Core Concepts of Quality #KSSdarzi17

"You must immerse yourself in an unfamiliar world in order to truly understand your own" - Unknown

Day One - Organisational Raid

Welcome to day one of the core concepts of quality module for the #KSSDarzi17 program. Day one was off site at a hospital trust where we are to carry out a raid - but more on that later. To start the day we grouped in our action learning sets and discussed the hypotheses that our induction week was perfectly designed to tell us everything we needed to know about the organisation and our role. We then regrouped in a full circle and shared our experiences and what conclusions about the organisation we could draw from our experiences.

We discussed the difference between neglect and coproduction as the level of input from sponsors on the induction week was varied and we reflected whether this was a reflection on the overall organisation.

One discussion was around language and the use of metaphors and the impact that this can have, excellently explained in the video above.

Organisational Raid - the process

As the first part the organisational raid we devised powerful questions to explore the culture of the organisation. The questions were open to collect subjective data from a variety of individuals across the system. We then used these answers to devise hypothesis around the culture. We were challenged to dive into the meaning of responses over accepting face value. Across the 5 groups we interviewed 15 people selected by the trust as well as interviewing other staff, patients and public across the hospital who had not been primed for our visit. We were also asked to consider the environment and layout of the trust as well as the visual environment in the context of the culture; Some Darzis also unwittingly tested the security response. As the day closed, we regrouped to conclude common themes that occurred from the discussion for analysis the following morning.

"By the end of the process, you will have a greater understanding of the culture than the CEO of 20 years"

Day 2 - Hypothesis Building

The groups split into 5 further groups from one of each interviewing panel to draw together general comments and hypothesis around the culture of the organisation. These were built around the themes of:

  • Information Flow
  • Relationships
  • Perspectives
  • Ideology
  • Other observations

Each group formed a paragraph to send a letter of reflections back to the organisation.

Delays, queues, waits & chaos

"Every system is perfectly designed to deliver the results that it gets"

Nick Downham introduced the concept of variability in a system by engaging the group in an exercise using a catapult and a simple instruction to 'try to get similar distances from the ball's flight'. It was evident that the results from the participants varied considerably and, employing the fishbone diagram to examine the sources of variability, it became clear that there were both subjective and objective factors. This made us question how we view system variability and highlighted the expansive influences on intended results.

Good outcomes result from intervention + context. When working we form our hypothesis about what will be effective, but NHS Improvement state that "70% of projects fail to deliver their promised gains." Why is this?

We were then introduced differing approaches to change: "JFDI" versus "considering the issue and re -framing the problem" which generally have a better outcome over time. These changes are less likely to be subject to gravity and institutional procrastination.

"Don't jump to conclusions with systems and processes, you wouldn't do it with your patients"
Is it a demand or capacity issue?

We were introduced to demand and capacity as well as the influences of failure demand and detractors from capacity. We learnt that you can't run a service on averages and that variation requires us to use a certain amount of leeway in the system. This lead us to reflect on our own systems function and frustration around it's design, as well as seeking the "perfect" answer.

Dice Game

The principles of demand and capacity were put into action in our group simulation using two dice. One represented system capacity and the other a demand for service. Each round represented a month, starting with extra capacity and reducing each month. The evidence from our simulation shows that reducing capacity to match demand (100% utilisation) resulted in the longest wait times for "patients." Reducing failure and making utilisation approximately 80% resulted in an acceptable level of waits. Our over-arching question is what level of utilisation will a system tolerate? Does this match with the patients expectations?

"The reason why we have pockets of excellence is that the system does not work as a whole, you can't point improve one part of the system and expect the rest to follow"

Day 3 - Sensing Quality and Building Reliability

We explored the trust placed in the health care system by citizens and the implications when harm occurs. Errors in healthcare could be considered as breach of trust in the special bond between clinician and citizen. We were careful to be distinct about the type of error.

  • Honest mistake
  • Wilful Violation
  • Reckless decision
  • Gross negligence
Violation = Deliberate deviation from a standard procedure

We reflected on where as individuals, teams and departments sit within Amalberti's graphic representation of migrations of risk in healthcare. There was an acceptance that we aim to operate in the legal operating space, however often due to numerous pressures and events we fall into the illegal-normal space. What draws us into this space? How could we identify when we are outside of the normal operating space? Can you be aware when you are within the system?

When harm occurs how do we react to this?

A moral acknowledgement of harm does not necessarily mean an admission of liability, but can make forgiving and understanding a little easier. How we investigate incidents (safety 1) can help us build resilience into the system and mistake proof (safety 2). How we frame tasks can influence a persons interaction with it and affect the outcomes. Energy follows focus.

Who is responsible for the bigger picture?

We experienced an emotive reportage from patientstories.org.uk given from the perspective of a family member. There were mixed feelings from the group as due to clinical exposure the story was not alien to some, questioning if we were operating in the illegal-normal verging illegal space. It was noted that despite high profile investigations such as Bristol, Mid-Stafforshire, Maidstone & Tunbridge Wells and Southern Health there continues to be slow implementation of change.

We discussed the reluctance of healthcare providers to be open about poor service standards but noted high performing providers showed a "radical transparency" regarding their overall function, as typified by Wrightington, Wigan & Leigh NHS Foundation Trust.

Action Learning Group

This was the first time that we had experienced action learning groups, different from action learning sets. There are small group discussion supported by a mentor to facilitate the discussion. Each participant had to discuss something they were finding difficult. There are a variety of approaches used within the group for example the subject remaining within the discussion circle or listening to the group discuss the issue. This was found both uncomfortable and extremely helpful (authors' experiences listed only!)

Day 4 - Collaboration and Spread

Thoughts on what spreads an idoleogy

Day 4 started with digesting the general election from yesterday and possible implications for our work and the wider future. We also highlighted who were the dedicated political followers in the group. Of particular interest was Jeremy Corbyn's handy work. Then we examined how ideologies grow and recent changes in technology and media will become more relevant to the younger citizen group. We explored the various elements of outrage, credibility, charisma and the changing meaning of truth.

We discussed in groups what prevents the spread of ideas. Some themes that were discussed were that we sometimes preach to the converted, silo-working often leads to an echo-chamber. The message may not suit the environment or it may be the wrong time. We also discussed influences that span boundaries and networks.

Everett Rogers Model of Diffusion

Everett Rogers goes some way to explain the timeline and involvement of the populace in the proliferation of ideas. However, it is noted that this is not without its critics and perhaps should not be employed solely as a a predictor for the development of ideas. It might, more importantly, identify groups of stakeholders where we might focus our efforts of engagement.

We discussed the difference between invention and innovation: innovation is invention that stick! These can be described by three steps: generating possibilities, amplifying your idea through marketing and eliminating if it doesn't work.

There were some discussion around the phrase "roll-out" of an idea. For some it created the idea of rolling over and being met with resistance. Conversely, if done well then objections could be met in a timely fashion, with all involved engaged in the process and invested in the outcome/implementation. For some, roads are rolled out with a smooth surface for travel and lead to places, but for others, it may cover up what is naturally already there and in appropriate use by those in the immediate vicinity.

"Hold your nerve, go beyond hope and fear, if you believe it's right; Be persistent."

Ultimately, we are trying to create order and not control; to foster a pull model not a push model of innovation and change. This requires prototyping and being aware of what you pay attention to during the process. The aim should be to generate independent curiosity in the stakeholders and getting them seek out alternatives to the status quo.

What will be the tipping point?

To end the workshop we regrouped in a circle to discuss how we are feeling and what reflections we have about the process so far. Comparing this discussion to the last workshop, the terminology used by fellows seemed far broader and reflective of their work and experience, and followed with a "debrief" in true Darzi Style.

Authored by Daniel Dodd and Stu Yeomans

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