Back in 2009 – 2012 I undertook a three-year piece of work on hospital discharge. It was back in the days of Primary Care Trusts and an inspection by CSCI highlighted to us that the Local Authority and Health could work better together to improve outcomes for older people leaving hospital, having been admitted on an emergency basis. And so, our journey began. It was long and difficult, with more than one episode of differing opinions along the way. But, it was also invigorating and motivating and gave me loads of scope to test out systems thinking on something multi-organisational, cross-sector and very politically sensitive.
I didn’t know it at the time, but I was developing an approach that would work for me repeatedly, in a multitude of situations. A flexible approach that allows me to adapt it (and my style) to different contexts. I have now badged it as my blended systems thinking approach. I constantly develop it and adjust my leadership style to different contexts and in relation to new research or other writings that I discover, and I am inspired by.
Nowadays, I am struck by how close we came to how people are now attempting system change. A little more boundary critique and a slight widening of perspectives even further and I think we would have come very close to something quite powerful in relation to improving experiences for older people. As it was, we made many improvements. It was work to be proud. For me, I got to do what I enjoy most – I worked with those on the ground and with end-users (patients, families, and carers) directly to make change. I used my position as a commissioner as an enabler to persuade others to think systemically. I gave others the voice they needed, the connections they required and the chance to do something differently. Make no mistake, implementation was difficult, very difficult, but worth it.
These are some of the features of the situation we were dealing with. The similarities to situations requiring system change are apparent:
Complex, inter-related problems
Our problems were complex and inter-related and therefore required the interaction and contribution from several actors, across numerous organisations. From the commissioners to the community providers to adult social care to the third sector to the ambulance service to carers and families and across areas to other hospitals. Not one service, organisation or group of people could improve the situation alone. There was a geographical dimension to our issues, a regional dimension, a local dimension, right down to a single person dimension.
We could use the framework of a living system to understand some aspects of our system. That is certainly one of the ways I viewed it, at the time. As well as being operationally closed, there were elements that self-organised and it undertook ongoing, meaningful interaction with the immediate environment. There were networks of relationships and emergent properties. There were flows of energy and there was data and information that kept things ‘alive’. Our system was, however, rather sick at times, with energy sinks and poor data and information exchanges apparent in our diagnosis. One thing for sure, this system did not exist in a vacuum. Where problems existed, it was often down to weak feedback systems preventing the system from self-regulating, self-correcting, and surviving at the level of effectiveness we wanted it to survive at. Instead, it was self-correcting to a lower level of effectiveness. Struggling, at times and yet surviving. Our systems were nested inside one another (patient, family, community, region, national) and all had the ability to influence and be influenced by each other. That’s how we knew that whatever changes we tried to make, they had to be simultaneous and at a variety of levels.
Was our system viable? Well, some would argue that it must be because it was surviving. But it was quite sick. Different operations often caused chaos for one another, there were oscillations in performance, resources weren’t always sufficient, performance monitoring appeared to be measuring the wrong things or was fuelled by inappropriate incentives and as for future planning…..well, who had time to think about that properly? There was a strong identity though. Everyone knew what they were there for and had a passion for the people they served. The structures, functionality and information exchanges had difficulties though, lots of difficulties.
Without going into details of our case study at this time (it would make this blog far too long. I’ll save that for another time), the things we did were focussed on the following:
We diagnosed the situation, gained greater understanding, and identified opportunities together
What did our patients, their families and carers need? For what purpose? Did we understand it? We certainly tried to. Whilst this was not all about diagnosis, the situation we were in required that we did diagnose, and we needed to diagnose together. We needed to build up a joint understanding and only by going on a journey of discovery, together, would this happen. Everyone involved had an in depth understanding of what we were trying to work with and improve and bringing all of that understanding together and sharing it, using systems thinking approaches and other techniques we were able to build up a picture that none of us, separately, had. We applied the theoretical underpinnings of systems thinking and maintained our credibility by ensuring that it was coupled with the expertise from across the system. The combination of front line and bigger picture thinking helped us to move away from false assumptions, provoke the status quo and really explore.
We built platforms and processes for collaboration
Barriers came down, boundaries were widened and a multi-agency group, all of whom had equal accountability for making improvements, was formed. We built a strong, shared understanding of our joint challenges. We drew in as many stakeholders as we could, and we didn’t just pay it lip service. Many of our actions were driven by patient, family, and carer groups. In fact, our Joint Protocol for the Transfer of Care had a whole section in it, written by carers. Well, written by me but dictated by a carers group. They were a fully integral part of making improvements in our system and trust me when I say they held us to account!
We harnessed our collective power across hospital boundaries, bringing in the perspectives and collaboration from hospitals in three separate regions. I, as the commissioner, worked as the networker, the collaborator who enabled three separate discharge teams, from three separate hospitals, to work together on a Joint Protocol for the Transfer of Care. (and yes, I did get sign up to it from all three areas). As the understanding and collaboration grew, the relationships grew, the learning grew, the power dynamics reduced, and the sharing and accountability strengthened.
We aligned our vision and perspectives
Once people became assured that we were working for the greater good, and not just the perspective of one organisation, perspectives became more aligned. Whilst we could not always improve everyone’s issues all of the time, we all knew that what we were doing was in the best interests of the patients, their families and carers and we were all focussed on the same vision of improvement. Some things were as simple as sharing data in more real time, even if this was just verbally via a phone call. Some things focussed on avoiding (or at least reducing) the adverse impacts of an action taken by one player as we worked together to find ways to improve the situation for all.
We developed learning loops
Quality initiatives were implemented as a direct result of feedback from patients, carers groups, black and ethnic minority groups, disabled people’s groups, older people’s groups, and a whole lot more.
Closer links and more real time feedback between Boards and operational groups were developed. Reviews of case studies and identification of common themes for improvements were used for learning. Documents were reviewed and streamlined to make processes easier and quicker. We also linked to other systems (like the whole system escalation system) that gave us information about how our system was performing. It gave us a monitoring loop, without being overly intrusive.
We developed shared procedures
In addition to our Joint Protocol for the Transfer of Care, which was a huge undertaking, we developed new pathways to draw into the process those who had been previously excluded i.e. social housing. It’s amazing how quickly things can get done when people/ groups/ departments/ organisations etc are seen as inside the system and are included in any decision-making processes for patients.
We accepted our collective accountability and responsibilities
It wasn’t every man for himself in our situation. If one went down, we all went down. It was an unwritten understanding and it worked. We worked together, failed together, got back up together and flourished together. Everyone involved took on responsibility for the outcomes. It wasn’t top down; anything but. Leadership and responsibility came from all angles. It felt, to me, like we were not part of a huge hierarchy. We made connections and flowed information between those who needed it, not via hierarchical channels. It made people feel included, important and ‘part of something’. It was an important lesson in identity that I have never forgotten.
We changed the procedures across organisations, developed a culture of sharing and collaboration, streamlined communication and processes, and eliminated barriers to better serve our populations. We did it together and we learnt together.
I brought in my technical expertise of systems thinking (and my own health and social care background) and yet I was fully aware of and made full use of the power of the understanding from within the system. Years after, and now having worked as a consultant for a number of years, I can absolutely say that I believe that those inside the system are the best ones to make change. I do, however, also believe that bringing in the appropriate theory and someone who can give a ‘zoomed out’ view is also essential.
We did not let the enormity of things get on top of us. We changed what we could, as best we could at the time. Lots of smaller changes can actually add up to a very powerful change. In fact, if we had made huge radical change we would have potentially ended up with a lot of unintended consequences. It doesn’t always take a huge radical ‘hero’ to make change. Quite the contrary, no-one was a hero in our situation. What we did have though, were a lot of very informed, passionate, and dedicated people who were determined and committed to making a change. The most important thing, in my eyes, were the networks we built. They allowed sharing, learning and joint actions to be taken. We adapted together, not separately, and everything was an opportunity to learn. I was lucky, I worked for a Director who let this happen. He gave me the autonomy to act and only ever stepped in when asked or when I had ‘hit a brick wall that needed smashing down’. He did the smashing!
This wasn’t one organisation making change, it was dealing with change from multiple areas on an ongoing basis. It took ongoing effort, massive effort, and it was worth it.
One thing I believe wholeheartedly, it was the systems thinking that gave us the confidence to keep going and I will be ever grateful for the opportunities I had to apply the systems thinking and to learn from it. They were lessons I will never forget.
Oh, and whilst we were focussed on quality and not delayed discharge figures, we did keep our delay figures to below national and regional average for around three years.