I’m not sure if I found the world of improvement and implementation or it found me. As a dentist and a surgeon I wasn’t taught about ‘change theory’, so ways in which to make change happen in human systems was something I came to quite late. When I did, I was taught that there were three things you needed for change: the will to change, that is, recognition and behaviours by the people who are going to do the change and in the leaders who lead that change; ideas, in essence a recipe for whatever the focus of the change is; and then the third and crucial element is a plan to shape how you intend to execute that change.
It seemed to me that how you execute that change was lacking in most human system change, and without attention to this, your desired outcome is less likely to ever be achieved. So how we do that became the most important learning.
My reading of the evidence, and my experience of the last dozen years in Scotland, would suggest that the great thinkers of the 50s and 60s like Deming, Juran and Shewhart were right. They knew that human systems needed certain things in order to improve. Their insight into the human condition - that you need an aim and a purpose to get you out of bed and to focus on whatever your work is - offers us the lesson.
Real, sustainable improvement requires a critical mass. People have spontaneously done ‘improvement’ for a long time without really being able to articulate that there’s a theory that academics have worked out. When you actually study the theories, and when people go on courses about implementation or improvement, there’s a kind of ‘lightbulb moment’.
In some sectors here in Scotland now where we have reached enough people who have an understanding of the measurement theory, understanding of small cycle testing, implementation testing, so that when somebody brings a problem to them, they can say, for example, ‘well have you tested in a small community’? We have government cabinet ministers who can draw driver diagrams and ask for a measurement over time. I don't think many countries in the world have cabinets who can do that so it seems to me that in Scotland we've reached a mass of people who are educated in this language and this way of working. They've begun to see results and nothing moves a set of leaders like results can!
The single most important thing we've done in Scotland has been to give leaders a new toolkit, a toolkit about implementation. They already know how to be cardiologists, police officers, fire officers or social workers. What they were not taught when getting their professional training was how to lead implementation. Now there’s a number of examples where you can go and learn how to do that you while you stay in your job and work on projects and become part of a community of practice. We must have 800 or so leaders across the public sector who can lead improvement at a proper scale, who not only understand the toolkit but also have the inter-relational skills required too because, after all, all improvement is about relationships.
The adoption of these approaches and theories is not unique to Scotland. We have some things to learn from other countries but we also now have some things to teach. There are really good examples that we can point to in health, in children's services, in early years work, and even inside the government where we’re improving our human resources processes. Our recent work with Scotland’s National Parks shows how you can use improvement science for different sets of priorities. Here, the priorities are tourism, cleanliness in the park, and biodiversity. Who'd have thought that the dentist and surgeon would be thinking about how you improve biodiversity? But the principles are exactly the same: work out what your purpose and aim is, measure your way to that, and implement the recipe of things that you might use to do it. It seems so simple when you say it out ‘loud and yet it's really difficult to do this within human systems.
We have learned so much from elsewhere. In healthcare, we've taken learning on older people’s care from Scandinavia, from parts of the American health and social care system, particularly in understanding how to make care safer, and we've taken approaches from some low and middle-income countries who excel in having to develop change and implementation strategies with no resource. All the time we’re looking at really inspiring examples across the world, the Nuka community-based health system in Alaska, and self-dialysis in Sweden, being just two.
I developed my improvement science knowledge in the United States over a decade ago, and when I returned to Scotland I hadn’t yet been in a position to actually try to improve anything. Taking up the opportunity to lead the Scottish Patient Safety Programme was such a privilege. The programme, was an attempt to improve the safety of our hospital-based care. We had evidence that we knew well, and an established, well-defined and known recipe for making the system safe that could be understood very straightforwardly. But what hadn’t been done before was implementation at scale, and now we had the knowledge and opportunity to do that.
It seems so simple now but it didn't feel simple at the time. We knew about hand washing, about how we use antibiotics, to check that you had the right patient and the right operating theatre (seems obvious, but no we didn’t always do that). So using the principles of implementation and improvement science, we established a method for undertaking each of the implementation elements reliably every time in Scotland.
Scotland is now a global leader in patient safety because of the work of thousands of colleagues across the NHS, using proper change theories of implementation.
I see improvement in frontline services all the time. The real life stories of how that improvement has changed the nature of care or delivery is what excites me most. The ability to draw a line between improvement and implementation and then actual change is unique in jobs like mine and not many people get to see that link quite as clearly as I do. This is what drives me to continue to try and implement. I see how wards and clinical teams are working to make things better so that we can have infant mortality at the lowest rate it’s been at for a long time, a 90% reduction in hospital infections and a 20% reduction in sepsis mortality.
I believe that we have achieved a culture change in Scotland’s health and social care system. Every morning, in every hospital across the country, there is a safety huddle at around eight o'clock and at those safety huddles all the senior leaders from the wards, the domestic department and the labs, meet and decide there if the hospital is safe that morning. And they share challenges, experiences and how they're going to make the hospital work that day.
Ten years ago it would have been completely unthinkable that health professionals would expose that thinking amongst our peer group. The safety culture in Scotland has been transformed and it's been transformed by implementation of task. The focus on hand-washing which appeared reductionist gave people something to do, to make a change that has been part of the drive to improve safety. The practices from the lessons learned here are now being expanded into community care, into mental health, and into some primary care environments.
There is no greater human endeavor than to improve the services for the citizens of the country. Whether you’re a health professional, a social worker, a politician, or a civil servant, you already have quite a lot of the content knowledge but what you often don’t have – as I didn’t - is the toolkit to implement those changes at scale. Despite not being well known inside professions, that knowledge is available.
The world works through collaboration and relationships. Conferences like the Global Implementation Conference here in Scotland in September are a crucial way to move this forward, providing learning on that implementation toolkit and sharing the best practice from other places.
What we do isn't a quick silver bullet. Implementation and improvement change theories don’t improve things by Tuesday, it takes time. But it works. The experience we’ve had in Scotland and my reading of the literature suggests that implementation and improvement science in its broadest sense is the only way to move the human system in the way we wish it to move. What better idea could we have than the ability to implement change?
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