NEW WAYS OF WORKING TO DELIVER NEW MODELS OF CARE May 2015 Optimity Matrix 1 st Floor, Kemp House 152-160 City Road London EC1V 2NP Phone: +44 (0) 20 7553 4800 http://www.optimitymatrix.com
TABLE OF CONTENTS INFORM... 3 PROBLEM STATEMENT: DELIVERY CARE DIFFERENTLY... 3 TRANSFORM... 7 STRATEGY, SOLUTION AND BENEFITS... 7 OUTPERFORM... 12 CASE STUDY... 12 Page 2
INFORM PROBLEM STATEMENT: DELIVERY CARE DIFFERENTLY Globally, organisations are realising that in order to maintain their position in complex and uncertain environments, they need to organise and operate differently. In the 1960s, management academics argued that organisations needed to organise themselves in ways that matched the rate of change in their environment 1. The terminology and language around this has evolved over the last 40 years but the fundamental assumption remains the same; organisations need to be adaptive, anticipating rather than purely reacting to change. This is no less applicable in health and social care in England. NHS commissioners and providers in England, together with their local government and voluntary sector partners, have an opportunity through the Five Year Forward View 2 to realise their ambitions to transform the way services are designed and delivered. There is an ambition to move away from a health service that just fixes people and makes them better when they are ill, to one which aims to promote and improve population health and well-being first and foremost and when people are unwell, deliver services that have been designed with them at the centre. The vision is for a more collaborative approach that advocates managing systems or networks of care that engage closely with service users harnessing their energy and ideas to mobilise change. 1 The Management of Innovation, T. Burns and G. M. Stalker, 1961, London: Tavistock. 2 NHS Five Year Forward View, NHS England, October 2014. Page 3
Organising health and social care in a changing world One of the drivers for implementing new approaches to designing and delivering care, apart from the oft cited twin drivers of increasing demand and decreasing resource, is the hyperconnected and rapidly changing world in which the people who deliver and consume health and social care now live. The 2014 UK Customer Satisfaction Index demonstrated declining customer satisfaction for the third year in a row 3 as consumers, particularly younger consumers, demand higher levels of convenience and speed in services. This is reflected in the decline in recorded patient experience of GP services in England since 2012 4. Whilst both the health and social care workforces are older than the average for other sectors, the number of millennial employees is growing. This group has been shown to value greater collaboration, openness and sharing in their working lives, a characteristic that is reflected in the health and social care workforce as much as any other 5. Designing and delivering services that take account of the complexity, uncertainty, volatility and ambiguity of the world today challenges leaders, managers and frontline staff within the NHS and its partners to think about how they must work together in different ways. Demographic changes can be anticipated well in advance; however, changes in consumer behaviour in response to a more connected world are less easy to anticipate as the rate of technology change rapidly accelerates. The hierarchical nature of the health and care systems has struggled to adapt to changing demographic demands, let alone adapt to the fast moving changes in service user behaviour. Hierarchical management combined with public sector bureaucratic structures can result in slower and more reactive decision-making, inflexibility and reluctance to work outside organisational or functional siloes. These operating models that maintained control and maximised efficiency in the midst of certainty in the mid-twentieth century are less effective today. 3 UKCSI Customer Satisfaction Index: The state of customer satisfaction in the UK. July 2014. Institute of Customer Service. London. 4 GP Patient Survey: National Summary Report. July 2014. NHS England and Ipsos Mori. 5 Generation Y in healthcare: leading millennials in an era of reform. LE Piper. Frontiers of Health Services Management [2012, 29(1):16-28]. Page 4
One of the constraints to change highlighted in successive evaluations of health and social care reform has been the inability of providers and commissioners of health and care to anticipate and adapt to the changing environment 6; 7. So how can leaders of health and care providers and their workforce manage and work together in and across organisations differently to enable responsive, innovative and collaborative ways of working that will better meet the health and care needs of the populations they serve in the future? The US health care system has been facing very similar challenges and has spent the last five years developing new models of care alongside new payment systems. In the US, the structural changes prompted by the Affordable Care Act, have precipitated amongst the most successful ACOs a change in their approach to organising as new ways of leading and managing emerge 8. One of the early lessons from an ACO Optimity has worked with over the last four years, is that creating an environment which enables wellness, health and care programmes to be delivered collaboratively is not compatible with traditional hierarchical organisational design. The leadership of the ACO needed to create an open system of communication and collaboration across the network of providers to deliver the benefits of integrated care for service users. New models of care need new ways of working Much of the focus to date in England has quite rightly been on removing the structural and financial barriers that stand in the way of establishing networks of care. Responses in England have included integrated care pioneer projects and the Better Care Fund, extensivist models of care, the vanguard programme for New Models of Care and the Prime Ministers Challenge, amongst others. In each case, the health and care economy follows a well-trodden implementation path, appointing a programme or transformation director who then establishes a programme management office (PMO) to deliver a programme of work across the collaborating organisations. This is often staffed by project managers recruited from outside the collaborating organisations and located at the host or lead organisation. The programme team is seen as removed from the day-to-day work of the collaborative system or network so ownership of action and deliverables is difficult to achieve. 6 Culture and behaviour in the English National Health Service: overview of lessons from a large multi-method study. M Dixon-Woods et al. British Medical Journal Quality and Safety. 2013;0:1 10. 7 Large-System Transformation in Health Care: A Realist Review, A. Best et al. The Milbank Quarterly, 2012, 90: 3; 421 456. 8 Accountable care organisations in the United States and England Testing, evaluating and learning what works. S. Shortell et al. Kings Fund. March 2014. Page 5
This traditional PMO approach can be highly effective for technical and infrastructure programmes, where the scope of the work is contained and bounded and where control and compliance are central to effective delivery. In complex, adaptive and uncertain contexts, such approaches to programme management are less successful 9. This paper sets out an approach which has been used in other sectors to accelerate change and acts as a model or proof of concept of how a network of care can operate differently going forward. 9 Project management in the age of complexity and change. A Jaafari, Project Management Journal. Vol 34; No 4; Dec 2003. Page 6
TRANSFORM STRATEGY, SOLUTION AND BENEFITS Optimity s approach to transformation is rooted in the five key principles of Wiki Management, an innovative management model, which enable a network of care to rapidly collaborate around shared goals and accelerate its capacity to innovate. 1. The network must first collectively understand what is most important to service users. Successful innovators in the technology sector have learnt that understanding what your service user values and how they interact with the services you provide in a way that is a positive experience for them, is the primary driver of success. There are examples of this in health care provision in England among some of the community interest companies that have been set up over the last eight years, who actively engage service users in the process of service redesign and delivery 10. 2. Collaborative networks thrive not on the intelligence and ideas of individuals, but on the intelligence of the many. As a company, Wikipedia is a good example of the power of collective intelligence, using self-organisation to generate and review content rapidly. Academics have started using online games 11 to solve large scale scientific problems more quickly by harnessing the power of collectively intelligence. To leverage collective intelligence across the network, groups must be diverse, empowered to think independently, have access to local knowledge and aggregate or synthesise the information generated. 3. Leveraging collective intelligence involves bringing people together in open conversations which can happen in number of ways 12. Decisions about the best course of action are genuinely shared and collaborative, not made in the highest reaches of the hierarchy. That way everyone one can see how what they are doing contributes to better services for their users. These conversations do not have to take place in formal contexts. One of the reasons that Google provides free meals to staff on campus is that this promotes conversations between different people and groups, resulting in creative problem-solving as well as providing an understanding of what everyone else is doing. 10 https://www.gov.uk/government/collections/community-interest-companies-case-studies 11 http://www.theguardian.com/technology/2014/jan/25/online-gamers-solving-sciences-biggest-problems 12 Wiki Management. Rod Collins, AMACOM Books, 2014 Page 7
4. In health and social care, there is increasing focus on outcome indicators. Whilst these are very important in determining the long term impact of the system, they don t help the network of providers understand and respond quickly to changes in the environment and they focus on the past which cannot be changed. Instead, the focus needs to be on a few critical drivers of performance that matter and are reliably predictive and actionable. The balanced scorecard 13 is a powerful tool that can be applied across organisational boundaries to a collaborative network. This should be designed in the context of few simple rules which everyone in the system understands and uses to guide their behaviour. At Wikipedia the four simple rules are (1) all articles are presented from a neutral perspective, (2) all articles need to be referenced to a published reliable source and (3) no original research is published and (4) all contributors should assume good faith when working together 14. 5. Where speed is of the essence, holding people accountable to their peers rather than through an upward management chain enables greater responsiveness and innovation. Rather, the manager acts as an integrator of ideas from across a diverse network, ensuring that groups continue to openly communicate the progress they are making as they deliver their idea and the impact it is having. In organisations which have embraced this approach, people are responsible for the delivery of results, expected to collaborate and focused on the needs of the service user at all times. Above all, no one person can kill an idea. In order to translate this way of working into the health and care sectors, leaders, operational managers and frontline staff need to reset their behaviours across the network in terms of management, meetings and measurement. Managers move from being in charge to being enablers, meetings transform from being sites of top down information sharing and political debate to spaces where collective intelligence can be harnessed and innovative ideas are continuously used to reshape services. The collaboration is then measured using a performance management approach aimed at encouraging people to work together for the good of service users. The main resource that organisations need to invest in this approach is time. It requires people across the network to reprioritise what they are doing and stop doing things that do not enable them to use the five principles. This is not easy and it is where the enabling manager plays a critical role. 13 The Balanced Scorecard: Translating Strategy into Action. RS Kaplan and DP Norton. Boston, MA: Harvard Business School Press. 1996. 14 Wiki Management. Rod Collins, AMACOM Books, 2014 Page 8
Figure 1: The Foundation of Wiki Management, Rod Collins, Optimity The population health and wellbeing focus for the new models of care requires an approach that is fresh and innovative but builds on the strengths and values of the NHS and local government. There are; however, well established hierarchies within each of the partners that make up the systems or networks of care. They are each statutory organisations in their own right, governed by internal bodies and accountable to regulators and national bodies for their performance. The organisational structures cannot be dismantled without significant risk to the business as usual of the organisations involved. The scope of these different organisations is also far wider than the scope of the network of care, at least in the early stages of implementation. Optimity has adapted the Wiki Management approach to our work with health and social care systems or networks, helping them put in place different ways of working that will enable them to be collaborative and innovative in ways similar to innovative organisations in other sectors. Page 9
In particular, the dual operating system, 15 advocated by the management thinker John Kotter, puts in place an innovation and transformation network that operates alongside the traditional hierarchies but is populated by the same people as are embedded in the hierarchies and is governed by five key principles outlined above. Figure 2: Dual Operating System, John Kotter, 2014 The steps that Kotter advocates in establishing a dual operating system include: 1. Ask for volunteers who are committed to the vision (assuming this is clearly defined); 2. Empower them to free up some of their time, by delegating, sharing with colleagues or reprioritising do not do this for them, it can only be self-sustaining if those doing this own the whole process; 3. Let this collaborative system harness the collective intelligence of the group they need to move from taking direction from senior managers to developing, testing and refining their own ideas that they believe will achieve clear outcomes; 4. Focus on some quick wins initiatives that you know will have high impact, build on existing strengths and communicate the success widely and loudly; and 5. Govern the dual operating system through facilitation the role of the governing body is to set the direction of travel (vision), be clear about the expectations for performance 15 Accelerate: Building strategic agility for a faster moving world. J Kotter. Boston, Mass. Harvard Business Press. 2014. Page 10
against a small number of indicators and unblock constraints that are escalated up to the board by those delivering the change. In the next section, we look at how this approach is being applied in a health and social care system in the UK bearing in mind the earlier comments about the specific governance requirements of the public sector. Page 11
OUTPERFORM CASE STUDY Client: Optimity is working with a local health and care economy in England to implement their vision for a new model of care across the whole system. The network that has been defined includes the acute and community health care, primary care, mental health and social care providers and has the active support of the clinical commissioners and local government. Problem statement: Using the Optimity System Readiness tool 16, a full risk assessment identified areas that the partners needed to make immediate progress in to realise their radical ambition to transform health and social care for the population they serve. The strengths which were identified by this assessment included: A shared purpose and understanding at senior leadership level; Partnerships founded on system-wide relationships; and Some early progress in integrated health information technology. One of the priority system challenges highlighted over the course of this diagnostic assessment was that a traditional programme management approach to transformation and system integration had limited impact over the previous 12 months. This was due in part to gaps in governance, resourcing and performance monitoring. Optimity Solution: The system partners recognised that there was an opportunity to not just refresh this programme, but radically redesign the approach to transformation across the system. Optimity proposed the dual operating system as a mechanism that would enable the system to deliver sustainable change over the next three years. Working with senior leadership and a network of champions from across the system, Optimity has been supporting the set-up of a dual operating system where a whole system model of care network is being established to operate in parallel with the existing partner hierarchies. Table 3 below sets out how this has been approached. 16 Preparing for Primary and Acute Care systems: Learning from accountable care organisations. Optimity Orange Paper, November 2014. Page 12
Figure 3: Setting up the Dual Operating System in a health and care economy Dual operating system set up steps Ask for volunteers who are committed to the vision Empower them to free up some of their time, by delegating, sharing with colleagues or reprioritising Let this collaborative system harness the collective intelligence of the group Set up in practice The senior leaders shared the organisational narrative which set out the journey that individual network partners were on to achieve a whole system model of care and its distinctive contribution to the vision of services that are genuinely centred around the needs of the service user. This formed the basis of a stakeholder activation plan aimed at identifying and involving staff in all of the partner organisations and at all levels in owning the change to be made. Senior and operational leaders communicated as part of the narratives and stakeholder activation plan that they were empowering staff to take ownership of initiatives that would contribute to the delivery of the whole system model of care. To do this, they would need to identify what resources they needed in terms of time and development in support, reprioritising their own workload if necessary and leveraging support from across all partner organisations. Whilst the ideas and creativity of individuals were supported, these individuals were encouraged to bring together groups from across the system who could work with them to challenge, test and validate their idea using systems thinking tools. The Optimity team modelled this approach with groups of staff during the set up phase of the dual operating system, working closely with a small group of champions from across the partner organisations. Page 13
Focus on some quick wins Govern the dual operating system through facilitation Two work streams from the integrated care plan were identified where some progress had been made and there was an urgency to deliver high profile quick wins or there was a risk of losing the confidence of the front-line staff and service users. These work streams were used as proof of concept sites for the dual operating system. Design groups were established harnessing collective intelligence from across the system and a wider implementation testing group took the output and were asked to challenge, test and validate the ideas generated by the design groups, identifying potential constraints and work-arounds as well as any system risks the design group had not raised. These groups hold each other to account for delivery against agreed outcomes and milestones. The leadership of the whole system model of care transformation was tasked with setting the direction of travel, acting as an enabler and unblocker of constraints for front line staff and holding idea owners to account for the delivery of outcomes against milestones. There are likely to be some failures, that is, ideas which don t achieve the benefits that were hypothesised at the outset. The governing body is developing its level of comfort with this new way of operating. The group is in the early stages of working through the key performance drivers and indicators to assess the impact of the new model of care across the whole system. One of the most significant early benefits of this approach that is emerging derives from the wider engagement with front line staff. This is resulting in much higher levels of awareness of how the new model of care could impact positively on the experience of service users and the quality of health and social care services delivered. Staff at all levels from across the network of care are working collaboratively to create service delivery models that can respond more flexibly and in a more joined up way. Page 14
Niamh Lennox-Chhugani Niamh Lennox-Chhugani leads Optimity s NHS and local government work in the UK with over 20 years of health management, advisory and research experience in health reform, transformational change and organisational responses to change. Niamh has provided research, evaluation and consulting on health reform and transformation for a variety of UK public sector clients as well as working with international institutions advising governments, payers and providers in developing countries on the impact of reform strategies. For further information contact: Dr Niamh Lennox-Chhugani, NHS and Local Government Lead, E: niamh.lennox-chhugani@optimityadvisors.com, T: +44 (0)20 7553 4841 Page 15
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