Selecting the right changes can be tricky business

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The latest in Maxine Power’s blog series explores how selecting the right combination of changes is a tricky business…

You’ve set your aim and you are ready to fire – how do you decide what changes you are going to make that will result in an improvement?

At Haelo we believe that the process of selecting changes is a team sport. Rather than having a few esteemed (usually old!) ‘experts’ in a room, we convene a design meeting, often referred to as an ‘expert meeting’. Somewhat ironically these are ‘experts’ in the real world – our experts are chosen to represent the system we are working in. For example, if we are working on infection prevention we need the team who deliver this. This means inviting healthcare assistants, doctors, estates, portering, allied health professionals, nursing, volunteer staff and patients into the room to figure out ‘how the systems under scrutiny work around here’ and to surface ideas for how to fix them. Of course our ‘traditional’ experts (microbiology, infection prevention and control) are in the room too but they are not ‘in charge’, they are part of the solution.

This notion of seeking solutions from the sharp end is the essence of collaborative working and is critically important for ownership of the process of improvement. It requires a flattening of hierarchical knowledge and an appreciation of tacit knowledge as a source of innovation and learning. It flies in the face of the medical model of ‘expertise’ belonging to, and being imparted by, the most senior person who ran the randomised controlled trial. It is so culturally disruptive that its introduction needs careful handling but its potency should not be underestimated.

So, you have the right people on the bus! These people become, what John Kotter¬†describes as your ‘guiding coalition’ – an army of system leaders ready to lead their peers into change. They are vital to your success. So, what next? This is where the fun starts. The diversity of this grouping is the strength in your programme but it’s also your biggest challenge. In her seminal paper ‘Overcoming Barriers to Quality Improvement’ Mary Dixon Woods describes how the most successful change programmes need to ‘convince people we have a problem’. In Haelo we start from the assumption that there isn’t a single method to achieve this. Each person will have their ‘switch’ that turns the kettle to boiling. Our job is to find that switch. For some the power lies in a personal story, for some its in the data, for some its in the evidence, for others it a desire to be the best but for all it is a deep and relentless quest to provide great service.

Choosing the right interventions requires a committed and focused group. The aim is the shameless dictator in this, for example if you want to lose 2 stone in 6 months your choices may be different that if you want to lose 1 stone over 2 years. So keep the aim on the wall.

I always start the process of planning changes by introducing the concept of a driver diagram. A driver diagram is a simple tool for focussing teams on the primary drivers of change and is sometimes referred to as the ‘logic model’. Once teams have this concept we ask them to brainstorm their ‘big ideas’ about what changes might result in improvement. This can be quite challenging for those who have been working in the field for some time and who ‘believe’ they already have the solution. Watch for this and check yourself if you find yourself shutting down ideas too early. It’s really easy to forget that you are in the room because the current process isn’t working but many of the stakeholders are firmly rooted in the present and will be sceptical about change.

Generally, 2-3 groups working at tables will come up with some common ‘themes’ and some differences. The job of the skilled facilitator is to broker an ‘ideas exchange’ which produces a prototype driver diagram. The first driver diagram is ALWAYS going to need refinement. So how is this done?

A cross reference between the evidence and the idea is always helpful. If the evidence is strong this is helpful. For example the evidence to support hand hygiene as an intervention to prevent the spread of infection. Where it is weak, for example the removal of rings and shirt sleeves ‘so called bare below the elbow’ it doesn’t mean it can’t be included but it will be necessary to have a strong theory about how this might work. The methodology of ‘testing’ as an implementation method is vitally important where these weak ties between intervention and evidence exist.

You then want to ‘sense check’ your driver diagram with stakeholders who aren’t in the room. Do they understand it? Does it connect with them? What expertise do we have in the system? And how might this change impact on their work. This ‘sense checking’ is an important process and often brings challenges for middle managers who see the change as ‘disruptive’ but the process of co- producing changes can be really helpful in bringing them on side to be supportive of change.

Your expert faculty will oversee this debate and will provide vital feedback from the system which will help refine your ideas. They need a constant reminder that the driver diagram doesn’t need to be ‘perfect’ before you get going. The changes selected are a starting point for an evolving set of interventions and theories of change. Your improvement methodology will allow you to test, fail and learn – mitigating against unhelpful disruption in the system.

Your driver diagram is a living logic which should be reviewed and tweaked in line with your learning. My experience is that a driver diagram can take 6-8 iterations to stabilise and beyond this changes are more minor. Don’t be afraid! Go for it, it’s really fun!

My top tips for selecting the right changes are:

1. Pull together your guiding coalition and use them to make the choices

2. Check their ideas against the evidence

3. Have a robust theory about why the changes will deliver the aim

4. Keep the driver diagram alive through constant review

5. Use your driver diagram like a road map to identify changes to others, help teams to locate their work and help when you are lost

What do you think?

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