It is customary at year endings to reflect on the year and ponder what lies ahead. I’m not really in the mood to ponder the bonkers-ness of 2020 and the Covid pandemic, other than, I reflect that based on a very unscientific and ad-hoc sample of my twitter friends and networks, that organisations that have previously invested at all levels in developing improvement capability seemed to really be able to leverage this investment during the year. This aligns with early findings from work from the Health Foundation’s Q Community.
I also reflect that it is also noticeable to me, that the converse also appears a little apparent. Organisations that have perhaps not invested so much, seem to have found even fewer reasons to invest in developing improvement capability to solve today’s covid challenges and tomorrow’s recovery, despite the immediate covid burning platform. This paradox, of those that arguably have the furthest to go in developing their ability to improve, yet seem to rarely to take a sustainable leap fascinates me. What is it that leads to this pattern? What is it about strategic choices that means that some organisations set off on improvement journeys and build in some strength, that sets a little in concrete path dependency, yet others barely start the journey or even reverse? And then seem to bounce around at the bottom of performance charts, or in and out of regulatory support frameworks, and intensive support offers over years.
So, when thoughts turn to 2021 and recovering from Covid in health and care services, this is what I am pondering. Nationally we have a pandemic to pay for, 40 manifesto hospitals to build and a recession to escape (and Brexit to adjust to). We also have growing waiting lists, a long term crisis in social care, ongoing workforce black holes and impending regional restructures. It feels a little 2006… only without the cash.
Chances are then that an acute driven focus on elective pathway redesign, waiting list reductions and diagnostic improvements for hips, knees, cataracts and hernias, to maximise theatre usage and improve daily lives for millions waiting is on its way. I can see many improvement professionals having much to add in this space: capacity and demand work, forecasting, waiting lists, one stop shops, same day surgery and so on. It is how many of us cut our teeth in healthcare improvement. It is time for a revisit and new cycles of improvement. I hope too that this is done with an eye to the learning from a similar focus back in 2006-2008, when such a focus prioritised hospital elective care, sometimes I reflect, at the expense of patient co-design and out of hospital care services, (semi-)non-elective care, maternity care and unplanned care services for those with long term conditions and/or social needs.
I hope that the learning, redesign and digitisation of urgent and emergency care, as well as growing demand for mental health care, social care, primary care etc. and the patient safety agenda isn’t forgotten in the rush towards elective recovery and productivity. The learning from improvement work at the Nightingale in London to build and embed daily improvement cycles into daily clinical practice strikes me as important here, especially when I compare this with my own personal learning, practice and research of improvement routines drawing on Toyota Kata. What particularly strikes me here is the tangible leadership expectation of improvement taking place everyday, the development of psychological safe spaces to talk about work problems and the clear use of PDSA, yet backgrounded and used without all the baggage, toolkits, paperwork and toolhead jargon (hurrah!). I hope this improvement learning can mean that we can really think about helping those organisations that can bump along at the ‘bottom’, what is it about the specific and long standing context for these organisations that leads to persistent quality and performance problems? Leadership whilst clearly necessary to set expectations to improve on its own is not sufficient, the Nightingale learning clearly demonstrates that some capability is also necessary. Quality improvement knowledge is a piece of the jigsaw that is needed too integrated with leadership, to learn and to practice and to experiment everyday, to see what we learn and keep going in complexity.
Making improvement real for me is just this. Everybody is expected to make time to do a small test of change or help someone with a tiny experiment, every single day. How can all of us use scientific thinking everyday, leaders, staff and patients together? Every single day.
Leading daily improvement experiments may help us all to keep moving our thresholds of knowledge as quickly as they did in the early days of Covid. Lots has been learnt imho this year about the interaction of elective and non-elective care, particularly for intensive care capacity and specialist expertise and how different ‘queues’ interface, and there is still so much more to find out together. Similarly, much has been learnt directly about whole system working and collaboration and mutual aid, more can still be uncovered. How can system wide rapid turnaround diagnostics be established, what is the capacity and flow impact when labs are several miles away? What are the inadvertent consequences on flow, safety and population risk when new systems lead to delays in ED flow for patients? What problems build up in other services when focus becomes tunnel visioned on one disease? How can we (and should we?) really build and co-design population health into services when that might mean slightly different (and arguably unequal?) services for different communities? What have we learned to support and improve staff safety, as much as we have focussed on patient safety? What are our next steps?
Looking forwards to 2021, I am also wondering does all that potential shift in priorities and opportunity for daily experimenting mean for improvers? I wonder how a focus on continuing to develop underlying improvement capability in organisations can be built in to the new priorities and associated national and regional asks and programmes, regardless of organisational form. Embedded as essential within everything as a basis of scientific thinking and improvement in all programmes rather than separated as isolated QI programmes and collaboratives. Embedding, integrated and aligned across all, to help organisations to meet these new asks, if that help is what is needed for those organisations, and at the same time readying for whatever will come next, whether that be another pandemic, or a specific priority for a local population or as a essential foundation of developing health and care people, in all roles. Role modelled by leaders. With a way to define, assess and measure that organisational improvement capability development.
This dynamic and path dependency view of improvement capability where those that start to invest, benefit by being more able to adapt to changing circumstances, matters for next years changes and those afterwards. Therefore for me, baking in improvement capability development requirements across new national and regional priorities for all staff, at all levels and for all types of organisations, integrated with other development needs (cultural, leadership, digital, analytical, clinical etc) seems to me to be essential. For me, using improvement as an integrated, multi-disciplinary team-based engine of health and care recovery may be a way to continue to grow improvement capability in those organisations that have started their improvement journeys, and to share their learning; and at the same time also a way to ‘enforce’ and ensure that those who have yet to find a reason to really start their journeys decide to do so.