Change Challenge: the findings in full

The full list of solutions developed by the crowd as part of the HSJ, Nursing Times and NHS Improving Quality Challenge Top-Down Change campaign. Those who asked to make their contributions explicit are listed under the ideas they submitted.

Adopt continuous improvement

“The evidence is clear from other sites where training within industry methodology has been used for several years: it is possible to have safe, more effective, lower cost care with less staff turnover.”

Continuous improvement methodologies like training within industry, or TWI, have a 70 year track record of encouraging employees to participate in improving their own work. It is based around paying respectful attention to every employee, constantly looking for lots of small things to be improved and making do with what you already have.

‘Setting up some volunteer pilot sites is a good first step’

The benefits of training all supervisors in this process will create bottom-up change while also improving standards across the board.

It has been used successfully in hospitals such as Virginia Mason in the US – reducing waste and staff turnover whilst increasing morale. Fairly recently it has also been used by staff dealing with the Ebola epidemic to standardise processes.

Implementing continuous improvement methodologies would involve setting up some volunteer pilot sites as a good first step. There would need to be some top-level involvement. Buy-in from the board would also be essential, it is also critical to ensure middle and immediate level supervisors understand TWI – and that it is very different to the “command & control” style that often typifies management in the NHS.

For the pilot sites, three core areas of TWI are important: job instruction, job methods and job relations.

Following the pilot programme, we need the sites to commit to writing up their experiences perhaps for journal submission to ensure learnings are shared. This will help to clearly define process and outcome as well as financial investment to see how effective introducing TWI is in practice in a UK healthcare setting.

Floating teams

“A small pool of staff that come in each shift get assigned to the ward that has need. Being hands-on frontline staff, they are in an ideal position to help identify training or resource needs.”

Organisations should create a specific team who are not allocated to one ward, department or community team but rather each day/week and are deployed to the area that needs them the most. These staff gain broad experience, share best practices and spread ideas across the organisation – supporting bottom-up change, whilst at the same time reducing the pressure caused by staff shortages.

‘The team needs to be supported by mentoring and training programmes’

The team will need to be strongly supported by mentoring and training programmes to attract participants to the career development opportunity this role presents.

The benefits of creating these teams would ensure staff within the teams gain beneficial experience in different areas, helping promote cohesiveness within an organisation and disseminating best practice and sharing new ideas.

These teams could also reduce agency bills for organisations and free up the time of staff working in areas with staff shortages.

They would have regular feedback sessions with division matrons etc - they can also help highlight areas for improvements and be targeted to have extra staff when available. The first clear step is to understand how to identify staffing gaps in the organisation. Then there needs to be investment in staffing capacity and a training programme and support system for the floating teams.

Some of the benefits of this scheme will be better communication and coordination between different departments of the organisation, as staff move freely between them, sharing ideas and best practice – a key component of creating bottom-up change. This will in turn lead to more standardised and efficient processes across the organisation. The scheme will also develop highly skilled generalists, with a broad understanding of the organisation and who are empowered to flex to meet the changing health needs of our populations.

Start with strengths, not deficits

“You’re already working on a foundation of identifying key values; implementing service improvement is not only possible but structured.”

With this approach to organisational development, the focus is on strengths, solutions, what is already working, what looks good, and what people want more of.

‘People engage more when they address a positive question rather than a problem’

It taps into positive emotions, values and engagement, and is different from the problem-solving approach on which many organisations tend to rely. Research has shown that people tend to engage more and become less anxious when they address a positive question rather than a problem.

The most common methodology for this approach is called Appreciative Inquiry (AI). Challenges are presented as positive objectives. The first step is to train a team in your organisation in AI techniques.

Once teams have been trained in this approach all future exercises with patients and staff can be based around appreciative inquiry techniques – opening up the creation of change ideas to all in the organisation. The other thing to consider will be providing ongoing support and training as the teams evolve.

They would need to share their expertise with others in the organisation – this will help everyone feel part of the change.

Self-organising teams

“This way of working will make a complete change in the way people work and think.”

To create bottom-up change, there needs to be a flatter hierarchy within your organisation – a way of achieving this is by gradually seeding your organisation with self-organising teams. In these teams, managers become “coaches”, who support the people around them. Supporting these teams involves giving people at a local level the autonomy to make decisions and create changes and also power over budgetary responsibilities – allowing them to deliver change from the bottom up.

‘Self-organising teams answer the challenge of creating smallness within large organisations’

The teams are given permission to fail and learn from these failures. Groups are set up to share learning across these networks. These small teams act as seeds in an organisation and are allowed to grow and become the norm across an organisation or health economy.

It will be important to protect such teams from unhelpful criticism in early days, until they are bedded in. Outsiders expect control from the top and often exert pressure to revert to the usual methods – managing these expectations will be crucial.

There is a lot of evidence that once an organisation reaches a certain scale it starts to lose efficiency and people no longer feel empowered to create change from the bottom up – creating self-organising teams answers the challenge of creating smallness within large organisations. The nurse-led Buurtzorg model in the Netherlands is one example of this.

Everybody’s ideas on board

“As long as someone is responsible for the capture and action of suggestions made, I think this can work.”

A simple, easy to implement tool: a board in a department or organisation on which a question is posed. Staff in the organisation are given a week to think about their suggestions and to write them up on the board. Questions should relate to an area of service delivery or staff or patient experience, and everyone is able to add their comments and suggestions to contribute to the overall discussion.

‘It can work if someone is responsible for the capture and action of suggestions made’

At the end of the period of discussion for a particular question, one individual collates all the suggestions and assigns the best answers to a team to take forward. The benefit of using a process like this is being able to develop locally owned improvement plans - truly creating change from the bottom up.

A common set of competencies for NHS managers

“Developing the whole cohort [through a shared approach] will ensure that good ideas in management are shared across the whole NHS… the intent would be to collectively encourage ambition, support development and raise the standards of management and leadership everywhere.”

Creating a new shared leadership development framework for all general managers will make sure that all leaders support staff to get involved in bottom-up change. This new framework will make sure every NHS manager understands the relevant techniques for supporting others as they progress through their leadership career.

‘This will ensure that all leaders support staff to get involved in bottom-up change’

We need to acknowledge that moving into a “management” role is not a promotion but a career change – we therefore need to offer people the right development framework to be successful leaders. The NHS leadership academy should quickly co-create a new leadership framework – this should be a “hand rail” to support staff, with sufficient flexibility that it can be used across a range of different organisations.

The framework should help managers understand how their ‘on the job’ experience can be used as a foundation, recognise and welcome shortfalls as an opportunity for improvement, be evidence based, provide inspiration and challenge in equal amounts and offer a clear appraisal system by which the individual can obtain recommendations for their personal development, and access suggestions for the next stage of development objectives.

Once the framework has been developed, it can be used to help ensure managers nationally are held to the same standards, which in turn will lead to a national reduction in overcontrolling leadership practices.

Back to the shop floor

“Embracing feedback good and bad. Taking action to address problems – not blaming but developing.”

Staff in management positions, who have no current clinical role, should spend at least a week a year, ideally more “on the shop floor” as part of the clinical workforce. This would provide an opportunity to listen to staff and patients, and to share insights and identify improvement actions.

‘This will improve the relationship between managers and the people they manage’

Staff will need to be supported to make space in their work schedules to make this a reality. To gain a real understanding of what life is like on the frontline, managers would be assigned common day to day tasks such as IT systems, organising transport, dealing with unhappy patients, and assisting junior members of staff.

The value of this approach will only be realised if managers take insights gained from working on the frontline and report them back and embed ideas and suggestions into their own processes. When done well this will improve the relationship between managers and the people they manage – allowing freer lines of communication and creating an environment more conducive to creating bottom-up change.

Space to innovate

“An improvement lab could be a place where staff are supported by a change team. It could have work areas where staff have access to undertake the planning of change – and be a safe place where they could discuss ideas.”

An improvement lab, open to all staff, would offer free training in quality improvement. But it would also be a literal, physical space in which ideas could be developed. An improvement lead or team would be on hand, supporting the move from idea to reality, and creating an environment in which staff feel safe in coming up with radical suggestions.

‘It would also be a literal, physical space in which ideas could be developed’

Implementing such a proposal would require funding and commitment from senior management. It would be necessary to find a space within which to base the lab, and for people to feel they had clear ‘permission’ to trial and test their ideas. Improvement leads will need to be prepared to engage frontline staff, and to support them as they develop and trial their ideas.

Funding and commitment from senior management would be needed. For this to really work, a culture of change needs to be developed – with a feeling that change is for everyone to be involved with. Areas that have successfully used this process already are Nottingham University Hospitals NHS Trust, Better for You Improvement hubs and Bromford Labs. 

Time to innovate

“Imagine a hospital where all staff were given time each month to work on change projects. Simply include time each month to work on an improvement programme which would support the area they work in.”

“Your role in change is not defined by your banding but by your willingness to lead on change. We need to rethink job plans to now include change work, imagine a hospital where all staff were given time each month to work on change projects.”

All staff would be given time within their normal day job to work on change or improvement projects. In doing so, change becomes an inherent and clearly specified part of every single person’s role – not merely the work of improvement leads or project managers.

‘Giving time to each member to undertake change will encourage involvement in such programmes’

Implementation would necessitate commitment from senior management: after all, it would involve a redrawing and reevaluation of how roles are defined and work allocated. A review of job descriptions would need to be undertaken, ensuring ‘improvement activities’ was added as a key element, and that support for training was in place. Workloads would need to be reorganised, but it would need to be clear that time to work on change and improvement projects was protected. The predicted outcome would be a clear shift in culture.

Providing protected time to each member of staff each month to undertake change – will encourage staff at different levels to get involved in change programmes.

Supporting staff to make quick changes

“Most important is that staff know they are allowed to undertake change and this is not dependent on your profession, grade or band.”

“People need to feel they have permission to make that change and not be blamed if it isn’t as successful as hoped….you can only learn through failure.”

“The people nearest the problem are the ones with the best ideas for a solution, and very often it doesn’t take much money or time.”

‘The learning should be disseminated to encourage others to get involved’

Adopting a ‘just do it’ methodology gives frontline staff the ability to quickly implement little changes that make a big difference. Small pots of money are set aside for the implementation of ‘just do it’ ideas; funds which can be accessed without excessive bureaucracy. In this way, an inability to access small amounts of money ceases to be a barrier to change.

Having put aside small pots of money, the first step to implementing such a programme is to define what qualifies as a ‘just do it’ idea. A clear process will also need to be put in place, detailing how individuals should put forward and enact their ideas. The impact of such changes should be monitored, and learning disseminated – this will encourage others to get involved in the scheme.

Drawing on the wisdom of the crowd

“The power of the crowd to come up with and refine each other’s ideas is enormous and social media can turn what might have been a stodgy workshop approach into a proper, democratic conversation.”

Adopting a challenge led, crowd based approach can help empower staff to tackle the challenges that block high quality, compassionate care. In this approach, senior leaders periodically pose challenges to their staff, who are invited to come up with solutions via a ‘virtual room’. This can bring down the barriers between staff and executive teams, opening up channels of communication. Using crowdsourcing or a free online platform effectively creates an online workshop, where individuals can ‘meet’ and discuss issues.

‘This can open up channels of communication’

The first step is to identify and define the challenge the organisation wants to work together to solve. From there, a small number of specific questions are drafted and posed to the crowd in an online space. Ultimately, a plan of action needs to be drawn up based on the outcome of the conversation.

Use your values to take the lead

“Having the freedom and being encouraged to make suggestions to improve care and service should be a basic condition for everyone and the more senior you are the more one has to listen to grassroots suggestions…including service users and their families.”

“Values play such an important role in our lives, being able to recognise, understand and articulate them is critical if we are to develop a genuine and meaningful alignment with those we work for and those we serve.”

While not all staff in the NHS are leaders in the managerial sense, all staff can be inspirational – all can offer personal leadership. Developing a coherent set of values and behaviours for an organisation can support this. From this, all staff can take personal leadership for their own and their organisation’s continuous improvement and transformation.

‘All staff can take personal leadership for continuous improvement’

Having worked to define the set of values – ideally co-created with staff and patients – they will need to be promoted widely within the organisation. It will also be necessary to identify and address leadership behaviours within the organisation that are not values-based. This could be through appraisal and/or training and more controversially through sanctions.

Being values-based means how you interact with others, the choices you take and how you prioritise your time is aligned with the values you espouse.

With values-based leadership and personal leadership we can generate the sort of commitment in which people lead and follow each other to a better NHS.

Use a change model

“No one change model has all the answers. The model often depends on the scale of the change being implemented. But execution must always pay attention to the human aspects of change.”

If we want to improve the outcomes of our change efforts, we need to develop ways of approaching problems that allow us to see things from multiple lenses.

Change models typically give us a mental model and a process to follow.

‘A change model can empower individuals to make transformations that work’

Change models can help support transformational change. All are based on research and practice, helping users achieve goals for change. Using such a model can be a valuable way of empowering individuals to make transformations that work. We need to develop ways of approaching problems that allow us to see things from multiple lenses.

Using a change model is simple. The NHS has developed its own model, for instance, which is freely available online. It brings together what is known to make change happen, and who needs to be involved to make change successful. It is worth keeping the model in the background rather than as the central focus of the project, but evidence shows that simply using a model makes a difference and tends to be associated with better outcomes.

Key considerations:

• Understand that models are there to help with our change practice; too much theory and the change will fail.
• Keep the model in the background; most people won’t join in the change because of a model but they will join in if we focus on the goals we want to achieve (and which the model can help us with).
• There is lots of technical jargon in change models and approaches. Keep this to a minimum; seek to translate the ideas to your health and care setting.

Empower everyone to be a change agent

Too often, those who want to challenge existing arrangements and bring about improvement in healthcare feel a sense of isolation. Building the quality improvement skills of every single person in an NHS organisation – and their confidence and willingness to challenge the status quo – is a powerful antidote to this.

Building the skills of every single person can end the sense of isolation of those who challenge existing arrangements’

Organisations can capitalise on existing resources to help spread this knowledge. The School for Health and Care Radicals, for instance, is a free virtual programme to connect those who want to deliver change. Hundreds of people, including patient leaders, have enrolled in the programme and completed its five modules.

Individual healthcare organisations could consider ways in which they could build on this ethos, and use online tools to develop ‘schools’ within departments. In doing so, resistance to change could be reduced, and the understanding that change begins with individuals be successfully spread. It would also enable individuals to take responsibility for, and control of, their own learning and development.

NHS online forum

“The NHS is currently guilty of not shouting enough about success (within the organisation) which is resulting in many different areas starting from scratch, making the same mistakes as others… It is as important to share ‘what you would do different’ as well as what worked well so that change can happen quicker and mistakes not be duplicated.”

We want everyone to be supported to get involved in change – to make this a reality we need people to be given inspiration and support. Online forums for change can do this and act as a tool to stop the same thing being repeated in different places.

‘A great first step will be to access forums such as Facebook, Linkedin, Twitter etc’

Leaders should encourage their staff to get out there and identify, use and promote the online forums that are available to them. This will require a change in culture when it comes to interacting with forums that do not originate within an organisation.

If staff are able to freely pose challenges to their peers and access tried and tested solutions, then this will speed up the pace of bottom-up change within and across organisations. Furthermore the NHS would reduce the waste caused by replication of learning in different places.

Although some people have advocated for the creation of a new platform to support this, a great first step would be for health and care staff from across the country to know about and access the forums that are already available, eg Facebook, LinkedIn and Twitter groups, NHSGather.net, regional forums etc. The key here is that staff should feel empowered to get involved, get inspired, share and learn. Online forums are as much about connecting people and building relationships as sharing case studies, policies, templates etc – a great development opportunity for everyone.

Transferable skills

Nursing staff are unlikely to stay in one trust or area for the whole of their career. Training should be more transferable. Current training processes are long winded and invariably result in having to repeat assessments. Training and assessments should be consistent throughout the NHS to prevent nursing staff having to be reassessed when they change jobs. This could apply to mandatory e-learning, medicines admin, venipuncture and cannulation and numerous other skills. It would save time and money in retraining and reassessment.

As we work for the NHS, surely a national “passport” of our skills and competencies could be produced. Provided this is maintained and up-to-date, it could be carried with us throughout.

The change challenge panel: Helen Bevan, Jodi Brown, Alice Chadwick, Nosmot Gbadamosi, Catherine Graham, Pete Thomond, Adele Waters, Astrid Grant, Alina Vollmer, Yosra Salaheldin, Amrita Ghosh, Shilpa Topudurti, Alyssa Best, Joseph Nkang, Lisa Herms, Robert Firth, Anu Martins, Rui Su.