Over recent months, I’ve been testing out a checklist to help organisations assess how ready they are to start improvement projects and see what else they need to put in place.
The checklist was developed from content originally published as part of the Health Foundation’s ‘Building the Foundations for Improvement’ report. This aimed to help NHS organisations mimic or adapt ideas that had already helped others build their capacity for improvement in different clinical and service areas.
Why a checklist?
The checklist is a common tool now in clinical practice and is often used to prevent urgent demands and lack of knowledge getting in the way of busy people delivering what we know is best for patients.
When confronted with a blank sheet of paper and asked to describe a better system, busy health care leaders often focus on what others need to do, rather than on what they themselves can change. Having a more structured approach, such as a checklist, which encompasses learning from what has worked elsewhere and how it might be adapted in a local situation, can be a valuable approach to change.
Taking the time to make sure the right culture, skills and infrastructure are in place to see improvement ideas through successfully is really important. As Donebedian’s work shows, it’s both structures and processes that need to change in order to build the culture of reflection, openness and excellence needed to implement meaningful change across an organisation.
A positive response
The response to the checklist has been positive so far from the commissioner and provider leaders who’ve used it. It can be hard to identify what is already in place (perceptions and assumptions vary) and to foster the type of enquiring mindset needed to build a safer organisation. Driven by the pressure to find an urgent response to a problem, there is often a tendency to default to an immediate solution, rather than one that will last. Used carefully, the checklist is a tool that can help leaders and people working on the front line to change this mindset and ultimately to help an organisation sustain improvement over time.
However, it needs to be clear that this is a journey. Early progress may be less about immediately changing outcomes, but instead getting structures and processes in place; involving a wider range of staff, improving morale, or building the knowledge of people working at the front line.
Unless leaders make connections and pay attention to the people they work with, they may overlook the benefits of the changes that are being made (Swenson et al, 2013; Berwick, 2013). This is where regular leadership visits and conversations with staff matter. Visible evidence of wards and teams showing steady improvement over time will also reinforce everyone’s confidence that they are making progress and have energised their system to continuously improve.
How should organisations use the checklist? Five top tips
1. Decide who is best placed to use the checklist
The checklist is probably of most use as a strategic tool for a trust board or executive team, with support from improvement or transformation leads.
2. Set aside dedicated time to work through the checklist as a group
The checklist helps you assess where there is work to do to build your organisation’s capacity for improvement. As with all improvement work, it isn’t something you should rush to complete. To get the most from the checklist you need to dedicate at least 3–4 hours to go through the points on the checklist as a group.
3. Bring in an experienced facilitator to lead an exercise to use the checklist effectively
Try to find an external facilitator with a strong improvement and coaching track record. It’s important to have someone with a fresh perspective who can challenge your assumptions – in a constructive way – and expose you to new ways of thinking. An experienced coach will also help to get the most from all members of the group; give the group the confidence to explore all promising ideas; and reinforce the importance of constancy of purpose over time – especially when you hit any barriers.
4. Find time to prepare for the exercise
Consider circulating a short reading list to members of the group before the exercise. The Health Foundation’s top ten resources for senior leaders looking to deliver organisational wide improvement in safety and quality can be found in their online collection. Group members could also prepare by using this gap analysis tool to identify their organisations’ key assets, strengths, gaps and challenges in terms of building improvement capability.
5. Make sure you have a realistic outcome
A risk with using any checklist is that you can end up with a long list of actions and no means of prioritising between them or deciding where to focus your time and resources. To avoid this, you could create a driver diagram or action effect diagram to help to develop a realistic delivery plan that’s not too daunting.
Remember, it’s far better to start small and build gradually over time on the back of the confidence and enthusiasm that come with early successes. If you try to do too much, too soon, the chances are you soon lose momentum and use up people’s good will and motivation.
Tricia Woodhead is part of our clinical faculty supporting the leadership, capability and capacity building of QI skills for improvement with a particular focus on patient safety.