We have been trying to help healthcare improve for at least the last 20 years. When ‘To err is human’ (IOM, 1999) was first published, it was so radical. To move the agenda forward, at first, we just needed more allies, people at scale to help argue the case for improvement and develop examples and case studies and inspiration for others. Volume mattered. About 10 years in, there was increased awareness that maybe it wasn’t as easy as we thought, the results weren’t coming in quite so quick, the evidence wasn’t growing enough and we had some rather significant and terrible events with some dreadful care as well as ongoing productivity and workforce concerns. This increased the urgency to improve with some recognition that a bit more skill and knowledge was needed, and lot more of it… we needed more ‘improvement capability’. This was outlined directly in the Berwick response (2013) to the Francis report (2013). But I’m not sure ‘we’ were that clear what we really meant by ‘improvement capability’, and if anything it has become a rather cliched and reified phrase that can mean many things to many people. Particularly a (flawed) assumption that more improvement training equals more improvement capability.
The thing about studying a particular concept for a while at quite some depth, as I did for improvement capability, is that it can be quite frustrating to hear the concept being talked about in a loose way like this. This last couple of years in English healthcare, I have repeatedly heard people talking about completing some improvement training, say a six sigma green belt or some tools training like, a PDSA, Mr Potato Head exercise, and then declare that they have built improvement capability. Whilst I am sure there is quite possibly some personal growth, and some skill and capacity development. I am not so convinced that it means that ‘improvement capability’ has been built. It seems rather a bold unconvincing claim to me. And yet this perception of ‘improvement capability’, much to my irritation, seems to be thriving, that an individual can go on a short training course about some aspect of improvement, and come back with some more ‘improvement capability’.
If only it were that easy.
Therefore in the interest of seasonal stress relief, this (possibly rather ranty) blog will outline several ways why I think that the current mainstream approach to improvement capability building is flawed, and an early exploration as to what alternatives there there may be.
My reasons why:
1. Following my PhD research on improvement capability, my view, based on the extensive evidence I reviewed, is that improvement capability is not a skill nor an attribute of an individual. Instead, it is a collection of pooled skills, knowledge and competencies and routines, that come together to solve issues and problems as part of a collective bundle in response to a situation and local context. This bundle of routines makes up the capability and those routines can continue to exist as part of the collective capability even if key players and individuals move on. The routines have to also keep changing and adapting too, to ensure they don’t become rigidities, endless tick boxes and paperwork or rituals that prevent change and innovation. Therefore, improvement capability is more than improvement skills that can be learnt on a training course, because it is the local adaptation and blending with other contextualised routines coming together collectively that build and adapt improvement capability over time rather than generalised knowledge and skills. Improvement capability comes from the dynamic adaptation in context and the learning that ensues in the ‘real’ environment overtime rather than the classroom. My view, you can’t build improvement capability by training in the classroom.
2. We have a hero worship problem in healthcare, and I don’t mean the Marvel sort. In the books ‘Beyond Heroes’ by Barnas and Adams (2014) and ‘Living Leadership’ (Binney, 2005) they describe in their own ways, how society has historically wanted powerful, driven saviour-like leaders and yet there is power in all of us to be ordinary heroes and that alternative approaches to leadership may help us survive and thrive better – and improve better. Yet an approach that keeps training ‘talent’ (often quite senior talent) up in small ‘dose’ improvement training courses with limited access for most staff, in many ways continues that ‘hero’ worship.
In my experience, typically after a course for improvement beginners, ~20 people who have learnt something of some improvement tools, like PDSA, run charts, the model for improvement, human factors, driver diagrams, 6S, visual management and creativity, often from relative improvement beginners themselves, a certificate is produced. Performance reports count the number of newly certificated heroes and completed small projects and declare improvement capability to have been built. In my view, the current approach of ‘teach one, do one’ is rather sink or swim and woefully insufficient. Spinning a coin for half an hour merely introduces some concepts; adapting those into clinical environments takes some thinking, and some substantial courage. Organisations, in my experience, have often asked (naively?) for miraculous cost savings or performance improvements on some of the most challenging and wicked problems in healthcare as a return on the training investment within ~6 months. In my view, it is both rather unlikely, and also extremely off-putting, and possibly even burnout inducing, for beginners who want to see what they have learnt in smaller, and psychologically safer, experiments and see if they have some success before trying out new skills on tougher challenges. To grow many more ordinary improvement heroes who work together collectively, I think we need to really think about sandbox development for new improvement skills and serious investment in local coaches for these staff as they learn the skills and adaptation needed to develop the improvement skills and routines to bundle into improvement capability. Perhaps, we need to extend the concept of improvement capability dosing to medication, therapy and district nursing, rather than just medication. Thus, improvement capability talent-based development strategies for (heroic) individuals is insufficient to develop a local, contextualised collective capability to improve. Local team based leadership and coaching by line managers, supplemented with experienced improvers is essential to build confidence and local engagement.
3. So this is the ranty one, where I am having a moan. Let me get it off my chest. I trained for over 8 years to be an independent improvement practitioner- that is a professional Chartered Engineer, registered with the Engineering Council etc, in the branch of engineering that many in healthcare might even call ‘improvement science’. Eight years minimum. 4 years of degree with 4 industrial placements and another minimum of 4 years in practice, being supervised by a more experienced engineer, developing a portfolio of competences with a viva and a panel at the end, to effectively give me a licence to operate as an independent improvement engineer. You can’t even apply before you are 25 years old. I did not go on a ‘~3 day’ course, play with some Lego and then declare myself proficient and as having improvement capability (I did play with Lego a lot though as part of my degree this is the primary attraction for all undergraduate engineers, who wouldn’t want to have a go a building a prototype photoplethysmograph with child’s toys?). If I went on a ‘~3 day’ course in medicine and then declared myself a clinician, I suspect all hell would let loose. Yet, for my engineering skills and expertise, this kind of ‘improvement expert’ declaration routinely seems to be acceptable in healthcare. (Really? Ok so I am exaggerating a little to make the point, I hope you can forgive that, I’m grumpy about this, my ego is suffering).
Why do we think this? There must surely be a bit more to improvement capabiilty than a load of short courses and certificates – else we would have loads of it by now. Just look how many people are claimed to have completed ‘QI’ or similar improvement (tool) training courses. Look how many management consultancies resell the same training over and over with a new brand name. But, I’m not sure this high volume, broad and shallow approach, which aims to train everyone a little bit, by the masses is working. If anything it seems a little bit to be dumbing improvement down into 3 questions, a driver diagram, a process map and a run chart without any relational elements to fit the largely tool-based training all into a short number of hours and days. There is more than rote learning of improvement tools needed to apply improvement approaches in practice together, to build improvement capability. I really think we need to go back to basics and think value rather than volume, deep and narrow understanding, and recognise that in practice, experience and relationships count way more than knowledge.
I think I have a few more reasons, such as improvement priority selection needing to be more strategic, being much more authentic in co-design and co-production, really focussing in what makes improvement capability a collective property of team relationships and how it forms between teams and across internal and external boundaries as a symbiotic part of an compassionate improvement and learning culture, what it really means for leadership and executives, what teams and individuals may need to lose before they can gain, the threats to ‘belonging’ that change and improvement work create, becoming much more precise about method and evaluation to ensure we learn together, accepting that improvement methods and approaches are not the only way to develop improvement capability and so on; but this blog is already getting too long.
Let me summarise, despite all our best efforts and good intentions, my reflections are that our current approach to developing improvement capability in English healthcare, remains in my view, rather limited and it is possibly becoming an improvement rigidity itself. A way of preserving status quo, rather than capability building. The typical, current approach to improvement capability building is for me still a skills based, training orientated, ‘hero, tool and volume’ based approach often targeted at senior leaders rather than those ordinary teams who ‘do the work’. This (arguably low risk) approach to improvement capability building has been necessary to build the improvement movement but now, imho it is insufficient, and too risk adverse, to build a collective and contextualised capability to improve in health and care. We need to move beyond this typical approach to local daily coaching and improvement dialogue in context and practice, within teams, and recognise the time needed to develop improvement capability and team relationships within a supportive, compassionate, learning culture will be much more than a few days or weeks. Riskier, for sure. We need to move beyond this volume based, heroic improvement tool training approach to ensure the investment in improvement capability development lasts, grows and delivers the better care we all want and need.
Healthcare Quality Improvement 
[…] I stepped out a little more, writing more of what I really felt needed to be said, even if in my head anyway, the risk of poor reception was higher. I rather self-consciously blogged about my very enjoyable lean podcast with Mark Graban, and added some other technically orientated blogs: about waste reduction, PDCA, visual management, lean cells and about unlearning. Increasingly though, I noticed my focus moving more towards what leaders in improvement need to get their heads around. I really feel an absence of this debate. What does it mean to sustain a transformation? How can we build more collective improvement? How can leaders use improvement to reduce burnout and bring joy in work, rather that just rely on positive thinking for resilience? What might a responsive improvement framework look like? What does it really mean to lead improvement, is it like bringing up a baby? How do we move towards improvement capability and what are we doing now that might need to change? […]