NHS Modernisation Agency

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1 NHS Modernisation Agency Spreading and sustaining new practices: sharing the learning from the Cancer Services Collaborative (CSC) Research into Practice Programme Summary Report No.3 October 2002 What do the terms spread and sustainability mean to staff? What are the factors that influence the spread and sustainability of new practices in the CSC? What are the practical issues for change facilitators to consider? How are spread and sustainability linked?

2 2 Spreading and sustaining new practices: sharing the learning from the Cancer Services Collaborative (CSC) Summary Report No.3 - October 2002 What do the terms spread and sustainability mean to staff? What are the factors that influence the spread and sustainability of new practices in the CSC? What are the practical issues for change facilitators to consider? How are spread and sustainability linked? Knowledge regarding effective ways of spreading new practices is required if ambitious, national programmes such as the CSC are to fulfil their goals. In addition, to ensure that benefits to patient care can be maintained, there is a need to consider how best to sustain these new practices. During the first half of 2002, the Research into Practice Team conducted in depth interviews with 21 national and regional CSC managers and clinicians to learn from their experience, the key factors influencing the spread and sustainability of new practices. Discussion of these findings is presented in this report. The key research findings common to both spread and sustainability are: Spread and sustainability are separate but closely related issues. The terms spread and sustainability are interpreted and used in different ways by CSC personnel, which may have implications for modes of spread and sustainability. Engaging and involving the whole team in planning and implementing new practices facilitates both spread of new initiatives and sustainability. Engaging clinicians is particularly important for spread. Dedicated time for people to meet, reflect and discuss is required both to facilitate spread and in order to sustain ongoing service improvement. The challenge of meeting multiple agendas in health care inhibits both spread and sustainability. In addition, differing priorities between CSC personnel and trust managers are evident. Influencing clinicians and managers to work co-operatively and linking new ways of working into the wider agenda can have a positive influence. The degree of engagement and commitment of senior and middle managers is influential. A high degree of commitment enhances spread and sustainability; a low degree inhibits both. However, to date, middle managers have not been fully engaged in CSC initiatives and only a few organisations have widely adopted improvement methodology. Effective data collection is highly valued and seen as important for both spread and sustainability. However, poor trust IT systems hamper this process. Adequate resources, including staff, are required. If a need for investment is clearly identified but resources are not available, this can limit both spread and sustainability. In addition, difficulties in recruiting and retaining appropriately skilled staff may have a negative influence on spread and sustainability.

3 3 What do the terms spread and sustainability mean to staff? The research findings indicate that there are differences in the way staff understand and use these terms, dependent upon the context in which they work. Spread With regard to spread, some research participants focussed on the formal roll out plans, whereas others defined it more broadly, acknowledging how new practices are spread both within and outside formal mechanisms. Differences also occurred as to what was being spread, and to whom. Examples from the data include: Spread of improvement(s) Spread of methodology Spread of both improvement and methodology Spread to every consultant within the tumour site Spread to one clinician in each team, the responsibility for spreading to other consultants in the team being the trusts responsibility In addition, roll out and adoption were terms frequently used in association with spread. However again, these meant slightly different things to different people. When outlining the meaning of these different terms, one participant identified that: Everybody you talk to will say something different. (regional facilitator) Sustainability Similar differences in interpretation between staff were identified with regard to sustainability - in particular about what was being sustained. Three types of sustainability were identified from the data: Target(s) achieved and sustained Sustained use of the formal methodology/process to review practice Change(s) in practice sustained and built upon It is interesting to note that two of the three interpretations of sustainability relate to continuous improvements. This indicates that for some, sustainability is not merely achieving a change and sticking to it, but involves a commitment to further improvement.... those changes have been sustained but they ve also been built upon. (regional director)...constantly reviewing where they are at, constantly making improvements... (regional director) These different interpretations may have implications for the effectiveness of both the spread and sustainability of new practices.

4 4 What are the factors that influence the spread and sustainability of new practices in the CSC? This section provides a brief overview of the research findings in this area. Please refer to the main report for further details. Spread Factors influencing spread fall into two broad categories, human dimensions and infrastructure. Personal engagement Sustainability Factors influencing sustainability fall into four categories: Team ownership Widespread staff involvement New practices embedded as normal work Understanding CSC principles & improvement methods... it has got to become part of your everyday work without even realising you are doing it. (regional facilitator) Human dimensions Co-operative relationships Power & influence Team ownership Human dimensions are sometimes intangible, but central to achieving effective spread. Engaging managers Involving managers in the improvement network Clinicians & managers working co-operatively The project manager actually has to identify the movers and shakers in each particular area so that they can influence their peers...i don t actually mean in the same professional group, but in the overall peer group... (national clinical lead) Infrastructure Time Funding Cancer networks Data National direction & support Coherence with the wider context Links between CSC & other initiatives Trust board influence & support so, firmly embedding, whether that s within the trust, within the cancer network, within the new strategic health authorities, the PCTs, whatever, is absolutely crucial... (regional director) Reinforcing factors The nature of the change The benefits it may bring Formal & informal feedback to staff Adequate resourcing

5 5 What are the practical issues for change facilitators to consider? The following actions have been developed from the full research findings. Spread Actively involve the team in planning and managing the change. Plan meetings in advance and try to make the process fun. Use missionary zeal with caution. Evaluate any personal reaction to your level of enthusiasm and modify your approach accordingly. Model appropriate behaviour and facilitate co-operative relationships between others. This should include; facilitating shared learning, adopting a no-blame approach and seeking joint solutions to problems. Consider using both senior clinical leads from within the CSC and local peers in influencing clinicians. Within multi-professional teams try to identify consultant support for the change and identify key team members with abilities and influence to undertake leadership/change agency roles. Reflect upon whether the individual or team you are trying to influence has an existing perception of the benefits of the CSC. Acknowledge this perception and use this to consider what approaches may be most likely to positively influence them. Collate a wide catalogue of evidence of the benefits of the CSC, including performance measurement data and case studies. Try to match the type of evidence to your audience and avoid over use of the same examples. Identify opportunities for influencing managers. Understand their priorities and assist them to see how CSC initiatives may help address these. Consider the potential implications arising from the reduction in practical support from project managers. Appraise mechanisms for managing these. Reflect on the balance of change agency input to a project with the degree of progress. If some teams are not currently receptive, consider if your input may be more worthwhile elsewhere. Consider withdrawing, but remaining in touch, so that if the team wishes to engage with the CSC at a later date, it can do so. Encourage the team to critically review network leadership and support. Explore the potential impact this may have on the spread of CSC initiatives and support the team to identify strategies to manage this.

6 6 Sustainability Acknowledge different perceptions of the term sustainability and in discussing this with staff, try to develop a shared understanding. Involve staff from all disciplines and across all levels including managers, in planning and implementing new practices. Periodically review the beliefs of the team in relation to the new practice including any positive or negative impact it has on their workload. With the team, consider how to integrate new practices into normal work and identify permanent staff members with responsibility for undertaking any new ways of working. If additional resources are required, assist staff in identifying these and seeking funding. Identify opportunities for influencing managers regarding CSC and try to establish areas of common ground in order to set joint priorities and approaches to service improvements. Assist the team in identifying future potential changes to their service. Collectively, try to negotiate linkages with other developments and agree a joint way forward. Encourage the team to critically review the culture of their trust and in particular trust board commitment to new ways of working. Explore the potential impact this may have on the sustainability of CSC initiatives and support the team to identify strategies to manage this. Explore ways of co-ordinating CSC initiatives with wider trust processes. Provide education to all staff, including managers, in improvement methodology. Work with teams in identifying opportunities for the whole team to meet on an ongoing basis to progress continuous service review and improvement. Develop awareness across the whole team to observe any improvements in the care of patients with cancer having a perceived negative effect on other services. Acknowledge these and identify ways to minimise this impact. In liaison with the team and the trust information department, consider how ongoing data collection can be most effectively managed.

7 7 How are spread and sustainability linked? A number of factors identified in this research relate primarily to either spread or sustainability. However some factors are common to both, indicating a relationship between the two. For example, engaging and involving the team in the change process can assist spread. This also promotes feelings of ownership and can therefore aid sustainability. In addition, many of the findings within this report can be viewed upon a continuum. E.g., a high degree of team engagement and involvement in the change process is a facilitating factor for both spread and sustainability, whereas a low degree is an inhibiting factor. The following table outlines factors identified from the data that are common to both spread and sustainability. You may find it useful to assess your current improvement work for each of these influencing factors. If so, for each factor, place a mark on the continuum to indicate your current status. This may assist in identifying priority areas to be addressed. It can also be a measure of progress if undertaken periodically throughout a service improvement. Facilitating factor High degree of team engagement Dedicated time is available to meet & discuss improvements Effective data collection /analysis methods are in place Inhibiting factor Low degree of team engagement No dedicated time is available to meet & discuss improvements Effective data collection /analysis methods are not in place Resources, including staffing, are adequate to meet the needs of the new practice Shared priorities between clinicians/teams and managers are evident Clinicians and managers work in a fully co-operative way General managers are fully engaged and supportive of the new practices Improvement methodologies are routinely used throughout the organisation Resources, including staffing, are inadequate to meet the needs of the new practice Different priorities between clinicians/teams and managers are evident There is no co-operation between clinicians and managers General managers are not involved nor supportive of the new practices There is no evidence of the widespread use of improvement methodologies in the organisation

8 E S E A R C H I N T O P R A C T I C E P R O G R A M M E Conclusion This research highlights the wide range of inter-related influences on spread and sustainability. Every change situation will be different; there is no one simple recipe to achieve success. We hope however, that this summary report will provide some suggestions which change leaders and facilitators may find helpful. The report provides a summary of some of the research findings only; more detailed information is available in a full report available from the Research into Practice team. Further reading: Fraser SW (2002) Accelerating the Spread of Good Practice: A workbook for Healthcare, Kingsham Press, Chichester, West Sussex Kerr D, Bevan H, Gowland B, Penny J & Berwick D (2002) Redesigning cancer care, British Medical Journal 324, NHS Modernisation Agency (2002) Improvement Leaders Guide to Sustainability and Spread. More about the Research into Practice Team... This summary report is the third in a series, produced by the Research into Practice Team. The team was established as part of the NHS Modernisation Agency, in order to help capture and share the learning gained through service improvement activities. The research aim is to identify factors that influence spread and sustainability of new practices with the NHS. Research outputs include the production of actionable knowledge that is of direct use to NHS staff. This will include tools and models to support change leaders and facilitators spread and sustain new practices. For full copies of this research report admin.rp@npat.nhs.uk Tel: For further information about the findings of this research, contact Elaine Whitby, Research Associate. Further copies of this and other summary reports are available from: (under Research into Practice). Our thanks to those who gave their time to share with us their experience and learning.