"Improvement! Clue’s in the title!”
That was one colleague’s curt response a couple of years ago in a discussion about NHS Improvement’s role. It was during one of those ‘cabaret style’ events when you long for some actual cabaret. But the line stayed with me. It’s a simple thing to say, but bringing it about – or helping others to – is complex.
It’s complex because people do improvement, not organisations.
The King’s Fund report published today shines a helpful spotlight on what it takes for organisations that have adopted an improvement method to create a leadership culture that supports success. Our experience working with the five NHS trusts involved with the Virginia Mason Institute (VMI) is encouraging us to reflect on how the traditional oversight model may need some recalibration to best support trusts undertaking this work.
So, what are we learning?
First, though there are tools and techniques to be taught, embedding an improvement method is not a technical exercise but a cultural one. It requires leaders to lead as coaches and allow staff time and space to come up with solutions. It demands patience with results that are more likely to emerge – and crucially to be sustained – incrementally. Above all it requires visible leadership commitment for the long term from a stable leadership team. It’s fair to say that, historically, the wider health system environment has not always been the most fertile ground for those characteristics to flourish at Trust level.
If we accept the existence of some inherent tensions here, how can we attempt to reconcile them? That’s not easy, but we can do some things at programme and national level. The VMI partnership is itself a long-term (five-year) commitment. NHS Improvement and the five trusts created a ‘compact’, which describes our expectations of each other. It hasn’t changed the world but it has at least acknowledged tensions exist, and in the process built trust and allowed honest feedback.
Developing people improving care
The publication Developing People - Improving Care provides, for the first time, a national framework for action on improvement and leadership development with specific pledges by 13 national organisations to ‘enable supportive and aligned regulation and oversight’. Easier said than done, but this is a significant step forward and a clear statement of intent.
Yet it has to work both ways. If the centre is going to reorient its approach, organisations must show how quality improvement approaches can be a key part of the answer for today’s problems. At times, improvement work can feel like a parallel set of projects while the main business goes on elsewhere. It has to be mainstreamed, which may also mean some compromises in philosophy – for example, accepting there will always be a place for ‘top down’ standards, but demonstrating how a systematic approach to quality improvement can deliver better results, more sustainably for patients.
The King's Fund report states 'Leading for quality improvement requires a shift in the relationship between the leadership team and staff.' It follows that the same could be said about the relationship between the centre and local organisations.
Continuing the journey
This is a journey, and we know we’re not there yet. But if one guiding principle lights the way, it is surely that central tenet of ‘Lean’ methodology – ‘respect for people’: the humility to approach things with, ‘big eyes, big ears and a small mouth’.
Much like the person who shouted out that remark that stuck with me two years ago, I’m sure we could all do a bit more of that. I know I could.
Written by Greg Madden, Senior Development Advisor – NHS Improvement Directorate.