Striking the Balance: Approaches to
Accountability and Quality
Improvement to Achieve Results
Helen Bevan
Chief Transformation Officer
Horizons, NHS England
Christina Krause
Executive Director
BC Patient Safety & Quality Council
@helenbevan @ck4q #qfA9 #quality2016

Speed Networking
“When do you feel most engaged
and energized at work?”
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Three ways to enhance quality
Quality
planning
Quality
improvement
Quality
control
Source: Juran
quality trilogy
All three are
necessary for
quality
outcomes
All three need
to be aligned
QP
QCQI
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Three ways to enhance quality
Source of model: Juran quality trilogy
Identify the needs of population, create aims &
metrics for outcomes & set out a series of steps for
meeting our aims
Ensuring high quality care
through monitoring,
inspecting, accrediting,
regulating & include
corrective responses
Achieve better outcomes
through a systematic
change approach with
strong leadership, adaptive
culture and people who are
skilled in QI methods.
QP
QCQI
@helenbevan @ck4q #qfA9 #quality2016

TRIZ:
Theory of Inventive
Problem solving
Stopping
counter-productive
activities and
behaviours
“Every act of creation is first an act of destruction”
Pablo Picasso
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www.liberatingstructures.com

Our TRIZ topic…
How can we deliberately create a health care
system that favours quality assurance over
quality improvement as a strategy for improving
care?
TRIZ
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Step 1
As a table group make a list of “to-dos” on
the first paper sheet in response to this
task:
How can we deliberately create a health care system that favours
quality assurance over quality improvement as a strategy for
improving care?
• Go wild!
• 5 minutes
TRIZ@helenbevan @ck4q #qfA9 #quality2016

Step 2
As a table group, go down your first list and ask:
– Is there anything that we are currently doing that
in any way, shape or form resembles any of the
items on list one?
– Is there an element of truth in here?
• Cross out anything that you do not currently do,
circle those that do
– Be unforgiving about these items and talk about
their impact
• 5 minutes
TRIZ@helenbevan @ck4q #qfA9 #quality2016

Step 3
As a table group, for each one you circled ask:
“what are the first steps that will help us stop
getting undesirable results?”
• Make a list of actions on a new sheet
• Be prepared to share some of your content
from lists 2 and 3 with the wider group
• 5 minutes
TRIZ@helenbevan @ck4q #qfA9 #quality2016

Intrinsic
motivators
build energy
and creativity
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Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity
@helenbevan @ck4q #qfA9 #quality2016

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
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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
@helenbevan @ck4q #qfA9 #quality2016

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
@helenbevan @ck4q #qfA9 #quality2016

The power of extrinsic drivers
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Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health
Foundation Constructive
comfort: accelerating
change in the NHS 2015
@helenbevan @ck4q #qfA9 #quality2016

Three types of levers for large scale change
‘Prod mechanisms’
targets
performance
management
price & payment incentives
regulation
competition
‘Proactive support’
relies on building
‘intrinsic motivation’ in
staff to make
the right changes to
improve
‘People focused’
education and training
national contracts
professional
regulation
clinical
quality standards
Type one:
Type two: Type three:
Source: Health
Foundation Constructive
comfort: accelerating
change in the NHS 2015
Less than 10%
of the potential
for
improvement
at system level
can be
delivered
through type
one change
@helenbevan @ck4q #qfA9 #quality2016

“I have some Key
Performance
Indicators
for you”
or
“I have a
dream”
Source: @RobertVarnam
@helenbevan @ck4q #qfA9 #quality2016

@helenbevan @ck4q #qfA9 #quality2016

https://www.youtube.com/watch?v=DKK-yFn7e_0
@helenbevan @ck4q #qfA9 #quality2016

https://www.youtube.com/watch?v=DKK-yFn7e_0
@helenbevan @ck4q #qfA9 #quality2016

@helenbevan @ck4q #qfA9 #quality2016

@helenbevan @ck4q #qfA9 #quality2016

What Is the Balance in Your System?
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Adapted from the Danish national quality strategy
@helenbevan @ck4q #qfA9 #quality2016

@helenbevan @ck4q #qfA9 #quality2016

What Is the Balance in Your System?
Table Discussion
@helenbevan @ck4q #qfA9 #quality2016

@helenbevan @ck4q #qfA9 #quality2016

Examples of Polarities to Manage
Old power AND
Transactional AND
Micro AND
Collaborative learner AND
Customizing AND
Wholeness AND
Complex AND
New power
Transformational
Macro
Expert advisor
Standardizing
Linear
Simple
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#qfA9

Positive results of focus on this left pole
Negative results of over-focus on the
left pole to the neglect of the right pole
Negative results of over-focus on the
right pole to the neglect of the left pole
Deeper Fear from lack of balance
Greater Purpose Statement - why balance this polarity?
*
and
Adapted from the Polarity Management map, Polarity
Associates
PolarityMapAction steps
How will we gain or maintain the positive
results from focusing on this left pole?
What? Who? By When? Measures?
Action Steps
How will we gain or maintain the positive
results from focusing on this right pole?
What? Who? By When? Measures?
Early Warnings
Measurable indicators (things you can count)
that will let you know that you are getting into
the downside of this left pole.
Early Warnings
Measurable indicators (things you can
count) that will let you know that you are
getting into the downside of this right pole.
Positive results of focus on this right pole

At Your Tables …
An opportunity to dive deeper on quality
assurance and quality improvement through
polarity mapping.
Using the worksheet on your table – explore the
concepts of:
Accountability AND Improvement
@helenbevan @ck4q #qfA9 #quality2016

Jeremy Heimens TED talk “What new power looks like”
https://www.youtube.com/watch?v=j-S03JfgHEA
old power new power
Currency
Held by a few
Pushed down
Commanded
Closed
Transaction
Current
Made by many
Pulled in
Shared
Open
Relationship
@helenbevan @ck4q #qfA9 #quality2016

So what does this mean for us in the
room today?
• Striking the balance … both/and, not either/or
• Understanding and applying within our own
contexts
• Turn to your neighbour …
What does it mean for you back home?
@helenbevan @ck4q #qfA9 #quality2016

Thank you!
Helen Bevan
@helenbevan
Helen.Bevan@NHSIQ.nhs.uk
Christina Krause
@ck4q
ckrause@bcpsqc.ca
@helenbevan @ck4q #qfA9 #quality2016