The life-cycle of improvement; and how to make it sustainable Dr. Martin Wale, Exec MD, QRS...

The life-cycle of improvement; and how to make it sustainable

Dr. Martin Wale, Exec MD, QRSVancouver Island Health Authority

The non-sustainable change:

• Does not solve the problem – and is therefore dysfunctional

• Creates the illusion of progress – and is therefore dishonest

• Brings improvement into disrepute – causing long-term damage to the process and future chances of success

How to do something different

• “Every system is perfectly designed to deliver the results it delivers” (Berwick)

So change the system

First and Second Order Change

First-order change Second-order Change

Underlying mental model Unaltered Altered

Specific way we do something

Changed Changed

Relationship to modernization

Predominant current approach to improvement

Enhanced approach; improvement with

creativity and innovation

ExampleReduced DNA’s by patient agreeing date for follow-

up appointment

Question need for follow-up appointment in Acute Trust. Alternatives: by telephone, in primary care, or not required

Impact Incremental improvement Innovation

© NHS Institute for Innovation and Improvement

Life cycle of an “improvement”

Time

Improvement

Life cycle of an “improvement”

Time

Improvement Implement

Sign-off

Next initiative

Measure

{

Plan

Intervention points

Time

Improvement

Planning time

Implementation rate

Efficacy

Fade

Life cycle of a “real” improvement

Time

Improvement

Planning

Implementation

Efficacy

Learning

?Efficacy

Conceptual and theoretical bases for spread of innovation

From Greenhalgh et al (2005, fig. 3.5, p 82)

NHSI Methodology

Co-production, co-production, co-production. And share credit.


Learning phase

“You have to go down blind alleys. But every once in a while you go down an alley and it opens up into this huge, broad avenue. That makes all the blind alleys worthwhile.”

Jeffrey P Bezos, President & CEO, Amazon.com

Creativity – discipline cycles


De Bono: mental valleys model


Understand and reframe

• Understand stakeholders

• Observe & inquire

• Frame and reframe

• Understand themes

– Relationship management

– Communications

– Measurement

– Project management


Understand Stakeholders

• Confirm sponsors, clarify roles

• Identify stakeholders and their roles

– Including for the implementation phase

• Consider

– What change in behaviour are you trying to produce?

– How will you do this?

• Identify key connectors


Stakeholder analysis model


Observe & inquire

• People do not always do what they say they do• People do not always do what they think they do• People do not always do what you think they do• People cannot always tell you what they need

From IDEO

“If you are not in the jungle, you are not going to know the tiger”

Tom Kelley


Observation

• Goals

– To gain new and extended insight into the issue.

– To examine solutions from other industries or healthcare systems.

– To gain inspiration or new ideas

• Wide search

• Think about second order change

• Explore novel connections


Observation

• Take notes & pictures

• Consider

– ? Observing for understanding

– ? Observing for inspiration

• Within the area

• Outside the area

– Analogous situations

– Extreme users


Observation techniques

• Keep an open mind

• Talk, so people will talk

• Give people time to talk

• Design tools to open dialogue

• Don’t correct misperceptions

• Five why’s

• Draw it, show me, think aloud

• Sit and watch


What to look for

• Pauses in action

• Things or qualities which prompt behaviour

• Work-arounds or adoptions

• Body language

• What people care about

• Surprising behaviours or uses of items


Frame and reframe

• Don’t be afraid to shift your perspective or position

• Present alternatives

• Talk to people


The Innovation Funnel


Life cycle of a real improvement

Time

Improvement

Planning

Implementation

Learning

Sustainability (finally)

The non-sustainable change:

• Does not solve the problem

• Creates the illusion of progress

• Brings improvement into disrepute

So you need to know in advance,so you can fix it

Questions?

Sustainability Tool in actionMAX Group 1 Group 2 Group 3

8.5 Benefits 4.7 4.7 8.5

9.1 Credibility 3.1 9.1 6.3

7.0 Adaptability 7.0 7.0 7.0

6.5 Monitoring 6.5 2.4 6.5

11.4 Involvement/training 6.3 0.0 11.4

11.0 Behaviour 0.0 0.0 11.0

15.0 Senior Leaders 15.0 5.7 15.0

15.0 Clinical Leaders 6.7 0.0 15.0

7.0 Goals & Cultures 3.3 3.5 7.0

9.5 Infrastructure 3.3 0.0 3.3


Time

ImprovementImplementation


Time

Improvement

Efficacy ?Efficacy

Questions?Energy

Time

The life-cycle of improvement; and how to make it sustainable Dr. Martin Wale, Exec MD, QRS...

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