Better productivity and experience: embedding an improvement system

The Guy’s and St Thomas’ vaccination service began in December 2020 as one ​‘pod’ at Guy’s Hospital. It soon expanded to seven pods, each across two sites.

The Care Redesign Improvement & Innovation team provided front-line support to the vaccination teams to establish a data-driven ​‘improvement system’. 

They gathered hourly time observations and introduced visual management tools to embed data and insight from leadership dashboards to front-line huddles.

The team also rolled out an improvement training and leadership programme for staff that enabled increased delivery of vaccinations. 

Hear from Joanna Turville, Director of Operations and SRO at Guy’s and St Thomas’ NHS Foundation Trust.

The two half-days of improvement training takes participants through problem statement and data gathering to understand the problem, root cause analysis, goal setting, proposal development, action and follow up. It includes a vaccination simulation and a compulsory project.

Anil Mathew, an Improvement Lead and Training Coach at Guy’s and St Thomas’ vaccination programme and Joanna Turville, Director of Operations & SRO for the vaccination programme, spoke with Henry Cann, Q’s Insight and Evaluation Officer, to share relevant learning from their work that can be applied to addressing backlogs in care.

‘In the first few weeks we had hundreds of patients arriving early,’ says Anil. 

This can create a ​‘too busy to stop to make improvements’ mindset and lead to issues in releasing staff for training to build improvement capability or taking time to change ways of working or implement new systems.

However, ​‘it was very obvious to us that if we applied an ​“operational delivery mindset” without improvement alongside it – we weren’t going to maximise our efficiency.’

Anil and Joanna worked alongside front-line teams to enable step changes in daily outputs, using co-developed key performance indicators (KPIs) rather than driving top-down big changes. 

The KPIs included quantitative, qualitative and quality measures, reviewed in daily huddles with staff and board members to identify challenges to be solved by staff with an improvement idea. 

‘There’s a golden thread,’ says Joanna, ​‘from the strategic objectives to front-line pod staff.’

From 250 vaccinations per pod per day, the team’s peak was almost 1,200 per pod per day – driven by improvements led by delivery staff to change pod layout, remove unnecessary processes and implement technological solutions.

Between December 2020 and March 2021, an individual assessment and vaccination was reduced from 18 minutes to 6 minutes 30 seconds (a 64% reduction), with further improvements since then.

Over 130 staff have had improvement training. This includes over 15 vaccine improvement champions who are ​‘trained and certified’ in quality improvement and become local leaders for improvement alongside their day jobs.

These improvement champions ​‘form part of the collective army of problem solvers,’ says Anil.

Staff report feeling satisfied with what they had achieved with process changes and increased efficiency. 

Qualitative patient feedback has frequently noted the team’s efficiency, and appreciation for the ​‘thoughtful and happy staff.’

Anil and Joanna reflected on the risk of ​‘overdoing improvement’ by trying to be too exact in its implementation, and alienating staff under significant pressure. 

Balancing the need for improvement thinking while keeping delivery staff engaged and supported helped build early momentum and lay the groundwork for more substantial changes later on.

Supporting staff wellbeing by providing spaces to listen and learn together helped embed the improvement culture. 

Engagement sessions were used to understand staff: ​‘It’s a dialogue between leadership and staff: ​‘How can we help? Do you have any ideas?’, says Joanna. 

‘People just want to be listened to.’

Embedding a data-led improvement system is not always easy: it demands ​‘acceptance and patience from staff,’ says Anil. 

‘What’s been important is clearly making the link between the minutiae of their daily work, and how this will benefit patients.’

It was also important to overturn a numerical targets-based culture. The data collected wasn’t just outputs, but included feedback from staff, volunteers and patients so staff had the reassurance they were on the right track.

Supportive, visible leadership is a ​‘glue that brings it all together,’ says Joanna. 

As well as securing senior buy-in for improvement work, this meant leaders seeing work in progress. 

This ​‘gemba with purpose’ (Lean terminology) involves regular time commitment from leaders at all levels, in this case to join huddles and see how they can help, while ensuring staff feel they have ​‘permission’ to try things.

‘Rather than an idea coming from the director of operations,’ says Joanna, ​‘if somebody on the front line had an improvement idea aligned to the strategic objectives and KPIs, then we start to turn the dial much quicker.’[ref]

For another example of how a learning systems approach can support staff at all levels to contribute improvement ideas, see UCL Partners’ blog about how a learning system was built at Nightingale London.[/​ref]

Watch the the recording of Q’s September 2021 Community Space workshop on addressing the impact of backlogs in health and care.