One of the things I have been pondering over the last few weeks as we approach the recovery phase of the COVID-19 crisis is: how will hibernated improvement activity (to redeploy capacity), ramp back up? How will we ‘un-hibernate’ improvement work? For it is imperative that we do that, sooner rather than later, to ensure we keep improving care for patients; as the argument for continued focus on improving care for patients remains, COVID-19 or otherwise. Yet, in health and care, how we do that might need to take quite different delivery formats to what has gone before, due to the new conditions and context we now find ourselves in.
Typically, in my experience in health and care, most improvement activity and training, regardless of improvement approach has typically been enacted via the medium of large scale workshops, kaizen events, conferencing, future search, open space, world cafes, rapid improvement events, scrums, big/small conversations, Obeya (Big) Rooms, community of practice discussions and improvement collaboratives. All type of activity that needs time, conference space, (often in hotels, sometimes in large meeting rooms), and many people coming together in what would probably be described as a large gathering. To some extent this ‘physical coming together’ is part of all of the delivery of improvement approaches, a way of enabling some relationship development, network enhancements and the togetherness needed to move past obstacles to change and develop a sense of community, mutual support and belonging.
Improvement training has long been offered digitally, available to support learners to learn at their own pace in their own time, from IHI, NHS England and many Universities, and perhaps this approach to training at scale may now become the new normal, for training at least. So it seems that, that element of our work may have an alternative, but improvement gatherings of people may need to change.
Some solutions to social distant improvement collaboration already exist. Over the past few years many types of improvement gatherings and events have been tested in virtual ways, using different collaboration platforms. Such as hackathons, electronic break-outs, discussion rooms and digital common rooms, online polling, real-time Q&A, virtual conferencing and other virtual innovation and improvement brainstorming, testing and collaborating through open source approaches and more. Some of these innovations arose out of necessity for teams working across geographies, shift-patterns and timezones, using asynchronous collaboration approaches as well as real time. The use of digital improvement has already offered a way forward to keep innovating and improving during this crisis with online collaboration for Covid-19 testing approaches, as an example. The use of digital also creates access for people who may not have previously engaged or been invited to participate from across organisations, weekend and night shifts and across organisations and most importantly it may help increase participation from those that use health and care services.
All this is going to be necessary, enforced by this health crisis, and using digital certainly gets over a lot obstacles related to the inability to hold gatherings of people. But whilst all these digital approaches will somewhat substitute for face to face improvement encounters, will they really be sufficient to help us to achieve what Improvers set out to achieve? Do we just want to digitise what we already do, or improve the processes we digitise as well? Will digital improvement delivery really help us to deliver our Challenge – the development of improvement capability and learning cultures in our organisations and systems, so that improvement is something done routinely, everyday by everyone for the benefit of patients and people receiving our services.
The challenge with face to face workshop delivery (of any kind and with any improvement approach) is that they tend to be episodic and intermittent (Locher, 2016). They occur out of the workplace, on a frequency of some kind, e.g. 1/month or 1/quarter and they effectively ‘batch’ improvement into the workshop as something separated from ‘daily work’. You can see this episodic nature in the picture below, illustrating the delivery style and time for different approaches. Often the idea is people turn up, share ideas and learning, perhaps work as teams together on a problem or set up a plan and either do some PDSA in the session or more commonly pledge to go away from the workshop to conduct some PDSAs or change activity and bring back that learning at a follow up workshop or meeting. I have led events like this for all my career, and they can be very effective for improvement projects, but they are episodic, and if I am honest I’m not that certain that a whole lot of PDSA goes on in between the face to face episodes. In addition, often you see the same faces at such events – so how is ‘everyone’ getting involved in practising improvement, ‘everyday’? How is this type of delivery medium demonstrating that improvement is part of everyone’s job? How do episodic interventions modify improvement capability and cultures?
There are alternatives. When I first started my career in chemicals, there was only 1 shift operator per shift on the plant I worked on, and on the site there was about 8-9 plants all geographically dispersed and the maintenance and engineering shops were elsewhere also. Too few people to run a gathering, as who then would run the plant? We didn’t have digital then for improvement work (in fact in my first role I didn’t even have a computer and I’m not that old, tho’ we were still using acetates for presentations). Instead, we had to be a little more manual. As an improvement engineer, I had to wear out my safety shoe leather, walking the floor, talking to the operating and maintenance teams in their workplaces about the issues they noticed, ideas they had, and what help I could give with that. I built relationships, networks and consensus across the teams through those conversations, dialling in others via the phone or radio as needed (and sometimes through conversations in the bait and smoke rooms too). I persuaded others to support their colleagues and me in working out new engineering spares processes or standard operating procedures to help improve safety and reliability. Asking all of us together to try them out and reflecting and keeping records of what we noticed and learnt. Some of you reading this will probably be going, ‘yeah, and this is what I do now’, yes, quite probably, but not everyone does and somehow (bizarrely imho) it seems this kind of activity is not often seen as ‘improvement work’ however it is what some improvement people do between events and workshops – yet I see this type of diligent improvement practice rarely discussed. Perhaps we may need to do more of this again, and more explicitly – perhaps over Skype and the phone more, as we continue distancing, but still that type of legwork.
Such a daily practice is a rather more low tech, and less costly approach to improvement practice that would be helpful in supplementing a more episodic digital offering imho. Arguably more intensive at first, for Improvers and leaders, a way of working that needs enacting every day, takes some work and some practice, and time, building day to day incremental learning on how to improve. Taking some time, persistence and commitment too. But this kind of leadership and improvement practice might help us achieve our challenge of developing improvement capability and learning cultures through daily habits and routines more quickly. This kind of habit might require that leaders need to commit time to this everyday, 30 mins or so daily at least in their diary – rather than an episodic 1-off day in their diary 1/months. This kind of sustained improvement practice might also require a different kind of leadership engagement and commitment, (perhaps compared with the commitment needed to turn up at a hotel or a virtual space for a speaking engagement in an improvement workshop).
A more robust and evidence based alternative has emerged over the last two decades to enable this kind of daily improvement habit with a less episodic nature. One of which I really feel would be a more reliable approach to developing an improvement culture than the one I tried to use early in my career. And one which could work well in parallel with episodic solutions, (digital or otherwise). I have written about it a few times on this blog, and that is the use of the Toyota Kata daily improvement practice pattern (Rother, 2009; 2016; 2017). This for me, takes away the episodic nature of delivery embedded in contemporary improvement approaches. Instead improvement practice becomes something that is embedded in daily operations through daily coaching of the line manager (the Kata Coach) with the Kata learner with a new role for improvement specialists – that of coaching the line manager also through the Toyota Kata pattern rather than the (false) stereotyped tool based expert. Kata pattern use helps to create short daily improvement update process that teams can engage with as a communication process without the batching and ‘gathering of people’ yet can be more structured and helpful for sharing learning (in my experience). Again you can see this difference in the time for delivery on the picture above. Experiments in my own practice over the past 20 months has helped me learn that it can also be done virtually and digitally on a very frequent basis with little additional preparation or reduction in efficacy.
Most importantly the daily use of the Toyota Kata mindset, thinking patterns and approach can help to develop good improvement habits and practices. This daily use helpfully supplements other improvement approaches. Leading to changed daily improvement routines and behaviours this helping to develop improvement capability and modify culture in teams, organisations and health and care systems. Using Kata in a virtual way with digital solutions, in partnership with more common digitally enabled improvement delivery approaches might help us, not only in practising improvement in a more socially distanced way, but also helping us to keep moving towards our bigger goals and Challenge.
Let us, Improvers, use these new rapid changes in our practice, enforced by this health crisis, to learn how we can also help to ‘improve improvement’. Helping us to deliver improvement capability and learning cultures in a better way routinely, so that we can continue to improve and deliver the best services we can for our patients now and for the future.
Healthcare Quality Improvement 