Tom Downes is Clinical Lead for Quality Improvement at Sheffield Teaching Hospitals NHS Foundation Trust. Dominique Allwood is Associate Medical Director for Quality Improvement and Consultant in Public Health Medicine and Quality Improvement at Imperial College Healthcare NHS Trust in London, and Assistant Director of Improvement at the Heath Foundation.
We spoke to them about the Flow Coaching Academy approach. The model was developed in Sheffield and is being implemented at Imperial. Tom gives us the ‘innovator’ view and Dominique explores the role of ‘adopter’.
What is the Flow Coaching Academy programme and how did it come about?
Tom: The roots of the Flow Coaching Academy are in the Health Foundation funded Flow Cost Quality programme which ran from 2009 to 2012. It aimed to improve care for older people, a really complex challenge due to pathways crossing physical boundaries between hospital and community, and organisational boundaries of health and social care. We couldn’t see how traditional health care improvement tools could overcome that complexity, so we innovated. We looked at how Toyota were using a methodology called Obeya, which translates roughly to ‘Big Room’. This is a space where Toyota bring together all the different stakeholders involved in developing a new car to share the prototyping process enabling them to overcome complexity, as nothing is developed in isolation.
We adapted it for our setting, bringing people together in our own Big Room to look at how to improve flow through the pathway for older people’s care. The process was led by two improvement coaches, one a clinician and one from outside the pathway who could coach staff to achieve measured improvement.
It was really successful, so we repeated it in respiratory medicine with different coaches and again achieved improvements across the whole care pathway.
The Flow Coaching Academy is our attempt to scale this approach and develop the capability for organisations to run Big Rooms across the UK. We’ve developed a one-year course with a curriculum of 18 days face-to-face training, involving action learning as the coaches are using the skills and knowledge they learn each month to coach staff in their own Big Rooms. When a set of staff from a different organisation have been fully trained we enable them to become faculty and set up their own local Flow Coaching Academy.
How is Imperial College Healthcare NHS Trust involved as an adopter site?
Dominique: To set up an academy, you first have to go to an existing flow coaching setting to learn. Three pairs of our staff went to Sheffield to train to be coaches over 12 months and during that time they set up their own Big Rooms at Imperial, which are still running now. Those coaches have now become our faculty and are currently training a further 24 coaches.
Tom: It’s more than a simple train-the-trainer model, as each of those Big Rooms set up during the training continues beyond that first year, hopefully leading to measurable and far-reaching improvement in each site.
We provide a member of our expert faculty on site the first time a new academy delivers the course. This gives them extra confidence, but also helps us, as we’re bringing back a dramatic amount of learning from each adopter site.
How much are sites able to adapt the approach to their local context?
Tom: Imperial are about halfway through delivering their first year of Flow Coaching Academy training. Already we are seeing how their approach has allowed them to engage their senior leadership differently. We are learning from the way they are reporting the programme to their board to accelerate and gain organisational support.
Dominique: Yes, at Imperial we are seeing Flow Coaching as a key part of our strategy to transform care and reduce unwarranted variation. We’re treating it as an intervention that builds knowledge and skills in our staff around improvement science and coaching, but also with a big focus on tangible impacts that the Big Rooms and the changes are having on patient care. So we are testing the best ways to align things with our regular governance and reporting structures without being too bureaucratic. I think we are thinking slightly differently about the model and how to embed it here to the way in which it was originally conceived.
Tom: It’s that ability to adapt to local context that made us want to develop the academies as a model for spreading this kind of improvement at scale in the first place. Rather than just focusing on spreading specific interventions that we knew worked, like Discharge to Assess (a new model of discharge where the patient has their needs assessed at home rather than in the hospital).
Discharge to Assess is now written into several NHS national policy documents, but it risks being perceived as a technical solution without an appreciation of how variation in local organisational structure, staffing, culture and behaviour will impact how it’s implemented.
We agree with the Health Foundation’s recent report that as much work needs to go into spreading the work as into the original innovation. There’s too much use of the word ‘roll out’ in the NHS, when actually innovations need an adaptive process of implementation. That’s why we’ve focused on spreading the capability and skills rather than specific interventions.
Are there any specific challenges to using this capability building approach?
Tom: The main challenge is time. You’d think replicating a solution would be a quick thing, but of course the reality is that building capability takes months and years, not days and weeks.
Dominique: The benefits of flow coaching are wide ranging – developing knowledge and skills, changing culture and behaviours and delivering tangible benefits to patient care. The expectations of the programme will differ depending on the organisation in which its landing in, partly influenced by their particular improvement approach.
We are also learning how improvement ‘fits’ with other ways in which the organisation operates. John Kotter talks about a dual system that combines ‘entrepreneurial activities’ with the organisational efficiency of traditional hierarchy, and how both are needed. In some ways I think we are seeing this. The Big Rooms being set up are non-hierarchical, focused on improvement, driven by data, making decisions in the moment with permission to fail and learn – different to the ways in which some parts of the organisation operate. For example, down the hall a meeting or committee might be working on the same thing with a very different lens of decision making and change. Whilst we need both, some of our people are involved in both conversations and can find that challenging. We’re still grappling with how to foster the culture of improvement, failing fast and constantly learning, alongside a focus on performance, regulation, accountability and governance. It’s finding the balance of quality planning, control and improvement.
What key ingredients do you think have helped or indeed would have helped to make the process of embedding this successful?
Dominique: I think a learning network would have helped. We spent quite a bit of time at the start talking to the other trusts and understanding the context and learning so far. That involved a lot of one-to-one conversations and I would have liked that to have been done in a more open forum so everyone could have learnt from it. That is being developed going forward.
Tom: One important ingredient was the time we spent codifying the programme. We gave a lot of consideration to identifying the fixed elements that are needed in order to reliably get the right result from the training programme, compared to the flexible elements that allow the programme to be adapted into the context of different organisations.
Another aspect is our focus on the difference between ownership and buy-in. We are replicating a concept and encouraging the next organisation to take ownership of it. If you visit the Flow Coaching Academy at Imperial or in Northumbria Healthcare NHS Foundation Trust, or Royal United Hospitals Bath NHS Foundation Trust, you won’t see the word Sheffield. Each academy is an equal learning partner in the developing network, so they have their own sense of local ownership.
Dominique: At Imperial, we wanted to keep most of it the same, but we looked at how it fitted with our improvement strategy and organisational priorities and thought about how we would pull this in during the programme. We’ve appreciated the guidance we’ve had from Sheffield and the faculty coming down to support us, but we’ve also needed that local flexibility around how we deliver it to land in people’s current context.
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