QUALITY - Microsystem Coaching Academy › UserFiles › File › Leadership_prese… · The West...

NHS West Kent Clinical Commissioning Group

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WEST KENT

Leading the Implementation of Clinical Microsystems in Primary Care;

The West Kent CCG Experience

Gail Arnold

Chief Operating Officer

Dr Debbie Taylor

Clinical Lead for QI and

Clinical Microsystems


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The next hour…..

• This session will explore the leadership challenge of

introducing clinical Microsystems to general practices

and partner organisations in West Kent.

• It will focus on the links to STPs in this programme of

work and its relevance to delivering Local Care in the

future.

• It will also look at some of the barriers to implementation

that were experienced and the tactics used to overcome

these.

• Finally it will give an overview of the range of

Microsystems completed in West Kent


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Where our journey began…

• In May 2013 Jonkoping, Sweden… and Esther opened

our eyes to the concept

• Reflected long and hard at home to find strategic fit with

what we had seen and our world in the NHS

• Challenges facing general practice and primary care

- recruitment, retention, finances, increasing demand

• Growing number of elderly frail patients and those with

multiple Long Term Conditions

• The challenge of co-ordinating care around a patient


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Mapping the Future 2013


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Patients at the centre

From all of this the CCG team decided that clinical microsystems was potentially a way forward

Who are supported by

the GP Cluster

Practice Support Team (Proactive Care)

Who are

supported by my GP

and the Practice team

Who are supported by

the Primary Care Hub (Reactive Care)

I am

supported

to stay healthy

by my

community

Pre

ve

ntio

n


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Health & Social Care Teams

Prevention

End of Life Care

LTC Management

Community Mental Health

Services

Frailty Services

Enhanced diagnostics

Timely Access to Consultant

Advice

Enhanced Medicines Optimisation

Service

Supporting Therapy Services

Integrated nursing Teams (delivering

care in surgery and patients home)

Ne

w P

rima

ry

Care

LOCAL CARE

In hospital care

Built on a Strong Bedrock of General Practice with the following characteristics

In A Suitable

Estate Sustainable

Supported By

Technology Efficient

Skilled

Workforce Accessible Timely Holistic

Patient

Centred

Population

Based

Healthcare

High

Performing

Recognition of

Deprivation

GMS

Element

Additional

Services

Item of

Service Fees

Incentive

Schemes

Estates

Management

QOF

Enhanced

Services

Recognition

of Homes

Financial Feed

A Vision for Local Care


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Presenting to the membership..

• Highly challenging of the proposal

• They did not share the Board’s vision of teams around

practices

• Questioned funding being spent on training microsystem

coaches which they felt should have been spent on

practices

• Struggling with the strategic context

• Did not necessarily want teams around practices

• Saw it as a diversion from the critical needs of practices


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However we pressed on….

…….. and in September 2014 send our first cohort of

trainee coaches to Dartmouth

Great teaching

International input and experience


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On return …..

• We had a team of coaches, but not practices to coach!

• Struggled to find practices to engage

• Our distance training was continuing but we were not

getting going with coaching to put our skills into practice

• It was easier to get other system stakeholders on board

than it was to convince our GP practices

• Practices did not want our agenda..


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WEST KENT Challenges 1

• Initial lack of experience

and confidence

• Interpreting US and

international examples to

fit with NHS

• Whose agenda were we

aiming at?

• Top down or bottom up?


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WEST KENT Challenges 2 • Interpreting Secondary

Care examples and

translating them to

Primary Care

• Suspicion in Primary Care

- we don’t need coaching

we are GPs! We don’t

want this system.


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WEST KENT Challenges 3 • Timing difficulty in

Primary Care in NHS with

winter pressures - time to

attend meetings

• Primary Care GPs self

employed - difficulty

releasing staff to attend


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WEST KENT Challenges 4

• Time to attend

meetings/ cancelling

due to work

commitments

pressure eg CQC

inspections etc.


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Challenges 5

• We don’t need help with

quality improvements we

have done 6 sigma and

other leadership models

• Can’t we have a whole

day session to fit with our

work?


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So we reflected hard on what we

were hearing

• What options did we have?

• How might we overcome some of the obstacles?

• Was it using microsystems to underpin introduction of our

strategic vision of models of care?

• How could we change the way general practice viewed this?

• Our coaches attended the Sheffield MCA which reinvigorated

us!!


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This is the approach we took

• We persuaded 5 practices to work with our first group of coaches

• In parallel we embarked on a programme of visits to all our 60 practices

• We stood in their shoes

• We tried to look at it their way, from their perspective, faced with their difficulties and challenges

• We changed our behaviours as a team to be ones which focused on how we could support our practices

• We met them where they were

• AND WE LISTENED VERY HARD


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What did we learn from this reflection

• Life in general practice is hard

• General practices are independent businesses

and many were struggling

• We have no authority, we can only influence

• It was pointless going to practices to implement our vision for a new model of care when their own practice issues didn’t let them see beyond that

• Time is money

• Our wish to work with them implied criticism of their performance/achievements

• We were the CCG, after all! They didn’t want our staff in their world.


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So we had a rethink..

• We changed the offering, their agenda not ours.

• We offered a microsystem as practical help for whatever

the practice wanted to work on

• All roads lead to quality improvement - framing

• We flexed our hours to fit with their day, sometimes we

coached early in the morning and sometimes late in the

day

• We created a budget in the CCG to support QI in primary

care (clinical microsystems) and we offered a

reimbursement package for backfill

• We took the burden in the CCG of producing packs,

posters, data charts etc.


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• We recognised that to practices this was an abstract concept and we had to make it real and personal for them

• We acknowledged that if we were to get traction and keep a practice interested we had to invest in lots of personal discussion with their leaders

• We became good at global aims and specific aims

• We are masters now at getting staff into the room and moving them to a shortlist of specific aims in no more than 1.5hrs (1 meeting)

• We’ve accepted the authority given to us by the CCG to go out and do this stuff

• We challenged our GP board members to use a microsystem in their practice


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We made a film to promote our work


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The clinical engagement

challenge…. 1

• We knew we needed our primary care clinicians,

especially our GPs, to support our work

• We knew that their time was precious

• We knew they were struggling with workload

• Time in microsystems was work stacking up


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The clinical engagement

challenge…. 2

• We knew they found it hard to share areas for

improvement – “we don’t need a clinical microsystem,

everything is good here”.

• Involving patients was a challenging concept for some

• Some practice managers felt threatened


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WEST KENT Success 1

• Lack of experience- We

gained it perseverance and

practice!

• Differences in NHS- We

made it fit!


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WEST KENT Success 2 • Secondary vs Primary Care-

We adapted models to fit!

• Suspicion we don’t need

coaching - we had champions

who shared successes, and

explained we were talking

about quality improvement.


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WEST KENT Success 3

• Winter Pressure – We

were patient and waited

• Self employed GPs

difficulty releasing staff-

We gave back fill


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Success 4 • Suspicions about spending money to train

coaches - We demonstrated that it was

more economical than sending people up

to London on day courses

• Time to attend meetings and cancelling -

We showed the benefits and how it could

save time and money in the long run, we

were flexible.


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WEST KENT Success 5 • We don’t need microsystems

coaching - we showed that

sustainable changes can be

made with this model

• Can’t we just have a day

course to get it over with - we

demonstrated that there is a

good reason coaching

happens in chunks with time

for reflection


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Connections

At the heart of everything its

about relationships first …


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Sharing Good

Practice Town Hall Event

AGM/PLT CCG

Workshops

Sharing good

Practice


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Feedback

“ “There is no other

environment in my practice

where I could safely have

said the things I have”

“We all had different

ideas about what the

process was”

“We’re amazed how much

you moved our practice

on in 1.25 hours”

“We haven’t had a whole

practice meeting like this

ever”


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Feedback

“I had no idea

the CCG could

help us like this

– I never

thought to ask”

“We have

never been

trusted to

come up with a

solution for

anything”

“Its been good to

be challenged

about why we do

things the way we

do”

I’m not very good at

data so I’ve never set

things out and looked

at them in this way”

“I don’t know what

you’ve done to my

team – I’ve never seen

them so enthusiastic”

“I can see lots of

ways we could

use these tools”


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WEST KENT Where are we now?

• We’ve trained 4 cohorts of coaches (14 )

• First 2 in Boston, following 2 in Sheffield

• Cohort 5 are in training now in Sheffield (4)

• We’ve appointed a GP clinical advisor

• We have a recurrently identified budget for this work

• 26 microsystems successfully initiated

• Using the methodology widely

• We’ve learned a lot from the 3 that failed


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Emotions


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WEST KENT Learning Points

Our vision was right, the timing needed to catch up

Our practices needed to want to participate

This is not in itself a fix for problem practices but it

is an answer to challenges in practices

Communication is key especially combined with

authority to act

Money is important …. But it still doesn’t replace

time


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WEST KENT Next steps

1. We have just introduced clusters in West Kent made up

of practices and community teams

2. Coaches have been attached to each cluster

3. We are branching out into non-practice environments

4. We are using the tools we have learned repeatedly in

practices

5. The skills from microsystems are percolating across our

CCG organisation

6. We continue to train more coaches with a view to

completing a microsystem in every practice


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10Top Tips from our experiences

1. Good Leadership

2. Champion within our organisation

3. Regular coaching support groups

4. Co-coaching

5. Select and connect to keen Practices

6. Avoid selecting practices in difficulty

7. Have clear coaching agreements

8. Develop champions

9. Be a strong cohesive coaching group

10. Share successes and good practices


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Some principles for leading change in a

complex adaptive system

• Think like a farmer, not an engineer

• Continually reframe the narrative to attract new

supporters

• Create a social movement

• Don’t over-plan – outcomes are not predictable

• Establish boundaries, create simple rules

• Replace directives and regulations with common

purpose, values, principles

• Dump the concept of ‘resistance to change’ – it’s

negative and draining


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Useful reflections from others

…….spreading innovations…..is essentially a social process that

hinges on effective person-to-person communication rather than

technological solutions or indeed the use of incentives and

penalties

(Gawande 2013)

. …people follow the example of those they know and trust

………there is no alternative to creating time and opportunities for

credible leaders and innovators to offer time and support to those

seeking to bring about improvements in care.

(Reforming the NHS From Within. Chris Ham, Kings Fund, 2014)


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The Seven of Pentacles 1

Under a sky the colour of pea soup

she is looking at her work growing

away there

actively, thickly like grapevines or

pole beans

as things grow in the real world,

slowly enough.

If you tend them properly, if you

mulch, if you water,

If you provide birds that eat insects

a home and winter food,

If the sun shines and you pick off

caterpillars,

If the praying mantis comes and the

ladybugs and the bees,

then the plants flourish, but at their

own internal clock.


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Connections are made slowly,

sometimes they grow underground.

You cannot tell always by looking

what is happening.

More than half the tree is spread out

in the soil under your feet.

Penetrate quietly as the earthworm

that blows no trumpet.

Fight persistently as the creeper that

brings down the tree.

Spread like the squash plant that

overruns the garden.

Gnaw in the dark and use the sun to

make sugar.


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Weave real connections, create

real nodes, build real houses.

live a life you can endure: Make

love that is loving.

keep tangling and interweaving

and taking more in,

a thicket and bramble wilderness

to the outside but to us

Interconnected with rabbit runs

and burrows and lairs.


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Live as if you liked yourself, and it may

happen:

reach out, keep reaching out, keep

bringing in.

This is how we are going to live for a

long time: not always,

for every gardener knows that after

digging after planting,

after the long season of tending and

growth, the harvest comes.

Marge Piercy


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