54
B3: Practical approaches to leading the integration of care services Wednesday 22 nd April 2015 International Forum on Quality and Safety in Healthcare – London 2015
B3: Practical approaches to leading the integration of care services
Wednesday 22nd April 2015
International Forum on Quality and Safety in Healthcare – London 2015
Elizabeth Bradbury, AQuA Director
Nicki McNaney, AQuA Affiliate
We have not been paid to:
•make this presentation
•provide advice
•attend this or any other conference
The programme of work we are discussing isn’t part of any funded research
Nicki McNaney is an Independent Consultant but does not have any conflict of interest in making this presentation as an AQuA Affiliate
2
Introductions and Conflict of Interest Declaration
Learning outcomes
• Discuss how learning communities can support complex change management
• Build on the recommendations from AQuA’s evaluation of its large-scale system integration programme
• Explore how AQuA’s framework of eight key enablers for the integration of care services can be used in your locality
• Test AQUA’s System Integration Framework to assess your current progress
3
Session aims and outline
• Discuss AQuA’s journey from early discovery -Integration Discovery Community – to Leading System Level Change during 2014/15
• Taking an ‘organised’ approach based on eight evidence based key enablers
• Discuss the model for large scale change
• Explore some key concepts of complexity through three metaphors
• Interactive – discussion points and activities, using insights and examples from AQuA’s members participating in the integrated care programmes
4
AQuA’s Integrated Care Programmes 2014/15
5
Leading System-Level
Integrated Care
Integrated Care International
Exchange Programme
Integrated Care Fellowship Programme
AQuA’s Integrated Care Programmes
6
Leading System-Level Integrated
Care
Integrated Care International
Exchange Programme
Integrated Care Fellowship
Programme
2014/15Integration
Discovery
Community
Integrated Care
Community
2011 - 2014
• Access to AQuA’s Member Portal
• Case Studies from the North West and international evidence
• Publications
• AQuA’s Integration System Framework and Tool
• Measurement Tool and Guide for Key Enablers (in final design phase)
• Engagement Events and Technical Workshops
• Executive and Team Coaching
• Faculty and Expert Support
• Technical Workshops and WebEx’s
• Access to Thought Leaders and International Experts
• Action Learning Sets
Learning Network
Bespoke Support
LearningResources
Toolkit
7
Integrated Care Discovery Community
What does integrated care mean to you?
8
How does it feel as a leader?
9
“I guess we feel that we are building the plane whilst we’re learning to fly.”
Programme participant (OPM)
10
Cultural: Between patients and professionals
Lateral: Across health, social care and communities
Vertical: Between hospitals and primary and community services
Horizontal: Across hospitals and specialist services
AQuA’s approach to integrated care
11
Integrated Teams
Integrated Services
IntegratedSystems
Focus on population outcomes and system
enablers
Focus on redesigning integrated clinical and
support services
Focus on redesigning direct care for
patients and carers in all settings
Integrated care - 3 levels
12
Integrated Teams
Integrated Services
IntegratedSystems
Focus on population outcomes and system
enablers
Focus on redesigning integrated clinical and
support services
Focus on redesigning direct care for
patients and carers in all settings
What level are you working at?
Do you have line of sight across system levels?
Creating urgency
What would be different for Sally Ford and her family?
14
• Greater independence Able to live at home longer
• Reduced isolation Increased opportunities to participate in community groups and local activities
• Confidence in managing own condition and care
Sign-off own care plan and agree who it should be shared with
Support to monitor own health
• Know who to contact when necessary
One main telephone contact number for advise and support
• Increased community support, specialist care available when necessary
Access to a named individual to coordinate care and support
• Support to plan for later stages in life
Agreed plan for last year in life
Value of driver diagrams
15Source: Integrated Care for Older People in Salford Salford’s Integrated Care Model and Operational Plan, June 2011
Mesosystem
Macrosystem
Microsystem
Adapted from: Bojestig, Jonkoping CC Sweden
Strategic aims and measures
Good Measures
Outcome, Process and Balancing Measures
Outcome measures show the impact on patients
Process measures show how well we do what we say we do
Balancing measures show any unintended consequences
IHI Triple Aim
Population health measures focuses on ‘Better Health’
Cost per capita focuses on ‘Value for Money’
Patient Experience focuses on ‘Best Care’
AQuA System, Service and Team Measures
System, Service and Team measures provide:•Balance of Health and Social Care outcomes•Line of sight across the levels of integrated care•Timeline (baseline – 1, 3, 5 and 10 years)•Measures should cover the 8 AQuA Integration domains
System
Service
Team
©2014 Advancing Quality Alliance
Stiefel M. Nolan K. (2012) A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost
Davidge, M. Clarke J. James L. (2009) How to Guide for Measurement for Improvement
Status Achievements
0. Starting line None
1. Early work Initial baseline and diagnostic work startedPlan agreed
2. Activity but no changes
Team actively engaged in project Staring to test change and using data to inform progress
3. Modest improvement Actively testing and implementing changesSome evidence of improvement
4. Significant progress At least halfway to accomplishing planImplementing changes with clear evidence of improvement against measures
5. Outstanding sustainable results
Achieved all aims according to planNew ways of working fully implementedRecognised as leading practice with evidence of sustained improvements Supporting spread and adoption
Where are you now?
AQuA’s System Integration Framework
© AQuA Action 2012
Integration to Improve• Safety• Experience• Effectiveness• Population health• Use of resources
Service and Care Model
Design
Service Userand Carer
Engagement
LeadershipWorkforce• Role design• Skills• Capacity
Information and Information
Technology
Financial and Contractual Mechanisms
Culture
Healthcare value
Governance
Example Domain A - Leadership
1
Commitment
2
Enabling
3
Implementation
4
Embedding
5
Sustainable
Delivery
Senior leaders
have agreed to
work on system
integration and be
personally
engaged in leading
integration activity.
There is
consensus
amongst senior
leaders about the
scale and scope of
system integration
with shared
objectives and
commitment to use
resources
differently to
improve population
level outcomes.
Senior leaders are
highly visible and
act as positive role
models, meeting
service users,
carers and front
line staff and
giving a single
consistent
message about
the purpose and
aims of integration
in order to win
hearts and minds.
Senior leaders
continuously build
networks based on
relationships with
partners and wider
stakeholders and
build clinical and
managerial
capability to work
effectively within
organisations and
across pathways.
Senior leaders
address gaps or
major problems
relating to
integration
together, celebrate
shared success
and drive
continuous quality
improvement to
achieve a shared
purpose, vision
and narrative,
design a new
system
architecture and
role model and
coach desired
behaviours.
© AQuA Action 2012 21
Integrated Care Framework Assessment
This informs:• Economy action plans• How the programme of support was shaped• Development of the framework and toolkit
Apr-12 Oct-12 May-13
Leadership 2.13 2.71 3.15
Governance 2.00 2.71 2.79
Culture 2.33 2.74 2.83
Engagement 1.25 2.00 2.21
Financial & contractual 2.08 2.21 2.79
Information & IT 2.08 2.03 2.27
Workforce 1.88 2.03 1.83
Service redesign 1.54 1.84 1.88
Activity: System Integration Framework assessment
© AQuA Action 2012
Integration to Improve• Safety• Experience• Effectiveness• Population health• Use of resources
Service and Care Model
Design
Service Userand Carer
Engagement
LeadershipWorkforce• Role design• Skills• Capacity
Information and Information
Technology
Financial and Contractual Mechanisms
Culture
Healthcare value
Governance
© AQuA Action 2012 23
What have you found out?
© AQuA Action 2012 24
What have the teams found?
Helps to with difficult conversations across partner organisations
Later scores may be lower as progress from planning to implementation – often ‘you don’t know what you don’t know
Helped to open initial partnership, explore different perceptions conversations about what teams needed to do
Useful to track progress over time –process measure
Where did teams initially focus their attention?
© AQuA Action 2012
Integration to Improve• Safety• Experience• Effectiveness• Population health• Use of resources
Service and Care Model
Design
Service Userand Carer
Engagement
LeadershipWorkforce• Role design• Skills• Capacity
Information and Information
Technology
Financial and Contractual Mechanisms
Culture
Healthcare value
Governance
Where did teams initially focus their attention?
© AQuA Action 2012
Integration to Improve• Safety• Experience• Effectiveness• Population health• Use of resources
Service and Care Model
Design
Service Userand Carer
Engagement
LeadershipWorkforce• Role design• Skills• Capacity
Information and Information
Technology
Financial and Contractual Mechanisms
Culture
Healthcare value
Governance
© AQuA Action 2012
Integration to Improve• Safety• Experience• Effectiveness• Population health• Use of resources
Service and Care Model
Design
Service Userand Carer
Engagement
LeadershipWorkforce• Role design• Skills• Capacity
Information and Information
Technology
Financial and Contractual Mechanisms
Culture
Healthcare value
Governance
Where was initial attention most important?
“Not all leaders realise they need leadership skills and some believe you can deliver everything you want with strict performance framework or contract. It’s about a narrative about how there are different leaders – leadership is important often more than performance management and contracting.”
Programme participant (OPM)
• Financial and Contractual Mechanisms
• Information and IT
• Governance
System Capability
• Service and Care Model Design
• Workforce
• Operational ConsiderationsDesign
• Defining vision, aims, scope and measures
Planning
• Service User and Carer Engagement
Foundation
• System Integration Framework and Assessment Tool
• Partnership development Readiness
Lead
ers
hip
Cu
ltu
re
Roadmap?
Me
asu
rem
en
t
©2014 Advancing Quality Alliance
29
30
31
Complicated ComplexSimple
Adapted from Brenda Zimmerman
• Formulae have only a limited application
• Raising one child gives no assurance of success with the next
• Expertise can help but is not sufficient
• Every child is unique
• Uncertainty of outcome remains
Raising a Child• Recipe is essential
• Recipes are tested to assure replicability of later efforts
• No particular expertise; knowing how to cook increases success
• Recipes produce standard products
• Certainty of same results every time
Following a Recipe A Moon Rocket
• Formulae are critical and necessary
• Sending one rocket increases assurance that next will be ok
• High level of expertise in many specialized fields & coordination
• Rockets similar in critical ways
• High degree of certainty of outcome
Defining the challenge
Large Scale Change working definition
Large-scale change (LSC) is the emergent process of moving a large collection of individuals, groups, and
organisations toward a vision of a fundamentally new future state, by means of high-leverage key themes,
distributed leadership, massive and active engagement of stakeholders, and mutually-reinforcing changes in
multiple systems and processes, leading to such deep changes in attitudes, beliefs, and behaviours that
sustainability becomes largely inherent.
Source: Paul Plsek (2008) on behalf of the Academy for Large Scale Change
Emerging Model of Large Scale Change
Source: Paul Plsek (2008) on behalf of the Academy for Large Scale Change
Identifying need for change
Framing/ reframing the issues
Engaging/ connecting
others
Making pragmatic change in multiple
processesAttracting
further interest
After some time
Settling inPossible outcomes1. sustainable norm 2. plateau3. run out of energy
Living with results and
consequences
Maybe later
Repeats many times in hard to predict ways
Time delay
Getting people on the bus
34
Collaborative Leadership
‘The capacity to engage people and groups outside one’s formal control
and inspire them to work toward common goals – despite differences
in convictions, cultural values and operating norms’
Source: The King’s Fund
Partnership working
• Co-ownership
– Joint responsibility
• Collaboration
– Working together
• Co-ordination
– Avoid duplication & confrontation
• Co-operation
– Help when can
• Co-existence
– Maintain own territory
Mat
uri
ty
Adapted from Cowan Global
Familiarity
Reliable Information
Clear Communications
Integrity
Shared Values
Shared Vision
Creating trusting relationships
Change/Uncertainty/Dishonesty
Conflicting Needs
Pressures/Stress
Complex/Poor Data
UnclearCommunications
Lack of Time /Prior Experience
DistrustSource: Richard Lauve
Trust
Where Vision and Storytelling Matter Most
Identifying need for change
Framing/ reframing the issues
Engaging/ connecting
others
Making pragmatic change in multiple
processesAttracting
further interest
After some time
Settling inPossible outcomes1. sustainable norm 2. plateau3. run out of energy
Living with results and
consequences
Maybe later
Repeats many times in hard to predict ways
Time delay
Source: Paul Plsek (2008) on behalf of the Academy for Large Scale Change
versus
What is a story?
“We have a list of measurable objectives”
“I have a dream”
Source: Paul Plsek
Leadership communication
The Western intellectual tradition to try to create action
Effective presentation – transformational storytelling – to spark action
Problem Solution
Get their
attention
Reinforce
with reasons
Analysis
Stimulate
desire
Source: Stephen Denning – The Leader’s Guide to Storytelling
What is storytelling in an organisational sense?
Although analysis can get to the facts and excite the minds of business leaders, to motivate people you have ‘to go to the heart’
Good storytelling:
•Goes beyond conventional approaches to writing strategy documents and typical methods of communicating with staff
•Translates the dry and abstract into a compelling picture of a goal, often succeeding where even the most logical arguments usually won't do the trick
•Sets out a compelling vision for the future, making it real by painting the future vividly and setting out clear themes for action
Source: Paul Plsek
How are you getting people on the bus?
42
The Road to the Future?
Source: Gareth Morgan
Some key questions….
1. Where might we be shying away from ‘a road less travelled’ and are at risk for just going round the same old loop again?
2. Where might we be better off with a ‘good enough’ plan that we can monitor and adjust along the way, to replace paralysis of over-analysis?
3. Where might we replace over-control and top-down prescription with simple rules, feedback loops and reasonable freedoms?
4. Do our organisational and partnership structures, processes and patterns support generative relationships where new ideas emerge, or are we in too rigid silos not sharing enough (power, knowledge, resources, decision-making, etc.) among ourselves and with others?
5. Where might we need to ‘let go’ in order to allow ‘creative destruction’ and its potential for adaptive new growth to emerge?
Source: Paul Plsek
Get a good enough plan
45
46
“Don’t worry about having your perfect project plan, you have to keep going and recognise it’s going to go up and down.”
Programme participant (OPM)
Planning at the expense of action – the perfect plan cannot be achieved.
“You do find you do take 2 steps forward and 1 step back, and previously there was a temptation when you took steps back for there to be a sense of despair …whereas now possible our patience and ability to just carry on has grown.”
Programme participant (OPM)
“The biggest lesson for health is that people don’t accept that when you do large scale change things aren’t going to work and at first fail they’re pulled in or cancelled we don’t allow ourselves permission to try and fail.”
Programme participant (OPM)
Complex and orderly outcomes can emerge from a few simple rules • Without a detailed
procedure or
plan!?!
• Without an avian
Chief Executive!?!
•Maintain a minimum
distance from all other
birds and objects
•Match speed with
neighboring birds
•Move toward the center
of mass of birds in your
neighborhood
Complex ‘flocking’
behavior emerges!
Source: Paul Plsek
48
What are your…..
How would you go
about developing
simple rules for your
programme?
What are your…..
?
49
“It has helped me with not being a control freak – I can let things run a little bit more and when you want something to go really well you don't have to feel like you have to be all over it - I’ve spent more time with their service leads rather than being all over it. Some simple rules and let them go forward…”
Programme participant (OPM)
To support the development of new neighborhood care teams to guide their development as a frame to guide practitioners to design something different and responsive for the local population
As system leadership teams to not
over complicate the complex and
role model new ways of working
Be more like a farmer than an
engineer or architect
50
The Complex Adaptive Leader
• Think more like a farmer than an engineer or architect
– Farmers create conditions that favor growth; they nurture, but cannot control everything
• Plans and designs can never be complete on paper
– Becoming comfortable with ‘a road less travelled
– ‘Good enough plans’ with adjustment as you go
– Do something and see what happens
– Attend to the underlying assumptions and simple rules
– Work on creating generative relationships
– Let go of ‘figuring it all out’ and ‘we’ve always done it this way’
Source: Paul Plsek
Life can proceed forward through constant tension and balance, because the system is adaptable
Where might you need to ‘let go’ in order to allow ‘creative destruction’ and its potential for adaptive new growth to emerge?
Source: Paul Plsek
Reflections and Questions
