Continuous Improvement: Change for the Better

Manchester Conference Centre, May 2015

Creating a quality culture

Max Moullin, Public Sector Scorecard Research Centre www.publicsectorscorecard.co.uk

Quality - have we lost the plot?

What definition of quality do most organisations use in practice ?

Conforming to the specifications of head office (or central government)

A.

Q.

So what is Quality in the public sector ...

“Meeting the requirements and expectations of service users and other stakeholders while keeping costs to a minimum”

Moullin, 2002

Insurance Claims Example

•  Insurance company has an average call waiting time of 12 minutes in its claims department - up to 25 minutes at busy times. Many complaints.

•  The manager is considering four options: A. employ 2 extra staff

B. reduce average call time by 25% C. divert most enquiries to the internet or

D. share services with another company.

What would you recommend?

"Don't just do something, stand there"

The White Rabbit (Disney's Alice in

Wonderland movie, 1951)

… and do some systems thinking

Systems Thinking: Insurance Claims

Reason  for  phone  call   %   How  to  address  Chasing  up  due  to  non-­‐response  

22   Process  claims  on  6me  

Don't  understand  claim  form  

16   Produce  clearer  form.  Help  on  web  site.  

Disagree  with  decision   20   Give  clear  reasons    Mistake  in  processing  claim  

12   BeFer  training  to  prevent  errors  

Informing  company  about  details  of  claim  

25   Adds  value.  But  check  that  all  stages  needed.  

Other      5   Inves6gate  further  

Two stages: analyse data. Take action!

In  addi'on  you  are  told  that  28%  of  calls  have  to  be  re-­‐directed  as  they  come  through  to  the  wrong  person,  while  5%  of  calls  are  re-­‐directed  twice.    

18:58

Developing a quality culture - some pointers …

©Max Moullin 9

Pointer 1: Focus on outcomes, not activity

"Effective commissioning must focus on outcomes. Only then will we achieve the high quality, value for money public services

that people deserve"

Sir Stuart Etherington, Chief Executive, UK National Council for Voluntary Organisations

Pointer 2. Manage performance across organisational boundaries

•  For example, research on teenage pregnancy

showed that 71% of young women between 16 and 18 who were NEET* for > 6 months were parents by 21

•  Therefore if you run a team aimed at addressing teenage pregnancy, working together with local colleges and employers is absolutely vital.

* Not in education, employment or training

Moullin, 2006

©Max Moullin 11

Pointer 3: Integrate risk management

'identifying and addressing key risks are essential for any high-performing

organisation and therefore any evaluation of performance without

considering risk is incomplete'

4. Take account of the cost of measurement

"Public sector organisations spend up to 20% of time on form-filling, auditing, measuring and reporting performance but only a fraction of this is ever used to gain relevant and new insights or lead to performance improvements."

Professor John Baillie

Chair of Audit Scotland

5.  Develop a performance management culture focussed on continuous improvement, innovation, and learning - and not a top-down blame culture …

©Max Moullin 13

Pointer 5: Focus on CI

"All performance targets are flawed, some are useful"

Max Moullin, "What's the Score",

Public Finance, 22 May 2009

with due acknowledgment to the quality management guru Deming who said:

"all models are flawed, some are useful"

COMPLACENCY

TUNNEL VISION

DATA MIS-REPRESENTATION

MEASURE FIXATION

GAMING

MYOPIA Concentrating on short-term

Emphasis on 5 A-C GCSEs. Schools focus on those on C-D margin

13 week target for planning applications

'led to more rejections'

% of offences brought to justice target led to more efforts on easy to solve

crimes

Follow-up appts for ophthalmology delayed to meet targets for new ones

3.5 hour wait for A&E is OK

Based on Brooks (2007), Ch 3.

UNINTENDED

EFFECTS

Auditors found 12 NHS Trusts had adjusted

waiting lists ‘inappropriately’

© Max Moullin,

Performance management culture

“Once we accept that all targets are flawed, it is clear that the priority is to

develop a culture focussed on continuous improvement, innovation and learning - and not a top-down

blame culture”

... but targets can be useful too

Max Moullin, 2009, What’s the Score, Public Finance

Hospital waiting times in England–thousands of people waiting a number of months

©Max Moullin 17 Source: Dept of Health

0

50

100

150

200

250

300

350

400

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Thou

sand

s

>6 months

> 9 months

Pointers for creating a quality culture …

6.  Use the Public Sector Scorecard to help you ...

©Max Moullin 19

The Public Sector Scorecard

OUTCOMES

PROCESSES

CAPABILITY

The Public Sector Scorecard is an integrated performance

management framework for the public and third sectors

“The Public Sector

Scorecard is groundbreaking”

Bob Penna, former Director of Research and Communications, New York Senate

©Max Moullin 20

The Public Sector Scorecard

What are the outcomes we really want to achieve for our service users and stakeholders?

How effective are our processes in achieving these outcomes? How can we improve them?

How can we best support our people and processes to achieve the outcomes required?

OUTCOMES

PROCESSES

CAPABILITY

©Max Moullin 21

SERVICE USER/ STAKEHOLDER

FINANCIAL

OPERATIONAL EXCELLENCE

INNOVATION & LEARNING

STRATEGIC key performance

outcomes

The Public Sector Scorecard

OUTCOMES

LEADERSHIP

PEOPLE, PARTNERSHIPS & RESOURCES

PROCESSES

CAPABILITY

Clarifying outcomes

Identifying process & capability outputs

Strategy mapping

Integrating risk management

Re-designing processes

Addressing capability

Developing performance

measures

Learning from performance

measures

How the Public Sector Scorecard works

©Max Moullin 23

Strategy maps •  Kaplan and Norton (2001) say a strategy

map ‘describes how shareholder value is created from intangible assets’

•  However with the PSS, it can be defined more simply as showing the relationships between capability, process and outcome elements

•  They are the vital link between strategy and performance measurement

Health  &  Wellbeing  of  

people  with  LTCs  

Effec=ve  use    of  resources  

Reduced  unnecessary  

acute  bed  days  

In  control  of  their  health  

Reduced  isola=on  &  anxiety   Reduced  cost  of    

unscheduled  care.  Sustainability  Effec=ve  personal  

 &  self-­‐care  Improved    

mental  health  

Reduced  A&E  admissions  for  

non-­‐A&E  pa=ents  

Integrated  LTC  &  mental  health  care  

Reduced  admissions  to  care  homes  

Consistent    good  quality    care  in  care  

homes  Accessible  shared  records  

Reduced    delays  

Carers’  needs  met  

Removal  of  non-­‐VA  ac=vi=es  

Re-­‐design  flow  

systems  

Reduce    unwarranted  treatment  varia=on  

Focus  on    resource  -­‐intensive    pa=ents  

BeNer  sharing  of  informa=on  

Emphasis  on  preven=on  &  early  diagnosis  

More  joined  up  working  in  H&SC.    

Change  public  percep=on  re  hospital  care    

Simpler  financial    

flows  &  risk  sharing  

Less  duplica=on  of  assessments   Integrated  

H&SC  teams  More  independence  

Reduced  hospital  admissions,  length  of  stay  &  outpa=ent  aNendances  O

UTC

OM

ES

PR

OC

ESSE

S C

AP

AB

ILIT

Y

Feedback on the PSS

'The strategy map is really useful as it simplifies a complex issue with a complex response into an orderly understandable approach'

Executive Director for Children, Young People, and Families, Sheffield City Council

.

©Max Moullin 25

'The SLC4L Strategy Map visually told the story of SLC4L, what we were trying

to achieve and how.

It helped all those involved understand the outcome and process measures the programme was trying to achieve, and

therefore being evaluated against.'

Programme director Sheffield Let’s Change4Life

.

©Max Moullin 26

How the PSS reduces the impact of perverse incentives

•  Measures user satisfaction •  Focus on outcomes, not activity •  Works across organisational boundaries •  Involves staff, users and other

stakeholders in developing measures •  Much more selective approach to targets,

not top down •  No blame culture – appraisal model

©Max Moullin 27

Key features of the PSS •  Focuses on outcomes and evidence-based

drivers of outcomes •  Provides a link between strategy, service

improvement and performance measurement •  Incorporates service re-design, organisational

culture and resource issues •  Ideal for use across organisational

boundaries •  Integrates risk management •  Culture of improvement, innovation &

learning, not a blame culture

Creating a quality culture: Recommendations

1.  Make sure you focus on the outcomes that matter to users and other key stakeholders

2.  What about your processes? Can they be more effective in delivering these outcomes

3.  How can your organisation improve its capability to support its people and processes in meeting the outcomes required

4.  Develop your performance measures around desired outcomes, processes and capability

5.  Develop a culture of innovation and continuous improvement and not a blame culture

6.  Use the Public Sector Scorecard to help you

Recommendations (continued) 7.  Performance measures and targets, where

appropriate, should be developed jointly with the organisations that are being held to account.

8.  If measures are not directly related to outcomes or evidence-based drivers of those outcomes, then they should be scrapped.

9.  If performance is below a target, then organisations or departments should be able to offer an explanation of any exceptional circumstances that have affected performance.

10. Public and third sector organisations need to develop their own integrated service improvement and performance measurement frameworks.

MAIN REFERENCES 1.  Moullin, M and Copeland, R (2013) Implementing and

evaluating behaviour change programmes with the Public Sector Scorecard. National Health Executive, Jul-Aug 2013, pp.16-18

2.  Moullin, M. and Copeland, R. (2012) Strategy Mapping for Behaviour Change with the Public Sector Scorecard. British Academy of Management Annual Conference Winner of 'best paper' prize.

3.  Moullin, M. (2009) What's the score? Feature Article, Public Finance, 21 May Chartered Institute of Public Finance and Accountancy, London.

4.  Moullin, M. (2009) Lean and Six Sigma – Can they really be applied to the public sector? Public Sector Executive, May / Jun 2009

5.  Moullin, M. (2004) Eight essentials of performance measurement International Journal of Health Care Quality Assurance. 17:3. Winner of International Literati Prize

Contact details:

Max Moullin, BSc (Soc.Sc.), MSc, FORS, FCQI, CQP Director, Public Sector Scorecard

Research Centre Visiting Fellow, Sheffield Business School e-mail: max@publicsectorscorecard.co.uk

Web site: www.publicsectorscorecard.co.uk