Blog - To Flow or Not To Flow

Wendy Lewis is the Whole System Flow Programme Lead for the Advancing Quality Alliance (AQuA), and you can follow her on Twitter @ERPwend. Here she shares her thoughts on the current state of play behind Flow, and some things she has discovered throughout AQuA’s journey in understanding this complex issue.

Wendy Lewis, Whole System Flow
Programme Lead

Our Chief Executive David Fillingham recently led a webinar for the UK Improvement Alliance (UKIA) on the subject of Whole System Flow; a subject that we at AQuA have been working quite intensely on with The Health Foundation over the past 12 months.

Having had the opportunity to work on our Flow discovery programme for the past year, I used the webinar to reflect on some of our learning to date. Some of the discussion and questions generated also really helped me to crystallise some key points that the improvement community may want to consider and contribute to.

Our thinking has led me to these main points:

We Still Rarely Talk About Whole Systems

Language is so important when considering flow. By using the title of whole system flow but then describing a patient pathway or service level improvements as the examples, we are pulling the opportunity for learning and line of sight below the system level. This is perfectly understandable, as this is where our energy, effort and money has been spent in trying to ‘fix flow’ through our NHS services.

Throughout our conversations and local discussions about this work, we’ve used the phrase “from a patient’s front door and back again” to loosely describe the system. However, we developed this definition:

The coordination of all resources across a locality to deliver effective, 

efficient, person-centred care, in the right setting, at the right time.

What we have found really important, is that the participants can describe the system they are applying this thinking to and be clear of its boundaries. If the focus for improvement is on an acute hospital pathway or a community based service - describe it as such. Our role as improvement experts is to then support and also challenge that work, and highlight the opportunities for applying whole system thinking.

We Rarely Talk To Whole Systems

Through AQuA’s programme this year, we’ve had the opportunity to work with both a wide variety of our members, as well as partners across health and social care, and asked them to define the current enablers and barriers to flow. The overwhelming response from our first co-design event was “We need the system in the room to talk about it and improve it!” Quite right too! This is a fair challenge and one that we have made efforts to address, but it does remain an issue.

How do NHS soaked improvement organisations engage with system partners from local authority, community groups and charities? When we have new partners in the room but the examples we describe are health-based (and usually centred on acute hospitals); this really doesn’t foster engagement and shared understanding.

We call it Patient Flow!

ARGGGGHHHHHHHHHHH! If only patients did flow as they would want to, and actually as we frequently promise, then they would flow through our pathways!

I’ve become increasingly aware of the language used about the recipients of our services, our patients, our customers within this work on flow. Bed blockers, delayers, usual suspects, frequent flyers… commonplace in our language as well as in the media. How should we lead the change in language that demonstrates respect and outdated, non-paternalistic, approaches to care provision?

Through our work this year we’ve described four elements that have to be understood alongside each other, in order to understand flow through our systems and how we might improve it:

• Patients 
• Workforce 
• Information 
• Finances 

And again, like with not having the system in the room to generate the right level of discussion, by not paying attention to these four elements in parallel throughout flow work, we run the risk of re-shaping a problem, rather than clearly defining and understanding it.

Reality check

The systems and services that we hold dear are under extreme pressure, with improvement priorities coming out of their ears. Where does a new improvement offer add value, not distract from mandated priorities, and support real transformation when capacity to even think about it is occupied? Applying new thinking to a highly reactive and defensive system -a challenge or unhelpful task?

In improvement we teach “go where the energy is”. I think in reality we in the NHS are seeking to fix what’s hurting us the most right now: A&E waits, delayed transfers of care, financial compliance, to name a few. Going where the energy is for improving the system is not the same as following the energy currently being spent on these pernicious problems. How do we support both? How do we create the head space for applying different and new thinking?

We also need to acknowledge how colleagues in our own improvement communities feel about flow. A lot of us have been involved in a whole range of these over recent times; some with support and drive from national structures, and others from local or regional initiatives.

Our differing levels of success and/or sustainability create a new issue; there is frustration, scepticism and even cynicism about creating another offer around improving whole system flow within 'Us Improvers.' However, there are sources of energy and support outside the NHS that could really help us refresh and reframe our thinking.

So – how do we respond to these points? How should we act on them? If we focus for another year on whole system flow - where will we get to?

AQuA Chief Executive David Fillingham CBE, alongside colleagues from The Health Foundation, will shortly be publishing a joint report on Whole System Flow. For more information, please visit the AQuA website or follow @AQuA_NHS on Twitter.

Learning to Improve - Getting the Right Kind of Practice - David Fillingham

How do we learn? Two examples spring to mind from my experiences this summer.

The first: my four year old grandson kicking a football in his back garden, being coached by his ever patient Dad to get more power and accuracy so that the ball landed in the back of the net at least some of the time. After an afternoon’s practice, some gentle praise and constructive feedback he was getting it between the posts more often than the England football team; maybe a ray of hope for the 2032 World Cup?

The second: it’s Olympic year and watching titans such as Andy Murray and Jessica Ennis-Hill turning in medal winning performances made me think of their own countless hours of diligent practice.

Practice is critical to learning. Yet it’s not necessarily true that all practice makes perfect. Recent research into the neurophysiology of learning has demonstrated that it requires the right kind of practice to get good at something – whether it’s kicking a ball, an Olympic event or improving healthcare. You need to practice not only frequently but also correctly. You need to practice with lots of supportive feedback so you learn from your mistakes and don’t hard-wire self-defeating habits into your attitudes and behaviours.

As it is for grandsons and Olympians, is it also true for health care systems? After two decades of striving to apply improvement method to the NHS are we getting any better at it? And what constructive feedback might help us to improve the way we improve? My own perspective is that of someone who has made many mistakes and not always sufficiently learned from them.

We have had a succession of national bodies leading improvement in the NHS in England: the NHS Modernisation Agency, then the NHS Institute for Innovation and Improvement, followed by NHS Improving Quality, and now, after the coming together of Monitor and the Trust Development Authority, NHS Improvement. I was privileged to lead the first of those bodies, the NHS Modernisation Agency, from 2001 to 2004 and I have worked closely in support of each of the successor organisations.

The NHS has never been more in need of effective national leadership for improvement than it is right now. Overwhelming service and financial pressures are placing a tremendous strain on front line staff and in many places standards of care are beginning to slip.

The formation of NHS Improvement gives me hope. Its new leadership, Ed Smith (Chair), and Jim Mackey (Chief Executive), are on record as saying that they want to see a step increase in investment in improvement method as a response to the challenges we face.

So, if we are to go through another cycle of ‘practice’ – with a new national improvement strategy due in the Autumn of 2016 – how can we make sure it is the ‘right kind of practice’? What sort of reflection might help us to avoid some of the mistakes of the past?

Here are four suggestions based on my own experience. Why not use the comments function below to say what your list would look like?

1. The NHS Modernisation Agency was successful at engaging clinicians in its work but it was much less effective at engaging boards and senior leaders. Investment in strengthening the ability of NHS boards’ to lead quality and safety improvement should be given the highest priority. Without it improvement won’t take hold in a sustainable way.
2. The Department of Health, NHS and other national bodies may provide funding and set overall direction, but it is NHS organisations and front line staff who are the real ‘customer’ for improvement support. We need to generate buy in and give all NHS organisations a genuine stake in being part of an ‘improvement movement’.
3. The wicked problems we face can’t be solved by organisations working in isolation. The ‘Sustainability and Transformation Plans’ in England create an ideal opportunity to develop improvement capability across whole systems of care not just in institutions.
4. If national improvement organisations attempt to deliver all improvement support themselves they pull talented people with good improvement experience away from front line delivery. I’d like to see NHS Improvement keep its core team relatively small and for them to work through a variety of regionally based partners. The aim should be to keep improvement practitioners close to the action, and to network them together in a vibrant learning community. 

The UK Improvement Alliance is made up of organisations whose mission it is to improve health and the quality of healthcare and who are seeking to learn and apply the lessons of the past. We aim to be a strong partner to NHS Improvement in England and its equivalents in Scotland, Wales and Northern Ireland.

Meeting the extraordinary challenges which the NHS faces is a daunting task. To succeed we’ll need to be on top of our game. Let’s commit ourselves to the ‘right kind of practice’ that which is imbued with the spirit of humility, reflection and learning.

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

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.

The King's Fund Improving Quality Publication

On 23 February, The King’s Fund published a paper called ‘Improving Quality in the English NHS’ in which it called for an overarching quality improvement strategy for the whole of England.

In the report, The King's Fund highlighted AQuA's work as a regional quality improvement organisation and how we support NHS organisations through shared learning, as well how AQuA's work might support the development of a national strategy (pages 19 and 21).

Chris Ham, Chief Executive of The Kings Fund, also published a blog, again identifying AQuA's existing support on improvement collaboratives, and also referenced the newly established UK Improvement Alliance (UKIA), of which AQuA is one of the founding members. 




We are delighted to receive this national recognition from The King's Fund and will continue to develop our work in Quality Improvement on both a regional and national level.