NHS Improving Quality was invited to take part in a recently held event that celebrated the work that is being done in partnership between the Pennine Acute Hospitals NHS Trust and AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP). Gillian Phazey, Learning and Organisational Development Manager at Pennine Acute Hospitals NHS Trust explains: 'The Learning and Organisational Development and Governance teams at the Pennine Acute Hospitals NHS Trust have been working collaboratively with AQuA to deliver a Quality Improvement Methodologies Programme (QuIMP) to support staff in developing knowledge and skills in this topic. The programme has been specifically designed to support colleagues wanting to gain an introduction to the fundamentals and concepts of quality improvement. So far, two cohorts of staff, from clinical and non-clinical areas of the Trust have completed the programme, and have completed quality improvement projects in their own work area to apply their knowledge. On 17th July a celebration event was held for cohort 2 where staff presented their work in poster or presentation form, the aim of which is to share and spread learning across the Trust. Projects were wide ranging, from introducing new processes to reduce complaints and drug errors, to improving patient experience by implementing new tools and techniques. The day was a great success with the Chief Executive and Chief Nurse in attendance. The Trust is highly supportive of this approach in equipping staff with these important techniques, and the programme supports not only our internal quality agenda and objectives, but more widely responds to the recommendations of the Berwick report. The next cohort is starting in September this year.' Fiona Thow, Patient Safety Collaborative Delivery Lead at NHS Improving Quality delivered a keynote speech, (link to presentation slides) providing a national perspective on the plans for improving patient safety and took the opportunity to introduce the national safety collaboratives. She also highlighted the need for organisations and individuals to think differently about safety for both patients and staff.

1. Building the will for a safer
culture in the NHS - thinking
differently about Patient
Safety
Creating a system
devoted to
continual learning
and improvement

2. Todays session:
• Set out the emerging plans for improving patient
safety in England
• Look at some theory around large scale change
• Consider the issues and challenges in designing a
national improvement programme, if change
happens at the microsystem level
Please ask questions or make your point at any
time – let’s have a discussion not a lecture!
2

3. Mid Staffordshire NHS Trust
Public Inquiry report
published Feb 13
Julie Bailey of Cure the NHS Campaign stands
outside Stafford Civic Centre

4. Key messages from the Francis Inquiry –
290 recommendations, 4,000 pages
• This was a system failure as well as failure of an
individual organisation
• No single recommendation should be regarded
as the solution to the many concerns identified
• A fundamental change in culture is required
across the NHS
• We need to secure the engagement of every
single person serving patients in the change that
needs to happen

5. QualityBetter
Old Way
(Quality Assurance)
QualityBetter Worse
New Way
(Quality Improvement)
Action taken
on all
occurrences
Reject
defectives
Old Way, New Way
Source: Robert Lloyd, Ph.D.
Requirement,
Specification or
Threshold
No
action
taken
here
Worse

6. ‘’The most important single change in the NHS in response to this report would
be for it to become, more than ever before, a system devoted to continual
learning and improvement of patient care, top to bottom and end to end.’’
‘’Our most important recommendations for the way forward envision the NHS
as a learning organisation, fully committed to the following:’’
 Placing the quality of patient care, especially patient safety, above all
other aims:
 Engaging, empowering, and hearing patients and carers throughout the
entire system and at all times:
 Fostering whole-heartedly the growth and development of all staff,
including their ability and support to improve the processes in which they
work:
 Embracing transparency unequivocally and everywhere, in the service of
accountability, trust, and the growth of knowledge.
Don Berwick Findings
A system devoted to continual
learning and improvement

7. Design Rules – some examples from the Design Day event
A system devoted to continual
learning and improvement
National v local – building the learning system to support a safety culture & continuous
improvement. Building networks that align to local clinical communities
Transparent sensible measurement - : “If you’re not measuring you’re not improving, if
you are measuring stupidly you are not improving, and if you are only measuring you
are not improving” – Mary Dixon Woods.
Inclusion – patients equity partnership
Preparedness – work before the work – don’t start too soon. Prepare staff,
communicate, build in evaluation from the start. Build in capability and embed as part
of the day job
Leadership, sustainability – what does success look like? Align system drivers

8. 8
The Patient Safety Collaborative for England
A system devoted to continual
learning and improvement
Key features:
 Learning from the past, adapting what works in improvement
 Systematic application across England with widespread
engagement
 Positioned as transformational not transactional change
 Set within the context of NHS England’s Patient Safety Plan
 Locally led; across all healthcare organisations and all sectors
– providers and commissioners
 Patient centred
 Engaged with clinical staff at all levels
 Focused on fewer priorities but at scale to demonstrate
results in year one
 Using a range of improvement tools, techniques, social
movement approaches and capability building

9. 9
• AHSN footprint
• 2-5m population
• Central and local funding
allocated for patient safety
• Quality Improvement expertise
and support form NHS IQ
available
• Linking good practice and
sharing learning widely
• Shared purpose
A system devoted to continual
learning and improvement
Patient safety collaboratives

10. Patient safety improvement – 3 strands
10

11. Patient safety collaboratives – core priorities outlined by NHS England
A system devoted to continual
learning and improvement
Topic area Patient Safety Topic
The
‘essentials’
Leadership Measurement
NHS
Outcomes
Framework
improvement
areas
VTE HCAI
Pressure
Ulcers
Maternity
Medication
Errors
Deterioration in
children
Other major
sources of
death and
severe harm
Falls
Handover
and
Discharge
Nutrition
and
hydration
AKI
Deterioration
in adults
Sepsis
Medical
Device
Errors
Vulnerable
groups for
whom
improving
safety is a
priority
People with
Mental
Health
needs
People with
Learning
Disabilities
Children Offenders
Acutely ill
older
people
Transition
between
paediatric and
adult care

12. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Creating a patient safety movement:
four things we can learn from the
great social movements
(Helen Bevan’s Slides)

13. Emerging themes in large scale change
Foundation Emerging direction
Organisation Community
Power through hierarchy Power through connection
Mission and vision Shared purpose
Making sense through rational
argument
Making sense through emotional
connection
Leadership-driven (top down)
innovation
Viral (grass-roots driven)
creativity
Led by expert opinion Allow all talent
Engaged patients Passionate users
Clinical networks Mass communities
Tried and tested, based on experience “Net Generation” principles
Transactions Relationships

14. What are the implications for improvement leaders?
• From “doing” improvement to “connecting” for improvement at scale
• Rethinking:
• who’s in the improvement community
• How we lead change
• Metrics of success
• New roles
• Curators
• Relationship leaders
• Storytellers
• Co-creators
• New mechanisms for connecting:
• Social media
• Web seminars
• Tweet chats
• New methods for leading improvement
• open innovation
• hacks/hackathons
• crowdsourcing
• Ideas channels

15. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore

16. Most large scale change fails to
achieve its objectives
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5%

17. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 1:
Focus on the physiology of change
as much as the anatomy

18. Anatomy of change Physiology of change
Definition The shape and processes of
the system; detailed analysis;
how the components fit
together.
The vitality and life-giving forces that
enable the system and its people to
develop, grow and change.
Focus
Processes and structures
to deliver health and
healthcare
Energy/fuel for change
Leadership
activities
 measurement and
evidence
 improving clinical systems
 reducing waste and
variation in healthcare
processes
 redesigning pathways
 creating a higher purpose and
deeper meaning for the change
process
 building commitment to change
 connecting with values
 creating hope and optimism about
the future
 calling to actionSource: Crump and Bevan

19. Anatomy of change Physiology of change
Definition The shape and processes of
the system; detailed analysis;
how the components fit
together.
The vitality and life-giving forces that
enable the system and its people to
develop, grow and change.
Focus
Processes and structures
to deliver health and
healthcare
Energy/fuel for change
Leadership
activities
 measurement and
evidence
 improving clinical systems
 reducing waste and
variation in healthcare
processes
 redesigning pathways
 creating a higher purpose and
deeper meaning for the change
process
 building commitment to change
 connecting with values
 creating hope and optimism about
the future
 calling to actionSource: Crump and Bevan

20. Anatomy of change Physiology of change
Definition The shape and processes of
the system; detailed analysis;
how the components fit
together.
The vitality and life-giving forces that
enable the system and its people to
develop, grow and change.
Focus
Processes and structures
to deliver health and
healthcare
Energy/fuel for change
Leadership
activities
 measurement and
evidence
 improving clinical systems
 reducing waste and
variation in healthcare
processes
 redesigning pathways
 creating a higher purpose and
deeper meaning for the change
process
 building commitment to change
 connecting with values
 creating hope and optimism about
the future
 calling to action

21. Intrinsic
motivators
build energy
and creativity

22. Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity

23. Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity create focus &
momentum for
delivery
Drivers
of extrinsic
motivation

24. Drivers
of extrinsic
motivation
create focus &
momentum for
delivery
Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity
•System drivers &
incentives
•Payment by results
•Performance
management
•Measurement for
accountability

25. Internal
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy and
creativity
Drivers of
extrinsic
motivation
•System drivers &
incentives
•Performance
management
•Measurement for
accountability
create & focus
momentum for
delivery

26. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Transformation is not a matter of
intent.........
it is a matter of alignment
Peter Fuda

27. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
NHS Change Model
www.changemodel.nhs.uk

28. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 2:
Build energy for change

29. @helenbevan #KPHsafety#KHPsafety#KHPsafety
burning platform
versus
burning ambition
@PeterFuda

30. @helenbevan #KPHsafety#KHPsafety#KHPsafety
Lessons for transformational change
1. In order to sustain
transformational change, we as
leaders need to move from a
burning platform (fear based
urgency) to a burning ambition
(shared purpose for a better
future)
2. We as leaders need to articulate
personal reasons for change as
well as organisational reasons
3. If the fire (the energy) goes out,
all other factors are redundant
@PeterFuda

31. @helenbevan #KPHsafety#KHPsafety#KHPsafety
You get the best efforts from
others not by lighting a fire
beneath them but by building
Source: Bob Nelson

32. @helenbevan #KPHsafety#KHPsafety#KHPsafety
Task
Talk to the person next to you
• What is “my burning ambition” for Improving Patient
Safety
• Try to make it personal: tell others why this ambition
connects with your personal motivations

33. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 3:
Frame to connect with hearts and
minds

34. @helenbevan #KPHsafety#KHPsafety#KHPsafety
Framing
Is the process by which leaders construct, articulate
and put across their message in a powerful and
compelling way in order to win people to their cause
and call them to action
Snow D A and Benford R D (1992)

35. @helenbevan #KPHsafety#KHPsafety#KHPsafety#KHPsafety
If we want people to take action, we have to
connect with their emotions through values
action
values
emotion
Source: Marshall Ganz

36. @helenbevan #KPHsafety#KHPsafety#KHPsafety@weatherbore
Factor 4:
build shared purpose

37. @helenbevan #KPHsafety#KHPsafety#KHPsafety
“A shared sense of
corporate purpose,
grounded in universal
values, is the highest
octane source of fuel
for organisational
action.”
Schwartz and Loehr (2004)

38. @helenbevan #KPHsafety#KHPsafety#KHPsafety
We know that ...
• Shared purpose is a common thread in successful
change programmes*
• Organisations and change initiatives with strong
shared purpose consistently outperform those
without it.**
*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)
**Management Agenda 2013 Boury et al (Roffey Park Institute)

39. @helenbevan #KPHsafety#KHPsafety#KHPsafety
From compliance to commitment
“We come from a culture of compliance
and top down performance management,
… It’s task-orientated to get things done. It
needs to be much more about
cooperation, about leading across
boundaries … Being able to focus on
shared purpose in those circumstances is
absolutely crucial.” NHS interviewee

40. @helenbevan #KPHsafety#KHPsafety#KHPsafety
....the last era of management was about how
much performance we could extract from
people
.....the next is all about how much humanity we
can inspire
Dov Seidman

42. Framework for Operational Excellence
©Alan Frankel and IHI 2013

43. “How” is still work in progress
• We need to create a “mass movement” for safety
in England
• A great Improvement Programme is just one part.
• We intend to do “lots of lots” – creating
networks, sharing good practice, frequent
persistent communication and PR, maximising
the role of champions / fellows, connecting the
dots, social media, building capability, etc -etc.
etc. etc. – plus some things we don’t yet know!
Hacks, crowdsourcing, MOOCs (thanks Helen)

44. THINGS TO MAKE
CHANGE HAPPEN
Where are we now?
Where are we going?
How are we going to get
there?
1.
2.
3.
3
Improving health outcomes across England by providing improvement and change expertise

45. Improving health outcomes across England by providing improvement and change expertise
Slides Courtesy of Janet Williamson
Director of Programmes, NHS IQ

46. Improving health outcomes across England by providing improvement and change expertise
If you can’t describe the
pathway and walk it, you can’t
change it.
I hear and I forget, I see and I
remember, I do and I understand.
Confucius, Chinese philosopher & reformer
1.

47. Improving health outcomes across England by providing improvement and change expertise
Be clear what your
ideal looks like
2.
Be BOLD, be ambitious

48. Improving health outcomes across England by providing improvement and change expertise
Focus on the vital few
things not long lists
3.

49. Improving health outcomes across England by providing improvement and change expertise
Know your improvement
methodology
4.
It does not matter which approach,
but stick to it
Don’t move into doing until you have
baseline, you have data and you are
clear about the issues you are
trying to solve

50. Improving health outcomes across England by providing improvement and change expertise
Understand the context5.
Today is about doing more
and differently but with the
same or less money

51. Improving health outcomes across England by providing improvement and change expertise
Building relationships and building
capability from the start
6.
Redesigning the process, the pathway and the
structures is easy, the biggest challenge is winning
hearts and minds and changing behaviour

52. Improving health outcomes across England by providing improvement and change expertise
Every day, seek to learn
and continue to learn
7.

53. Improving health outcomes across England by providing improvement and change expertise
Improvement requires
personal resilience
8.

54. Improving health outcomes across England by providing improvement and change expertise
Once you operationalise things you are
not in an improvement roll, so STOP
9.

55. Improving health outcomes across England by providing improvement and change expertise
Happy staff make happy improvers10.

56. Improving health outcomes across England by providing improvement and change expertise
SUMMARY
Stand in the patient/carer shoes
Go see
Go search out
Do change together
Focus on key things
Involve all
Learn

57. Improving health outcomes across England by providing improvement and change expertise