‘Which improvement approach is best?’

Without doubt, this is the question I have been asked most during the last 4 months since returning to paid up employment:

‘Which improvement approach do I think, is the best?’

I find it sometimes a tricky question to answer, because it can reveal so many different things, which depending on the context, I don’t always want to reveal.  It can potentially reveal information and clues about my professional background, and potential tribal allegiances, about my view of improvement priorities, my perspective of ‘how’ to do improvement work: top down or bottom up; frontline or corporate centre; clinically-led or patient led, internal team or external consultancy; my knowledge and experience and even my view of the world.

My view has changed.  I did used to think that…. or kind of think that, Lean was the best approach.  I think gave that impression. Not in the way many view Lean now mind, codified as: value, value stream, flow, pull and perfection (perhaps Lean has even ossified like this?).  But as both continuous removal of waste AND respect for people and society rather than any tools or techniques.  With 4 True North goals, Lean’s version of the IHI Triple Aim: quality, leadtime, cost and morale. Those to me were common to most ways of respectful problem solving, and in a way, just how you were taught to think and work as an industrial engineer and improvement leader.  Choosing the way of solving the problem and selection of the best ‘approach’ part of the skill set for each problem and context.  Sadly, I see Lean often ‘defined’ and ‘practiced’ in very mechanistic and inexperienced ways, where arguably ‘over-standardised’ tools are used [e.g. office based ‘sterile’ 5S] to ‘make it easier’, where money and results dominate whilst customers, service users (patients), people and society are barely mentioned.

When I came into healthcare I found it very confusing: why is there so much debate about which improvement approach is the ‘best’, (I don’t remember this debate in any earnest in industry), why does there seem to be so many arguments, aren’t they all really the same underneath?  With a focus on the customer (service user, patient), emphasis on flow and reducing variation and a requirement to support those doing the work, to improve the work?  [And as an experienced industry improvement professional what the h*ll is this newfangled IHI-QI approach, that doesn’t seem to be used anywhere else but healthcare, and yet seems broadly the same but just with different jargon, coupled with loads of clinical terminology and metaphors?, Yes, jargon barriers work both ways, folks.]

So what is my view now?

I suppose I have mellowed and take a view that there are many benefits of using different approaches in different circumstances, though I think it helps for improvement beginners to just use one at first, with all its jargon and peculiarities, (whilst signposting it is not the ‘only or best’ one).  I consider that learning and practising more than one overtime also important, to learn the strengths and weaknesses of each, to develop some level of mastery, to be able to cut through and translate the jargon, to recognise that the seemingly different tools and techniques on the surface in look and name, are similar in usage and to learn when and why some suit and some don’t (often through failed tests of change) in different contexts, cultures, organisations and sectors whilst working collaboratively across a supply chain (or care pathway).    

All of the approaches have strengths which can be helpful in different circumstances: lean in reducing lead time and its relentless focus on the flow of value, together with a blueprint for a ‘management method’ for organisational or system improvement; IHI-QI for its collaborative method and ability to engage folks in improvement activity; 6sigma for its focus on variation and product/process consistency.   The approaches, to me, seem to have similar ‘tools’ for similar tasks, such as the Model for improvement or the lean A3; the driver and fishbone diagram; patient safety walkarounds and gemba walks; collaboratives and yokoten (translates as horizontal deployment); to name but a few.  These improvement approaches all also have plenty of downsides, not least the lack of evidence of their effectiveness, regardless of approach chosen.

However for me, the strength of improvement approaches is in their similarity in helping folks solve problems and serve their service users and patients better. Consistency of purpose in improving care, rather than consistency of approach seems to me to be more important, (although I am mindful of potential fidelity problems). I prefer to put my energy and passion in to the ‘doing’ of improvement for this purpose, rather than using energy considering which improvement approach is best.  What’s your view?

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Finally Phinished

I finally graduate on Monday… two days time.  I have designed, researched, written, rewritten, printed, submitted, defended, corrected and completed my PhD thesis.  Some 340 odd pages and 120k of words (I count the appendices!)  Probably more like 500k words before seemingly endless revisions and the culling of pointless paragraphs and sentences, that ended up nowhere.  As well as 2 journal papers, 2 book chapters, 4 ‘formal’ blogs, 7 conferences, 2 summer schools, 1 award and 1 lost suitcase.  

Just about 4 years of my life, of hard work, of realising how little I ‘know’.  Learning, painfully at times, how hard it is to write well (or even approaching something like ‘well’).  And with it, I have developed an endlessly growing gratitude and respect for supervisory teams and other academics who think so carefully, precisely and meaningfully about questions, topics and issues.  They spend so much of their precious time both formally and informally supporting students, reading and re-reading thesis chapters over and over, as well as providing as much encouragement as critique (and quite often contradictory feedback😉) and offering to both mock-examine and examine the final copy.  [Thank you, you know who you are!]

I’m now sat here, on a drizzly English summer afternoon, wondering what to do with myself, so used to am I, at getting out the PhD laptop.  Just to bash out a few more words here or there, or read a couple more papers or even just to rewrite a paragraph from the day before.  I still have a bits to do, perhaps a couple more journal papers that could be submitted… maybe (if I can bear the thought of rejection and re-writing again?).  Though now, almost without a university IT account, continued work for submission is harder, no easy library and journal access, no free citation software… and now back in the cut and thrust of managerial work, less time to think, reflect and consider potential submissions.  For me, on reflection, this ‘thinking’ time, a chance to slow down and breathe is the luxury and privilege of the PhD.  At first this time felt slow and frustrating, already now I am looking back on that protected time with some envy.

Now I have this great big PhD sized hole in my time, what am I going to do next?  Well, I have the afore-mentioned potential journal papers and the graduation ceremony itself still to do and a rather neglected family to give some time back to.  I also have returned to working in the NHS in England, working in one of the national regulatory agencies with an explicit remit to improve care.  I feel pretty damn lucky to have a role working in the exact same field as my thesis and to have the potential opportunity to use and share my learning to benefit our work and ultimately patient care.  A kind of non-post-doc, post-doc if you will, with my own variation of ethnography.  With a role where I can focus on putting my learning and contribution into practice, rather than a focus on seeking further ‘contribution’ to knowledge.  Perhaps it could even be described as the next stage for me, ensuring ‘Impact’ from my learning.  For me, ensuring patient care would – eventually – benefit from my work, was always one of my main drivers and sources of motivation.

Am I glad I did it?  Yes, yes, yes, despite the ups and downs of academic work, receiving disappointing critique, missing events because of the need to ‘write’ and temporarily losing ’employee’ identity, I have mostly loved it.  I have gained so much more than I was worried about losing.  I have been lucky enough to meet some amazing people and travel all over the world, to learn and share my work.  Now,  I am able to return to what I love to do, help to improve services and care for patients, with so much more knowledge than I had before.  What will I do differently now?  Try to keep learning, remaining open to other ideas and trying to remain a somewhat more critical thinker than I was before my PhD.   I also want try to stay connected with a research world interested in how and why services improve (or don’t), and help to connect more with a practitioner world that is constantly trying to improve services and yet has little time to actively reflect and consider those same questions.  We all have much to learn and much to share from each other for the benefit of patient care.  

Am I glad I have finished?  Yes.  Am I missing it?  Well, I’m not missing literature searching, but everything else? Just a little.

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What do you mean by improvement capability?

capability

As part of my PhD, I have been investigating how improvement capability is conceptualised in the research literature and by regulatory agencies in healthcare.

As a improvement leader, I realise now, that I used to use this term rather imprecisely, ‘my job is to develop improvement capability’ and so on, yet I’m not sure I really thought about what I meant when I said it.  I perhaps assumed, that everyone I talked to and I had the same view of what it was and what developing improvement capability meant.

Attached in this link http://q.health.org.uk/news-story/developing-improvement-capability/ is a blog on the Q Community website, detailed an element of my research trying to tease out what is meant by improvement capability and what different conceptualisations of improvement capability mean pragmatically for improvement leaders.

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Q Community

I have some exciting news I would like to share with you. You may have heard of Q* – it is an initiative being led by the Health Foundation and supported and co-funded by NHS Improvement. Through Q, people with improvement expertise are coming together to form a community – sharing ideas, enhancing skills and collaborating to make health and care better.

As part of a pilot phase, I successfully applied to join the community. I needed to demonstrate knowledge in, experience of and commitment to collaborative improvement.

I will be joining 445 others from across the UK – including those at the frontline of care, managers, researchers, commissioners, policymakers and more. It is hoped that by bringing together such a broad range of people working in health and care improvement, Q can be a vibrant source of innovation and practical problem solving for the system as a whole.

Over the coming months, I will be helping to test different ways the community will connect, share and collaborate on improvement challenges.

I will keep you in the loop about the different things I learn through Q and the connections I make. There will be more opportunities for others to join over the next 12 months. If you would like any further details I recommend visiting the Health Foundation website.

 

*Thanks to the Health Foundation for their suggested messaging about the Q Community.

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The day after the night before

Concentrating on my thesis seems rather difficult today, it bit like it does when you have a really bad hangover and you start to remember all the really embarrassing things you did the day before, that you wish you didn’t.

Yesterday, we voted to leave the EU; our neighbours.  We voted to ‘reduce immigration’ and ‘reduce regulation’ and to ‘take back control’.

My thesis is about regulation; and when I started it, I was pretty sceptical about it. I understand very well why regulation is often despised and people want to reduce it.  Yet, as I indicated in my last blog, I have had to wildly revise my views, I had misunderstood the purpose of regulation, I had misunderstood the nature of regulatory enforcement; and I learnt that the tide of regulation continues to grow, even under supposedly de-regulatory regimes and even when it is perceived to ‘fail’.  Regulation – despite all its faults arises to try to reduce market failure, protect us in the ‘public interest’ and crucially reduce issues of inequity.   The parallels with the EU debate seem so similar, and so by leaving the EU – it seems reasonable to assume, that some aspects of inequity and market failure that EU regulations were trying to resolve may quite easily increase.   Yet, the inequity that has grown particularly since 2008, ironically seems to underpin the voting logic for people who chose to leave.

The inequity felt in the post-industrial north and other areas, articulated in this tweet, showing the difference between inner Manchester and outer Manchester in many ways to me is driving the anger felt by those who have felt left out of the ‘new’ growth.  Voters that have felt invisible to the political establishment, and usurped by ‘others’ – labelled as immigrants: in school place applications, in the misery of the daily commute, in the lack of affordable housing or decent job security, in the doctor’s surgery and as hospitals reconfigure their services creating perceived winning and losing geographies for both healthcare services and jobs.   In Greater Manchester, of the new jobs developed in the so called Northern powerhouse, very few have been created in the poorer northern outskirts of the conurbation.

These feelings of inequity, of losing out, of being controlled by ‘faceless bureaucrats’, of being left behind, of being shut out, from many of the changes that have been made in the name of austerity or globalisation (or maybe even for improved clinical outcomes), this to me at the moment, is what has driven this leave result.

Perhaps, this underlying social inequity together with this leave outcome of the referendum, will force us back to thinking about why we were in it to begin with, and as reality sets in, why were some of the seemingly bonkers regulations developed in Europe there?  Were they really trying just to control us, and get one over us?  Or were they there to, within the confines of the political constraints they had, try to reduce some of these inequities that exist?  To ensure that doctors didn’t have to work godforsaken hours and potentially cause harm, via the European working time directive.  To ensure that manufacturers didn’t undercut workers’ wages in different countries and then profit from this exploitation on the EU free market.   To ensure women didn’t lose out if they had a baby.  To ensure we shared out growth more equally among us in Europe than we have done historically.  It seems, given the growth in inequality across Europe and within the UK since 2008, these regulations didn’t go far enough, were obsolete or were inadequately enforced or maybe didn’t cover the inequity that needed regulating, perhaps because this was still a Westminster prerogative, and by voting against Europe, this is a two fingered salute in response to the EU, and also to Westminster.

In my view, the best thing now for our villages, towns and cities has got to be a recommitment to fairness, to reduce inequity, and improve lives for those who feel dispossessed, devalued, isolated and lost, through truly listening to them and working together to try to move forward on these issues, across all areas including in healthcare. With the change in Tory leadership, and maybe Labour leadership, new political opportunities arise and perhaps a General Election will be called early.  We need to reach out to these voters and promise to focus on the growing inequity and help to redraw the political landscape, and refocus the current divisive national narrative, so that our great nation can become one again.  Perhaps then we can have a new day after the night before, only this time without the dreadful hangover.

[I kind of had to get how im feeling about this off my chest! Got a thesis to finish!!]

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Regulation and Improvement – Polar Opposites?

0715_magnet-800x480Picture from By Ernie Smith / Jul 14, 2015 (iStock/Thinkstock)

Three years ago, when I started my PhD about regulation and improvement in healthcare, if someone had told me that by the end of it I would end up defending the need for regulation, (specifically social regulation), I wouldn’t have believed them.   Not one iota.  At that point in time, regulation in healthcare was from my perspective a wholly unnecessary top-down burden.  It adds to costs, it wastes time, it is rigid and inflexible, it leads to risk-adverse behaviours out of fear of non-compliance, it creates mountains of paperwork, it offers pointless inspection reports and external ‘support’ with only rare occasions of useful insight, and finally and most importantly for me, it obstructs and hinders improvement efforts through its need to ‘control’.  Whereas I felt that improvement was its polar opposite.  It was interested in understanding care from the patients view, it is a bottom up process with those closest to the work improving the work, it is creative, exciting and innovative and much better at delivering results (and from my perspective as a QI leader, I was in ‘control’ instead).  I wonder now if my subconscious personal PhD aim was to ‘prove’ the futility of regulation and the superiority of improvement approaches.  Yet, as I have delved into the academic regulatory and improvement literature I have had to quite radically modify this polarised, and biased viewpoint.

Let me clarify two things. First, what do I mean by social regulation – I use a broad definition, which indicates that regulators are bodies that have the authority on behalf of the public to influence behavioural change in organisations (Selznick, 1985).  This means, that regulators don’t have to have ‘legal’ regulations to enforce and they can be a number of types of public bodies and are not limited to being a ‘regulator’ nor are they necessarily inspectorates.  Using this broad definition means that even national or regional, or corporate improvement agencies can be argued to conduct regulatory activities.  The regulatory literature also uses the word ‘enforce’ a lot.  Unfortunately, it is a word that sounds rather ‘coercive’ especially to improvement practitioners yet, the literature is explicit that enforcement strategies can use a full range of approaches, from the stereotypical deterrence approach of punishing sanctions through to friendlier, persuasive strategies such as education, improvement support and training aiming for a more voluntary take up of new requirements (Hutter, 1989).

Second, why does social regulation arise? The literature indicates that there are two main reasons, market failure and public interest (Walshe, 2003).  Social regulation such as that used in healthcare arises for both of these reasons.  For example, market failure arises because in some geographical areas of the country or specific sub-sets of populations there is inequity in service provision, and public interest regulation arises because of the harm and safety impact of poor quality care.  Self-regulation and/or local improvement activity has simply been inadequate to protect against these problems and given that much harm is caused by the health system rather than by individual healthcare organisations or individuals there is a need for an agency that takes a system rather than organisational view (Brennan and Berwick, 1996).

I used to argue that organisational improvement could resolve the poor care issues highlighted: ‘If only we could do it right’ and ‘if only they would let us’, just like other high performing organisations, say like Virginia Mason.  Yet the evidence is growing that improvement approaches, whilst critical to develop learning to improve patient care; are insufficient to resolve the wide array of complex performance and quality issues in healthcare (regardless of whether they are industrial or clinical, lean or IHI-QI etc).  Over the last eight years, at least eleven systematic reviews of such improvement approaches have taken place and indicate inconsistent evidence regarding the benefits of such approaches, frustratingly coupled with inadequate research quality (see for example: (DelliFraine et al., 2010; Nadeem et al., 2013; Taylor et al., 2014)).   This is not to say that regulation as an alternative is without the problems I highlighted at the beginning.   Those problems are still apparent, and similar evaluative work for regulation and its accreditation cousin, also finds inconsistent evidence of its benefits (see for example (Greenfield and Braithwaite, 2008; Flodgren et al., 2011; Mumford, 2013)).  Further, both can have priorities ‘captured’ or distorted through vested interests or dominant groups overpowering patient perspectives.

What I have discovered though, is that there is a growing body of theory and evidence arguing that regulation and improvement should not be seen as an ‘either/or’ choice but instead as a complementary mix of interventions (Sinclair, 1997).  This blends both the ‘benign big gun’ (Ayres and Braithwaite, 1992) from the regulatory enforcement menu with the supportive persuasive approaches, with local flexibility and experimentation of improvement approaches within and potentially across organisations.  This ‘responsive regulation’ approach (ibid) can build on the best of both regulatory and improvement approaches.  This can help to: ensure regulatory flexibility linked to the local circumstances, encourage and support improvement experiments with patients, develop learning networks and reduce the regulatory burden through collaboration between regulatory agencies and healthcare organisations.  That said, this approach still has the potential to use punitive approaches of enforcement with organisations on the rarer occasion that this may be needed.  An iron fist within a thick velvet glove.

This type of regulation was supported in the Berwick review (2013) of NHS care in England, and my research indicates that the trend towards variants of responsive regulation is continuing across devolved health systems in the UK but that this is not without its challenges.  These link to regulatory roles, resources both financial and skills, and ensuring collaborative relationships (Furnival et al., 2016).  This adaptive combination of regulation and improvement can focus on supporting healthcare organisations to develop their improvement capability and ensure delivery of better quality, performance outcomes and processes for patients depending on local circumstances.

Reflecting now, on my views from three years ago, I wish I had known more about regulation then and its relationship and indeed similarity with improvement. Some of the decisions and actions I took previously whilst in improvement roles may well have been different and may have led to much better care experiences and outcomes for patients.  I also feel quite strongly that there is a huge opportunity to grow understanding and practice across the rich fields of regulation and improvement.  There is much mis-conception of both, only by working together in collaboration can we truly improve care for patients, carers and their families.

References

Ayres, I. & Braithwaite, J. (1992) Responsive Regulation: Transcending the De-regulation Debate. New York: Oxford University Press.

Berwick, D. (2013) A Promise to Learn – A Commitment to Act. Improving the Safety of Patients in England. National Advisory Group on the Safety of Patients in England.

Brennan, T. A. & Berwick, D. (1996) New rules: regulation, markets and the quality of American health care. : Jossey Bass.

DelliFraine, J. L., Langabeer, J. R. & Nembhard, I. M. (2010) Assessing the evidence of Six Sigma and Lean in the health care industry. Quality Management in Healthcare, 19(3), 211-225.

Flodgren, G., Pomey, M. P., Taber, S. A. & Eccles, M. P. (2011) Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane database of systematic reviews, (11).

Furnival, J., Boaden, R. & Walshe, K. (2016) Emerging hybridity: a comparative analysis of regulatory arrangements in the four countries of the United Kingdom. 10th International Organisational Behaviour in Healthcare Conference. Cardiff, UK: Society for Studies in Organizing Healthcare.

Greenfield, D. & Braithwaite, J. (2008) Health sector accreditation research: a systematic review. International Journal for Quality in Health Care, 20(3), 172-183.

Hutter, B. M. (1989) Variations in Regulatory Enforcement Styles. Law & Policy, 11(2), 153-174.

Mumford, V., Forde, K., Greenfield, D., Hinchcliff, R. and Braithwaite, J. (2013) Health services accreditation: what is the evidence that the benefits justify the costs? International Journal for Quality in Healthcare, 25(5), 606-620.

Nadeem, E., Olin, S. S., Hill, L. C., Hoagwood, K. E. & Horwitz, S. M. (2013) Understanding the Components of Quality Improvement Collaboratives: A Systematic Literature Review. Milbank Quarterly, 91(2), 354-394.

Selznick, P. (1985) Focusing organizational research on regulation. Regulatory policy and the social sciences, 363-367.

Sinclair, D. (1997) Self‐regulation versus command and control? Beyond false dichotomies. Law & Policy, 19(4), 529-559.

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D. & Reed, J. E. (2014) Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ quality & safety, 23(4), 290-298.

Walshe, K. (2003) Regulating Healthcare. A Prescription for Improvement? Maidenhead, UK: Open University Press.

 

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Healthcare Engineering

I have been fortunate to be asked to write a blog for the IMechE about healthcare engineering to support their campaign in this area.  This builds on some of my previous writings in this blog.

If you want to read it – please follow this link

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