If we look globally at those healthcare systems that deliver outstanding performance in cost and quality, a common characteristic is a systematic approach to capability building for improvement (Read the attached paper The next leg of the journey: How do we make High Quality Care for All a reality? if you want to see some of the evidence). Research on large-scale change shows us that if cost and quality outcomes are to improve dramatically, it will be through the engaged improvement efforts of frontline clinical teams that do the work, effectively supported by their leaders. The skills and capabilities that are required already exist within the NHS system, but only in pockets. Evidence suggests that bringing “outside in” change capability (consultancies and external experts) can add momentum, new perspective and skill in the short-term. However, in the longer term it is “inside out” change, the capacity and capability of the system to change itself, that will create the sustainable improvements in cost and quality that we seek.
By “capacity” we mean having the right number and level of people who are actively engaged and able to take action. “Capability” means that those people have the confidence, knowledge and skills to lead the change. The evidence shows that, on its own, wholesale formal training in change management techniques will not deliver the results we seek. Capability building needs to be “hard-wired” into the day-to-day practice of our staff. Initiatives such as The Productive Ward demonstrate just how much energy can be unleashed by encouraging frontline teams to question how they work and providing simple tools and skills development to support them, on the job. Across the NHS, we need to find the mechanisms to tap into, mobilise and upskill the huge pool of latent individual and organisational energy for change.
As the NHS organisations that are furthest forward with their change efforts demonstrate, it is a systematic approach to capability building, linked to the actual work that people do, that helps to deliver real results. Different groups of staff and leaders have different roles to play in our change efforts but everyone has the potential to be a change agent. We need to create one million NHS change agents!
In seeking a whole organisation or whole system approach, there are probably two groups that are immediate priorities; the most senior clinical and managerial leaders of our organisations and the local service improvement leaders and facilitators who support change at the frontline. My hypothesis is that focusing on these two key groups will create the biggest impact and fastest transmission process of change skills across the system by ensuring that leaders are able to engage with and support the front-line clinical teams who deliver the change.
Recent external research reports from both NHS London and the National Nursing Research Unit about the roll-out of The Productive Ward programme highlight that having a full-time or substantive time facilitator, with the skills and resources to support frontline clinical teams to make change, is a critical success factor. Many thousands of such people already exist. The results of the 2009 NHS National Innovation and Improvement Survey haven’t been published yet, but I can tell you that of the 2,000 plus senior NHS leaders who completed the survey, 67% said that their organisation had a dedicated improvement team and 37% reported that there were more than five people in this team. When we add the local facilitators that support specific change initiatives and regional and national improvement leaders, we have a veritable NHS improvement army. We need to harness these people and ensure that they are equipped with a skill set that will enable them to support cost and quality improvements, from project initiation through to benefits realisation.
I’ve attached a document which sets out some initial ideas about the competency set for an improvement leader in the era of quality, innovation and productivity. It would be great to get your feedback on this skill set. What skills do NHS improvement leaders need for the future? Are these the right list of competencies? What would you add or take away? Can you suggest a better way of framing these skills? How would you go about building skills across the entire system?
Within the health and healthcare improvement world, there are differing opinions about the skills that a healthcare change agent needs. Often views are highly polarised between those with an “organisational development” perspective who focus on helping individuals and organisations to achieve their maximum potential and those from the “technical systems” school who focus on system and process redesign. We need a comprehensive model that incorporates both perspectives. The “classic” NHS model for improvement skills is based on the “Discipline of Improvement for Health and Social Care” that was published by the NHS Modernisation Agency in 2003. This focuses on four categories:
· Process and systems thinking
o How to understand your work processes and systems and all the linkages within them, looking for ways to increase capacity and reduce demand and waste
· Personal and organisational development
o How to recognise and value differences in style and preferences, including yourself, and build a culture that supports improvement
· Involving patients, users, carers, staff and the public
o How to involve and understand the experience and needs of your patients, their carers and your colleagues
· Making improvement a habit: initiating, sustaining and spreading change
o How to build improvement into daily work: making it something that we do not think about as special, but we just get on and do it.
These are timeless competencies that should form the core of our thinking about skills for change agents, but I also want to suggest three new categories that are essential for the coming era:
· Delivering on cost and quality
o How to work with cost as a core dimension of quality, determine return on investment and realise (and release) cost and quality benefits
· Problem solving/internal consultancy skills
o How to identify, define and solve problems in a systematic way and present your recommendations
· Innovation for improvement
o How to build innovation into improvement processes so that we get better outcomes from improvement initiatives.
There has been a lot of debate in the context of leadership development about whether “competencies” are enough, and whether it is more important to be “emotionally intelligent” than to be “competent”. Of course, it goes without saying that NHS change agents have to be highly emotionally intelligent. I guess this tells us what we have known all along, that successful NHS change agents need to be multitalented superstars!
We need to design our approach to capacity and capability building as systematic implementation for large-scale change. We have to align it to other key strategies, such as actions to mobilise people to the quality and productivity challenge, develop leadership capabilities, generate ideas, utilise evidence-based practice and deliver results. We need to plan it effectively, calculating upfront how much extra time, effort and skills will be required to execute the changes and create the space and resources for it to happen. The NHS Innovation and Improvement Survey identified that, for frontline staff, having insufficient time within their roles to dedicate to innovation and improvement activities was a major barrier to change. We cannot just assume that people will fit it in on top of existing busy jobs. An article by Harold Sirkin and colleagues in the current edition of “Inview” (the NHS Institute’s journal for senior NHS leaders) suggests that if anyone’s workload increases by more than ten per cent as a result of an implementation initiative, it is likely to run into problems. This is why it is so important that we build capability building into everyday work and view every initiative to reduce costs and improve quality as a profound learning opportunity for our leaders and staff.
We are building on strong foundations. The NHS reform process has led to a ten-year investment in skills for change. There is outstanding capacity and capability for large-scale change in the NHS, probably more than in any other national healthcare system in the world. We just need to help it to happen everywhere, across the entire NHS system.