‘Have you an idea for improvement? If so, let’s go! Here’s a way to make it happen. Everybody can be involved, every little helps, anything and everything. The more the merrier!’
This seems to me, to be our overriding improvement approach in health and care. Pretty good, huh? Positive and I’d say looking back over the last 15 years, pretty effective, from few improvers and projects to many, all over the country. Consider the rise of QI training academies, the newsletters indicating how many projects have been done or certificates issued, hits on websites or tweet-chatters, conference attendees and growth in network members. A massive collection of improvers. We have many more thousand flowers blooming, and parks of flowers, than we used to, and surely that must be a good thing? More improvement activity, more improvers equals more improvement in health and care doesn’t it?
Or does it? What if it doesn’t? What if all that ‘capacity growth’ has really just been a load of hot air. What if it is just adding to the waste of overburden many staff feel everyday? Adding to the confusion of improvement brands and risk of elitism. What if we haven’t really developed any long lasting improvement capability at all?
Lots of plans, workshops, post-its, big inspiring speeches, training places and certificates, mostly leading to mostly one off small scale projects in many different areas: falls, UTIs, triage times, outpatient clinics, diagnostics, booking processes, discharge processes, therapy appointments, home visits, baby clinics, joy, retention, nutrition, PJs, stickers in notes and so on. All important for sure. Some lasting longer than others with seemingly good results, many not, with poor sustainability of many improvement initiatives . An amazing, fabulous swirl of energy and noise and positivity and activity. A few critiques, asking for better evidence of results and data, maybe some contraindications of unanticipated consequences. Nevertheless, a lot of hard work and fun. But we are not really sure if big dials have really moved, for anyone, and if things really just carry on much the same as before. Kind of kamikaze kaizen. Some might even call it firefighting.
What if it was different? What would it take to move from lots of small and largely unrelated improvement projects to something more aligned, cohesive and strategic? Where the small projects together accumulate into something a bit bigger? Greater than the sum of the many marginal gains in key areas? What if we asked everyone for ideas to improve in particular challenged areas, or if we explicitly said we want your ideas on how to copy this great idea in your unit? What if we rewarded those with the self-discipline and humility to copy and focus on the more mundane and tedious task of making improvement actually work in practice, instead of asking for yet more new improvement ideas before we have even evaluated the last batch of improvement ideas? A collective approach to implementing changes and sustaining them across a smaller number of priorities, reducing the overburden and building system wide improvement capability. Perhaps this would be more likely to help us to move the big dials more quickly?
Increasingly, I am reflecting on the ‘Hoshin Kanri’ (strategy/policy deployment) approach to these kinds of problems. Strategy development might help us clarify our plans and priorities. As long as we do actually prioritise, not just write a very long list of lots of urgent things that are important, rather than actually prioritising. Prioritising is about making it clear and communicating which goals are the ‘vital few’ rather than the ‘important many‘. Say no more than six big breakthroughs or Challenges per annum, per system. When that, not insignificant and rather politicised task is completed, then the hard work of making that a reality, strategy deployment begins implementing improvements to close the ‘gap’, between the planned goal and reality. (In health and care that seems ever more difficult to do as the timelines between plan development iterations become shorter).
I have written about Hoshin Kanri before, and how it can help align plans and execution approaches (in some circumstances as it may not always be appropriate). Hoshin kanri can sometimes be portrayed as a lean tool, with lots of visible artefacts called x-matrices and paperwork. But in my experience when implemented and viewed as a ‘tool’, it can become less effective, and disengage leaders and staff. Instead, for me, Hoshin kanri is more effective when viewed as a collective consensus seeking approach that links strategic goals (sometimes called True Norths), strategy development and strategy execution practices: that is an improvement system. Crucially this connecting together is done through ongoing dialogic engagement approaches with all staff, not just leaders, called ‘catchball‘. Catchball helps to prepare the ground for new initiatives (nemawashi). The process of catchball, when done well, helps to ensure clarity for teams on their day to day deliverables (the numbers) and their required improvements using a systematic approach (the breakthrough goals; and in in Toyota Kata language, ‘the Challenge‘). Breakthrough goals, therefore, are not ‘recovery’ to the ‘numbers on the big dials’, if normal standards are not being met. Therefore, not the usual improvement projects worked on by many in health and care, where performance to standard has drifted and needs recovery, thus a ‘project’. That, in this context, is just part of delivering the day to day – business as usual, not a breakthrough goal, not a Challenge connected to an improvement system.
Instead Challenges and breakthroughs are about experimenting and learning to change the standards, and implement a new future state (a future state map, can also be called a Challenge map). Imagine the Challenge of a 3 hour ED standard, for example, instead of 4 hours (how controversial!) or a Challenge to deliver 50% more safe and appropriate care for the frail elderly in non-hospital settings in 3 years with multi-professionally skilled staff (also controversial!). In other words, improvement, now linked to system-wide or organisational strategic goals or ‘Challenges’. Rather than the scattergun and populist approach of ‘anyone’s good idea, every little helps, the more the merrier’. Quality, not quantity. Focussed on what needs to be done to improve, learn and achieve breakthrough goals systematically, rather than ‘improving’ anything and everything.
Hoshin Kanri can then ensure focus on the agreed priorities, the Challenges and how they cascade back and forth through a system and organisations. What might 50% more community frail care mean for a voluntary sector partner, patients, service users, families and carers, a GP practice or a community division in a Trust; then what might it mean for a occupational therapy team in that Trust, and then for the specialist therapy equipment supply team? How does a big goal, a future state and Challenge like 50% more in three years (lets say 10,000 more episodes p.a. for a locality), translate into more concrete and specific goals in shorter timescales within each team along that pathway? [clue, it helps if these are not abstract percentages].
‘Does that mean our team will be doing 4000 more occupational therapy assessments a year? How will we do that? Gulp!’ How do the people in this teams and receiving those services feel about those goals? Catchball can help to draw out these emotions, increase engagement and improve the Challenge setting process, and then connect that to local, and daily, accountability and improvement practice processes.
What ideas for improvement in alignment with those goals do teams now have? How might progress towards that future state be tracked, how might experiments be conducted on different processes through smaller goals on the way to that Challenge? How might the understanding of current position be shared and obstacles unblocked and learning shared? Routines to share learning daily, weekly, horizontally and vertically across a health and care system quickly and systematically through daily improvement practice and coaching through the line and visual management communication processes. Ensuring all can know the current state of play when working towards a Challenge, including patients, families and carers, if they want to know, and even participate, so that learning, practice and progress can feel like inclusive, fun and is celebrated, even though ‘that Challenge is tough, man. It makes me want to hurl‘.
Sounds good, huh, even the hurling ambition. A potential way of aligning daily improvement work towards big goals, involving all in that everyday, a way of experimenting and learning collectively towards those goals and modifying culture and building improvement capability as we go. Moving away from our worrying yet increasingly engrained habits of any improvement project is a good idea, in fits and starts, let’s just have as many as we can. Quite something to try to learn and practice. The promise of Hoshin kanri and improvement coaching together. Collective improvement: an idea for aligned, sustainable improvement.
You can read and reflect more about how this might be done in Mike Rother and Gerd Aulinger’s book ‘Toyota Kata Culture‘ and Pascal Dennis’ prize winning ‘Getting the right things done‘.
Healthcare Quality Improvement 
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