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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Reflections from OBHC – finding a research community

Earlier this week, I was lucky enough to attend the 10th International Organisational Behaviour in Healthcare Conference (OBHC) held at Cardiff University Business School, which was focused on ‘Attaining, sustaining and spreading improvement: Art or science?’.  I had submitted an abstract for an aspect of my PhD work and was pleased to receive feedback and be invited to present at the conference, though nervous at the same time, and my supervisors both encouraged me to attend.

When the programme was published I was pretty excited about this conference. When reading for your PhD, often the same authors of papers pop up repeatedly, particularly when highly cited, and it seemed to me that attending this conference with me, would be many of the ‘academic celebrities’ whose work I have been studying.  And not only that, but some of my friends from the Health Foundation PhD programme; together with faculty from the ‘GenerationQ’ quality improvement leadership development programme, which I completed in 2010, would also be there, presenting their research linked to the programme.  Without them I would not have been doing a PhD at all, what a way to re-connect.

Photos: Academic Speed-dating (credit: @cjpope on Twitter); Health Foundation PhD Award colleagues at Cardiff Castle with myself and and beautiful outdoor shot at Cardiff Castle (credit: @emmajonesphysio on Twitter).

Prior to the workshop there was a day set aside just for early career researchers and PhD candidates. This session was wonderfully facilitated by Professor Catherine Pope from Southampton University, who told us transparently, that she would shout at us repeatedly until we did what she wanted – which was just as well given the decibels we created later. It involved over an hour and a half of ‘speed-dating’, when all of us got to talk to a different person for four minutes each time about our areas of research and interest, and in case we needed an ice-breaker – what we were fearful about.  This is how the decibels were created, it was outrageously loud!  Yet fascinating and fun at the same time, and a great way to put names to faces and a way of meeting each other quickly, and facilitating coffee time chats, networking and reflections throughout the conference.  That evening we were also treated to an exclusive tour of Cardiff Castle together with prosecco and canapes, lovely….  a change from PhD Life!

The following day the conference opened with a keynote from Mark Drakeford, Minister for Health and Social Services in the Welsh Assembly Government. He outlined a fascinating perspective on ‘Prudent healthcare’ in Wales describing a health and care service where professionals ‘only do what they can do’ rather than trying to do it all.  Other intriguing keynote speakers included Professor Stephen Shortell and Professor Louise Fitzgerald, who both commented on improvement, transformation and change with differing perspectives, reminding me so much of the value of differing theories to help see issues in a new light and to help create new spaces and opportunities for improvement in healthcare, both as a science and as an art.

The conference seminars were absorbing. There was so much opportunity to learn about differing aspects of healthcare organisational behaviour such as knowledge mobilisation, nursing care home operations, innovation and improvement processes, governance, brokering change, submitting to academic journals and many other areas -all also linked to healthcare improvement and change.   These sessions were also a great way to be introduced to new areas of literature and theories that I have not yet explored.  My presentation session related to regulation and governance and I was delighted to hear about other work in the area and feel welcomed as part of both that specific research community and the OBHC community at large.  I also valued the feedback and recognition for my research as part of my thesis which can feel like a lonely and vulnerable way to travel at times.

From my perspective, the conference was an overwhelming success at developing research and researchers and providing a place for respectful challenge and support for a community wanting to use research to understand and improve healthcare. Well done to those from OBHC, thank you for welcoming me into your community, and my particular thanks to Dr Aoife McDermott, from Cardiff Business School, whose research I am building on, and who not only encouraged me to submit an abstract but also supported me hugely through the conference in many, and some unusual, ways.

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How not to be lean

How not to be ‘lean’

Last month an opinion piece was published in the prestigious New England Journal of Medicine decrying lean or ‘medical Taylorism’ and arguing that amongst other things that approaches used to standardise care have gone too far, and it is time to remember the patient, and the perennial favourite reason of ’we don’t make cars…’.

Needless to say, in the lean community, there was a bit of a to do! (see Mark Graban’s fab thread and comments here). Not only was it perceived that the authors were incorrect to say this as the criticisms are surely about ‘fake lean’ not ‘real lean’, but also that they compared lean and Taylorism to be the same thing.  Ouch! How to hit the lean raw nerves!  Though there are plenty of things to learn from Taylorism.

Now this might be a controversial opinion too…but some of the criticisms in the article of lean (in this case in US healthcare) are surely familiar to most of us in the lean community? They are not new, and whilst some of the statements in the article may be inaccurate, if we are all truly honest I doubt that any of us have NEVER accidently fallen into the trap of some of them.  Maybe it happens whilst we were learning our practice or at times of immense pressure – we are all human after all.  (At least, I hope it is not just me!). I believe it is time to be more reflective and honest about when and why ‘fake’ lean practice sometimes happens, either unintentionally or intentionally because then, we can think about what we can learn from that, and what we can do to change the situation.

So, taking a deep breath, here are my five ways of not being lean.  These are my reasons (excuses?) for unfortunately practicing ‘fake lean‘, from my experience in both industry and healthcare… Needless to say, there are probably a load of other reasons too…maybe I’m not brave enough to own up to all of them yet.

Wanting to be the Expert / Lack of Humility

As a graduate industrial engineer….I thought I was special and very knowledgeable ‘a lean expert’, I have a degree in this for goodness sake.   I thought with all the exuberance of youth that being lean would be easy.  I thought hey I can apply these principles that I have learnt about lean production in automotive in the process sector, no bother, it will be easy.

It wasn’t, the context is hugely different, different production processes, different cultures and different products. As ‘an expert’, it is easy and arrogant to think, I have seen this type of problem before, and I remember the solution from that and go and implement it, then I’ll save a load of time and bother.  It requires much more effort and humility, to listen, observe and talk to those who do the working or ask for help.

Money, Money, Money

If lean is a way to improve quality, remove waste, add value and ensure respect for people and society, why in business cases and sales pitches does the ‘return on investment’ and just how much money can be saved through lean always seem to be the main emphasis?  Often closely followed by a long list of all the ‘lean tools’ that will be taught. On reflection, I think perhaps it is fair that an organisation might think that lean is about money and tools, if that is how lean is ‘sold’ to them, particularly if gain-share contracts or similar are involved.  That lean is often perceived as a money saving tool is arguably a product of our own making.

Sticking to objectives / Silo Working

Understanding the history of the organisation and why they are in the position, and how that came about, to me has become critical. Once, I worked in a factory implementing a number of lean cells with huge improvements in inventory and lead-time reduction leading to improved cash flow, improved workforce morale as expected.  However, the financial position of the business was so precarious, the factory still closed, partly due to the financial impact of the inventory reduction activity.  A more careful understanding of the wider picture may have developed a more nuanced plan and been more respectful and careful about managing expectations with employees.

Further, few organisations I have worked with have not tried some variant of lean or similar (six sigma, lean six sigma, IHI-QI, agile, TQM, CQI, TPM, TOC, BPR, BPM, LiA etc etc). For me now, understanding the story of previous attempts to use progressive management practices, is critical to developing new ways of working and change in that organisation.  In addition, I find it now vital to understand the wider commercial and regulatory environment, as well as customer needs and notice if this is changing, to allow adaptation in improvement solutions and improvement/management system if needed.  For certain, I never used to take enough notice of this….maybe I still don’t take enough notice.

Lack of Courage

Sometimes, in my experience, it is hard to gain traction or commitment for a change in working practice, for so many reasons.  Often it is worthwhile to enquire more into the source of this problem.  Sometimes, it is easier to back away from this challenge and do something else, and rarely positions are just entrenched.  Sometimes, it is easier to ‘just do something’ that you know is not in keeping with lean principles, because of the pressure to act and to be seen to do something.  Sometimes cutting corners is enough, reducing the fidelity of lean practice (watch that pressure to make an A3 easier to fill in and reduce ‘the paperwork’).

Sometimes, these things might happen to just keep face, to continue to be accepted by the organisation, or even wanting to keep your job and not be seen as a troublemaker or lose a trusted advisor role.  Many of us do not have the financial security or position of being able to walk away from a role or contract and accept some of the compromises.  This is the art of being able to ‘rock the boat and stay in it’. Sometime, I’ve also ‘rocked the boat’ too much, and fell out of it too, this I find, is as hard to live with, as rocking it too little.

Taking comfort in the Status Quo

One of the great strengths of lean is the development of standard work and having the self-discipline to stick to it, because it has been tested to be the best known way of working. Thing is, it doesn’t really stay the best known way of working for long.  Sometimes, not too often I hope, I have found it easier to keep working with improvement teams and clients encouraging them to improve in the way that I have always done, than find the time to change myself and my standard work, leading me down a route of outdated practice and that no longer fits the local working environment and context.

So, five areas of practice that could be interpreted as ‘fake lean’ and reduce my credibiltiy as a lean practitioner.  My view, I am always learning and I need to reflect on when these things happen, to recognise the patterns and think about how to act differently the next time those situations may occur or are occurring so I can maybe change the outcome for the better.

On reflection though, there is an air of familiarity to these reasons/excuses.  Are not these just the kinds of problems that organisations we work with typically have too?  So, what are the processes we use to help them with these problems, and how as a lean community are we going to use them to improve what we do?  How are we going to stop not being lean and reduce the prevalence of ‘fake lean’?

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