Q Community Masterclass:
Coaching, Mentoring and
Positively Supporting Others with
Improvement
13 July 2017
Welcome to Your Day
SW AHSN
• The SW AHSN mission is to improve the health and patient experience of people in the South West by supporting and accelerating innovation and quality improvement.
• The SW AHSN holds a unique position in the South West, bringing together likeminded people from academia, industry, life sciences, local government and the voluntary sector to work with the NHS in pursuit of a common goal – to improve people’s health and patient experience.
SW AHSN & Q
Warm Up Exercise
FINISHED FILES ARE THE RESULT OF
YEARS OF SCIENTIFIC STUDY COMBINED
WITH THE EXPERIENCE OF YEARS
www.q.health.org.uk
The Q Community
What is Q?
A Community of People…….
………Committed to improving Health & Care
Where a wide range of knowledge and experience is welcomed and shared……….
……..And, where there are no limits on innovative ways of working.
‘Q at its heart is cross-boundary and multidisciplinary, and will involve patients and people seeking to influence or working with the health and care system at every level’ (The Health Foundation)
What Q Expects of You
Engage in Q with Integrity
Committed to and actively participate in multi disciplinary working
Share your Knowledge and Experience with Others
Listen to and Respect the views of others, even if different to your own
Provide Constructive Feedback and Value the contribution of others
Share and Spread your Learning within and beyond Q
What does being a Q Member mean?
• A ‘home’ for improvers
• Raising the profile of improvement
• Knowing more about ‘who is doing what work’
Having
• Spread and share learning beyond Q
• Building and strengthening networks and contacts
Doing• Polite, respectful
• Challenge constructively
• Giving Feedback
• Contributing to building Q
Being
Engage. Connect. Commit.
Pledge – What can you/will you do next to contribute to Q and to other members and support Q to grow?
Members Update
Connect
• Find two other Q Members in the room
• Introduce yourselves
• Identify any shared points of interest and experiences
Engage
• What brings you to this session today?
• What is your experience of coaching and mentoring?
• What do you want to get out of today?
Commit
• What were your pledge commitments? How have you progressed with these?
• Any other Q activities you have been involved with/have plans for
Key Learnings from Today
Engage
29 September 2017
Systems thinking: Q visit to Department of Engineering, Cambridge
University
11 October 2017
South West Q Masterclass, Woodlands Castle, Taunton
30 October 2017
Leaders in Healthcare conference, Liverpool
23 November 2017
National Q event, Liverpool
28 February 2018
South West Q Masterclass, St Mellion International Resort, Saltash
10/3/2017
Connect
Visit online:
http://www.swahsn.com/
http://q.health.org.uk
Follow on Twitter:
@sw_ahsn
@theQCommunity
#Qcommunity
Make Connections
Build Your Network
Strengthen Your Connections
Commit
• Q is Growing - Wave 4 Recruitment is about to start! Anticipated that
there will be 2000+ Q members by end of the year
• Piloting the Strategic Leadership for Q - Based on the ideas of
shared resources and a ‘commons’ based approach
Health Foundation
SW AHSN Individuals
One Final Thought For You as Q Members
‘ You are a treasure in the making…….Badly needed’
Don Berwick, Q Community Event,London 20 October 2016
Coaching Skills For Improvement
Dee Wilkinson
GP/Executive Coach, Coach Supervisor, Mediator
Absent Friend & Facilitator : Sue Mellor – MA Research Coaching & Mentoring, Coach Supervisor
SMMCC
The mind is like a parachute
Best used when open: So, lets get curious
Welcome
Engage
Connect
Commit
SMMCC
SMMCC
Our session
• Bring to awareness the skills we are using on a daily basis
• To review the differences between coaching & mentoring
• Use the GROW model in a real conversation (no role play)
• Practice Session
”Never forget the importance and brilliance of simplicity”
SMMCC
Reaching your own potential
On a scale of 1 - 10 How much of your own potential are you using?
What do you require in order to improve?
SMMCC
SGW: The Differences Between Coaching & Mentoring?
Coaching is the very opposite of telling someone what to do
Gilbert & Whittleworth
SMMCC
Why a Coaching Approach?
"Good management of NHS staff leads to higher quality ofcare, more satisfied patients and lower patient mortality. Goodstaff management offers significant financial savings for theNHS, as its leaders respond to the challenge of sustainability inthe face of increasing costs and demands"
NHS Staff Management and Health Service Quality
Michael West (Aston Business School / Dept of Health) 31 August 2011
In other words, staff engagement and effective team leadership ultimately save lives.
SMMCC
Adapted from www.performancecoachtraining.com Carol Wilson 2012
Principles of Coaching
SMMCC
Coaching is…..
….“a process which enables people to work out what it is they want to achieve and then to act on the solutions identified. …. This is accomplished through a style of dialogue between coach and coachee which assists the coachee to gain new insight and clarity of thought and then to move forward with energy and purpose.” Carol Wilson, The Performance Coach, 2012
….“the art of facilitating the development, learning and performance of another.” Myles Downey, Effective Coaching, 2003
“I cannot teach anybody anything. I can only make them think.” Socrates
21,700,000
SMMCC
Coach as a detective
Noticing with awareness:
• Language, words, phrases
• Changes in voice, behaviors, body language
• Congruence
• Excitement
• Energy
• Values
• Focus
• Assumptions
SMMCC
Nancy Kline describes Assumptions
“Assumptions are not dry. They sound it, but in the actual, they are glittering, terrifying, velvety, teeth baring, rock-a-bye, grave, generous, power-hungry things. The presence of assumptions at the very core of our lives is actually an electrifying concept. And searching for them competes hands down with the best forensic thriller you couldn't put down”.
SMMCC
Foundation Skills for Coaching Conversations
• Building rapport
• Listening
• Asking impactful questions
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Listening
•Level 1 – Peripheral
•Level 2 – Apparent
•Level 3 - Global
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SMMCC
Quick Listening Exercise
• Find a partner
• One listen first and one talk
• What are you most proud of?
• For 1 minute each – don’t start until the timer says go!
Explore Alternatives
•“The test of first rate intelligence is the ability
to hold two opposed ideas in mind at the
same time and still retain the ability to
function” F. Scott Fitzgerald (1896 -1940)
SMMCC
Coaches ask questions that:
• Challenge assumptions that limit thinking
• Focus on positives
• Make use of what is already there
• Encourage small steps
• Help gain different perspectives
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The GROW Model
Sir John Whitmore
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Skills Practice
• In threes Coach, Coachee, Observer. Choose a current project you are working on.
• Have a coaching conversation using the GROW model
• 15 min coaching
• 5 min quality feedback
• 1 hour total for each person to take a turn
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GROW
15 minutes coaching
5 minutes quality feedback
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Learning Points
•Feedback key learning points
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Please do contact us for any further information or clarification
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Suggested Models & Resources
➢ GROW Model – You Tube South West Coaching➢ Coaching for Performance (Grow Model) – John
Whitmore➢ Change & Transition – William Bridges➢ Quiet Leadership – David Rock
Picture use from https://creativecommons.org
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FLOW
Coaching teams to discover great care
Paul Harriman
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Aims / Objectives
• To describe how a combination of
team coaching and improvement
science creates improvement
• To describe the Flow Coaching
Academy
• To give you a taster of a Big Rm in
operation
FLOW
Great care is
discovered not
decided
Steve Speir modified by Tom Downes
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Quality: The IOM’s Six Aims
High Quality care is care that is:
• Safe – no needless deaths
• Effective – no needless pain or suffering
• Patient-Centered – no helplessness in those served or serving
• Timely – no unwanted waiting
• Efficient – no waste
• Equitable – for all
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Improvement
The combination of a change
with a method to attain a
superior outcome
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Model I: Bad Apples
The
Problem
Quality
Frequency
FLOW
The Simple, Wrong Answer
Blame
Somebody
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The Cycle of Fear
Increase
Fear
Micromanage Kill the
Messenger
Filter the
Information
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Model 2: Positive deviance
Quality
Frequency
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Model 2: Continuous Improvement
“Every Defect is a Treasure”
Quality
Fre
qu
en
cy
FLOW
“EVERY SYSTEM IS
PERFECTLY
DESIGNED TO GET
THE RESULTS IT
GETS.”
Paul B. Batalden, MDCo-Founder The Institute for Healthcare Improvement
Founding Director, Center for Leadership and Improvement,
The Dartmouth Institute for Health Policy and Clinical Practice
11
FLOW
Flow Coaching Academy aka Improving
Flow Programme• Born out of Flow, Cost, Quality and the
Sheffield Microsystems Coaching
Academy (MCA)
• It is a 5-year programme to learn how to
coach mesosystems
• Aim is to develop 10 partner local FCA’s
by 2020
• Spread via a social franchising model
FLOW
Team Coaching
Improvement
Science
Pathway
Improving Flow – The Elements
QI
Global Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking and
visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
A P
S DDefine
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
Pathway
Improving Flow – The Elements
FLOW
Clinical Microsystems
• 1992 – Quinn – ‘Intelligent Enterprise’
• Studied the ‘best of the best’
• They are organised around the frontline interface with the customer
• ‘Smallest replicable unit’
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Microsystem Improvement
• Nelson, Batalden, Godfrey 2000 – 2007
• Looked at the characteristics of high
performing clinical microsystems
• Formulated a curriculum to develop high
performing microsystems
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Cystic
Fibrosis
Service
STH,
Sheffield
Healthcare
System
FLOW
Skin Cancer Mesosystem(each microsystem has workgroups: *doctors, ^nurses, +admin clerical, #managers,
@support workers)
Start End
High Level Value Stream Map of Patient Flow
Dermatology
*^+#@
Plastics
*^+#@
Operating
Theatre
*^+#@
Pathology
*^+#@
Oncology
*^+#@
Primary
Care
*^+#@ Clinical Scientist
Pathologists
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“The principal task of the mesosystem is to
enable the work of the microsystems for the
population(s) of patients served.”
Paul Batalden
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Ownership not Buy In
‘If you want to make true and lasting
change, ask the people who do the work
how to go about it’ Daren Anderson, MD
VP/Chief Quality Officer
Community Health Center, Inc.
FLOW
FLOW
Team Coaching
Improvement
Science
Pathway
Improving Flow – The Elements
QI
Global Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking and
visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
A P
S DDefine
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
Team Coaching
Improving Flow – The Elements
FLOW
Coaching
”It is not telling people what to do,
It is giving them a chance to examine what
they are doing in the light of their intentions.”
Peter Senge,
MIT and Society for Organizational Learning
FLOW
‘Improvement in health care is
20% technical and 80% human’
Marjorie Godfrey, MS, RN
The Dartmouth Institute For Health Policy and
Clinical Practice
People and Behaviours
FLOW
The Team Coaching Model
Transition PhaseReflection,
Celebration & Renew
`
Pre PhaseGetting Ready
Action PhaseArt & Science of
Coaching
Godfrey, MM (2012) In Press
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Getting Started - The Team Coaching Model
Pre-PhaseGetting Ready
“Meeting them where they are”
Action PhaseArt & Science of Coaching
Transition Phase Reflection, Celebration & Renew
*Context
-Review of past
improvement efforts and
lessons learned-tools used
-Preliminary system
review-Micro/Meso/Macro
*Site Visit
*Resources(data)
*Logistics (time)
*Expectations
-Clarity of aim
-Leadership & Team
discussions about roles
and logistics
*Relationships
-Helping
-Keep on track
*Communication
-Virtual
-Face-to-Face
-Available & accessible
-Timely
*Encouragement
*Clarifying
-Improvement
Knowledge
-Expectations
*Feedback
*Reframing
-Different perspectives
-Possibility
-Group dynamics-new skills
*Improvement Technical Skills
-Teaching
*Reflection
on improvement journey
-What to keep doing or
not do again
-Review measured
results and gains
-Assess team capability
and coaching needs &
create coaching
transition plan
*Celebration!
*Renew and re-energize
for next improvement
focus
*Evaluate coaching
Godfrey, MM (2013)
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Action Phase
TransitionPhase
Pre-Phase
Pre-Phase
Action Phase
TransitionPhase
Pre-Phase
Action Phase
TransitionPhase
Pre-Phase
Action Phase
TransitionPhase
Pre-
Phase
Action
Phase
Transition
Phase
Pre-
Phase
Action
PhaseTransition
Phase
The Team Coaching Model Over Time
28Godfrey, MM
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Coaching skills
Helping Active Listening
COM-B Reframing
Ladder of Inference
Resistance
& Reflection
Solution Focused
ARTS & PEARLS
Giving & Receiving Feedback
Time Management
Coaching Roadblocks
Troika Consulting
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Coaching in practice
• Co-coaching
• Weekly meetings
• Effective meetings
Habit formation, helping teams to do the
right thing
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Coaching in practice
Clinical Coach
Flow Coach
FLOW
FLOW
Our approach
The Big Room
(Oobeya)
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A place to meet
Physiotherapist gives an
account of the test of change
to get a patient home on the day they
were discharged by the GSM
consultant
Senior
registrar
General
Manager
GSM
Matron
Service
Improvement
Social
Services
Manager
Community
Services
managerPhysiotherapist
Secretary
Discharge
Liaison
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Weekly meetings
• Rhythm– Regularity
– Consistent
– Discovery & action orientated
• Pace– Conducted effectively
– Flattened hierarchy
– Communications
– Ground rules
– Reaching agreements
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Ground Rules
• Coaches likely to do this early on
• Agree how you will work with each other
• Put them up in the room you meet in
1. If you oppose you must propose
2. No side conversations
3. Start on time, finish on time
4. Use effective meeting roles
5. No question is a stupid question
6. No individual blame
7. Stick to the agenda
8. Car park off-track discussions
FLOW
Making decisions together
• Consensus
• Seeing the whole picture
• Deciding where to focus
• Voting
FLOW
Communication Strategy• How will you communicate in a way that invites
“everyone to get in the game?”
• Determine process and stick to it!
• Creative options– Newsletter
– Emails
– Intranet
– All Staff monthly town hall meetings
– Buddy system
– Screen Savers
FLOW
Team Coaching
Improvement
Science
Pathway
Improving Flow – The Elements
QI
Global Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking and
visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
A P
S DDefine
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
Improvement
Science
Improving Flow – The Elements
Global Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking and
visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
A P
S DDefine
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
People vs. System
“80% of the problem
is the system not the
people”
W. Edwards DemingProfessor of statistics at New York University
(1946–1993)
Author, lecturer, and consultantPhoto © 2014 The W. Edwards Deming Institute Blog
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FLOW
improvement - The
structure
Diagnosis -
Change
Ideas
Treatment
- PDSA
SDSA
‘Standardise’
Value
inVolve
Vision
Values
Visualisation
Assessment
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking
and visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
A P
S DDefine
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
Build a Big
Room
Pre-
Phase
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
FLOW
Assessment Assessment
5Vs - Measurement to understand the system
Value stream map
with data
Lead times
Cycle times
Patient survey data
Staff survey data
Activity data
Benchmarking to
find best-practice
Relational
Co-ordination
Financial Data
Spaghetti diagrams
Outcome dataPatient stories
Supply time
Work in progress
Incident data
Stakeholder
mapping
FLOW
Themes
‘Post-it
Frenzy’
Build a Big
Room
Pre-
Phase
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
Themes for Improvement –
Broad topics for
improvement
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Pre-
Phase
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
Global Aim – Defines the
scope of the process to be
improved, the possible
benefits (measures) and why
its important to do this
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Change
Ideas
Brainstorming
Change Concepts
Benchmarking
and visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Pre-
Phase
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
Change Ideas –
techniques to
more deeply
understand and
generate
possible change
ideas to improve
the process
defined by the
global aim
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Change
Ideas
Brainstorming
Change Concepts
Benchmarking
and visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Pre-
Phase
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
Driver diagram –
organising
multiple aims and
change ideas
linked to a
specific aim
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking
and visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Define
measures
Pre-
Phase
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
‘The model for
improvement’
FLOW
The Model for Improvement
A P
S D
Specific Aim
Change Idea
Measurement over time –
Measurement Plan
FLOW
Global
Aim
Themes
‘Post-it
Frenzy’
Build a Big
Room
Specific aim
Change
Ideas
Brainstorming
Change Concepts
Benchmarking
and visits
Process/Value
Stream Map
Fishbone
Spaghetti
Diagrams
Selection criteria &
Multivoting
Change
idea
Standardise
Define
measures
Pre-
Phase
A P
S D
A P
S D
Coached weekly
meetings
Patient
stories
System
data
Reflective
learning
A P
S D
FLOW
FLOW
improvement - The
structure
Diagnosis -
Change
Ideas
Treatment
- PDSA
SDSA
‘Standardise’
Value
inVolve
Vision
Values
Visualisation
Assessment
FLOW
The Five Vs
“To do things differently, we must see things
differently. When we see things we haven’t
noticed before, we can ask questions we
didn't know to ask before.”
John Kelsch, Xerox
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FLOW
Flow
Flow is not about the what
of clinical care decisions,
but about the how, where,
when and who of care
provision.
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The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
FLOW
The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
FLOW
Value
Value = Outcome + Patient experience
Cost
FLOW
The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
FLOW
• Combination of ‘Push’ and ‘Pull’
• Push: discomfort with the status quo
• Pull: the belief that it can be better
inVolve: Developing the ‘Will’ to change
FLOW
• Patient stories:
– in isolation often dismissed as anecdote
• Data:
– in isolation can be perceived as dull or manipulating
Data + Patient story:
Powerful & engaging
inVolve: Engagement
FLOW
‘Improvement in health care is
20% technical and 80% human’
Marjorie Godfrey
PhD, MS, RN
The Dartmouth Institute For Health Policy and
Clinical Practice
inVolve: Engagement
FLOW
The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
FLOW
Visualisation: seeing the process
When does a blood test add value to a patient?
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Visualisation: Big Room
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Visualisation: Big Room
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Visualisation: Big Room (Oobeya)
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The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
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eVidence
All improvement is change,
not all change is improvement.
We need to measure to
differentiate.
The percentage of patients who were directly discharged increased by 34%
The in-hospital mortality dropped by over 13%
Midnight bed occupancy dropped by over 60 beds (no similar change in previous years)
In one year >10,000 patients discharged to home support in 1.2
days compared with 5.5 days
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eVidence
Rm 1
Rm 2
Rm 3Rm 4Rm 5
Bloods
WHWReception
Waiting room
Sub-wait
Tray
Notes trolley
Notes
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The 5Vs
Value
inVolve
Vision
eVidence
Visualisation
FLOW
Vision:
• The ‘diagnosis’ is complete
• What does successful ‘treatment’ look
like?
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Vision:
FLOW
Vision:
FLOW
Themes For Improvement
CHANGE Themes
Ward rounds and
MDT processes
Coding
Medicines Management
Q
FLOW
Analyse the process
• Number of steps
• SECS
• Transfer of ‘object’ from one person to
another (loss and probability of error)
• Delays
• Added Value
• Bottlenecks
FLOW
500 grains/60 secs
270 grains/60 secs
170 grains/60 secs
270 grains /60 secs
Bottlenecks
FLOW
500/60 secs
270/60 secs
170/60 secs
270/60 secs
FLOW
Allow autonomy
Enable Mastery
Create sense of purpose
How to motivate
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Sustained Improvement requires behaviour change
Motivation
Capability
Opportunity
Maintenance
Can’t
Habitformation
necessity
concern
Routines
Conceptual Model - Susan Michie & Martin Wildman (Adapted)
OwnershipData & Stories5Vs
Flow RoadmapImprovement ScienceTeam Coaching ModelLeadership & Rhythm
StandardisationPlaybooks or SOPsVisual Management5sMetrics that MatterCommunication Tools
83
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Change Curve
Time
Motivation,
Perf
orm
ance
Elizabeth Kubler-Ross, 1969
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The Everett Rogers curve
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‘Improvement in health care is
20% technical and 80% human’
Marjorie Godfrey, MS, RN
The Dartmouth Institute for Health Policy and Clinical Practice
86
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Session aims
• To practically demonstrate the potential of
Flow
• See and participate in a Big Room
meeting
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Royal United Hospitals Bath
NHS FT
Sheffield Teaching Hospitals
NHS FT
x 10
South Warwickshire
NHS FT
x 6
x 6
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Flow Coach
• External to the pathway
• Objectivity and balance
Clinical Coach
• Credible, engaged clinician
• Within skin cancer pathway
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Learning session 1
3 daysLS2 LS3 LS5 LS6 LS8 LS9 LS10
Learning session 4
3 days
Learning
session 7 3 days
Oct 2015 Jan 2016 April 2016 Sept 2016
Learning
session112 days
Team
Coaching
Improvement
Science
Pathway
QI
FLOW
FLOW
FLOW
Standardise
A P
S D
A P
S D
A P
S D
A P
S D
FLOW
To infinity…
and beyond!
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Big Room in action
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Skin Cancer
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Exercise 1
• Form 2 groups
• Green Dermatology
• Blue Plastics
• 4 lanyards- put them on
• Data packs for each group
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Plastics and Dermatology
What does the data tell you about your
service?
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Let’s form a Big Rm
• 4 reps from each service (lanyard on)
• A coach (me)
• An agenda (agreed last time)
• A patient story
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Sarah’s story
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Skin CancerWhat has actually happened
(so far)
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‘1 patient 1 visit’
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• Katie’s story
• 28 days to 9
• Where clinically appropriate some patients
treated on the day
• Testing joint clinics
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Thank you