Scaling down and scaling up

Helen Bevan
@HelenBevan
Jen Rodgers
@jenfrodgers
#GiantSteps19

What we will cover this morning
• Principles for scaling up
• Principles for scaling down
• A spread challenge: person-centred visiting
• A new role for scale and spread: the convenor
@helenbevan @jenfrodgers #GiantSteps19

For personalised services at scale, we have to take a
view from both the balcony and the dancefloor
From the balcony:
• See the big picture of care across the whole
system and identify the biggest opportunities
• Create standardised care pathways that deliver
high quality, safe care to our population
From the dancefloor:
• Step into the shoes of individuals
• Understand health and healthcare from the
perspective of their lives
• Co-produce with consumers, families and staff at
the point of care
• Make sure this addresses “what matters to me”
Balcony and dancefloor framework from Ronald Heifetz

Across the globe, people are questioning the
conventional “spread” model
Pilot project Rolling out
“If we opened our eyes we would see the wonderful irony. Trying
to manage human change through pilot and roll-out has actually
grown something. A proliferation of project managers”.
John Atkinson

Because the reality is often different

The reality of spreading up
…A dynamic, reciprocal
interacting, iterative and
evolving activity...not
linear and mechanistic
…developmental,
contextualised, adaptive,
learning and social
process
Diane Ketley

The key thing to remember about spread
in health and care
In health and care improvement, we often try
to design spread complex care processes as if
they were complicated & it doesn't work.
Complex isn't higher-order complicatedness. It
is a fundamentally different kind of system!
See: morebeyond.co.za/7-differences-
between-complex-and-complicated-systems/
@helenbevan@helenbevan @jenfrodgers #GiantSteps19

Seven differences between complicated and complex
Complicated Complex
Causality Linear cause-and-effect pathways allow us to
identify individual causes for observed effects
There are no clearly distinguishable cause-and-effect
pathways
Linearity Every output of the system has a
proportionate input i.e. Newtonian physics
apply.
Outputs are not proportional or linearly related to
inputs; small changes in one part of the system can
cause sudden/unexpected outputs in other parts of
the system
Reducibility We can decompose the system into its
structural parts and understand the functional
relationships between these parts in a
piecemeal way.
The structural parts of the system are multifunctional
i.e. the same function can be performed by different
structural parts
Controllability &
solvability
Systemic contexts and interactions can be
controlled, and the problems they present
can be diagnosed and permanently solved
These systems are prone to high levels of surprise,
uncertainty and interventions causing unexpected
changes and even new or worse challenges.
Constraint
(openness)
Environments are delimited i.e. governing
constraints are in place that allows the system
to interact only with selected or approved
types of systems.
Complex systems are open systems, to the extent
that it is often difficult to determine where the
system ends and another start.
Knowability These systems, because they are closed and
can be deconstructed can be fully known or
modelled
We cannot transform complex systems into
complicated ones by spending more time and
resources on collecting more data or developing
better theories
Creativity &
adaptability
Complicated systems need an external force
to act on them in order to introduce change
These systems are able to observe themselves, learn
and adapt. They are creative.
Source: Sonja Blignaut @sonjabl

7 interconnected principles
Complexity
Spread in health and care is a complex activity
occurring across a complex system
• Complexity around innovation, the process of
spread, the context of spread
• Health and care is a complex adaptive system
• Match complexity of the approach to spread
with complexity of the situation

Complex systems are driven by the quality
of the interactions between the parts, not the
quality of the parts. Working on discrete parts
or processes can properly bugger up the
performance at a system level. Never fiddle
with a part unless it also improves the system
@ComplexWales
Source of image: Eclipse

An independent initiative
Supported by specific
tools & information
Within a
clear
boundary
Improve
smoking cessation rates
amongst people living
with asthma and COPD

An independent initiative An inter-dependent initiative
Improve
the response to
someone presenting
to primary care in a
mental health crisis
Primary
care
Emergency
Department
Mental
health
service
Supported by specific
tools & information
• Social and
collaborative
• Built on shared
purpose
• Multiple methods
Within a
clear
boundary
Improve
smoking cessation rates
amongst people living
with asthma and COPD

Innovation development and spread are inter-
dependent
• How an innovation is developed influences
spread
• Early involvement increases commitment and
ownership
• Increased focus on role of adopters in
adaptation and spread
2. Development of innovation

Source: adapted from
Mary Uhl-Bien

Source: adapted from
Mary Uhl-Bien
1. Complexity
'How to master the art of creating the
‘adaptive spaces’ that enable
innovations to spread' – with Prof
Mary Uhl-Bien (4pm UK time, 4 Dec,
Zoom meeting):
https://q.health.org.uk/event/how-to-
master-the-art-of-creating-the-
adaptive-spaces-that-enable-
innovations-to-spread-with-prof-mary-
uhl-bien/

NHS and Virginia Mason Institute partnership
Multiple levels of “adaptive space”:
1. “Best day of the month” – a formal space for cross-organisational
dialogue
2. Driving improvement – a formal space for strategic level dialogue
3. Rapid Process Improvement Workshop – a space for building
connections across rank and status
4. A daily huddle – a space for cross-professional dialogue
Most CEOs would not relish six hours in a windowless room with their regulator
but these CEOs each declare the meeting ‘the best day of the month!’ Why?
Because the meeting resembles a protected relational space, where individuals
are all working towards the same shared goal of service transformation.
Nicola Burgess, Warwick Business School
https://www.health.org.uk/news-and-comment/blogs/making-time-to-talk-the-challenge-
of-spreading-knowledge

Focus on the value rather than the innovation
• It’s about what others will value rather than
what you want to spread
• What problem of local priority will it solve?
• What benefit will it offer?
3. Value

The perspective of the individual is pivotal
• Changing behaviours is hard
• The more work routines affected, the greater
the spread challenge
• Generate energy for change, skills and
confidence by building motivation
4. The Individual

From an
inward to an
outward
mindset
5. Leadership

Networks build communities, energising and
connecting individuals
• Spread will happen more through relationships
than any other factor
• Create a “pull” for innovation by building
communities to energise individuals and maintain
momentum
• Support networks and encourage connections
with other networks
• Support use of network building mechanisms; eg
platforms like WhatsApp, Slack, Facebook groups
and other social media
6. Networks

Spread happens more through
relationships than any other factor
• [To be published] evaluation of NHS hospital
systems [trusts] that undertook comparable
Lean initiatives with vastly different outcomes.
• The difference? The level of social connections
between those working to lead improvement
Source: Nicola Burgess, Warwick Business
School, evaluation of the partnership between
the NHS and Virginia Mason Institute

Knowledge flows generate learning to enable
spread
• Collate and share local feedback and
evaluation of innovation adoption and impact
• Share knowledge through networks
• Build a culture of learning and transparency,
sharing and seeking knowledge from others
Learning

Sharing knowledge and learning for
spread at multiple levels
Source: Harold Jarche
Social Networks

1. Our healthcare systems need to act like Complex Adaptive Systems in
order to evolve and thrive – and for innovations to move from the
margins into the operational core.
2. To act like a CAS, health and care leaders must regularly create temporary
cross-silo ‘adaptive spaces’ (eg hackathons, Labs, virtual communities,
tweetchats) where new ideas can find allies, get prototyped and improve
enough to embed in the core and spread.
3. Adaptive spaces are the location where the system needs/benefits focus
[pull] of a new idea becomes strengthened – beyond merely supporting
an innovation focus [push].
4. Currently the day-to-day efficiency drive in healthcare too often smothers
the creative innovation and learning drive (embodied in adaptive spaces)
5. The approach is underpinned by inter-dependent relationships,
connections and trust
6. Significant implications for how we support improvement: programmes
vs. platforms
(Thanks to Matthew Mezey)6 conclusions about scaling up

A growing interest globally in the concept
of “mass customisation” for health and
care
Combining the personalisation and
flexibility of individualised services and
taking it to a level of scale to cover a
population
People don’t want
more choice; they
want what they
want, where, when
and how they want it
Irma Jason

We already segment based on patients’ clinical
characteristics; population health starts with
segmentation
1. More holistic segmentation delves into not only the
2-dimensional view of patients (clinical), but rather
the 3-dimensional view (who these patients are, not
just what problems they present with)
2. How do we get this more holistic view?
Psychograhics
30
We need holistic segmentation
(not just clinical)
Source: The IHI

Is about someone’s values, attitudes, personalities,
and lifestyles, and are the key to understanding
their priorities and motivations.
B. Walker. “Two cutting-edge ways to use psychographic
segmentation in healthcare.” Patientbond 2016.
31
Psychographics
Source: the IHI

Depending on the situation and the need - we make the
decicion together on what suits me and the situation best!
Segmenting by psychographic charactertistics
Independent
and committed
Worried and
committed
Traditional and
unscathed
Vulnerable
and worried
Before During After
Make an
appointment
virtually
Consulting
Waiting
list
Called up
Self check
Reception
Your own
contact person
Waiting
room host
Reading a
journal
Video
meeting
Letter
Calls
Source:Swedish Association of Local Authorities and Regions

Scaling up and scaling down
Source: thethinkingcanvas.com

Working with personas: the example of
Esther
Esther is not a real person, but her story has led to
impressive improvements in how people flow through
the complex network of providers and care settings in
Sweden
Esther is a person who needs care and attention from more
than one health and care provider. To support Esther in good
health there is a need for all health and social care providers
to collaborate seamlessly across organisational borders.
Esther came from Jönköping in Sweden.
She has inspired thousands of people to
improve the health and care system all
over the world

Esther is a persona
A persona is a characterisation that helps focus
problem solving and design.
The best persona incorporate real experience
that identifies key themes based on qualitative
user research, quantitative data and discussion.
The result should be someone people feel they
can identify with.

Archetype versus stereotype
• An archetype refers to a generic version of a person and is neutral
• A stereotype refers to the attributes that people think characterise
a group
• A stereotype has little to do with the individual, and so mostly tries
to characterise them based on group affiliation or association. In
other words, inferred characteristics.
• With a persona, you're
describing relevant attributes of
some typical people, not
inferring attributes based on
some group affiliation or
prejudice. Hence, a persona is
better described as an archetype

Tackling physical health inequalities for
people with living with mental ill health

Over to you (shortly)
How would you spread person-centred visiting
across Victoria?
• What approach to spread?
• Have a go at designing a persona:
• A consumer or family member
• A member of staff

Why and how did this change happen?
But a very little reflection will clearly convince any thinking person that…
If you take away a sick child from its Parents or Nurse, you break its
heart immediately Dr George Armstrong
Separating (ill) children from
their parents causes harm

Recognise these reasons?
• Platt report received muted reception
from professional groups
• Not practical for the following reasons:
– Need for rest and recuperation
– Infection control
– Interference interruption of work-flow
"Marking the 50th anniversary of the Platt Report: from exclusion, to
toleration and parental participation in the care of the hospitalized child".
Journal of Child Health Care. 14 (1): 6–23.

2.18 I am supported to manage my
relationships with my family, friends
or partner in a way that suits my
wellbeing.

STRUCTURAL barriers to person-centred
culture

Project
50
Scope
• Engagement
workshops
• Core principles
agreement
Test
• Test solutions to
the ‘stones in our
shoe’
• Share this learning
Implement and
spread
• Integrate into
training and
assurance
• Create information
materials

What hopes and fears do you or others have
about person centred visiting?
“This will mean people
turning up at 3am on their
way home from the pub” “Patients need rest
and recovery, not
a party”

Communicati
on
Flexibility Facilities Welcoming
attitude
Patient led Key events/
times
Impact on
family/
homely life
Processes
What matters to people?
52

Patient Led
We are guided by patients: when the people who matter will visit, how they
would like them involved in their care, and when they want to rest.
Partnership
We work in partnership with the people who matter to patients.
Flexibility
We have no set visiting times.
Welcoming
Welcome and encourage the involvement of the people who matter to patients.
Respect
We respect peoples’ individual needs and act on an individual basis to ensure the
safety, privacy and dignity of all patients. This means there may be times when
we need to ask people to leave a clinical area temporarily.
Core Principles of Person Centered Visiting

1. A conversation supported by a reliable process
for the person to designate those people that
matter most to them
2. How they would like them involved in their care
3. The absence of set visiting times
Three Characteristics

What change can we make that will result
in improvement?
55
As a relative, what matters to me is being made to feel welcome,
asking if I can be involved, and knowing what
to expect, or a plan

Admission
conversations
Privacy and
dignity
What change can we make that will result
in improvement?
56
Welcoming
behaviours

‘Must do with me’ Criteria
What matters to you?
Who matters to you?
What information do you need?
Nothing about me without me
Personalised contact
Source: Healthcare Improvement Scotland 58

Admission conversations
• Supported by changes to
the initial sit down
discussion
• Helps to create rapport
• Experience demonstrates
that the meetings take, on
average, 10 minutes – and
are a worthwhile
investment.
59

Privacy and dignity
60
Increase staff confidence in having
appropriate conversations by:
• Providing written information to
support
• Encouraging daily reflection using
safety briefs
• Creating opportunities for staff to
observe their peers and leaders

The difference
61
The visiting in here has been excellent, my husband has been
allowed in whenever he wants which is great. We're retired but
I'm with my husband all of the time, so I especially want him with
me when I'm unwell.
Patient in Acute Medical Receiving Unit,
Glasgow Royal Infirmary

The Nurse explained to me and my dad that we would be able to
visit with my mum at any time when she was in the ward. It's
such a relief because being her carer and being with a person all
of the time it's difficult to leave them in hospital,
but doubly so because it's my mum. It's great
knowing I'm not restricted to visiting times
or my dad.
62

• Improved patient and family experience
• Reductions in complaints
• Reduction in falls
• Lower readmission rate
• Reduction in medicine related errors

Over to you
How would you spread person-centred visiting
across Victoria?
• What approach to spread?
• Have a go at designing a persona:
• A consumer or family member
• A member of staff

Everret Roger’s diffusion of innovation
curve
Innovators

Everret Roger’s diffusion of innovation
curve
Innovators
Adopters

The key role of the “convenor” for enabling spread:
• Acting as interface between
innovation and ‘usual
business’
• Creating an adaptive
environment for spread
• Lessening ambiguity for
adopters in complex change
situations
• Strategically coordinating
spread across a whole system
• Mobilising networks, crowds
and influencers
@helenbevan

Programme manager vs. convenor
• Designs a plan
• Accountability within a
governance system
• Ensures that delivery
milestones are met
• Deals with risk and
ensures that barriers
are overcome
• Works with emergence
• Builds commitment to a
collective goal
• Builds relationships
• Seeks win/wins
• Makes sense of things for
adopters: the why?
• Enables spread across a
whole system
Independent
Complicated
Interdependent
Complex
PROGRAMME
MANAGER
CONVENOR

• Find out “what matters to
me?”
• Start from people’s interests,
strengths and abilities
• See people in their wider
context - not just their
healthcare symptoms
• Build on assets - don’t just
minimise deficits
• Spread happens one person
at a time
• Cultivate a co-design mindset,
not just an expert one
• Start with shared purpose
• Design for a complex
system (CAS), not a
complicated one
• Create adaptive spaces
where people can learn
and share
• Build an outward mindset
• Involve potential adoptees
right from the start
• Evaluate, reflect and learn
as you go
Scaling down Scaling up
@helenbevan

A role description for a convenor
1. Convenor: creating spaces where people can come together to learn and
share and influencing people to take part
2. Choreographer: bringing diverse people together, building bridges
between their different worlds and creating the “dance”
3. Co-producer: ensuring that consumers, families and staff at the point of
care are true partners in making and spreading change
4. Connector: helping people make links with each other, within the system
and beyond
5. Capability-builder: supporting people to use proven methods and tools
for making and spreading change
6. Clarifier: helping people make sense of the changes from their own
perspective and reducing ambiguity
7. Coach: providing support and mentoring to help guide and steer change
8. Community-builder: building a shared purpose and a sense of “us”
Source: adapted by Helen Bevan from the work of John Bessant

Scaling down and scaling up

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