Clinical leadership in improvement - PowerPoint Presentation

Clinical leadership in improvement Professor Matthew Cripps@matthew_cripps1

What will we cover? 2 What is leadership in improvement? The journey to improvement leadership Role and foundations of leadership in improvement Tools and techniques How do our minds work? What are the basics of optimal improvement? Bits and pieces – e.g. saboteurs, planning fallacy, knowledge transfer

3 What is leadership in improvement? Helping people choose to do difficult things that make things better, and showing them how Key elements Processing Knowledge transfer Prototyping “Failure is the opportunity to try again more intelligently” Persuasion Behavioural science Persistence If you know you’re right, never give up – but make sure you a re right!

How did we find ourselves here? 4 Does anyone set out to be an improvement leader? E.g. I ended up here out of frustration, laziness and ego… “Why do I always have to be the one to say No?” “What would we be doing differently if I lived in a world where I got to say Yes?” And so began the accidental invention of the RightCare approach…

Evolution of NHS RightCare Atlases of Variation & Health Improvement Packs Clinical and Financial Engagement Improvement processing Clinical leadership The “Way in” – indicative data and “Where to Look” Intelligence packs – “What to Change” Knowledge transfer and shared learning – “How to Change” Prototyping – “what’s wrong with this?”

Role and foundations 6 What’s the Point? Is the primary purpose of improvement – 1. To improve the health system Or; 2. To keep the NHS financially viable

What’s the point? 7 In reality it’s both – Deciding where to improve should focus on population health need AND account for the need to stay afloat This leads to the first algorithm for healthcare leaders (Where to Look)… Where are we letting our population down the most in terms of their healthcare? And; Where are we wasting the most money doing the letting down? And how does the leader lead this?

The role of the leader 8 Ensure and guide through EASE – E vidence-based positioning, choices and decision-making A wareness – the first step to improvement S implicity – embrace reductionism E nablers – inputs, processes, outputs & outcomes Push vs Pull “It is said of a good leader that when the work is done, the aim fulfilled, the people will say “we did this ourselves”” – Lao Tzu

Evidence-based positioning 9 Knowing you’re right before you’re belligerent… If we ensure we take evidence-based positions, then we know we’re doing the right thing. How many of us do this now? For most of us – not as much as we could…

Intuitive and considered thinking:‘Thinking Fast and Slow’ 10 Daniel Kahneman , Nobel science prize winner, psychoanalyst and behavioural economist - “we all think fast and slow” His research shows beyond statistical doubt that If we give a predominance to either fast (intuitive) or slow (considered) thinking… This makes us are more often wrong than if we balance the two Where are you on the scale? Intuitive Considered

How do you get nearer the middle? 11 Seek further evidence Ante/ Pre-mortem planning - Imagine failure – assume you follow your first thought and it goes horribly wrong – what might have happened? Why? Argue with yourself…

Clinical leadership in improvement –evidence you’ll like… 12 There is a statistically significant correlation between higher quality, outcomes and patient satisfaction and more clinicians on the boards of NHS organisations Clinical Leadership and the Changing Governance of Public Hospitals, Public Administration 2015. Veronesi , G., I. Kirkpatrick and F. Vallascas Clinicians on the Board: What Difference Does It Make?’, Social Science & Medicine , 77, 147–55. (2013) Veronesi, G., I. Kirkpatrick and F. Vallascas

But… 13 The same study found that, in the absence of extensive financial involvement, more clinical leadership leads to less efficiency Add in extensive financial engagement and this goes away A role of leadership is to make sure everyone is involved, as much as possible - “I never achieved any significant improvement without a manager and an accountant standing next to me” – Professor Sir Bruce Keogh

Awareness – the first step 14 We have to know where we aren’t very good in order to know where we can get better This leads to a key concept of leadership – Embrace negatives to create positives, e.g. Where aren’t we very good? Leads to “how do we become good?” (In planning) What could go wrong and how do we mitigate?

A key principle of population healthcare improvement 15 If we aren’t aware of clinical and financial variation, then we can’t head off in the right improvement direction “What good is running if you’re on the wrong road?” – German proverb Variation allows us to discuss and conclude Where we are different Where those differences aren’t warranted (and therefore where we should focus our improvement effort) What we would look like if we didn’t have those differences How to change ourselves so we eliminate those differences

Simplicity 16 “Great things are done by a series of small things brought together” Vincent Van Gogh “The simple answer is always the best” William of Ockham “ If you can’t solve a problem, then there is an easier problem you can solve: find it” George Polya

What can ancient Greece and medieval England teach NHS improvement? System Vs Pathway - do people design complexity or simplicity better? Thales’ principle of reductionism and Ockham’s Razor Components (steps in pathways) are simpler to understand than whole systems (e.g. FE, UC) Break down to simple components, design optimal and build back u p into complex systems Mild heart conditions treatment – change lifestyle first, before prescribed drugs. Learnt this via reductionist research on body chemistry and physiology.

The simple answer is always the best 18 Already simplified the “way in” to improvement (where we should focus) – Where are we letting down our population the most, in terms of their healthcare, and where are we wasting the most money doing the letting down ? Leaders need to help teams and systems to simplify – The causes of the problems healthcare improvement leaders need to tackle How to identify the solution The process of improvement

Simplifying the problem 19 Overuse and Underuse Overuse – leading to Waste Patient harm (even when the quality of care is high) Underuse – leading to Failure to prevent disease Inequity

Simplify how to identify the solution 20 Get everyone to agree what we would look like if we were as good as we could be

Simplifying the improvement process 21 Where to Look (Diagnose) What to Change (Design) How to Change (Deliver)

Why won’t everyone just do what I think? 22 “What we wish, we readily believe, and what we think, we imagine others think also” – Julius Caesar It might be that what you think is wrong. But, often its because how we convey what we’re thinking doesn’t tick other people’s boxes So, do we seek to change the boxes they want ticked (huge cultural and behavioural shift) or is it simpler just to… Tick their boxes?

The decision-making table 23 Consensus Medic General Manager PH officer AHP Nurse LA CEO CFO Provider

Is that all? No…. 24 Meeting the needs of differing perspectives/ objectives/ mandates are part of the equation But that alone won’t tackle everything…. …behaviours and how our minds work matter at least as much… An understanding of behavioural science can help all leaders and their teams

What is behavioural science? 25 According to LSE: Behavioural science is the cross-disciplinary, open-minded science of understanding how people behave. It cross-fertilises and brings closer together insights and methods from a variety of fields and disciplines, from experimental and behavioural economics to social and cognitive psychology, from judgement and decision-making to marketing and consumer behaviour, from health and biology to neuroscience, from philosophy to happiness and wellbeing.

Meet Linda 26 Linda is in her mid-30s At university she studied political science and her dissertation was on women’s rights in the post-industrial political landscape In her teens and early 20’s she was politically active regularly attended feminist events and political marches Which of the following do you think most likely describes Linda now? 1. Linda is a healthcare manager in a CCG 2. Linda is a healthcare manager in a CCG and member of the CCG’s equality and diversity working group 3. Linda is a healthcare manager in a CCG, member of the E&D group and a politically active feminist

Linda’s probabilities 27 Healthcare manager / member of E&D group Healthcare manager Healthcare Manager / E&D Group / active feminist

Broken rules 28 This is representativeness trumping statistical fact - a rule of probability is that the more detail you add the less likely a thing becomes But our minds over-ride this because Options 2 and 3 represent the type of person we feel Linda is and our minds latch on to this: Our intuitive thinking has latched on to available evidence and given it more weighting than it deserves Even if I had said that Linda is a healthcare manager and chair of the E&D group. I haven’t made option 2. more likely than 1, just as likely

Principles of the human mind 29 By and large, humans believe they are rational creatures. But… Our minds are highly susceptible to making systematic errors and then covering up the fact that this has occurred. Our minds also make it easy for us not even to wonder whether a systematic error might have occurred .

Behavioural science – influencing us all 30 A poorly chosen font makes us pay less attention to the message in a document, and to be more inclined to disagree with it. If you nod whilst seeking to persuade someone, they’re more likely to be persuaded People in good moods relax, their considered thinking switches off and they are more likely to make errors of logic. If you frown while you think, you’re less likely to be tricked by your intuition

Pick out the most important words in this NHS RightCare narrative… 31 Welcome to your practice level data pack on cardiovascular disease (CVD). This pack helps to identify variation and opportunities between demographically similar general practices on key indicators along CVD pathways. The focus on practice-level variation is to help CCGs to target their improvement support to the member GP practices that will most benefit. To this end , GP practices have been compared with their own demographic cluster group and not with the CCG’s. CCGs and practices can use this pack to target population healthcare improvement and work together to bring quality and value up to that achieved by similar practices, working closely with NHS RightCare and its Delivery Partners.

Switch it off! 32

Switch it off! 33

Lazy brains 34 Human minds are inherently lazy As a result, intuition overrides consideration by our very nature

Lazy brains – answer this question… 35 A bat and ball cost £1.10 The bat costs one pound more than the ball How much does the ball cost?

Lazy Brains 36

Lazy Brains 37

So how does intuition work? 38 Intuition relies on recognition (pulling things from our minds that were already there) – clinical education and training uses this fact extensively But where there is no recognition to be had, e.g . with an innovative improvement opportunity, our intuition does not consider this and switch itself off, leaving the stage clear for our considered thinking to take over… Instead, it tries to override our considered thinking, fill in gaps it can not fill in and flood us with confidence that we know what we can not possibly know “ O ur excessive confidence in what we believe we know, and our apparent inability to acknowledge the full extent of our ignorance” – Daniel Kahneman

How should a leader account for this? 39 “All I know is that I know nothing” – Socrates Always consider that you might be wrong Make sure your team feel comfortable saying what they think, including when they think you’re wrong (they’re very good at knowing!) Always consider that others might be wrong too! Especially if they make quick decisions and don’t change their minds very often Intuitive Considered

Break 40

Decisions, decisions 41 Understanding behavioural science is all about enhancing decision-making NOT manipulation (unless the individual using it is being manipulative ). Behavioural Science IS Understanding how the mind works and the strengths and weaknesses inherent in this Why do people make the decisions that they do? How do they make them ? Using this knowledge to lead, build cases and help decision-makers increase proportion of correct decisions and successful delivery If we understand how the mind works when it considers information and makes decisions, we can account for it and increase the rate of good vs bad decisions (our own and those of others )

An unambiguous statement 42 Ann approaches the bank

Ambiguity 43 With balaclava on head and gun in hand, Ann approaches the bank

Ambiguity 44 Seeing the ducks on the river, With balaclava on head and gun in hand, Ann approaches the bank

Inputs vs processes vs outputs 45 Which is most important? Two minutes in pairs… You can have the best inputs in the world but if there’s no (consistent) process, what are you going to do with them? Your process can be optimal but if the “way in” isn’t you’ll use it on the wrong things Dangerous as means you’re good at delivering the wrong stuff If you don’t have well articulated outputs, how will you deliver what is needed and know you’ve done the job? And how will you enthuse stakeholders to join in at the beginning?

46 Ambiguity – our issue We believe the most important parts of any process are the ‘ way in ’ and ‘ way out’

Our experience of ambiguity 47 In local health economies, we found that when decisions were made on which programmes to prioritise and deliver – there was no clear process on ‘the way in’ or ‘ the way out’ for Executive, Clinical and programme leads Ambiguity and inequality were rife Projects which were sub-optimal were getting through the decision making process as a result, colleagues with innovative ideas were disenfranchised and the population wasn’t getting the improvement it needed

48 Algorithms & decision-making Over 200 studies into decision-making via algorithms vs decision-making without them 60% found that algorithms led to significantly better decision-making 40% found that there was no difference This is essentially a 100% victory for decision-making via algorithms – they never lead to lower value decisions and most often lead to higher value ones. How does this manifest in healthcare? E.g. without algorithms, experienced radiologists contradict themselves 20 % of the time when they see the same image on different occasions .

Use decision trees 49 The use of clearly defined decision criteria reduces ambiguity and increases the quality of projects selected Worked with the frontline to enhance CCG 2018/19 improvement plans You all have these in place… But are you using them? Leaders can ensure that they are used…

Do not proceed No Are there any health benefits? Ideas & Cases Is it a must do? Can it be delivered? Does it save money? Can it be made deliverable? Prioritise Yes Yes Yes Yes Yes No Do not proceed No Does it increase value*? Yes Rate of Return <12 months Rate of Return >12 months High Priority RoI * >£250k Medium Priority RoI * >£100k Low Priority RoI * <£100k Medium Priority RoI * >£250k Low Priority RoI * <£250k Set Timetable for completion of case outline* Blackpool CCG Decision Tree for prioritising reform proposals No No No High Priority RoI * >£500k

Enablers 51 Leaders don’t need to understand all of the components of an improvement approach… But they do need to make sure T he components are there They are fit for purpose and are followed Someone understands and coordinates their use People skilled at the components are all engaged and involved

Four principles of sustainable healthcare improvement 52 Get everyone talking about the same stuff What should we talk about? Where to Look principle How should we agree? Algorithms Talk about the fix and the future Understand past to understand and fix problems, but Not to assign blame Demonstrate viability Clinical case – evidence and do-ability Business case – logistics, finance and do-ability Isolate the true reasons for non-delivery Resist cognitive ease! Fight availability! In a supportive way!

Five key ingredients to delivery of optimal population healthcare 53 Clinical leadership Indicative data Comprehensive engagement (and consensus) Evidence (data, research and knowledge) Effective improvement processing

Three rules of Business Processing for improvement 54 Rule 1 Have a business process fo r i mprovement Rule 2 Only have one business process Rule 3 Use your business process

Start to finish improvement 55

A few more bits and pieces… 56 Keep your team fed and watered Champions, saboteurs and common myths Information frames , primes and anchors Beware Cognitive Ease! Beware the planning fallacy! Problem-solving and your internal encyclopaedia

Attention to detail and interpretation 57 The Depletion Effect – when we’re tired/ low on energy Eight Judges on the Israeli Parole Board were unwittingly used for an experiment: They were fed high glucose foods at morning, lunch and afternoon breaks every day. The overall rate of parole requests that were approved = 35% The rate just after food = 65% The rate just before food (when most hungry/ depleted) = 1%

Champions and saboteurs 58 Find your champions – they inject pace and enthusiasm from the outset Identify your saboteurs and target them Plan A – convert them (they make the best champions) Plan B – make sure they don’t get in the way

Saboteurs 59 When your saboteur knows more than you do, you can’t win the technical debate – find another angle Two effective approaches – Work out what the real problem is (breast cancer surgeon) Defer the debate until you can win Use variation (clinicians – HbA1c) Find technical allies (finance, procurement, contracts, analytics) Learn yourself ( statisticians)

Common myths in healthcare leadership – assume these are wrong! 60 We always do evidence-based best practice medicine We do LEAN! We can’t use this data – it’s old We don’t spend the money We’re too busy We’re special and different

Framing, priming and anchoring 61 Priming is a mental reaction to one stimulus caused by another stimulus. It has a very powerful influence on our minds. Framing is a subset of priming. Understanding its principles and affects allows us to eradicate priming we don’t want and enhance priming we do. Physical Priming If you nod your head when conveying a message, more people will accept what you’re saying. Equally, s haking your head has the opposite affect Verbal priming Grey, old, frail, retired, 83, palliative, Grandma, doddery, wrinkled.

Framing, priming and anchoring 62 Rule 1 – you can’t say “population healthcare improvement” too many times It’s a frame, a prime and an anchor

Information framing 63 Three ways of conveying information – Numbers Pictures Narratives Don’t assume everyone likes it the way you do - i f you want everyone engaged, engage everyone!

Anchoring 64 A form of priming that is hard to mitigate Anchoring hooks our brains to a starting position that our intuition convinces us is robust and then keeps us close to.

Anchoring and performance targets 65 Aim for the 75 th percentile…. The ambitious will aim beyond the 75 th The normal will aim for around the 75 th The less ambitious will aim for below In NEW Devon in their first year of RC they aimed for 115% (on basis that their peers were not optimal so neither was 100 %) Whatever they achieved in that year, the evidence of anchoring shows they would have achieved less if the anchor was 75%

Anchoring and collective self-belief 66 Enthusing the down-trodden – If you ask a project team lacking self-belief – think of 4-6 occasions you have broken through these barriers before and successfully improved the system, they will come up with 6 examples with relative ease. If you ask another group to think of 12 occasions, they may get to 12. However, the last few may be hard to recall and the task will therefore feel difficult. The group that thought of 6 is more likely to believe in itself than the group that thought of 12. All because the selection of the anchor made the task easier.

Beware cognitive ease! 67 When you ask a difficult question, people rarely answer it They think they’re answering it but cognitive ease is at play “Does this variation present an opportunity to improve?” becomes “Can I justify this variation and ignore it?” “How do I enable better shared decision making and supported self-care?” becomes “Can I fit SDM and supporting self-care into my already busy schedule?” Don’t assume anyone’s first answer is necessarily their best!

68 Beware the planning fallacy! Teams plan via “the inside view” – what we think we already know about ourselves. Our intuitive over-confidence then layers on loptimistic bias to convince us this is robust. But, “the inside view” ignores the experiences of others and our own negative experiences (pessimistic/ realistic bias ), e.g. Likely but unknowable causes of delay (sick leave, delays in things out with our control, bureaucracy, etc ) Slow down once initial enthusiasm flags and attention moves to the next new exciting thing

69 The planning fallacy in action Date Scottish Parliament Building plan - cost projection July 1997 £40m June 1999 £109m April 2000 Government set a cap of £195m Nov 2001 £241m Dec 2002 £295m June 2003 £376m 2004 Completed at cost of £431m

70 Mitigating the planning fallacy The Ante- or Premortem approach – When close to a major planning decision, bring together the team and conduct the following exercise: “Imagine we take this decision and are now a year into implementing the plan. It has been a complete disaster. The initial decision was very wrong. Spend 10 minutes writing a brief history of that disaster.” This allows for group doubt (people suppress their doubts once they feel a decision is inevitable, for fear of not being perceived a team-player) and opens up the creativity of knowledgeable people to consider “what might go wrong?”

71 Problem-solving and our internal encyclopaedia Conscious use of knowledge transfer expands on use of availability. Leaders significantly enhance their capabilities if they do this. Opening up our internal encyclopaedia creates the impact of multiple advisors/ good decision-makers in one person. Devised a test to nudge natural aptitude by priming people to think about two things they know a lot about and encouraging them to transfer knowledge from one to the other . If you practice this you can make it a habit: “ Describe something you are passionate about from your personal life, that has nothing to do with healthcare, and tell us what it can teach us about improving the NHS ”

72 Five minutes in pairs… One of you to describe something you are passionate about from your personal life, that has nothing to do with healthcare (2 mins) Then work together to identify something it can teach us about improving the NHS (3 mins)

Summarise…. 73 P rocessing, P rototyping, P ersuasion, P ersistence Maximise impact via EASE - E vidence-based positions, A wareness, S implicity, E nablers Use knowledge transfer and behavioural science Stick to what you believe BUT only once you’ve ensured that what you believe is not always your first opinion! If it is, that is probably your intuition fooling you and you should probably believe something different. Say “population healthcare improvement” over and over

Generics of optimal improvement processing 74Step 1 – Awareness is the first step to improvement Step 2 – Find a champion Step 3 – Engage the right people to design optimal Step 4 – Understand the problem (use data) Step 5 – Convert data into knowledge and design optimal Step 6 – Use delivery levers to implement So, when did it all begin? Knowledge transfer from the ancient world….

Roman calendar c. 250BC - 49BC 75 355 days in a year 10 months (most years) Added an extra month every so often to catch up with the lunar cycle Extra months were determined by the College of Pontiffs (a set of priests with a focus on astronomy) Current situation – the system sort of worked and they muddled through year to year (sound familiar?) Problems – e.g. harvest would often officially occur weeks before or after the crops actually needed to be harvested

Egypt 48BC – Gaius Julius Caesar 76

What happened? 77 Step 1 – Awareness is the first step to improvement Senators had begun to notice lower corn supply in years prior to extra months and wondered whether the current system was fit for purpose (= unwarranted variation ) Step 2 – Find a champion Step forward Gaius Julius Caesar, enjoying a prolonged visit to Egypt, in the arms of Cleopatra (= strong change leader ) Step 3 – Engage the right people World’s leading academics Mathematicians, Astronomers (lunar cycle) Epicureans (pre-cursor to modern scientists) Senators and other land owners (farmers) (= expert and stakeholder engagement )

What happened? 78 Step 4 - Collect and analyse data - understand the problem Trawled back through all the calendar and seasonal records, star charts, religious festivals (= produced a data focus pack ) Step 5 – Convert data into knowledge and use to design optimal Met with all the engaged experts in Alexandria Library until had the answer (= optimal design event ) Step 6 – Use delivery levers to implement Took over the republic of Rome, made himself Dictator, enforced the change (= slightly tenuous link to – isolate the reasons for non-delivery )

What happened? 79 Optimal design – 365 day year over 12 months Extra day every fourth year to re-align with lunar cycle In time, led to increased corn supply to Rome which was used as a form of welfare benefit ( population healthcare improvement ) 2,066 years later, we’re still benefitting Knowledge transfer: The process itself Moral of the story: If you lead improvement properly you create a sustainable solution

Conclusion – leading improvement is a tough but satisfying life Alexander the Great complained to Aristotle that leaders are constantly criticised Aristotle said - “If you want t o avoid criticism - say nothing, do nothing , be nothing” @matthew_cripps1