Lessons from the Northern Care Alliance: Creating the “perfect storm” to drive system-wide change

To continue with our Future of Health series, we have looked for examples of successful delivery of impactful and sustainable change in our current challenging context and would like to showcase the work of the Days Kept Away from Home Collaborative at the Northern Care Alliance.

Driving sustainable change in complex systems is at the heart of the leadership challenge in the public sector. To make change happen we need a whole raft of processes, tools, mindsets and behaviours. But to make change stick we need the right conditions to create the “perfect storm”. The “perfect storm” doesn’t come about by chance however, system-wide leadership can enable the conditions to align perfectly to create positive change which is sustainable – and that’s what the Days Kept Away from Home collaboration has been doing.

The Days Kept Away from Home (DKAfH) programme is a Discharge Integration Frontrunner initiative aimed getting more people back home from hospital (rather than entering residential care). The programme began working across a variety of test wards to embed strengths-based approaches, recondition patients, and ultimately improve outcomes for people by discharging them back to their usual place of residence as soon as possible with only the care they need as opposed to longer stays in hospital, increased deconditioning, more care needed as a result, and an even longer length of stay in hospital waiting for the care to be put in place.

I’ve been in conversation with Jack Fallows, Quality Improvement Site Lead for Bury Care Organisation (part of the Northern Care Alliance group) and part of the DKAfH collaborative, to understand what conditions for success were put in place and became key elements of the programme and how this has contributed to the hugely positive impact the programme has achieved in improving outcomes and avoiding unnecessary costs. Throughout I reflect that many of the conditions are aligned with how we at IMPOWER manage change in complex systems.

The “perfect storm”

1. People, not processes

Throughout the programme, the language used was identified as an important motivator for frontline staff and so words like ‘flow’, describing a hospital process, were actively excluded from the conversation. Instead, the collaborative talked about a person’s journey and getting people back home to make it a recognisable issue, one that staff could visualise, relate to and understand as making a real change to a person’s life.

This is similar to how we would make sure we are describing a specific behaviour in simple terms when applying behavioural science to influence and change the behaviour. We recognise that it is people, frontline staff, who can affect sustainable change, and they are far more likely to do that when they see the problem in real terms.

2. A well-evidenced single story for the system

Data from across the system, not just one indicator, was showing a worsening picture from acute trust targets being missed repeatedly to increasing care costs for the LA and poorer outcomes for people leaving hospital. This single story brought together by the collaborative and told by the data emphasized the need to do something differently, or the outcomes would continue their trajectory downwards and costs on their trajectory upwards creating the “burning platform” to jump from into transformation. Providing an agreed baseline from which to start from is a key part of our change programmes given that we need to know where we are now for us to be able to measure where we have got to, and more importantly what our goal is.

3. Key partners standing together to solve the problem

While this was a hospital led project, there were no barriers between Social Care and Health colleagues. The Director of Adults Social Care, Adrian Crook said “I have been working in and alongside hospitals for nearly 30 years and have done many quality improvement projects. Never have I ever seen one that delivered as much improvement and improved outcomes as this”. The 18 test wards were partners too, with the emphasis being that what your ward is doing to make a difference is of the utmost importance. Results have been amplified as learning is shared, and all wards begin to participate after the test phase. The National buy-in to the programme also supported the sense of urgency to make the change happen and helped system leaders to stand together with the collaborative team to drive the initiative forwards.

Having a clearly articulated ambition which is inclusive of all stakeholders is a key factor in setting up a successful change programme where all partners are able to subscribe to the same vision, shared outcomes and successes – this also means they are more likely to stand together around issues and work them through as a team rather than shifting blame around the system.

4. One clear aim

While there are many metrics which are important to give us the whole picture of how a system and the organisations within it are performing, some measures are more tangible for frontline staff. The one clear aim for the DKAfH collaborative was to increase the % of patients discharged back to their usual place of residence. For frontline staff to focus on a measure of impact that they can see directly benefits patients and is clearly the right thing to do for them was highly motivating. Getting it right for the patient also improved the other flow-focussed metrics that leadership teams usually monitor for example: Length of Stay reduced by 0.56 days across the 18 test wards and they were able to discharge 10 more people per month back to their usual place of residence compared to before the programme. Importantly, each ward had access to their own ward-level data and trends so that they could track their own performance and understand what works for them.

5. Leadership making space for the work

By providing the space and time for people to do the work meant they were given the permission needed from leadership to engage fully in the programme as part of their day job rather than on top of their day job. This gave the programme the importance it needed and meant that people have had the development and practice time to be upskilled in Quality Improvement processes, tools and techniques.

Investing in transformation means more than just resourcing the programme with the capacity and capabilities to manage it, it’s also about making sure that frontline staff are given the time to prioritise the programme as well as leaders’ role modelling the dedication to achieving the ambition.

These five conditions were in place for the DKAfH programme, and Jack and I believe they were key to its success and the sustained results. It is heartening to know that many of the aspects of the DKAfH programme are very much the way we work at IMPOWER, meaning that the way we work is not only compatible with how frontline teams work, but also produces the right results. We have recently released a series of blogs assessing the recent announcements and discussing what we think the response looks like in Acute Trusts, the same delivery challenge but approaching it in a people-centred, sustainable way.

A huge congratulations goes out to all those frontline staff, Quality Improvement teams and leaders involved in the DKAfH programme and collaborative. Your work has changed the outcomes for so many patients for the better and has gone some way to take the pressure off colleagues across the system and leaders working to make their organisations sustainable.

To find out more about DKAfH and who to contact for more information click here Discharge Integration Frontrunner Programme :: Northern Care Alliance