On an ambidextrous NHS
We are now in year six of the 10-year health reform programme. We see many important successes: reductions in waiting times, improvements in clinical quality, innovative workforce changes. Yet despite the energy and resources that have been invested, we are yet to see the kinds of dramatic improvements in care delivery, clinical quality and productivity that our system is both capable of and needs to achieve. Even in the places where we see significant improvement, it tends to be in isolated pockets and not system-wide.
Yet we have the knowledge to make a profound difference. The Ten High Impact Changes, published two years ago, demonstrated that millions of unnecessary visits and bed days could be saved and patient experience transformed, by adopting the practices of high performing NHS organisations. More recently, the NHS Institute’s Delivering Quality and Value programme and the Foundation Trust Network’s orthopaedic benchmarking project showed how, by reducing wasteful variation between organisations, we could save many millions of pounds across the NHS system.
So why don’t we just adopt best practice and transform our organisations? The NHS Institute recently interviewed 30 NHS chief executives, commissioners and providers. They were selected as being among the highest performing and most improvement-orientated leaders in the NHS. A key message from the interviews was the challenge of managing the short term (achieving financial balance, hitting all mandatory targets and managing operational issues) at the same time as seeking to create a different future for the longer term. Many of the interviewees said they are committed, at a personal and organisational level, to an ambitious improvement agenda focused on safer, more effective, patient-centred care. However, this is being put on hold as they deal with current problems. There was a view from a number of the chief executives that financial stability is a pre-requisite to create the space, investment and sense of calm necessary for more radical change.
A concept that is emerging strongly from global research into high performance is that of the ‘ambidextrous organisation’. Across countries and industries, many of the best performing organisations are those that have developed the capability to operate at both ends of the change spectrum at the same time. They are meeting the contradictory demands of exploring new, often uncertain, opportunities while continuing to successfully operate the existing business. These organisations are able to keep everything running and at the same time change everything. This is a perfect description of the capability needed by NHS organisations. The success of the reform programme depends on nothing less than transformation in the functioning of organisations that make up the NHS. We cannot allow this goal to be overwhelmed by short-term delivery issues. We need to find ways to encourage and develop greater organisational ambidexterity across the NHS. This is a significant challenge in a system where the immediate focus of performance management and the political cycle encourage bias for action rather than the reflection, strategy and engagement necessary for transformational change.
Global research into transformational change programmes in healthcare, suggest a common theme: it takes time to achieve radical change, typically much longer than organisations originally envisage. We can change the structures, the processes and the roles but the biggest gains come from changing behaviours. We need to create an ‘infrastructure’ to support and sustain behaviour change; inspiring leadership, new support systems and capability to work and behave in new ways. There aren’t any short cuts. Performance may decline before it improves, as happened when the Veterans Administration in the US embarked on a radical change programme in 140 of its hospitals.
The scenario is the reason why the NHS Institute for Innovation and Improvement has embarked on the Delivering through Improvement initiative. It is a coalition with some of the most motivated and capable local leaders in the NHS. We want to develop, validate and spread approaches for driving organisational improvement across the NHS. The participating NHS leaders are going to test new ideas and approaches, on top of their existing improvement strategies. Collectively, we are seeking to reconcile the gap between transformational aspiration and operational reality. We want to offer insight into what it would take to move NHS organisations (as Jim Collins put it) from ‘good to great’ and to create a roadmap for getting there. Watch this space.
27th July 2006
On a life-saving campaign
In an earlier column I wrote about a bold campaign in the US, initiated by the Institute for Healthcare Improvement, whose mission was to save the lives of 100,000 people who would otherwise have died in hospital over a period of 18 months (Good Management, page 31, 23 June 2005).
The campaign was based on six evidence-based interventions that save lives and reduce hospital mortality rates. The first was deployment of rapid response teams to bring specialist expertise to patients whose condition was deteriorating anywhere in the hospital. The second was a set of actions to reduce hospital deaths from heart attacks. The next three reduced hospital-acquired infections, ventilator-associated pneumonia (VAP) and central line and surgical site infections. The final intervention sought to prevent adverse events through reconciliation of patient medication.
The 18 months ended on 14 June. The official estimate of lives saved was 122,342. The sign-up rate was phenomenal: 3,103 hospitals enrolled in the campaign, representing more than 80 per cent of all discharges and over 75 per cent of all acute care beds in the US.
Commentators believe that the 100,000 Lives Campaign has changed the standard of care in the US. The list of hospitals that have not had a single case of VAP or a central line infection for at least 12 months is growing. The outcomes are starting to challenge conventional views about the inevitability of healthcare-associated infections.
So what can the NHS learn from this overachievement of a national improvement goal?
First, quality specifications and clinical standards are not enough on their own to engender wholesale change. They create a ‘push’ effect - an externally driven dynamic that tells providers what they should do.
The 100,000 Lives Campaign demonstrated the power of the ‘pull’ approach. It framed the change proposition as an irresistible emotional and logical argument that fits with the values, beliefs and life experiences of clinicians and managers.
The campaign suggests new methods for ensuring spread and adoption of best practice. Campaigns are emergent, self-fuelling and bottom-up, yet success depends on meticulous planning and strategy. You have to design for pull as much as for push.
The campaign perspective challenges much of the way we have learned to organise and lead change in the NHS. We need to move beyond the push of the top-down performance improvement approach and beyond the uncoordinated pull of lots of individual local projects. For instance, the campaign’s focus on mobilisation, evidence-based interventions and frontline action could help give real teeth to practice-based commissioning.
The message of a life saved is a compelling rallying call. Yet the impact of the 100,000 Lives Campaign is beyond measures of clinical quality. It is also a powerful strategy for redesigning cost and increasing value.
A recent report in the US showed
that high-quality, reliable clinical processes cost less to provide. This is in addition to lower mortality rates, fewer adverse events and fewer patient re-admissions.
The campaign is now moving forward. The next goal is full implementation of all six campaign interventions in all participating hospitals by January 2007.
How can we design our future improvement systems so staff at all levels can unite around specific aims and exceed national goals?
Background Information
For more on the 100,000 Lives campaign go to
http://www.ihi.org/IHI/Programs/Campaign/
30th March 2006
Helen Bevan on motivation and productivity
What steps might you take if you wanted to bring about a double-figure increase in staff productivity in your organisation? I have spent virtually a whole career in process and system improvement. I can advise you about a range of powerful strategies for improving the ratio of service outputs to staff inputs by eradicating ‘waste’ and ‘non-value-adding’ activities.
These strategies involve systematically reducing variation in work processes, job roles and clinical practice with the aim of providing speedier, better care at lower cost.
But can such strategies backfire? By following such approaches, could we inadvertently end up with lower productivity? As NHS leaders, we need to take account of a growing body of evidence about ‘discretionary effort. This is the degree to which individuals are personally committed to helping the organisation by putting in more effort than is actually required to do the job. It is what we are willing to do at work because we want to.
Discretionary effort is not about spending even more hours at work. It is all the various forms of initiative, interest, motivation, responsibility, dedication and loyalty that we control ourselves as individuals. Work is contractual. Effort is personal.
To summarise the evidence, discretionary effort is critical to conversations about staff productivity because it represents a range of performance 20-40 per cent above what is typically realised by an organisation. It is unseen, unquantified and unbudgeted, yet it has a significant impact on bottom-line results. For instance, the Hay Group compared offices of a company where the leadership style encouraged discretionary effort with offices that did not. It found that the offices with discretionary effort generated 43 per cent more income.
Discretionary effort is linked to level of engagement; the extent to which all of us feel a positive emotional connection to our work and are able to fulfil our personal goals and values through work. Engagement is more than the mere ‘buy-in’ that is required of staff once important decisions have been made. Buy-in represents a low level of agreement. Engagement is both an emotional and intellectual commitment. It implies ownership of the change process by everyone affected by the change.
As NHS organisations strive to provide better care with less resource, staff are under increasing pressure to produce results. Too often, the important decisions about change get made by a select few or by hired-in ‘experts’. The risk is that the very strategies that seek to maximise the outputs of individuals create the opposite effect of an understandably cynical and disengaged workforce.
In the recent HSJ survey of middle managers across the NHS (pages24-26, 2 February) only 18 per cent of respondents said that they were ‘happy’ in their role and only 23 per cent felt ‘valued’.
For large-scale change to be successful, it requires changes to mindsets and behaviours, not only to processes and systems. This can only happen when staff feel emotionally connected and have a true sense of ownership of the change.
The greatest leadership challenge of the next era is how to fundamentally redesign services to ensure sustainability in improved quality and value and contained costs. We need to do this in ways that truly engage staff to boost performance.
The success rate of our productivity efforts could soar. We need clarity of goals, a common purpose and an enabling environment where the natural creativity and energy of our staff can flourish. As leaders, we have to take a personal stance; building, maintaining and protecting trust and integrity; making work more meaningful and rewarding; connecting great results with great personal and organisational values.
Organisations that figure out at a corporate level how to mobilise the discretionary effort of its entire workforce are the ones that will win the productivity battle and succeed in the NHS of the future.
Helen Bevan is executive director of service transformation at the NHS Institute for Innovation and Improvement. The NHS Institute has teamed up with HSJ to run a series of trust-hosted events in May and June that will help managers learn from the experiences of high-performing peers in areas such as length of stay, theatre management and the 18-week target.
For more details on the Good Management Live events go to
www.goodmanagement-hsj.co.uk/gmlive
9th February 2006
Helen Bevan on good practice
A few months ago, I was a judge for the acute healthcare organisation of the year category at the HSJ Awards. The criteria looked for 'organisational excellence'.
Most of the entries were able to demonstrate excellence in their operational performance. Most were currently achieving or exceeding key national targets. However, when considering other characteristics of the entries, two factors were striking.
Read the full article
Good Management Live Events 2006
