How can healthcare organisations make change when standing still is not an option?
Stream: Change
This year’s International Forum on Quality and Safety in Healthcare , which took place at London’s ExCeL centre was subtitled ‘Together to Regenerate Health and Care’.?
Across three days of presentations, workshops and discussions it brought to light many examples of change making, but also many areas of the lives of people in communities across the world where change was necessary, including changes in the quality or content of healthcare they receive.? There was a collective sense that, post-pandemic, healthcare should not return to business as usual but grow afresh with greater focus on equity, community and reduction of harm.
Jason Leitch, National Clinical Director, Scottish Government, in his final summing up of the forum presented a challenge to this view. In twenty years from now we will have 21% more disease to treat.? To deliver healthcare at the level and cost we deliver it now, we would have to eradicate all cancer completely to break even.??
Across the three days of the forum, there was a strong message that small changes are not enough to solve the challenges presented to the industry of healthcare in a changing world.? Challenges like equity, environmental sustainability, demographic and economic change cannot be tackled by assumptions made before these challenges were properly conceived.? Health inequity rests on prejudice, discrimination and unchallenged assumptions.? If outcomes vary for non-white communities because of systemic racism, assumptions about the inevitability of such variation will not change outcomes. What is needed to bring about equity for all is not a change in degree but a change in kind.
Healthcare change in the common imagination is often reduced to two things: new treatments and better delivery of them.? This can be described as a view of improvement in healthcare that is change in degree, that change is really about a bit more of something or a bit less.
At the heart of quality improvement in healthcare lies the complex idea of change.? To carry out quality improvement requires an aim, which will be a desirable future outcome where a set of planned steps alter or mitigate drivers that create outcomes so that we get closer to the future that we want.??
Helen Bevan, Chief Transformation Officer at NHS Horizons, and Goran Henriks, Chief Executive of Learning and Innovation at Qulturum, presented to the conference a session titled ‘The Future of Change’. In this session they shared a number of useful tools to begin quality improvement through the lens of taking action now, based on current trends to arrive at a future that is better than the present.
The pair shared a quote from organisational guru the late Mike Hammer: “The secret of success is not to foresee the future. It is to build a system that is able to prosper in any of the unforeseeable future”.?
For Bevan and Henriks, when looking at potential for successful large-scale change in health systems, there are a number of recurring themes.??
Both propose that everyone in an organisation can contribute to establishing and leading a culture of change. While successful quality improvement in healthcare requires rigour, knowledge and resources and a strong organisational culture that values curiosity, learning from success and failure and mutual respect for agency, skills and knowledge, that is not enough on its own to drive change.?
The drivers of a thirst for change and a thirst for improvement come from people at all levels of seniority and at all stages of careers recognising first the need for change and secondly having the curiosity to explore, listen and make common ground with those who recognise the same imperatives.? This they referred to as moving together.
They also discussed other factors in change-making:?
Changing yourself.? Self-education is one of the hardest things in change.? It's much easier to ask others to change. Often the largest barrier to overcome is moving from "what does change mean for me?" to “what does change mean for my mission?”
Co-production. From the perspective of both equity and change making, co-production begins with the establishment of respectful, curious and authentic relationships with others, both with lived and learned experience. Creating the conditions for emergent change: all the voices we need should be engaged from the beginning.? We must let the road map emerge from these discussions.
Systems for learning. Quality improvement and changemaking require a commitment to sharing learning between projects, individuals and organisations. For organisations to learn they need both data and the lens and capability to reflect upon them. Data does not simply exist for the purposes of reporting, it is also a picture of what is happening now and what is likely to happen in the future.?
Leaders. Any group of people has people who lead. Some lead in decision making, others in horizon scanning, others in building cultures of respect and dignity. Change makers do not have to be the ultimate leaders of an organisation, but will see success more readily in organisations where leaders have created the culture, capability and capacity for change to be put into action.
Creating conditions.? Change making is more than having ideas. Those leading change generate spaces and for others to be involved in the making of change.? Change requires more than lone voices. It requires a broad belief that change is possible, change is necessary and the availability of resources, knowledge, information and capabilities. ‘What’ and ‘how’ need to flourish together alongside ‘why’.? Change making involves nurturing and growing the potential for change.
Leading transitions. Change making is also about change following-through.? Those making changes ‘on the ground’ need support, check-ins, a sense of agency and to be recognised and celebrated for their part in any transition from one way of doing things to another.?
领英推荐
Networks. Networks, both formal and informal, help to spread knowledge and learning and create bonds between people and teams who otherwise may feel isolated or without others in their immediate environment who are undertaking similar activities or sharing similar goals.
Allies. We have to work with and through power to achieve our intended outcomes. For this, we need allies, outside of our echo chamber.
The pair introduced Bill Sharpe’s Three Horizons exercise, a conceptual model for thinking about current assumptions, emerging changes and possible and desired futures. The objective of the exercise is to look at what we think of as the current state of play around an issue or activity, to identify changes that are currently happening which will affect the state current situation and then to find a path or transformational ideas that might lead us towards our preferred outcome.
These are plotted as three lines on a horizontal scale that ranges from ‘Now’, through ‘Near Future’ to ‘Far Future’.
The first horizon emphasises what’s known, what’s taken for granted, what we assume ‘will always be with us,’ and focuses on maintaining stability. On this line is what the near and far future will look like if we don’t change anything. This could be considered as the line most aligned with management, of doing the same or similar things with the same assumptions.??
The third horizon is what’s already changing. It emphasises emerging changes that represent transformational shifts from the present. These might be understood as pockets of the future that are emerging in the present,? the transformative, the visionary, the break with past traditions and current assumptions. This is the world as written about in future scanning articles and promised by visionary leaders, for good or ill.
Between the line representing what would happen if nothing much changed in what we do and the line representing what might change if huge changes happened affecting what we do is the second horizon, the horizon of our possible change. This is the considering actions taken in the present to resist change, to adapt to change, or to build on change; the focus is on creating and managing change in positive ways.
This second line is the domain in which quality improvement and change-making operates within healthcare systems and communities.
As the pair described it, horizon one is what is viable or not viable for our current way of working. Horizon three is what may be possible. Horizon two is the question: ‘how can we build a path between what is and what might be?’
Juergen Graf, CEO of University Hospital Frankfurt, in a presentation on the role of patient safety officers presented a very good summary of a horizon one situation. As CEO, he expressed that in Germany’s secondary healthcare system, the responsibility is structure and compliance, processes done right and showing they have been done right. The endpoint is quality for patients. Germany has more staff and more money than other countries, but people don’t live longer than comparable countries and aren’t happier. Graf spoke about the impact of demographic change in German healthcare. From 2030 onwards, an ageing healthcare workforce will see a lot of professionals retire, at the same time as approximately 20% of patients will be over eighty years old.??
Jason Leitch shared a similar picture for NHS Scotland in his speech closing the forum .
Both concluded that as we get better at healthcare, healthcare becomes more expensive to maintain. Our successes in healthcare in the 20th and 21st century have meant that people live longer. Leitch presented this in terms of generations. His great grandparents were more likely to develop illnesses in their forties and die. His grandparents were more likely to develop health problems in their fifties and die. His parents were more likely to develop illnesses in their fifties and continue to live. As Leitch put it, we have got much better at treatment, but have plateaued on prevention.
Another horizon one challenge was shared at the conference by Elaine Mead from Improvement Care and Compassion Scotland, in a session about leading around healthcare, climate change and climate emergency. Healthcare generates a lot of waste, has long supply chains and uses a lot of carbon. If action is not taken, the environmental impact of healthcare will contribute to the conditions of rising global temperatures, which are already increasing the health risks for people across the world.
An example of a horizon three change is the arrival of Artificial Intelligence as a major disruptive force. Pierre Barker, Chief Science Officer at the Institute for Health Improvement, told the conference that 38% of physicians are already using AI powered tools in one form or another, including to write discharge summaries, care plans, progress notes and even for ‘assistive diagnosis’. AI tools are being used increasingly to write content and to summarise data. Challenges with AI tools include the data upon which they are trained, which has the potential to amplify existing prejudices or errors as much as it does to correct them.??
The likely trajectory of AI is that it will provide an ever greater range of opportunities to replace human cognitive or communicative functions in society, including in healthcare. While it will be possible to continue to provide healthcare, the likely direction of its spread is likely to impinge upon healthcare spaces from without, even if not adopted from within.?
Ruth Yates of the Advancing Quality Alliance shared a number of quality improvement projects that had utilised AI to power an eBooking system that allowed patients to rebook more easily and a staff IT dashboard that gave easy access to positive feedback, which improved working culture. These were examples of horizon two thinking, looking at new developments and looking at how they might be applied to existing challenges and problems.
Addressing environmental sustainability is another example of horizon two thinking. The worst possible world is that health systems continue to create large environmental impacts while climate change accelerates. Jen Leonard of Barts Health NHS Trust shared how their trust had taken on environmental sustainability as a Quality Improvement challenge . This began in 2018 when Barts began to work on QI, setting up WeImprove as a platform for staff to submit QI projects, spreading QI capability through training and supporting QI projects through a QI faculty.
Part of leading environmental sustainability through QI was being able to show examples of what good looks like, so that teams could develop their own metrics. Another important part was developing exercises to show teams in the Trust what waste looked like and to clearly define the context that the only way to reduce impact was to either reduce activity or reduce carbon density.??
Examples of sustainability QI projects that grew from this Trust-wide improvement culture-building included a move from ethyl chloride swap to coolsticks, the REACH model where Ambulance crews can call the REACH team directly to get expert clinical advice for the patients they are seeing, which has saved 156 metric tonnes of co2 emissions through non-conveyed patient activity, and a project to reduce nitrous oxide wastage through decommissioning pipeline manifolds, which is estimated to save 3,200 tonnes of CO2 a year.
As journalist and activist Rebecca Solnit says in the forward of the third edition of her book Hope in the Dark ?“the world often seems divided between false hope and gratuitous despair. Despair demands less of us, it’s more predictable, and in a sad way safer. Authentic hope requires clarity — seeing the troubles in this world — and imagination, seeing what might lie beyond these situations that are perhaps not inevitable and immutable... When you recognize uncertainty, you recognize that you may be able to influence the outcomes — you alone or you in concert with a few dozen or several million others.”