HoW-CGA Chapter 3: Team approach to change

Clinical guidelines
i
Authors:
Simon Conroy
Topics:
Comprehensive Geriatric Assessment (CGA) in acute settings
Date Published:
28 August 2018
Last updated: 
28 August 2018

Designing solutions and delivering change is more effective when delivered by a core team of people who invest in engaging with a network of stakeholders. You may wish to start thinking about the advocates of improving care for frail older people in your service early. Inviting everyone who can help you reach your goal is beneficial in planning change, in explaining the need for change, and in sharing practical tasks in making change happen. Mutual support provided by the team will also help you deal with frustrations, and review your progress.

This is chapter 3 of a series. See the full series here

Designing solutions

Quality improvement leaders should be unwavering in their goal, confident they will reach it, and humble enough to ask everyone to help them get there17

Designing solutions and delivering change is more effective when delivered by a core team of people who invest in engaging with a network of stakeholders. You may wish to start thinking about the advocates of improving care for frail older people in your service early. Inviting everyone who can help you reach your goal is beneficial in planning change, in explaining the need for change, and in sharing practical tasks in making change happen. Mutual support provided by the team will also help you deal with frustrations, and review your progress.

As support for change widens and ownership of it expands, late adopters are also likely to get on board with your project.

It is better when members of the team have personal interest and stake in the change. People who may become part of your core team include:

  • Senior medical practitioner in your service (such as a surgeon, anaesthetist, emergency physician, urologists, and other specialists depending on your service)
  • Senior nursing practitioner in your service
  • Practitioner with geriatric expertise
  • General manager in your area with access to and influence in organisational and financial decision-making processes
  • Practitioners involved in multidisciplinary teamwork (such as a social worker, physiotherapist, occupational therapist, discharge co-ordinator or case manager)

Multi-disciplinary teams

In your improvement teams you will be working along the premise that high-quality care for frail older people is not ‘done’ by geriatricians. As evidence suggests, effective assessment and management is done across multiple domains (medical, psychological, environmental, social and functional), accompanied by case management and iteration of management plans. As such, it requires a co-ordinated multi-disciplinary effort. See a short video illustrating how multi-disciplinary teams operate.

Successful improvement initiatives often involve developing a clinician-led approach to improvement and involved professional bodies to counter the tendency to see improvement as management-led and imposed. They involve representatives from all areas and professions involved in designing the change, though in the NHS, input from a senior medical doctor is usually critical. Multidisciplinary teams with enough external support also ensure the skill mix required to deliver the improvement (13). Designing joint decision making ideally can help to generate a sense of shared purpose.

It’s a very complex social dynamic isn’t it, the way a unit functions and I think consequently you have to have people signed up to the shared objectives, and in the past, as we have gone on this journey we have got outcome data that shows that we make things better we get more people home, and we have a much lower readmission rate so based on those broad concepts we know what we are doing works. (Consultant Geriatrician)

Identifying the right team to involve in planning organisational change may include activities such as:

  • Process mapping
  • Stakeholder mapping (who are the key people to influence?)
  • Mapping skills available / skills missing
  • Considering questions such as how many people do we need, where do we get them, and who to ask for resources?

Team approaches to engaging others may include activities such as:

  • Corridor conversations and quick reviews may be more suitable for busy practitioners than organising formal meetings.
  • Making sure you are not missing out key people who need to be consulted or who have influence in the right places
  • Systematic targeting via existing departmental meetings

Key challenges

Getting data collection and monitoring systems right

This always takes much more time and energy than anyone anticipates. It’s worth investing heavily in data from the outset. External support may be required. Assess local systems, train people, and have quality assurance.

Excess ambitions and ‘projectness’

Over-ambitious goals and too much talk of ‘transformation’ can alienate staff if they feel the change is impossible. Instead, match goals and ambitions to what is realistically achievable and focus on bringing everyone along with you. Avoid giving the impression that the improvement activity is unlikely to survive the time span of the project.

Leadership

Getting leadership for quality improvement right requires a delicate combination of setting out a vision and sensitivity to the views of others. ‘Quieter’ leadership, oriented towards inclusion, explanation and gentle persuasion, may be more effective. This may require additional training.

The NHS Change Model

Shared purpose

“A clear sense of shared purpose is essential to any successful change. Organisations whose communities are strong, passionate and committed to delivering improvement and outcomes, create shared purpose as a common thread. Shared purpose connects us with our commitment and contribution to our core values - the things that bring us into health and care to deliver outcomes that matter to local communities, beyond just what we do as individuals, teams or organisations. We need to know not just what problems we are trying to solve and why it matters, but what our vision is for the future and why that future matters.”

Living Our Local Values Toolkit  http://www.institute.nhs.uk/building_capability/living_our_local_values/living_our_local_values.html

Leadership

Leading Large Scale Change is a guide provides principles to apply within various healthcare setting http://www.institute.nhs.uk/leading_large_scale_change/information/leading_large_scale_change_homepage.html

Other Resources

Building communities, engaging others

Skilled for Improvement? Learning communities and the skills needed to improve care: an evaluative service development, 2014. http://www.health.org.uk/sites/default/files/SkilledForImprovement_fullreport.pdf

Public Narrative Participant Guide introduces Public narrative as a storytelling based technique that enables connecting to people and calling them to take action https://www.ndi.org/files/Public%20Narrative%20Participant%20Guide.pdf

Corridor Conversations: Clinical Communication in Casual Spaces. In: The Discourse of Hospital Communication. Tracing Complexities in Contemporary Health Care Organizations, 2007.http://link.springer.com/chapter/10.1057/9780230595477_9

Story Telling http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/story-telling.aspx

Quality improvement through clinical communities: Eight lessons for practice, 2012.
https://www2.le.ac.uk/departments/health-sciences/research/soc-sci/pdf-resources/Quality%20improvement%20through%20clinical%20communities_Eight%20lessons.pdf

Leadership

The NHS Leadership Academy brings together tools and resources to support the Healthcare Leadership Model 
http://www.leadershipacademy.nhs.uk/resources/healthcare-leadership-model/supporting-tools-resources/

Process Mapping

NHS Scotland Quality Improvement Hub guidance on process mapping http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/process-mapping.aspx

Process Mapping – An Overview http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/process_mapping_-_an_overview.html

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