Research Question 4: What are the implications of these findings for managers, implementation

There are various stakeholders in the implementation of change in healthcare, ranging from

commissioners, to clinicians, and to patients. This thesis has examined the implementation of a change programme in healthcare which has helped to identify various learning points and considerations required for three key stakeholders; healthcare managers, implementation teams, and commissioners. The

following section discusses the implications for these stakeholders as a result of the findings in each chapter.

7.4.1 Implications for senior leaders and managers in healthcare

For senior leaders and managers of healthcare organisations, the findings from Chapter 3 are important as they indicate that even though a programme such as PCS can be resourced with an implementation team and prioritised in the organisation, there are many other aspects that need to be considered to ensure that there is a return on the investment made. These aspects include having an experienced and effective implementation team, having effective communication about the programme in the organisation, and

targets that are relevant to the services and promote sustained improvement. For managers in healthcare, the findings indicate that their support of staff needs to be observable (page 101), and that if they feel that their staff are having to implement work because it has to be done rather than for its’ benefits to patients or the service (page 101), then they should be able to challenge the implementation team and make changes to make the work more relevant. However, as indicated above, this is easier said than done when the implementation team believes that certain work has to be carried out to achieve commissioned targets.

In the Productive Series literature there is talk about improving communication and processes ‘from board to ward’ (e.g. National Nursing Research Unit and NHS Institute for Innovation and Improvement, 2010b), representing the highest part of the organisation to the frontline staff. With the increased role of commissioning in healthcare, this line now needs extending beyond the managing board of the

organisation to commissioners, so that what is being commissioned is relevant to the staff at the frontline and more importantly, is beneficial for the patients they care for.

Analysis in Chapter 4 found that although resources were invested in the PCS programme by way of providing an implementation team, there was a lack of resources within the clinical services to be able to carry out PCS work, such as the ‘5S’ Stock Inventory, effectively (see page 115). As staff shortages in the NHS are reported, both in the acute sector (see Francis, 2013) and community (see Foot et al., 2014), this finding is timely and demonstrates the difficulty in needing to innovate to become more efficient with insufficient staff resources. Currently, most healthcare organisations, “...have very little capacity to analyse, monitor, or learn from safety and quality information,” (Berwick, 2013, p. 27), which is, at its essence, what the PCS programme aims to achieve. Therefore although this appears to be an inherent problem at a macro-level in healthcare, to start addressing this at the micro-level, it was proposed that managers needed to be aware that there may be a significant investment required during improvement innovations in order to create benefits and improvements later on down the line. The issue with this is that it can be difficult for managers to know whether an innovation is worth investing in, particularly when using initiatives that are new to the organisation. With the pressures of waiting lists and contract expectations, there needs to be open communication lines between commissioners and managers so that

options can be discussed, so that for instance, managers feel able to negotiate with their service’s commissioners or management boards as to whether it would be acceptable for patient contacts to be reduced while staff invest time in making improvements that might increase patient contacts in future, or improve “patterns of care” (NHS England, 2014a, p. 5). This might also be improved with more

communication between commissioners of CQUIN and service commissioners, if they are different.

In Chapter 5, it was identified that staff did not understand what was required for the ‘Interruptions Audit’, and so not only were they not able to make improvements, but wasted time carrying out the audit incorrectly. It was concluded that managers and their staff should challenge Implementation Teams if they don’t understand exactly how an intervention is going to make improvements. One of the features identified as being required for the spread and sustainability of service improvement is allowing staff to stop and reflect on their processes (National Nursing Research Unit and NHS Institute for Innovation and Improvement, 2010a), particularly in regards to efficiency and purpose, yet in the implementation, staff were given this additional task to do (the ‘Interruptions Audit’) and had no understanding of why they were doing it or what benefit might come from it. This indicates issues with the communication between Implementation team, and managers and their staff. Senior leaders and managers should ensure that their staff have a voice and feel able to exercise it, and that they have time to reflect on processes in order to improve them. However, it can be perceived that it is more time consuming to challenge and address an issue than to just ‘get on with it’, and more ‘organisational slack’ (Damanpour, 1987) may give staff more space to take time initially to save time later on down the line. Again, staff shortages and high demand in healthcare make this a difficult prospect. As referred to on page 125, this also highlights the tension of aiming to reduce slack in organisations through initiatives like PCS and Lean which may also reduce the organisation’s ability for innovation to thrive (Nohria and Gulati, 1996).

7.4.2 Implications for Implementation Teams in healthcare

In Chapter 3, it was identified that managers and implementation teams should ensure that there is effective communication not only about the programme, but that there is clear communication when

improvements occur directly as a result of a programme, to help with more accurately evaluating a programme’s impact. As there were many factors identified that were likely to have reduced the effectiveness of the implementation (e.g. lack of communication), it was also suggested that managers and implementation teams should work hard to mediate these factors so that individuals have a greater likelihood of engaging with the programme. It was also found that managers were not always engaged in the programme, and as previous research emphasises the importance of tangible support from managers (White et al., 2013; Wilson, 2009) it was proposed that implementation teams should ensure that they invest in engaging managers in the process.

One of the key findings highlighted by the PCS implementation team’s focus group was that although the commissioning process enabled the programme to be implemented in the organisation through the provision of funding, the commissioned targets, or the way the targets were manifested through the programme, led to the programme not being relevant to some services. There was often more emphasis on achieving the commissioned targets than on making sustainable improvements, and one did not always lead to the other. The implication of this for implementation teams of pay-for-performance schemes is that they should ensure that the methods used to achieve the targets are relevant to services and promote sustained improvement.

The findings from Chapter 3 also suggest that implementation teams would benefit from having some experience in implementing change, as it is not something that ‘just happens’ but is a complex process that requires many considerations. This is not to say that the implementation team did not plan the rollout of modules effectively, but issues such as ineffective communication and the recognition that the

programme was not relevant to services was discovered by the implementation team at the end of the process (as evidenced in the focus group data, see page 97). The implementation team will have learnt from the process, but they would have benefited from that learning for this implementation. The findings also highlight the need to make this learning accessible to implementation teams. The PCS material contains plenty of guidance that may have improved the implementation (e.g. noting the importance of

engaging managers and team members in discussing the programme, see NHSI, 2009f, p. 20), but due to many reasons (e.g. time constraints, increased emphasis on completing the commissioned targets, and the PCS Team feeling the PCS material was too long-winded), there was little reference made to the PCS material during the implementation. The Productive Series programmes are designed to be led internally by organisations, but this study has shown that provision of the material and resources to implement the material does not guarantee that implementation teams will adhere to it, or effectively implement it.

The qualitative analysis in Chapter 4 identified that potential mechanisms for change in the WOWE module (e.g. timing and tracking movements around the work area) were usually not carried out as the PCS Team didn’t feel that staff would engage with them. This again may have been different had members of the PCS Team had experience with change initiatives before, but the chapter concludes that implementation teams should not let their preconceptions about innovations and staff stop them from experimenting with interventions that may be of benefit (see page 122). However other parts of the analysis highlighted two other scenarios – those where PCS work was carried out but was not relevant to services (see page 97), and those where staff did not expect there to be benefits before carrying out PCS work, but then experienced them (see page 91). This indicates that there needs to be a certain level of flexibility among all parties when assessing the resources to be invested into innovation. Previous research on the Productive Ward that found that allowing teams to choose the modules to implement for their different contexts gave them a sense of ownership and involvement (Morrow et al., 2012). However this implementation was inflexible, as the modules and order of module implementation was dictated to staff. Had the services been able to choose which modules were most relevant to them, their

implementation of them may have been more effective. This suggests that Implementation Teams should allow flexibility so that staff are empowered to choose the areas of practice they need to address.

In Chapter 5, it was proposed that Implementation teams would benefit from having some expertise in Information Technology, as this enabled the relevant reinvention of the PSAG Board into the PSAG Screen. The results also found that staff carried out the ‘Interruptions Audit’ incorrectly as they did not

understand it, and that it was not made relevant to some roles (e.g. administrators). Therefore it was recommended that Implementation Teams ensure that they remain reflective in order to keep innovations effective and relevant for staff in different service contexts. This also highlights the importance of implementation teams sharing their learning with other organisations, as highlighting these issues may prevent other organisations making the same mistakes. In Chapter 3 it was identified that there was a lack of knowledge transfer (Berta et al., 2005) to the implementation team (see page 102), and the literature review noted that there was a bias towards the publication of positive results (Wright and McSherry, 2013), and both of these issues have the potential to reduce the effectiveness of an implementation because the Implementation Team or organisations are not aware of the challenges in implementations that need to be considered. However, Bate and Robert, 2006, cited in National Nursing Research Unit and NHS Institute for Innovation and Improvement (2010a) note that the increased competition in healthcare can promote inward-looking innovation, where organisations become less inclined to share achievements in order to keep up the appearance that they are performing well. The Researcher proposes that because of the increased competition in healthcare (Sturgeon, 2014), organisations may have less motivation to share learning with other organisations, who were once allies within the NHS, but who are now their potential competitors. It would therefore be interesting to see how the healthcare innovation literature evolves in the coming years as a result of the NHS becoming increasingly fragmented.

In the qualitative analysis of data in Chapter 6, it was identified that the PCS Team adapted the original guidance in the material by changing the method of data collection and data analysis (see page 160).

Although this enabled the data to be analysed more efficiently, the data collection process became more arduous for staff, there were various shortcomings with the reliability of the data (see above, page 184), and the lack of data resulted in only one measure being taken. This raises the point of programme fidelity, and we see here that lack of adherence (Allen et al., 2012) with the programme’s advice contributed towards this. The PCS PM changed the process for two main reasons; because the original programme material appeared long-winded, as it advised using hand-written calculations rather than using an Excel spreadsheet, and because there was a lack of trust in the accuracy of the data recorded in the

organisational software system, SystmOne. This suggests that innovations like PCS would benefit from being provided in an electronic format and a manual format, so that those unfamiliar with computers can benefit, but also so that those that can use computers can take advantage. This also suggests that although IT systems have been increasingly used to record patient data and staff activity over the last decade (Waterson, 2014) there are still doubts about its accuracy and this should be borne in mind when assessing studies that use software such as SystmOne to collect staff activity data.

This has highlighted a tension, as on the one hand, implementation teams are advised to make innovations relevant to the context (in this instance, the PM felt that in this context, organisational data was less accurate than manually collected data), yet this decision had a negative impact on the innovation itself.

Similarly, the PSAG Board was reinvented as the ‘PSAG Screen’ by the PCS Team to fit the context, but had successful outcomes. This shows how difficult it is for implementation teams to get it right, and that because it is often unknown how the context will affect the success of the mechanism, there is an element of experimentation required. Again this reinforces the need for implementation teams to pilot innovations and remain flexible to service contexts. This also again reinforces the benefit of using Realist Evaluation which addresses contextual variation.

7.4.3 Implications for Commissioners in healthcare

For commissioners, the findings from Chapter 3 highlight how commissioned targets can affect an implementation. There was no data collected directly from the commissioners themselves, however the data analysed indicated that even though the PCS implementation team were told by staff that the targets were not always relevant for them, they were persuaded to comply with irrelevant work regardless, as they were part of the commissioned requirements. The main issue identified in the data in this chapter arose because in the main, generic targets were given that were not service-specific. It is important to note that this may have been less of an issue for an implementation of the Productive Ward, as it could be argued that wards of different specialities are relatively contained and have many working aspects in common with each other. However the study here found that the diversity of specialities (or the high level

of functional differentiation, Kimberly and Evanisko, 1981) in a community service setting was not appropriately addressed in the generic targets given by the commissioners, or more specifically, in the generic way that the programme was rolled out to accommodate the targets set by the commissioners. In this sense, this could be attributed to the implementation team, as they decided how the programme should be rolled out in order to achieve the commissioning targets. However, commissioners should still continually check that their targets are relevant and if possible, remain flexible so that if they aren’t seen to be relevant, they can be adjusted to be made relevant to services. This reinforces recommendations that pay-for-performance measures, “...should be reevaluated periodically and be replaced or updated as necessary,” (Eijkenaar, 2013, p. 127).

The analysis in Chapter 4 identified that the commissioners’ target of reducing stock by 30% led to staff trying to generate a one-off saving, when it would have been more beneficial for the target to be more process-oriented so that processes were put into place to continue to keep stock levels at a minimum beyond the conclusion of the implementation. The PCS Team incorporated a process (e.g. encouraging staff to implement minimum and maximum stock levels) but this was not mandated by the commissioners (and was not in the original PCS material). Again the focus on the one-off saving might have been down to the PCS Team’s interpretation of how this target should have been implemented, particularly as this was the method advocated in the PCS materials, but this did highlight that achievement of the

commissioned target did not promote continuous improvement. This highlighted the need for change programmes like PCS to be implemented with a perspective of sustaining the improvements made, not just for the duration of the initiative but beyond, so that improvements becomes embedded in

organisational practice.

However, in Chapter 5, it was proposed that this challenge was largely met by the process that was used to satisfy the commissioning target of saving 10% of time taken to find patient information. The

implementation of the ‘PSAG Screen’ ensured that a process was available in the software system which had the potential to continue to minimise the time taken to find patient information. However the

qualitative analysis found that staff were not always aware of the screen and so did not gain the potential benefits from it. This indicated that within pay-for-performance targets it would be useful to measure the exposure of the intervention to staff, and how much they use it, to ensure staff are aware of it and have a greater understanding of its impact. In addition, that there was a sustained process put in place for this one-off target and not for the WOWE target suggests that it is not just the targets that are salient, but what is put in place to achieve those targets. There may also be a difference between commissioning for short-term projects such as a programme implementation, and ongoing commissioning, for example for service contracts. Where ongoing contracts are commissioned, Key Performance Indicators might be reported monthly, whereas in this short-term project (e.g. one year), there was only one measure required. This suggests that short-term projects would benefit from regular periodical reporting as early as possible, to reflect that ongoing processes are being put in place that can be sustained beyond the programme implementation.

Although this discussion argues for more process-oriented targets, these could be argued to be implicit in the targets requiring all teams to ‘complete’ the programme to varying levels (see target 1a,1b, 2a and 2b on page 59). This was to be measured using self-evaluations completed by staff which took the form of

Although this discussion argues for more process-oriented targets, these could be argued to be implicit in the targets requiring all teams to ‘complete’ the programme to varying levels (see target 1a,1b, 2a and 2b on page 59). This was to be measured using self-evaluations completed by staff which took the form of