The 10 High-Impact Habits of Successful Service Improvers

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The 10 High-Impact Habits of Successful Service Improvers

The 10 High-Impact Habits

of Successful Service Improvers

Core components for successful

service improvement

July 2012


Contents

Foreword...................................................................................................................................................................................................4

Introduction..........................................................................................................................................................................................5

The 10 Habits of Highly Effective Service Improvers.....................................................................6

Habit 1 .......................................................................................................................................................................................................7

Habit 2 .......................................................................................................................................................................................................8

Habit 3 .......................................................................................................................................................................................................8

Habit 4 .......................................................................................................................................................................................................9

Habit 5 .......................................................................................................................................................................................................9

Habit 6 ....................................................................................................................................................................................................10

Habit 7 ....................................................................................................................................................................................................10

Habit 8 ....................................................................................................................................................................................................11

Habit 9 ...........................................................................................................................................................................................11-12

Habit 10 ................................................................................................................................................................................................12

Issues & Barriers .........................................................................................................................................................................12

Further Information ................................................................................................................................................................12

3


Foreword

The dedicated staff working in the NHS across the Midlands and East have

helped transform the NHS beyond recognition over the last 10 years.

Over the last ten years we have substantially

improved health outcomes. Mortality from

circulatory diseases and cancer have fallen

massively across the region and the incidence of

C Diff and MRSA has been hugely reduced due to

the determined efforts of staff.

We have transformed access to the NHS. A decade

ago 25% of patients referred for treatment waited

6 months or more for admission to hospital.

Today, everyone across the country has the right to

treatment within 18 weeks of referral.

In primary care we have seen improvement and

transformation in the quality and safety and access

across a service admired around the world.

However, we have a growing and an increasingly

ageing population, that is living longer and

expecting ever more from the NHS.

The next few years are going to be tough for

the NHS, meeting the growing demands with

existing levels of NHS funding. It is not an option

to continue doing more of what we have always

done, we need to do things differently and to

radically transform the way in which we deliver

services.

This booklet sets out 10 habits which successful

service improvers exhibit. These habits have been

identified by a review, with Capita, of the attributes

displayed by successful service transformation

programme boards and teams from across the

cluster. By sharing these habits with you, we hope

that they will be adopted by you and your teams

to further improve services for patients, and place

your organisation in a strong position to meet the

financial challenges facing the NHS.

Keep sharing and let’s make service transformation

a habit.

Dr Stephen Dunn

Director of Policy and Strategy

NHS Midlands and East

4


Introduction

Service improvement, relating to the need to drive-up the quality and costeffectiveness

of healthcare, remains foremost in the ambitions of provider

and commissioner organisations across NHS Midlands and East.

The pace of this service change now needs to

accelerate further as the NHS shifts towards a

structure which is increasingly clinically driven,

places patients in greater control of the care

received and gives greater focus to strongly

evidenced patient experience and outcomes.

The purpose of this short guide is to equip

providers and commissioners with a picture

of the common ingredients which are present

in organisations delivering successful service

improvement and the key success factors involved

in those where service improvement is flourishing.

The findings reported here are drawn from a

comprehensive service improvement capacity

and capability review, commissioned by NHS

Midlands and East, funded by the NHS Institute

for Innovation and Improvement (NHSI) and

conducted through April-June 2012. The review

distils responses from a detailed online survey,

collating a picture of activities and opinions from

71 commissioning and provider organisations, then

further enriched through focused interviews and

case studies drawn from approaching half of these.

There are 300-400 individuals working in dedicated

service improvement posts across the SHA cluster,

in addition to the many thousands of staff

working in service improvement as part of their

role. Most organisations have a dedicated service

improvement team and the vast majority have

service improvement plans in place to meet the

SHA’s key ambitions, with over half already having

initiatives in place to deliver these too.

Our ambitions for the NHS in the

Midlands and East

The particular themes that we summarise here,

respond to the following key questions:

• What are the common skills, capabilities and

behaviours which make some organisations

particularly successful at service improvement?

• What are the common barriers which prevent or

impede successful service improvement?

Recognising that the structure of the healthcare

system is in transition, this guide is potentially of

value to both organisations which are either at

early stages of their development, such as newly

formed commissioner or provider organisations,

or more mature organisations seeking to spread

effective skills and methodologies.

Through the many case-study examples that

participant organisations have described to us in

the course of this review, it is also clear that there

remain very significant opportunities for wider

application of these approaches. Opportunities

exist to extend the scope or scale of delivery, apply

proven methodologies across a wider portfolio of

services or provide insight into structures or skills

which make a real difference to successful delivery.

Ten case studies that reflect successful service

improvement have been profiled in the

accompanying publication ‘Making improvements

a habit - Practical case studies from the service

improvement front line’, July 2012.

5


The 10 Habits of Highly Effective Service Improvers

The critical factors that appear consistently across those organisations

delivering effective service improvement are highlighted below:

10 Habits of Effective Service

Improvers

Habit 1:

Habit 2:

Habit 3:

Habit 4:

Habit 5:

Habit 6:

Improvement leaders establish a clear

vision / case for change, which is linked

to the organisation’s strategy and

expectations

Board Directors provide visible leadership

and support for service improvement

Clinicians lead and drive implementation

of service improvement activities

Clinicians and other staff at all levels,

together with wider stakeholders, are

engaged in service improvement activity

Service improvement is focused

improving patient care, whether it

relates to clinical or support services

Providers and commissioners jointly own

and support service improvement

Habit 7: The organisation supports service

improvement with robust planning,

project management, implementation

processes and accountability for delivery

Habit 8: Service improvers use evidence, data

and information to measure baseline

performance and results of improvement

activity

Habit 9: Organisations support service

improvement with a dedicated

improvement team with specialist skills

and tools, which works with service

delivery teams to support them in

delivering the change

Habit 10: The organisation provides resources

and training in service improvement

techniques for front line delivery teams

Engagement to Mobilise

• Appropriate local structures to

engage with clinicians, patients and

the public

• Engagement in co-design of service

changes

System Drivers

• Strong alignment of service

improvement, QIPP and CIP priorities

• Quality – seen as the key driver for

effective change

Leadership for Change

• Formal structures, owned at board

level

• Strong, committed and engaged

clinical leaders

• Appropriate balance of top-down and

bottom-up priorities and programmes

Our Shared Purpose

Widespread endorsement

and engagement

in a collective vision

Spread of Innovation

• Allow capacity and time to share and

spread learning

• Work outwards from pockets of

good practice

Improvement Methodology

• Consistently applied methodologies

• Access to a range of approaches,

including all of the commonly cited

methodologies

Transparent Measurement

• Agree expected savings/benefits

at initiation and the approach to

measuring them

• Introduce routine reporting

Rigorous delivery

• Supported by robust programme/

governance structures

• Apply consistent and replicable

approaches

6


The 10 Habits of Highly Effective Service Improvers

This document summarises these recurrent

attributes of good service improvement mapped

against the key elements of the NHS Change

Model. These attributes are also reflected in the

service improvement approach of many of the

organisations included as part of this assignment,

and permeate the case studies which support this

review:

Habit 1:

Improvement leaders establish a clear

vision / case for change, which is linked

to the organisation’s strategy and

expectations

This relates to the need for organisations or health

economies to ensure that service improvement is

underpinned by a clear vision and case for change,

which is clearly linked back to overall direction and

strategy.

The case for change and vision at a health

economy level is typically constructed in one of

two ways. At one level, the vision is articulated

as a set of principles which bring together public

sector organisations into an alliance focusing

on improving health, reducing inequalities and

improving choice and the distribution of services,

or responding to QIPP (Quality, Innovation,

Productivity, Prevention – the NHS’s overall

programme of transformational service change).

All local healthcare systems have agreed Integrated

System and Reform Plans,that outline how they

are implementing the productivity improvements

required of QIPP.

Alternatively, visions are aimed at specific activities

– generally the construction of a new hospital.

Partnership arrangements tend to be stronger in

the latter scenario, where the goal is felt to be

more tangible and visible.

The extent to which a vision is shared across the

health economy relates more to principles and

the need to change, and not necessarily to how

the change should be delivered. Nevertheless,

whatever the emphasis, these vision and strategy

statements are generally underpinned by system–

wide delivery programmes where partners are

working together to put delivery plans into place.

There is a clear differentiation between how

large scale transformation and single service

improvement activities are seen – the former

seen to require formal coordinating activities,

while the latter are more generally perceived to

be “part of the day job”. While having a clear

vision is important for all service improvement

activities, having a system wide vision is more

applicable to large scale transformation. As

a result, organisations differentiate between

system transformation, internal transformation

and cost improvement activities and the extent

to which these activities are combined in a

single programme varies. There was no apparent

advantage to having fully integrated programmes

– the key was the recognition that these different

activities should be visible to each other, if not

explicitly linked.

Development of a system vision should be

inclusive of all relevant parties. Where the vision is

developed collectively by all partner organisations

through workshops involving the most senior

leaders, the potential to secure buy-in and shared

understanding of the case for change is much

stronger. This is an important factor for clusters to

consider in developing CCG capabilities.

7


The 10 Habits of Highly Effective Service Improvers

Habit 2:

Board Directors provide visible leadership

and support for service improvement

Formal leadership structures are clearly important,

both to demonstrate support for the vision and to

hold individuals to account for delivery against high

level goals. These structures should be focused

specifically on the improvement programme and

typically include well-defined Programme Boards

with Executive Director leadership, nominated

executive workstream sponsors and senior project

leads for particular change programmes. Internally,

organisational governance structures are used

to track progress and to make explicit links to

CIP (Cost Improvement Programmes) and quality

improvement obligations.

In addition, effective leaders support service

improvement activities on an informal basis,

across the organisation, and at an individual

service or departmental level. Successful activities

include: explicit actions by the Chief Executive to

support service improvement, sharing of savings

between departments and corporate contribution,

visibility of senior leaders (both Executive and

Non Executive) throughout the organisation (e.g.

Board to Ward sessions and Executive walkabouts),

promoting and supporting staff in their activities,

however small in scale and scope and coaching

and mentoring of staff by executives.

Habit 3:

Clinicians lead and drive implementation

of service improvement activities

While sound clinical leadership it is clearly an

important factor, the mechanisms for securing

clinical leadership are less clear, with many

alternative structures in place. Clinical leadership

is effective when operating at both a formal

and informal level. On a formal basis, successful

transformation programmes include clinical

champions in their workstream management

arrangements – whether as formal workstream

leaders or as clinical change agents working

alongside project leads. Equally, however,

organisations should also encourage clinicians to

take the lead in identifying, planning and delivering

small scale service improvements. In proactive

organisations, clinical leadership is not limited to

clinicians in formal management positions, nor is it

synonymous with medical leadership.

The formation of CCGs is seen as positive in

generating clinical leadership of redesign activities,

with GPs being nominated as leads for specific

initiatives or service areas and engaging in

discussion with provider colleagues on a peer to

peer basis.

Clinical Senates can also be used to drive crosssector

service improvement. These are still relatively

new bodies and not in existence everywhere, but

their contribution can be a positive vehicle for

generating clinical dialogue and debate about the

services that need to improve and how that might

be achieved.

8


The 10 Habits of Highly Effective Service Improvers

Habit 4:

Clinicians and other staff at all levels,

together with wider stakeholders, are

engaged in service improvement activity

We have differentiated between clinical leadership

and engagement, to reflect the fact that clinical

and non-clinical staff at all levels should be

encouraged and supported to participate in service

improvement.

A balance between top down and bottom up

change is important and this balance varies between

organisations. Large scale changes and formal

transformation programmes tend to be balanced

more towards the top-down approach, while

individual, department-specific improvements are

more likely to be driven from the bottom up. This

may reflect the nature of large versus small scale

change, with the former requiring a structured,

collective approach, in which understanding the

bigger picture is important, and the latter needing

to be driven by people with specialist knowledge of

how the service works, and how patients experience

it on a daily basis. The delivery of health services

often crosses boundaries between departments and

organisations and always involves patients / service

users and often carers.

Successful engagement of stakeholders (of

whatever background) relies on openness and

honesty about what is possible, as well as

engagement at the right stage of the process.

Nevertheless, it is interesting that the degree

of patient and public engagement in service

improvement activities is highly variable with

surprisingly little emphasis on a principle of when

and how to engage patients.

Current practice appears still to be focused

on engaging patients in validating work (i.e.

consulting) rather than on working with them to

co-design pathways or services. This may reflect

the difficulty in accessing patients and service

users systematically. Nevertheless, there are many

examples where organisations successfully work

with patients and other stakeholders at varying

stages of the improvement process. These include

the use of real time patient experience tracking

tools and mystery shoppers to ascertain views

on current services, use of Trust Governors and

Membership to recruit patients into service reviews

and social marketing techniques to support formal

consultation processes, patient focus groups to

support redesign of specific services and use of

specific engagement tools such as “Experience By

Design”.

Habit 5:

Service improvement is focused

improving patient care, whether it relates

to clinical or support services

Having a focus on patients is a critical feature

of successful service improvement, among both

providers and commissioners, with quality as

the key driver for service improvement (with

derivation of savings as an important bi-product).

This focus on quality is also a critical factor in

securing clinical buy in and leadership. Having a

focus on quality and improving patient pathways

and experience is also an important incentivising

factor for staff. While many organisations have

mechanisms for recognising staff contributions

to service improvement (including awards,

budget enhancements), the importance of the

intrinsic values of front line staff should not be

underestimated.

Balancing quality with the financial pressures

is a key challenge for health economies – the

underlying issue at present remains the need to

release savings, the theory being that improving

services and patient flows will improve efficiency

and cost effectiveness. At a macro-level, this

involves not only improvements to specific

pathways but also integration of services and

provision of care as close to patients as possible.

9


The 10 Habits of Highly Effective Service Improvers

Habit 6:

Providers and commissioners jointly own

and support service improvement

A feature of large scale transformation in health

economies is the generation of ownership and

support across organisations, and specifically

between providers and commissioners.

This also illustrates the differentiation between

large scale transformation and small scale service

improvements. Providers are generally able to

deliver small scale improvements at an individual

service level without cross-health economy support,

whereas commissioners rely on support from

providers to make change happen. It is therefore

not surprising that there should be a difference in

perception of the importance of this as an enabler

for service improvement generally.

Habit 7:

The organisation supports service

improvement with robust planning,

project management, implementation

processes and accountability for delivery

The ability to deliver service improvement,

particularly across health systems, is reliant on

sound mechanisms to support implementation, and

to secure accountability for delivery. This includes

having a programme management infrastructure

that crosses organisational (or intra-organisation

divisional and departmental) boundaries, which

drives planning, progress tracking and benefits

measurement, as well as providing brokerage for

cross-boundary disputes and issues resolution.

Most health economies across NHS Midlands

and East have such arrangements in place, but

many providers also have their own internal

governance structures to secure internal delivery.

These vary in scale and scope. Some internal

programmes are responsible for Trust-wide,

large scale transformation initiatives only, while

others encompass programme management

for wider cost improvement programmes.

Small, departmental or service specific service

improvement activities are not generally covered

by programme management arrangements, being

seen more as “part of the day job” for clinical

teams. However, where transformation programme

teams include service improvement support staff,

these individuals are also available to support

delivery teams in local service improvements (albeit

to varying degrees).

There is no clear evidence for whether any of these

approaches works better than others in supporting

effective service improvement. The key is that

large scale transformation is supported by clear

programme governance, to ensure that benefits

are realised and individuals are held to account for

delivering them.

10


The 10 Habits of Highly Effective Service Improvers

Habit 8:

Service improvers use evidence, data

and information to measure baseline

performance and results of improvement

activity

Undertaking service improvement activities is of

little value if there is no mechanism for evaluating

the impact and spreading intelligence about

improvement. Measurement and spread of results

is one of the areas of greatest deficit across

the region; indeed, even measuring baseline

performance is not always easy.

In the current financial climate, measuring the

impact of service improvement on the financial

bottom line is important and the majority of

organisations are able to do so. However, with

quality and patient experience as key drivers for

change, using a balanced scorecard approach to

measurement is critical, and it is in non-financial

evaluation that organisations are most challenged.

Where sound programme management

arrangements are in place, organisations are clearer

about setting baselines and agreeing benefits

and key performance indicators at the outset

of a project, and are more likely to have routine

reporting mechanisms in place.

Habit 9:

Organisations support service

improvement with a dedicated

improvement team with specialist skills

and tools, which works with service

delivery teams to support them in

delivering the change

The presence of a dedicated team, with specific

service improvement skills, working with clinical

and service delivery teams is a critical feature of

successful service improvers. This does not detract

from the belief that service improvement is a

core part of everyone’s job, rather, it reflects the

fact that service improvement skills and tools are

still viewed in the NHS as specialist rather than

generalist skills.

Some organisations subscribe to the view that such

teams should be gradually phased out as skills are

embedded into routine practice, but had conceded

that this was not feasible and plans to disband the

teams had been shelved. There is no clear evidence

on whether service improvement delivery is more

successful with or without a specialist team – the

key factor is that specialist skills and support should

be available, and service improvement teams

should support operational delivery teams and not

11


The 10 Habits of Highly Effective Service Improvers

Habit 10:

The organisation provides resources

and training in service improvement

techniques for front line delivery teams

undertake the improvement activities themselves.

In short, having a dedicated team in place does

appear to be associated with a more confident

approach to service improvement.

Typically, “core” service improvement teams are

small (5 or fewer) although several organisations

have a practice of seconding staff into the team to

encourage skills development. There is a mixture of

approaches to linking service improvement teams

with PMO resources and there does not appear

to be a significant difference in the range of

improvement activities as a result.

The NHS Institute’s model of large scale change

and the emerging NHS Change Model are

important tools for supporting organisations to

implement and embed change. The deployment

of tools to support service improvement activity

is widespread, with the most popular tools and

approaches being those which are logical and

simple to follow (such as PDSA, Lean), but also

ones which organisations can adapt. There is

clearly a need to promote the value of industrystandard

tools in a way that gives staff confidence

around their applicability and usefulness.

Given the importance of service improvement as a

key feature of operational service delivery, ensuring

that staff have access to appropriate training and

resources is an important factor.

In terms of important skill sets, there is a difference

between training in specific technical service

improvement skills (for example, Lean, Six Sigma,

Statistical Process Control, Benchmarking), more

generic skills (such as Programme and Project

Management, use of data and evidence) and what

might be termed attributes rather than specific

skills.

The acquisition of technical skills can be

(and typically is) addressed through training

programmes or insourcing for specific projects.

The key skills which must be available internally

include such attributes as passion and enthusiasm,

clinical leadership, creativity and a willingness

to work together and share ideas, tenacity and

resilience and understanding the impact of

change. Organisations take varying approaches to

development of capability, from ad hoc training,

secondments to project teams and “learning by

doing” to structured development programmes

and academies.

12


Issues and Barriers

Issues and Barriers

A first step towards implementing effective service

improvement is to identify and minimise the main

barriers to change. The most commonly recurring

factors drawn from the review are highlighted

below:

Barriers Preventing Effective Service

Improvement

1 Lack of organisational capacity/capability/

resources

2 Organisational culture

3 Lack of stakeholder engagement

4 Poor planning, project management,

implementation processes/accountability

5 Competing priorities

6 National policy/politics/external events

7 Data quality/availability

8 Organisational boundaries/strategy

Lack of organisational capacity/capability/

resources

This was the most often cited barrier to successful

service improvement. For commissioners it was

often a function of the transitional nature of their

respective organisations, whereas for providers, the

problem was more likely to be financial pressure,

difficulties in releasing staff from the day job and

pressures on staff that are squeezed between

managing day to day performance and the need to

improve services.

Organisational culture

Another common barrier, the perception of service

improvement as something special and separate

from operational management, militates against

the embedding of service improvement into day

to day management practice. At a local level,

differences in organisational culture, typically

between commissioners and providers, can also act

as a barrier. There is a perception that organisations

have different goals and priorities which can make

development of relationships and trust difficult.

Lack of stakeholder engagement

While this was an important theme in the survey, it

featured little in interviews as a negative, but was

expressed as an important enabler, the absence of

which was influential.

Poor planning, project management,

implementation processes/accountability

The main problems associated with planning and

project management centred on bureaucratic

processes, failure to hold individuals to account

for delivery, failure to understand critical

interdependencies and loss of momentum as time

went on and priorities changed.

Competing priorities

The main conflicts here include competition

between the drive for improvement versus

operational performance management, i.e.

delivering more from the current system rather

than supporting changes to the way things work to

secure improvement.

National policy/politics/external events

Given the transitional status of commissioning

structures, some commissioners were taking a very

short term view and not taking forward long-term

projects, although were keen to support new

organisations to develop their capabilities.

Data quality/availability

An enduring problem for non-acute providers and

commissioners. Good quality data on outcomes in

particular was highlighted as a problem.

Organisational boundaries/strategy

A final barrier was a perceived lack of consensus

on the need for change and a cross-boundary

vision between different organisations in a health

system.

13


Further information

Recommendations

The wealth of service improvement examples

summarised here presents providers and

commissioners with a useful resource for their own

service improvement activities.

To effectively sustain and accelerate the pace of

service improvement, five key recommendations

arise from this review for service improvement

leads:

Recommendation1: Consider the applicability

of the structures and processes that have been

successfully applied to small/medium scale

projects (across individual service areas or single

organisations) which can now be applied to wider

large-scale transformational projects.

Recommendation 2: Explore how the “10

habits”, described in this paper are currently

embedded in your own organisation, and the

potential to embed these further. Evidence would

suggest that best outcomes are achieved when all

‘’10 habits’’ are adopted and sustained.

Recommendation 3: Explore how the specific

case study examples, outlined in the accompanying

report ‘Making Improvement a Habit: Practical

cases from the service improvement front line’

, might be applied locally, either in terms of the

service areas tackled or the methodologies and

processes that have been evidenced here.

Recommendation 4: For those involved in the

design and organisational development for new

organisations, through the current NHS reforms,

consider how the future structures can include the

principles and approaches outlined in these “10

habits”.

Recommendation 5: Consider the approaches

taken to sharing examples of successful service

improvement, and explore opportunities to create

more effective networks to spread examples

of good practice, share skills in specific service

areas or tools/methodologies and work across

organisational boundaries.

Acknowledgements

The capability and capacity review which informs

this guide was commissioned by NHS Midlands

and East with funding from the NHS Institute for

Innovation and Improvement

NHS Midlands and East and Capita Consulting

gratefully recognise the time commitment made

by all of the participating organisations who

contributed to the survey, follow-up interviews and

development of case studies.

If you would like more details about the findings of

this review please feel free to contact the following

NHS Midlands and East individuals:

Judy Hall, Programme Consultant - Productivity

Improvement judy.hall@westmidlands.nhs.uk

Laura MacPherson, Programme Manager –

Strategic Projects Team laura.macpherson@nhs.net

Jatinder Singh, Programme Specialist-Productivity

Improvement Jatinder.Singh@westmidlands.nhs.net

Finding Out More

Full report: Delivering Successful Service

Improvement, Capita and NHS Midlands and East

June 2012

Case studies: Making Improvement a Habit:

Practical case studies from the service improvement

front line, NHS Midlands and East, July 2012

© NHS Midlands and East July 2012

Victoria House

Capital Park

Fulbourn

Cambridge

CB21 5XB

01223 597500

www.midlandsandeast.nhs.uk

www.twitter.com/NHSMidlandsEast

All rights reserved. Not to be reproduced in whole

or part without prior permission.

14


Prepared by NHS Midlands & East – Strategic Projects Team

Not to be reproduced without permission

ADMPT/10113/140912

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