Four routines that foster continuous improvement
31 January 2020
By Nicola Burgess
Over the last two decades, many organisations in the UK's National Health Service (NHS) have been implementing quality improvement methods with the aim of delivering the best possible care at a sustainable cost.
As a result, thousands of innovative improvements large and small have been implemented in pockets throughout the NHS, creating a rich and diverse knowledge base about how to improve healthcare delivery processes.
Mobilising knowledge effectively from one context to another presents a lingering challenge, especially as this kind of ‘tacit’ knowledge, derived from personal experience, doesn’t lend itself to being easily transferred.
The problem stems in part from how we learn. Organisational learning like individual learning is relational, in other words we tend to listen more to people whose views we personally like and respect.
Healthcare professionals are renowned for their social forms of organising, characterised by close-knit professional groups of a similar professional status and experience. These close-knit groups can be difficult for other healthcare professionals to access (just like the playground clique) and knowledge thereby becomes ‘locked in’.
Yet, mobilising knowledge across professional groups, departments and organisations is vital if the NHS is to be able to drive improvement across the broader system.
The five-year partnership between the NHS and Virginia Mason Institute (VMI) provides an interesting example of how to create receptive contexts for knowledge mobilisation across organisations, departments and professions.
Since early last year I’ve been leading an evaluation of the impact of this partnership on each of the five NHS trusts involved. This work, funded by the Health Foundation, isn’t due to report until 2021, but we are already seeing some interesting findings emerge.
The partnership aims to develop a culture of continuous improvement capability in five NHS hospital trusts through the adaption of VMI's ‘production system’.
The VMI has an enviable reputation for quality and safety of care that they attest to their adaption of Toyota’s production system, commonly known as Lean. Through this partnership, a set of routines has emerged that creates regular and predictable formal spaces for informal and reflective dialogue at every level.
Here are four methods that have helped innovations spread:
1 Best day of the month
At partnership level, the CEOs from each of the trusts are involved in a six-hour monthly meeting known as the Transformation Guidance Board. This also includes senior members of NHS England and NHS Improvement (NHSE/I) and senior representatives from VMI.
Most CEOs would not relish six hours in a windowless room with their regulator but these CEOs (and their regulator representatives) each declare the meeting "the best day of the month!"
Why? Because the meeting resembles a protected relational space, where individuals are all working towards the same shared goal of service transformation.
At this meeting, conversations are frank, honest and reciprocal. Talk is reflective on all sides, from CEOs reflecting upon what is working well, what is not and why not, to the regulators reflecting on their own behaviour and the role they need to play to drive the level of improvement policymakers desire. In short, the meeting offers valuable learning to all participants.
2 Driving improvement
Each of the five NHS hospital trusts holds an internal three-hour meeting every month with senior managers, focused on a shared goal of driving improvement across the organisation.
While this Transformation Guidance Team meeting is formally structured, the conversation is fluid, reciprocal and supportive.
This strategic level meeting must also find ways of incorporating dialogue with staff and patients to ensure strategic alignment of improvement goals with organisational strategy, and that the strategy is rooted in practice.
3 Rapid Process Improvement Workshop
The Rapid Process Improvement Workshop (also known as a Kaizen event, which as part of Lean promotes a culture of continuous improvement) is a popular vehicle associated with Lean.
It brings together a temporary team of staff who each have a role to play in the process under focus but often do not know one another or the contribution they each make to the same process. This includes representatives from varied departments and professions: from porters to consultants.
Over three to five days, a case for change is made and participants are guided through a series of steps that lead them to acknowledge the existence of a problem, out of which a shared desire to improve can emerge.
On the first day some participants are noticeably anxious: expressing trepidation about what the week has in store for them, or feeling like "it’s all a waste time, I already know my part of it".
But by the end of the week participants are on first name terms with each other, regardless of rank or status, and engaged in dialogue that is frank, informal, respectful and constructive.
4 A daily huddle
The daily ‘huddle’ has been a prominent practice change that has featured widely across many wards and departments in our partner hospitals.
A short stand-up meeting, usually lasting around 15 minutes, it features a structured discussion, often with the help of a visual management board, around the daily issues and performance in the department.
Again these meetings are formally paced, but allow informal interactions to take place. The aim is to foster ongoing dialogue about what is going well or not and why, what needs to improve, ideas for improvement and the success or otherwise of those ideas.
It may seem simple, but the reality is that although we are all really busy, nothing quite drives improvement like making time to talk.
I am reminded of a recent interview with one of the partnership CEOs. I was asking how he turned his organisation from the worst performing hospital on every metric to one of the best.
The answer was unequivocal: talk, facilitated by a common goal, fosters a receptive context for sustainable improvement.
He said: "If you take the kind of human side stuff and all the things we think about - relationships and all those sort of things - we think that we come to work every day and we pass people in the corridor and we know each other and all this. Well, we don’t.
"We work in our own microcosms, right, and what this [the NHS and VMI partnership] has done - it’s got the consultants and the doctors talking and getting on first name terms with the physiotherapists and the porters and the pathologists and people that they wouldn’t come into contact with, and I think that that is extraordinary in how people then start to develop the way in which they work together to continuously improve."
Burgess, N., Currie, G., Crump, B., Richmond, J. G. and Johnson, M. (2019) "Improving together : collaboration needs to start with regulators", BMJ, 367, l6392.
Johnson, M., Burgess, N. and Sethi, S. (2019) "Temporal pacing of outcomes for improving patient flow : design science research in a National Health Service hospital ", Journal of Operations Management.
Follow Nicola Burgess on Twitter @DrNicolaBurgess.
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