Getting ready for change

Michelle Church updated 2019

by Michelle Church, Improvement Advisor

‘Change matters. It forces us to act.’ – Will Storr

I started out writing this blog post like a report, out of habit. I want to develop a new writing style that is more appropriate for blogging, and it’s proving harder than I thought. This got me thinking, ‘Why is changing so challenging?’

 

A bit about habit…

I recently learnt that around half our waking day is habitual (see this study by Neal et al, which looks at experience-sampling diary studies), and that all of us have neurological loops that drive our behaviour. In Charles Duhigg’s, The Power of Habit, he explains that researchers at MIT discovered a simple neurological loop: cue, routine and reward.

They discovered that when designing new routines it is essential to identify the trigger for the action, otherwise old behaviours will continue. Also it turns out we don’t need to change the cue and reward for the change to stick. In fact, their research concluded not to: change only the routine. For new habits to form, we need to keep the same cue and reward.

Modes of thought

I have learned about how our brains are wired to be energy efficient. Daniel Kahneman, winner of the 2002 Nobel Memorial Prize in Economics, argues that we have two modes of thought: fast and slow.

The first mode of thought is fast. This is our natural state – automatic, intuitive, effortless. In this mode we create habits (patterns such as our route to work) to make living efficient. In the work environment these habits become the routines and processes that drive nearly every aspect of our working lives.

The second mode of thought is slow. It is deliberate, reflective and analytical. We go into this mode when planning a trip overseas, or learning something new.

When we experience change, when we learn or change a routine, we think more slowly and it takes effort. This may seem obvious, but it has transformed my ability to support improvement work. I have a greater understanding that the resistance to change is because we don’t like disrupting our habits – it goes against our energy-saving neuro-programming and reward structures.

There’s some good news, though, as it seems that we are also neuro-programmed for change. In The Science of Storytelling, Will Storr observes that we are alerted to things that might threaten our sense of control, becoming curious to discover the whole story and regain a sense of control. Our ability to be curious is a great starting point for improvement. Despite the effort required, most of us love to explore and learn.

Stepping outside of your comfort zone

If I’m honest, I normally want to explore a good castle or hillside and quickly return to my creature comforts. My experience of change that involves deep learning or changing my habits, where I am not sure what the change will involve and it seems beyond my control… well, it can often feel like the pits. James Nottingham sums it up well in his visual journey of the learning challenge. He uses the image of a pit to illustrate the obstacles that people encounter in learning something new, and how it takes them out of their comfort zone.

Learning pit

Source: Challenging Learning

Combining John Fisher’s Personal Transition Curve with this image of the learning journey can help us to understand how individuals might respond to change, and consider what might move people into acceptance and take up new behaviours.

In addition to understanding the challenges associated with learning something new, it is also important to consider what motivates people. Daniel Pink (author of Drive, which explores human motivation) argues that intrinsic reward, doing something because we find it gratifying, is as just as important as biological and extrinsic rewards.

Discovering the personal and relational, intrinsic and extrinsic motivations is essential to understand the reward we all need.

Breaking habits

Change is challenging, as habit is such a dominant force in our lives. However, understanding the reasons why we find it difficult to change, tapping into people’s curiosity and desire to learn, and understanding their motivations can help us to break away from old habits, and create new ones.

 

Living and Dying Well with Frailty Collaborative – Learning Session One

Picture 1

On 19 September 2019, 21 teams  taking part in the Living and Dying Well with Frailty Collaborative came together for the first learning session where they learned how to test their ideas using a range of improvement methods, and how to measure their activities and the impact they make. They also heard from each other about the frailty work being undertaken in the various Health and Social Care Partnerships and GP practices, and had time as a team to look at their project charter and develop their plans for their next test of change during the learning session action period.

Living with Frailty

People are at the heart of what we do, so we started the day by hearing from those living with frailty. We heard about the experience of Mr Lucas, who featured in our video. He spoke about how the support that he receives from services and family helps him to live independently with frailty. Mr Lucas is one of Dr Paul Baughan’s patients, the Living Well in Communities (LWiC) National Clinical Lead for Palliative and End of Life Care and GP at Dollar Health Centre.

 

twitter-logo (2)“I hope I’m as able as Mr Lucas when I have moderate frailty. I love how it was the carers, reading and music that helped him live well with frailty.”

 

We also had Hugh Donaghy join us for the day. Mr Donaghy is a carer for his mother and spoke to Professor Graham Ellis, the LWiC National Clinical Lead for Older People and Frailty, about his experience of providing care to someone living with frailty. Hugh discussed how technology is helping him to support his mother in her home, the blurred line between being a carer and a relative, and the challenges of hospital stays: each time his mother comes out of hospital, her frailty increases.

 

twitter-logo (2)

“Carer experience of mum with long term conditions going in to hospital ‘each time she comes home she’s that bit frailer’ – how can we build resilience when someone comes back home?”

 

Picture 2

I want to be involved in the Frailty Collaborative because…

Alec Murray, Associate Improvement Advisor, led a short ice breaker with the teams using Slido to ask the teams how they felt about being involved in the collaborative, creating the word cloud below…

LS1 Word Cloud

It was great to see people and care at the centre.

Throughout the day there were a number of questions asked on Slido. We didn’t have the opportunity to respond to all of these on the day, so we’ve pulled together our answers in this form: Slido Questions and Answers

Learning about Improvement

The teams then had the opportunity to learn about Quality Improvement Methods and Measurement for Improvement, led by the Living Well in Communities Improvement Advisors and Associate Improvement Advisors (Nathan Devereux, Scott Purdie, Dianne Foster, Tom McCarthy and Michelle Church).

Quality Improvement Methods

When we designed this session we wanted to explore with the teams a range of Quality Improvement concepts and tools. We held an introductory WebEx where we polled the teams to find out how much knowledge and experience everyone had in using QI tools. The teams told us that there was a real mix of skills and experiences in the room, and the results indicated that we should spend a little bit more time on the change package. Therefore the session was designed to give everyone a flavour of some of the approaches that might help teams in the action period.

At the end of the session, the teams were asked for their lightbulb moments:

“Build on existing practice and evidence with data”

 

“Small steps to improvement are better than a leap of faith”

 

“Even failed attempts are learning and a critical part of improvement”

 

“Don’t reinvent the wheel – SHARE”

 

“In order to spread change, you need to explain to others why it’s important, how it works and have a narrative”

 

Measurement for Improvement

As this was the first session we aimed to get everyone on the same level, so that teams were prepared for the first action period. We covered some of the practical elements of measurement for this collaborative, including the data collection method.

The collaborative is focused on three core measures, which represent an increase in involving people in conversations about their needs and care, and also a shift to more planned activity.

In the session we introduced the measurement plan tool designed to help teams collect this data and also provided time for teams to consider what their measurement priorities are, including local priorities and measures which take account of interventions (such as polypharmacy).

It was great to discuss measurement of the collaborative at the first learning session and particularly to hear the views of teams about how best to approach what can be one of the trickiest parts of improvement – measuring whether you make a difference.

Learning from Across Scotland

We had 15 teams and national organisation representatives host tables where they presented on what work they have undertaken on frailty in their area. This was ‘world café’ style, where everyone had an opportunity to go to three tables and hear about work in other areas and ask questions.

There were some great discussions, and the feedback we received indicated this was a very popular session. It was beneficial for them to hear about what is happening in other areas and have the chance to discuss challenges faced, as well as successes.

For example, Rebecca McLaren and Eileen Downham from the Angus team presented work on their Enhanced Community Service and community multidisciplinary team (MDT) meetings. The challenge faced in Angus is that a person can be registered to any of eight GP practices because practice boundaries overlap. The group were particularly interested that a medicine for the elderly consultant from hospital attends the community MDT meetings.​ If a consultant can’t attend then an advanced nurse practitioner attends in their place.

North Lanarkshire HSCP has been working with hospital at home and 30 GP practices to test MDTs. They found the challenges were around data and how home visits can be recorded. Also whether it is possible to measure the quality of ACPs, and creating an infrastructure to support people wishing to stay at home.

For a full list of these topics please click here. For more information about anything which was discussed, please get in touch via email – hcis.livingwell@nhs.net – and we can put you in touch with the relevant team.

Team planning

Teams were then given time to work together on their project charter and action planning for the first action period of the collaborative.

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If you are undertaking similar improvement work you may find the below resources helpful:

National Change Package

Project Charter Template

RACI Action Plan

 

twitter-logo (2)“Fantastic reasons to be at #LWiCFrailty today. But “a goal without a plan is just a wish” so now time for action! Thanks for a useful day of sharing & learning @LWiC_QI @eFI_Midlothian”

 

What next?

Away teams will share their learning with the Home Teams and begin their tests of change, or continue with any tests already underway. They will be documenting their progress and recording data over time, with the support of the Improvement Advisors and Associate Improvement Advisors who are area leads for each of the teams.

For more information about the collaborative please visit https://ihub.scot/improvement-programmes/living-well-in-communities/our-programmes/living-and-dying-well-with-frailty/

For the PowerPoint slides from the day from all sessions, please click here.

Improving Care for People with High Levels of Need

HRI 1 PNG

(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

The High Resource Individuals team within Living Well in Communities is supporting Health and Social Care Partnerships (HSCPs) through a series of data Deep Dives, to understand how those with the highest level of need interact with services.

Thomas Monaghan, Improvement Advisor, from Healthcare Improvement Scotland’s ihub, and Nathan Devereux, Associate Improvement Advisor, have been contributing to the wider work on High Resource Individuals by exploring ways of improving pathways of care, with support from the Local Intelligence Support Team (LIST) and Information Services Division (ISD).

These Deep Dives help partnerships explore their data on these individuals and identify areas for improvement.

Who are High Resource Individuals?

High Resource Individuals (HRIs) are the small number of people who use a high percentage of hospital and community prescribing resources and inpatient bed days.

Continue reading “Improving Care for People with High Levels of Need”

Living Well In Later Life

What sorts of things come to your mind when you read the phrase ‘Living well in later life’? How can quality improvement help achieve this and why is the QI community across health and social care getting involved?

Surely how one lives, is not something that anyone other than the individual can control? Living well is about making your own decisions, about exercising choice. So why, one might ask are the health and social care organisations developing a programme that seeks to focus attention on this?

In a nutshell, what we are trying to do, through a series of projects is to empower older people and their loved ones to make decisions about how to live well in later life and provide guidance to help them navigate through the maze of choice of care solutions so that informed decisions about how one wishes to live well can be reached.

Continue reading “Living Well In Later Life”