October 2023:  Our ICS-wide Improvement Hub was launched in September 2023 to act as a digital platform to signpost system partners to our aligned improvement approach, QI training opportunities, updates on local QI projects and our OD/QI Community of Practice and to act as a portal for people to submit improvement ideas that spanned across organisational boundaries; these ideas would then feed into an ICS-wide Design Collaborative Huddle to determine the best way to provide support.  The digital platform is registered as a sub domain of the wider ICS web page, and is continually evolving as system partners add on more information and updates.  The web page is https://qi.healthandcarenotts.co.uk  The web page was co-developed with over 200 system partners associated with our OD/QI Community of Practice, and we started it initially as a focal area for people working within the health social care and voluntary sector.  We would like to expand it to citizens as it evolves.  Our key challenges included the continuity of capacity to support across the Provider arm and ICB due to workforce changes and job cuts across the system.  This uncertainty hindered progress as people were uncertain about their future portfolios and whether they could offer support.  Our key learning was around the website development – agreeing the content and trying to engage people to support it was critical and took longer than we anticipated, but the technical knowledge/ accessibility requirements were over and beyond our experience.  Key advice would be to engage IT support as quickly as possible to help with the initial design and signposting (especially to engage with digital committees to get resources to support and to get information governance/digital sign off internally – this may take months to reach and get signed off by the appropriate bodies) and to identify someone with experience of web development to help pull a tender together.   Think about who and how you will update future content, testing a draft version across a wide range of users with accessibility issues and engage as wide a range of stakeholders as possible to help create content. To hear more about our learning, please email ceri.feltbower@nottshc.nhs.uk

We are now at the midway point of the Design Collaborative Huddle (DCH) Integrated System Development (ICS). Much like out other colleagues in the NHS we have been experiencing the impact of the NHS being under immense pressures and disruption. We have continued to focus on our ‘state of readiness’ with our work and the focus on quality improvement has never been so more acute in particular in supporting patient safety. We wanted to share with you colleagues and partners thoughts and reflections on engaging in the design process so far, so I have used their words with their permission to describe their experiences; pre conditions that have enabled us to progress forward with this work has been the continuing development of a vibrant Quality Improvement and Organisational Development Community of Practice (CoP). The CoP established and reasonably well represented across the system which has been the vehicle to leverage co-design/co-production. In addition a provider collaborative approach has been a pre-cursor to enable us to work on design and development in the right way with an Memorandum of Understanding (MoU) coproduced and in place.

Collaboration across organisational, geographical and professional boundaries

A critical element to partnership working within the Integrated Care System has been developing a collaborative space which the idea’ of the Design Collaborative Huddle is key. We have representatives within our ‘core design group’ which are made up of the provider and ICS quality Improvement teams from the NHS and Social Care including Organisational Development and Digital expertise drawn from Nottingham and Nottinghamshire. I asked colleagues to share their thoughts and experiences of being involved in this development opportunity who are meeting on a regular basis to design the ‘Design Collaborative Huddle and ePortal’. Colleagues reflected on their learning so far with a strong theme coming out about the importance of relationship building and inclusiveness:

So far, I have learned to focus on building relationships rather than leading with ‘what we need to need….’ It has been pivotal in meeting new system partners through this process, and ensuring that we each know who we are, what are our priorities, how do we work and more importantly, how do we work together.  I keep meeting new people and feel that we spend a lot of time ‘circling back’ but this is a necessary step to building relationships.

The engagement is working well, and levels of interest.  It is great working with system peers on this! Also, the will of organisations to align to this. Challenge is time to progress on top of day job, but mitigations in place via Hub Lead role and support.

I have learnt that there is a growing need to better bring colleagues together in the ideas, discussion and planning of improvement.  I have learnt that through the huddle, we have a visible and valuable opportunity to test at a system level, a deliberate and consistent approach to support innovation and improvement.

Investing time in relationships and engagement is essential – don’t underestimate the time needed for this. Creating space for connection and being happy dealing with ambiguity and emerging thinking/approaches – tendency for many to be action orientated but building the network has needed to start with the principle of connecting and understanding first before we get into action orientation

Identifying early and recognising the variability in capacity of all partners to engage and commit to representation where some organisations simply do not have the available infrastructure (resource, etc…) to attend with regularity – working on some considerations on how to reach out from those with more capacity/infrastructure to do so

Also being able to rapidly pivot in thinking and practice seems valued. It has meant not being too tied to one ‘solution’ but recognising that other ways of viewing the need/direction of travel and that multiple opportunities are available.

Including and inviting people seems a key learning. Limiting the project to a ‘steering group’ leads to lots of limitations around ideas and actions. Inviting people from many parts of the system enables new energy and ideas to emerge. The level of social interaction between people seems also very important to the work we are doing. It all sounds obvious in a way but this project has definitely modelled this and gained the benefits.

I think I have learned it is important to pay attention to the smallest interactions so that we hear what is happening in the relationships with which we are involved. What is happening at a micro level may well be happening at system level as well.

Challenges

On reflecting collectively with colleagues about what the challenges have been so far, the current environment that the NHS is operating in is proving to be the biggest challenge in terms of its impact on capacity. Time to meet has been a strong feature in terms of a challenge in amongst the flux and change of a constantly shifting environment. And yet, time is fundamental to investing in relationships and the bringing expertise together to co design. Setting out colleagues’ reflections in their own words really captures this moment in time:

Our greatest constraint in the current climate and the permission and release for colleagues to engage and come together.

Underestimating the impact of a fluidly emerging system architecture and governance compounded by transient leadership has made it difficult to move at a pace we would like due to challenges in identifying the right stakeholders to secure involvement and engagement.

I have learned or re-learned that the capacity to reflect and take a reflexive stance is probably the very heart of this work and improvement generally. It is not about reflecting on what worked well or did not work well-important though that is—it is about the capacity and ability/space to step away and ask questions of yourself and of others like ‘what is this telling us about how we can best think and act in this context at this time?’.

I have also learned that ‘emergence’ presents all of us, even when we might think we are used to working in this way, its own particular challenges. The desire to manage and control what others are or are not doing surfaces –certainly inside of me it did. This emergence particularly opened up questions of roles, skills and likely contribution to the effort. It makes sense through the lens of emergence that we won’t know what is needed of us until it becomes apparent. Setting out the detail of what is expected prompts in me anxiety in trying to hold tension between emergence and formal systems imposed by organisations and assumed to be relevant to systems working.

Progress

Colleagues have described progress to date in the context of collaboration and reflection which has been the foundation to this project so far. These thoughts are expressed in their own words set out here. These words give us a strong sense of the importance again of building relationships, holding a safe creative space to speak openly and freely and feeling valued.

Being able to hold and share ideas and thoughts freely without thinking that you will be shut down. The best of conversations occurred when we just allowed one another to speak without being censored by someone saying that’s not practical or affordable—enabling free flow of ideas seems very important and again I think results from trust and an emergent improvement culture.

What has worked well has been the opportunistic steps, conversations, exploration.

The tremendous amount of appetite and desire to make a difference and try out something that will give a greater chance of successful improvement is clearly there and needs harnessing and targeting with alignment to priorities

Through co-production and the committed co-production approach our system has signed up to and progressing in to practice.

Don’t forget to reflect on the environmental context we are working in when assessing progress – it remains a significantly challenged operational environment with many competing priorities and demands with an ongoing wave after wave of pressures ranging from a COVID pandemic that has still yet to abate and emerging further conditions (respiratory., etc…) that are impacting system resilience coupled with a sustained and unprecedented set of recovery challenges that are here to stay – this does take the attention of many away (rightly so) from developing networks and other strategic initiatives that will benefit in the longer term

I am relatively new to the project. I am struck by how much preparatory work has gone into the relationships and emerging partnerships before any visible manifestations like events and specific projects. This trust building clearly has taken time, effort and conversation but has allowed people and the wider system to give legitimacy to the work. The reflective spaces created allowed for exploration of what was happening and of course to get a sense of each person’s worldview and assumptions about system improvement

We recognise that this is a unique opportunity for us to open up access to contribute to working groups, our Community of Practice, etc… in the design and testing of a system approach as well as providing insight/advice on the developing framework/architecture

Next Steps

1.     To start the design huddle approach through 3-4 deliberate areas of larger scale transformation.  Stroke, PSIRF, CORE20+ and Frailty/Multi-Disadvantaged.

2.     Co-design across partner teams and route to first system-based test of the model on some agreed key priorities

3.     Framing and securing system leadership support for the positioning of the project within the context of a wider approach to continuous improvement in the system – we are designing in parallel the architecture and framework within which the DCH and associated process can be articulated

4.     Test out the ‘ePortal Design’ with small scale design ideas from point of care staff in a targeted area to manage potential demand whilst learning what QI infrastructure may be needed to support this.

How you can get involved?

As a collaborative we constantly aspiring to learn and improve. We would welcome feedback from our colleagues in the Q-community

Get in touch by using the comments section below or reach out to us on here please as we welcome your feedback and thoughts in this reflective space