A Brief Buurtzorg Reflection - Wirral

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

This final blog in our Buurtzorg Diaries series comes from our Wirral locality members, who share some brief thoughts from their visit.


"Motivated and positive staff"


"Clients feedback positive experiences and enjoyed time spent with nurses"

"Client and nurse empowerment and ownership"


"Nurse-driven principles"


"Self-organised teams allows staff innovation"


"Care plans tailored to patients needs" 

"The team and patient is the most important in the organisation, not the hierarchy"


"Align actions to visions"

"Nurses allowed to nurse and care to deliver person centered care"


"Lots of different solutions to issues/conflicts"


"Simplicity in nursing model and organisation of teams"


"Coffee first…then care (the conversation and relationship with patient as important as the hands on care)"


"Vitality of nurses – wellbeing of staff important (visits on bikes very much promotes staff well-being)"


"Like-minded people working together" 


"If a consensus cannot be reached the team have to ‘live with it’ i.e. not dwell on the issue and to accept differences"


"Better outcomes for clients and nurses"

"Bring in additional support when needed, family and community support"


"Importance of coach role and back office"

Tuesday, March 20, 2018

Buurtzorg Diaries - Integrated Care, Not Integrated Teams - Manchester


Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

In our latest blog blog from our
Buurtzorg Diaries series, members from the Manchester locality share their thoughts from the trip. 

“Buurtzorg feels right and fits well’ – SC, district nurse, Manchester

This blog is not an attempt to present a complete picture of either Buurtzorg or Amstelring as organisations – but rather to share a few ‘take home’ messages of a group of clinicians and managers who went to see Buurtzorg self-managed teams in action (March 2018), and to learn from Amstelring (who changed into an organisation with self-managed teams). 

By sharing our learning and thoughts we hope to build a collaboration of the willing who are prepared to lead by example and work in a way that really values people, trusts them to ‘do the right thing’ and enables them to build trust with the clients with whom they work – so here goes!

Be under no illusion – the client really is front and centre in both organisation and all they do – as Buurtzorg’s model makes clear.



The person needing support

The focus is on continuity of care and developing the strong bond between patient and member of staff.  Total patient holistic care was highly valued and the clients we met were clearly impressed with the staff working with them who knew them all well. W

We were also impressed that the staff made choices, sometimes, not to complete tasks but to simply listen / talk when it was more appropriate to do so; which built a culture of trust. The only protocols in the organisations were clinical; all others were removed in favour of simple goals and simplicity itself. 

Informal networks

Teams are based, and often live, in the community in which they work. Highly visible, they are often based in previous shop premises on the high street and people walk in from the street to seek access to the team. With small areas to cover, the team are also seen out and about on their bicycles; spending very little time commuting between visits.

Clients had access to all their care records via iPads in the home, as did their carers where they wanted them to.  All clients / carers could message staff via this route, as well as phone their team out of hours if necessary; although calls to teams were extremely rare – teams citing rates of one or two calls at night a year.

Buurtzorg team

Our reflection is that the current system in which we work in the UK is based on distrust rather than trust - rules are made for the 3% who don't do a good job rather than the 97% who do.

The small teams in Buurtzorg who share responsibility for management / planning roles within their team, seem to encourage people to ‘step up’ and hold both themselves, and each other, to account; whereas in the UK it feels more as though by making many people responsible, no one is responsible.

In Buurtzorg teams spring into life when a group of nurses collectively decide that they want to work together. Within the organisational infrastructure that Buurzorg provides, they operate as self-managed teams (almost individual ‘franchises’) with high levels of individual and mutual accountability. Teams rotate roles, operating with a framework of activities that prioritise the quality of the relationship with the customer, productive client facing time and longer term prevention.

The clinicians within our team saw true autonomy for the nurses who they felt were both personally and professionally more enriched and had more job satisfaction. Simplicity was key to their approach but this didn’t prevent a clear, open and safe approach to governance.

The willingness of the organisations to cede control of the teams stood out, as did the complete lack of traditional management structures and the simple systems for enabling the teams themselves to manage poor performance amongst themselves.  

The access to coaching support seems to be highly valued if infrequently required. Interesting to note that, of four coaches originally appointed by Amstelring, only two were ultimately successful in their roles; 2 of the 3 managers were unable to make the transition to coaches.

All staff reported that team size was crucial; 5 staff minimum to provide safe capacity but no more than 12 in total, with 8-12 cited as the ‘magic number’.  Any attempt to go over 12 had led to a breakdown in team functionality.



Staff as customers and client




Experienced staff were highly valued. Working on the assumption that in fact the staff are also customers of Amstelring (since happy staff provide safe and efficient care), the focus of the ‘back office’ function comes to be ‘delighting’ employees.

Support services should be just that - a back office function - and not an industry in itself. The net effect of this is that the back office teams constantly focus on ‘keeping it simple’ when providing support, removing obstacles, acting as a firewall to prevent bureaucracy creeping into the work of the clinical teams, and always, always, taking steps out of processes and working to simplify.

The single IT system helps, as does an approach which, for example, allows staff to notify the office of contract hours changes by email, text, letter or phone; whatever is easiest.  Teams work in a flexible way which was valued as a two way deal; good for clients, good for staff.

Leadership was pivotal in ensuring that the organisations took actions which embodied their visions; demonstrating to the workforce, through action, their commitment.  For example, the teams at Amstelring were charged with interviewing and appointing the coaches from the existing managers that applied. Even allowing for this, only 2 of the 4 coaches ended up being right for the job (2 previous managers could not make the transition).

Amstelring were demonstrating the value they place on good coaching ("we would rather have no coach than a bad coach") and interesting that the decision to delegate this process to the self-managed teams was considered deeply symbolic and consistent with their vision.

There was a sustained and deliberate focus on the future – where you want to be / get to – rather than dwelling on the past, as well as a belief in the power of shaping the wider system / world to be better - "this is our alternative to what you think you need” rather than just saying that what existed wasn’t good enough.

Formal network

Referral processes were simple and referrals to other teams appeared minimal. The principle of the team was to act as generalists, recruiting specialist help if and when needed.  Integrated care, not integrated teams, was the order of the day.

Conclusion

Inspiring, motivating, challenging and ‘do-able’, the lessons from Buurtzorg and Amstelring are timely for systems who really want to make a difference to the quality of peoples’ lives – clients, staff and communities.  If these ideas are of interest to you and / or you would like to find out more or become involved in work in Manchester please contact one of the team via peta.stross@mft.nhs.uk or siobhan.reading@srft.nhs.uk 

Monday, March 19, 2018

Blog - Adopting Systems for Quality Improvement in Health & Care - David Fillingham

Following the recent launch our paper A Sense of Urgency, A Sense of Hope at a joint event with The King’s Fund, our Chief Executive David Fillingham takes a further look at the need for health and care organisations to adopt systems for quality improvement.
David Fillingham

It has been a long, difficult Winter for the NHS. Staff have worked incredibly hard to care for increasing numbers of patients at a time of tightening finances. Sadly, despite these great efforts, we have inevitably seen too many stories of long waiting times and a worsening experience in many places. Whilst the NHS has a marvellous ability to cope in adversity, the sense of it being in crisis is growing.

On one of the snowiest days of the year, the 1 March (allegedly the first day of Spring!) over a hundred hardy NHS folk battled their way through blizzards to a King’s Fund / AQuA event in Manchester where we launched AQuA's framework on building a system and culture of improvement, entitled A Sense of Urgency, A Sense of Hope.

By a show of hands delegates indicated that they were very familiar with the extreme pressures facing the NHS. They also recognised that the current political and economic context is such that, the sustained and large-scale investment needed in health and social care is unlikely to happen anytime soon.

The 'hope' rests in the fact that there is a strong evidence base, in other sectors and in healthcare, that the strategic application of improvement methods can improve both quality and productivity. This is not to say that more spending isn't needed, it is, but until the day it arrives there is a great deal that the NHS can do for itself to tackle the waste, delays and duplication in the system that are such a source of frustration for staff and patients alike.

The problem is that our improvement efforts are too often small-scale, piecemeal and not sustained. Organisations which have achieved transformational results, such as Jonkoping in Sweden, Virginia Mason in the US or Salford Royal and East London Foundation Trust here in the UK, have adopted a long-term approach to building their respective improvement systems.

AQuA's publication is based both on a review of the published evidence about how they have done that and on reflections on leading and supporting improvement efforts on the ground.

Our framework has five interdependent elements:
  • Vision and Strategy - developing a plan that inspires and engages everyone. It should have bold aims, measurable goals and commit the organisation to building improvement capability at every level.
  • Leadership and Culture - in an improvement culture patients and families are full partners in their care. Staff are empowered and supported to use their energy and creativity to solve problems, and leaders are positive role models who coach others in their chosen improvement approach
  • Building Capability - there is a commitment to train all staff in improvement method and to give them the time and encouragement to use those skills. Leaders and coaches will have more advanced know how and there will be a small number of genuine experts. The Board will itself commit to receiving development to carry out its own improvement leadership role effectively
  • Developing an Operating System - improvement methods will become 'hard wired' into the organisation with goals being cascaded via a process of 'catchball' and expertise focussed onto the biggest challenges. Over time an improvement approach will become "the way we do things around here" and an accepted part of daily work
  • Aligning Support Services - staff working in HR, Finance, IT/Information and Estates have a great contribution to make. They will be fully engaged and these functions redesigned to support an improvement culture.
Last year NHS Improvement, alongside other national NHS bodies, published their strategy Developing People,Improving Care. This exhorts NHS organisations to make just these kind of investments in their own improvement capability.

The newly revised CQC inspection framework asks questions as to what progress is being made on the ground. Not only do organisations need to adopt such an approach if they want to emulate the best, now they are actively being encouraged to do so by inspectors and regulators.

This kind of work takes time and is a difficult path. It's all too easy to become overwhelmed by day to day pressures. Succeeding requires courage, curiosity, persistence and optimism.
But the prize is a great one...that of seeing staff glow with the pride using their own experience, energy and ideas to transform the care that patients receive.

Feel free to share your thoughts with us via Twitter @AQuA_NHS or get in touch via AQuA@srft.nhs.uk to request a hard copy of our paper.

Monday, March 12, 2018

Buurtzorg Diaries - Bringing Buurtzorg Home - Wendy Lewis, Whole System Flow Lead

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes from Wendy Lewis, AQuA’s Whole System Flow Lead.

Well reflecting on a great three days where we really got under the skin of this Buurtzorg thing - it really is as good as the hype, in fact it might be better!

From the welcome we received, the honest responses and challenges to our questions to the bikes, strange contraptions for putting TED stockings on and the inspirational speakers, this has been a really stimulating and heart-warming learning experience.

As the final group discussion took place this morning, I noted the key issues we’re really wrestling with:

  1. What's the compelling narrative we need to create that will get this work across the start line? WE get it now, how do we help THEM get it?
  2. How do we create the space for self-led teams without actively seeking the obstacles and obstructors that we foresee we’ll have to overcome?
  3. Can we achieve our organisations' expectations of Buurtzorg by using a too tentative approach to testing or implementing? 
  4. Matthias van Alphen talked about how ridiculous it would be to describe someone as 'a little bit pregnant', or a little bit autonomous... Can we agree to approach this properly where self-led means self-led?
Finally, a perspective from Brendan from his experience, instead of the usual discussion if how we adapt the Buurtzorg way to our systems, we need to approach it differently:
  1. How do we change the context to fit the Buurtzorg model?
  2. Can we adopt the principles within the context we work without compromising the model?
Some questions to ponder as we return home and prepare for module three in May!


Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Wendy Lewis (@ERPwend) on Twitter for the latest.

Thursday, March 8, 2018

Buurtzorg Diaries - Buurtzorg Life Poem - Jacqueline Williams, East Cheshire NHS Trust


Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Our latest learning comes as a poem from member Jacqui Williams, Associate Director for Service Transformation at East Cheshire NHS Trust.


This is our reflection of our time in the Hague,
We’ll try to give detail - and not be vague
Monday - the day our adventure began...
7 nurses let loose across Amsterdam
We’ve tried all modes of transport - car, foot, tram and bike
All thirsty for knowledge about the ‘Buurtzorg life’.

Nursing teams in neighbourhoods - where lives are laid bare
Early intervention, practice prevention and promoting self care
Really ‘knowing’ your patients - that's how it should be
Therapeutic relationships with continuity
Goals and solutions that are owned and are shared,
Everyone’s equal, with time given to care.

So, what has struck us about this philosophy?
A return to core nursing values ‘create simplicity’
Systems and support that don’t hinder or burden
A ‘no blame’ culture - and commitment to learning

Nurses self managing - committed to their job
Accountable, responsible, professional Buurtzorg!
All of this is what we can see
With a feeling that this was ‘how it used to be’

So, what next? We challenged our brains
Thinking about what, when and how we might change

Jos de Blok’s words echoing in our minds
‘Coalitions of the willing’ - we need to find
Review what we have - trade in ‘process and tools’
Reduce the bureaucracy - ‘relationships not rules’

Take the best of our past, our present practice too
There’s lots to celebrate in what we currently do

Give our nurses confidence, freedom and competency
For safe effective care that brings real quality
Nursing in different countries, different cultures, but we share the same aim

Great patient care - Buurtzorg?
The clues in the name.

Stay tuned to our news page for more blogs where other teams will also be sharing their experiences from the trip.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.

Wednesday, March 7, 2018

Blog - Early Adopters & Spreading the Message - Norah Flood

In part four of our Person Centred Care blog series, Norah Flood, AQuA member and Assistant Director of Clinical Networks at North West Boroughs Healthcare NHS Foundation Trust, discusses the Trust’s implementation of Person Centred approaches and the importance of early adopters.

Noah Flood
‘We already do that’ and ‘I will not allow my patients to make a bad decision’ were the two stand out responses received when introducing the concept of Shared Decision Making (SDM) into a recently merged Community Physical Health and Mental Health organisation.

Fortunately, there were also plenty of open doors to be knocked on that welcomed the structure of tools to support the practitioner and patient to reach a decision together.

Initially, these doors belonged to the high volume services, possibly surprising, as a common concern among practitioners was the perceived extra time it would take in engaging in SDM conversations with patients. However, the case for enhanced compliance, reduced DNAs and increased patient satisfaction soon overcame those concerns.

Even better was the tangible evidence produced; demonstrating that patients did want to share in the decision, actually did know what their preferences were, and so did engage fully in their treatment plans.

Leaders in the field are essential but more crucial are the fast followers. What we found was that spread and adoption in Community Physical Health Services was both rapid and successful. Possibly because services were proactive in seeking out support to engage in SDM and adopted, or created, patient information to assist patients in determining what was best for them.

Equipment Services, Dietetics and Weight Management, Podiatry, and MSK became self-sufficient in utilising SDM and developing tools to support patients. Furthermore our Intermediate Care services introduced SDM and achieved a cultural shift in how risk was assessed and managed. This is best demonstrated by Jim's story.

An early advocate of SDM came from our Secure Care Services, who utilised this approach to support the introduction of the Trust’s smoke free policy. Tools to support service users to stop smoking were co-produced with service users, ward staff and pharmacy.

The response was both positive and immediate and the concept of Shared Decision Making was soon transferred to the unit’s multi-disciplinary team meetings; now the service user has the opportunity to fully participate if not lead their MDT.                                                                  
News travelled fast and on the back of one success came enquiries and suggestions for where else Shared Decision Making could be applied.

Another early adopter was our CAMHS services, where it was always felt that continuity of practitioner was of the upmost importance and while no-one denied that, it was realised that not all practitioners are skilled to offer the full range of interventions.

Therefore, tools were developed to assist families in deciding which therapeutic intervention they preferred to receive, and how that decision was affected if it meant moving to a different therapist.

This approach was spread to other services by the ‘share and adopt’ method, and Shared Decision Making has become something we already do across the organisation.

You can share your thoughts with Norah on Twitter via @NorahFlood1  or @AQuA_NHS, or feel free to leave a comment below.

In our next blog we hear from another of our members, Caroline Poole, Clinical Improvement Lead at Pennine Care NHS Foundation Trust; who explores a systems approach to measuring person centred care.


Stay tuned to our news page for more updates!

Buurtzorg Diaries - A Self-Led Start to our Trip – Emma Walker & Siobhan Reading

Early in March, several AQuA staff and members embarked on an exciting study trip to the Netherlands, to learn more about the Buurtzorg health and care system.

Throughout the week, they’ll be sharing their learning and experiences of the trip in a series of blogs. Starting off the series, our Strategic Portfolio Lead Emma Walker and Programme Support Officer Siobhan Reading bring us up to speed after landing in The Hague…

Emma Walker
Siobhan Reading and Emma Walker
AQuA and member colleagues excitedly arrived in The Hague for our Buurtzog study visit to see how self-led teams work in the Netherlands.

It was quickly apparent from the initial welcome meeting with our Buurtzorg hosts that we were not just going to observe self-led teams, but the programme itself for us was going to be very self-led.

Teams were given their programme for the next 3 days and then we all had to work out how to get to various points across the city - some by 7.30am the following morning!

Initially, folk talked about getting taxis, but it didn’t take long for their adventurous spirit to creep forth and you could see why these folk had been chosen as they quickly embodied self-led ‘ness’ and a can-do approach; working in small groups (with good old Google) to work out which tram, from where and when they needed to get to by when (how did we manage before the wonders of smartphones?)

So, we are off with our phones, clutching maps on bikes, trams and foot to explore the 3rd city of the Netherlands to see how Buurtzorg works in practice - not only observing nurses with patients today, but also visiting a Buurtzorg office, seeing how the very streamlined back-office function works and how social and health care provision in the community functions together.

Siobhan Reading
Today I was surprised to learn that setting up a Buurtzorg team requires an entrepreneurial streak!

You have to be prepared for the challenges of business planning, budgets and watching your overheads.  You also need to have identified if the model will work within your neighbourhood by reaching out to GPs and other community organisations.

AQuA staff and members alongside Buurtzorg colleagues

It’s not enough to just have a team of nurses. With no formal support the team has to be prepared to make all their own decisions regarding staffing and working practices.

For anyone who's had a desire to set up their own business or be free of line management maybe the Buurtzorg model can apply to more than just healthcare.

However, taking on that responsibility might not be for everyone…

Teams from localities across East Cheshire, Manchester, and Wirral will also be sharing their experiences from the trip, so stay tuned to our news page for more.

Alternatively, you can follow Emma Walker (@EmmaCherub) or our Whole System Flow Lead Wendy Lewis (@ERPwend) on Twitter for the latest.