The slide deck from the workshop that Helen Bevan, Goran Henriks and on Anette Nilsson ran at the Jonkoping Microsystem Festival, Sweden on 28th February 2019 #qmicro

1. Doing change sustainably
28th February 13.15 – 16.45
Helen Bevan
Goran Henriks
Anette Nilsson

2. Aims of the workshop to:
• Think about how we go about change so it is sustainable right
from the start
• The role of both structure and agency in doing change
sustainably
• Understand the connection and tension between sustained
change and sustainable change and plan for it
• Use all the expertise and wisdom in the room so we can co-
coach each other

3. The Fundamental Law of this workshop
The sum of the expertise of
the people in the audience is
greater than the sum of
expertise of the people on
stage
Dave Winer
“
“
Source of image: www.citynet.com

4. A human spectrogram
On a scale from 1 to 10, how much experience and/or
expertise do you have in healthcare improvement?

5. A repertoire, menu,
toybox, or palette of
options for organising
generative interactions
LIBERATING STRUCTURES

6. A repertoire, menu,
toybox, or palette of
options for organising
generative interactions
LIBERATING STRUCTURES

7. 1. Expert-less: requires only a few minutes
to introduce; novices can succeed after a first
experience
2. Results-focused: likely to generate
better-than-expected purposeful results
3. Rapid cycling: fast iterative rounds are
very productive
4. Seriously fun: boosts joy, freedom &
responsibility
5. Inclusive: together, everyone is invited to
shape next steps
6. Multi-scale: works for everyday solutions,
projects, strategy, movements
7. Self-spreading: simple to copy without
formal training
8. Modular: the parts can be combined &
recombined endlessly
Licensed via Creative Commons
Intended attributes or characteristics of Liberating Structures

8. A first activity:
Understanding the problem we are trying to
tackle

9. Brainstorming TRIZ
Getting stuck in our
thinking
Getting stuck in our
thinking

10. TRIZ
How could we deliberately design our
improvement work so that change and the gains
will not be sustained?
TRIZ

11. Step 1
As a table group introduce yourselves to each other create a
list of “to-dos” in the first column (List 1) in answer to the
question:
How could we deliberately design our improvement
work so that change and the gains will not be
sustained?
• Go wild!
• 10 minutes
TRIZ

12. Step 2
As a table group, go down list 1 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?’
• Mark the items from list 1 that apply
• Be unforgiving about these items and talk about their
impact
• 7 minutes
TRIZ

13. Step 3
As a table group, go down your list of marked items and ask:
What are the first steps that will help us to create change
that is sustainable?
• Make a list of actions on list 2
• Identify one big idea for action
• Time available: 8 minutes
TRIZ

14. Transforming health care by moving
from hospital closer to home
Specialized
care
Primary Care
Support for
body and soul
Everyday life
Ref: Jönköpings län

15. ”Patient billion”
Agreement government and SALAR
Patient compact
Agreement between patient and
caregiver increase co-production for
better health and care.
Access
Improve and develop quality of service
to increase availability in primary care.
PatientkontraktVarför patientkontrakt?

16. Patientkontrakt - Patient compact
#patientkontrakt #patientcompact
Shared
responsibility create
better health and
care

17. Patient CompactWhy Patient Compact?
Why Patient Compact
• Believe in patients abilities and empower them to manage their health with
support from care givers. Create a partnership.
• This will influence health care to deal with challanges and limited resources.
• Availability, coordination and participation is a challange
• Increase person centered health care to better suit a patient perspective
• It´s neccesary to develop services in co-production
• Respect and care the time spent for both patient and care givers

18. PatientkontraktWhat is Patient Compact?
• Shared responsibilities - where patient and care giver in an agreement know who does
what and when
• Empower the patient to trust their own capability and use it
• Create good relationships built on trust and caring for time spent both from patient’s
and care givers’ perspective
• Patients know their next step - where to turn when they need health care, creating
security
• Make sure everything is connected - a shared overview, cooperation and coordination
with plans and support based on what matters for the patient?
Purpose with patient compact
Creating possibilities for improving health and care

19. Shared responsibility
Patientkontrakt
• Improve health and care
• Empower patients to believe in their
own capabillities and use it based on
what is important and matters to them.
• Empower the patient and create
possibilities for a partnership with health
care.
• Both patients and caregivers care for
time spent
• Co-production between patients and
caregivers
What is Patient Compact?

20. National measurement of patient experiences
Patientkontrakt
Did the caregiver involve you in the decision
about your care/treatment?
Did caregivers show interest for
patients experiences?
Patient satisfaction about health
care access.
Why Patient Compact?

21. Patient’s perspective as a compass for change
Patientkontrakt
To handle her Parkinson's disease,
Sara Riggare spends an hour with
her neurologist and 8765 hours of
self-care every year.
Why Patient Compact?

22. PatientkontraktWhy Patient Compact?
Patient compact formed by co-creation
Developed together with patients and from a patient’s
perspective
• 30 pilots
• Design team
• Cooperation between
authorities and organisations
• Knowledge inventory and
concept development
• Interviews
• Workshops

23. ”It feels good to think we will have an
agreement where I am an active part and I
am expected to do some. It proves care givers
care about me and what I can do”
Patientkontrakt
Deeper understanding of what really matters
for patients
”I am healty but live with
a disease”
”Make an appointment
that suite my schedule”
”Most important is to
know where to turn to
when I need it and always
feel listened to”
”Challenge the legislators. I am
the owner of my information
and decide who can read it”
Why Patient Compact?

24. ”Health is in joy be occupied by
doing your life tasks”
- Inspired by the German philosofer Gadamer

25. Patient contract a concept in four parts
Values make it happen
Agreement
Shared agreement between
patients and care givers
Care contact
Person with a coordinating
responsibility
Time plan
Patient and care givers agree on
the time for an appointment
Coordination
Planning, overview and support
for coordinated care
Involvement Coordination Access Cooperation
PatientkontraktVad är patientkontrakt?

26. You and health care - how does it work?
1) Can you live your life fully? Trusting that if you need healthcare you know it will
be easy to get help
2) Do you have an agreement with your care giver based on what matters to you?
Where you know what to do to feel healthy and what to do if you are sick. And
what your care giver will be doing to support you?
3) Is it easy for you to have access to your care giver?
4) Do you have continuity with your care giver? (when it is needed)
5) Do you know your next step?
6) Do you and your care giver have an agreement on your next appointment?
7) Do you have an overview of your different plans in healt care and support with
coordination when it is needed?
PatientkontraktFollow up Patient Compact

27. What will your patient compact look like?

28. Contact Appointment Home
PatientkontraktPatient Compact in Practice
Patient Compact in practice

29. ”One size doesn´t fit all”
We develop services together in co-production
The value of a service Patient Compact

30. What is a service?
The value of a service Patientkontrakt
”In co-production a service
occurs that none of the
people involved had been
able to create by them
selves”

31. People are different, have different needs and
expectations in different situations
Independent and
commited
Worried and
commited
Traditional and not
worried
Vulnerable
and worried
The value of a service Patient Compact

32. The value of a service
is created between
patient and care giver
#patientkontrakt #patientcompact
The value of a service

33. Services – how does it work today?
• Today a lot of services are based on a
service based logic
• The sector of product production is now
replaced or higly supplemented
• Health care still have challenges to make
this transformation
The value of a
service
Patientkontrakt

34. Depending on the siuation and the need - We make the decicion together on what
suits me and the situation best!
Online
reservation
Self check-in
Reading
journal
Before During After
Advice
Waiting room
host Video meeting
Waiting list Reception Letter
Contaced by
phone
Personal
contact
person
Phone call
Independent and commited
Worried and commited
Traditional and not worried
Vulnerable and worried
Customizing a service
The value of a service Patient Compact

35. Make it a natural part of what is going on
Patient CompactSupport from SALAR

36. Tap into existing networks and merge
with work already going on

37. Totally
Not at all
No units All unitsHow many units are working
with the new concept?
Once the unfamiliar has become familiar we
have a culture change
Patient CompactFollow up Patient Compact
To what extent is the
concept integrated
in ordinary work as
it is meant to be?

38. Let´s go back stage some thoughts behind the
national support to support the power to make it
happen…

39. Every person, every meeting every time!
Micro
Meso
Macro
It is here it
determines if it is
working or not
Make it happen!

40. Design a program to support Make it happen!
Micro
Meso
Macro
Make it happen!

41. Learning forum
support from SALAR
– make it happen
Learning forum
• Support teams with integrated competece to
build infra structure in a local context
• Swedish national network for learning,
sharing, co-production by implementing
patient compact
Follow up, measure and visualize
• Visualize in different ways how the
implementation of the concept go from
word to action nation wide
• Visualize outcome measurement from
different perspectives in national patient
survey
Storytell
• Capture learning, knowledge and stories
that show the way how to move forward
• Show value both from patients’ and
proffesionals’ perspectives
Influencers

42. Practice and input, share,
learn and get inspiration
from each other to act
Meeting places for
national network
with purpose to
support power to
make it happen
People with patient experiences in the
room and on stage
Learning forum

43. More support
• Webb side all is
transparent
• Movies from macro,
meso, micro
• Stories tell us about
the culture in a
systematic way
• A toolbox as support
• Zoom meeting
Skärmklipp från hemsidan?? Olika filmerna???

44. Big vision
act in small steps
Stories with a clear message
1. WHY Patient compact?
2. For whom by when?
3. What do we expect to happen in
behavior
4. How will we do it?
5. Long and short lens at the same time

45. AGENCY
The ability of an individual or group to choose
to act with purpose.

46. Patient compact is a four-part concept
Value base as a driving force
Agreement
Shared agreement
between patients and
care givers
Care contact
Person with a
coordinating
responsibility
Time plan
Patient and care givers
agree on the time for an
appointment
Coordination
Planning, overview and
support for coordinated
care
Involvement Coordination Access Cooperation
PatientkontraktWhat is Patient Compact?

47. It´s all about people and understanding
culture and structure
Create opportunities for everyone to take ownership of how they will
make this happen – empower and support INFLUENCERS
Sustain
Sustain
Sustain
Sustain
Change as a condition -
sustainability

48. Make it easy to do - every person, every
meeting, every time
Hospital, primary care, community, inhabitants -
training in different ways at the same time
ACTIONABLE

49. We don´t see the culture change from the
kitchen window
• 7 questions for the micro system level
• Meso level standard ”onepage” with
current summary for sharing will spread
7 questions for meso level.
• National survey for the macro level and
index map - tell us where we are
• Patients’ and employees’ stories as a
receipt 7
Imagine the future - at the same time
work here and now! Long and short lens at
the same time

50. Culture eats strategies for
breakfast, lunch and dinner….
• Where will we play/work?
• How are we going to get implementation
power?
• Who are the influencers who will make it
happen?
• What opportunities do we need to create,
which will be crucial to being in place, in
order to succeed from words to action?
• What is it for soil, culture that needs to be
created for it to grow and survive?
Ability AND CULTURAL
LEADERSHIP is about several
related choices

51. mål!Vad vill vi åstadkomma?
Hur vet vi att en förändring är en förbättring?
Vilka förändringar kan leda till en förbättring?
mått!
idéer!
test!
Förbättringsmodellen
Planera
GörStudera
Agera
PGSA-cirkeln
Ref: Nolan, Deming m fl.

52. Make it a natural part of existing work

53. Tap into existing networks - merge with work going on

55. Stearing board
PatientkontraktWhy Patient Compact?
Representing different national networks
• Region director
• Health and care director
• Communication director
• SALAR
• Network for close care

56. 1
Pilot project,
focus groups in
three regions
Result: Patient
Compact a four-
part concept -
values make it
happen.
2
Get ready for
scale-up- all
regions do their
pre-work for
building
capacity for
scale- up to
implement the
value concept
Patient
Compact.
3
Go for action –
make it happen
Integrate in
already existing
work. Made by
many.
Build local
ownership. Be
open and share.
Have fun build
network with
friendship.
4
Keep calm carry
on, follow the
stories related
to the concept
related to the
effects and
result. Catch
learning and
share with
others. Social
movement
Work at all level , macro, meso, micro at the same time and learn
from different perspective.
Four phases

57. Three streams at the
same time
• Lived reality from people, we sometimes
call them patients
• Current state ,system experience from
guiding the journey
• Research
Do it at the same time!

58. How does Patient Compact
contribute to capacity
building where abilities
strengthens both for
patients and professionals
for ability to interact and
learn how to co – produce
for better health and care?

59. Tomorrow's flowers
are hiding in the seeds
that are sown today

60. Some definitions for doing change
Change that is sustained:
When new ways of working and improved outcomes become
the normal way of doing things and don’t slip back over time
Change that is sustainable:
When the change is built upon and develops over time as
circumstances change, through a process of continuous
improvement.
We need both!

61. The predominant approach in recent years has been STRUCTURE but globally there is a big
shift towards AGENCY
We need to consider both structure & system for sustainability
Structures and systems
Goals
Formal authority
Methods
Quality assurance
Regulation
Programme Management
Incentive systems
Activation
Relationships
Connections
Ability to make choices
Capability
Social action
Solidarity
Social movements

62. The power, individually and
collectively, to make a positive
difference
#qmicro

63. Source: @NHSChangeDay
65
#qmicro

64. Source: @NHSChangeDay
66
#qmicro

65. Source: @NHSChangeDay
Problematic: changing
a “permission culture”
can take years
The good news: we can
usually build agency
much more quickly
67
#qmicro

66. Where there are powerful ‘winners’ from
change, sustainability may be high, but not
where there are powerful ‘losers’.
Plant

67. Mark Jaben on the science behind resistance
What NOT to do
But what we do do
Engage people here

68. Mark Jaben on the science behind resistance
What NOT to do
(but what we usually do)
We don’t need buyers (who “buy-in” to change)
We need investors
What TO do
Engage people
here
Engage people
here

69. Standardisation/consistency
Follow a consistent approach
Sustainability
Implement evidence-based
Results through compliance
Individual competence
Work based on tasks
Continuous improvement
The courage to do what’s right
Transformation
Innovate and experiment
Results through commitment
Collective competence/learning
Work based on relationships
Some of the tensions/polarities we see in quality improvement
AND
AND
AND
AND
AND
AND
AND

70. These tensions are
polarities, not problems
Problems
• Have one best or right answer that
provides a solution
• The solution solves the problem and it
goes away
• A definite end point where you can say
that the problem is solved
• The solution to the problem usually
contains no alternatives
Polarities
• Are unsolvable problems that need to
be managed
• Often two positions that are in
opposition
• Usually expressed as from one
polarity to another
• A tension, not a choice with a best or
right answer

71. Sustainability through
structure
Sustainability through
agency
AND
Positive results of focus on this pole Positive results of focus on this pole
Negative results of over-focus on this pole to the
neglect of the right pole
Negative results of over-focus on this pole to the
neglect of the left pole

72. Crossing the
commitment line
74
You’ve crossed
the line!