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In my eight years as an improvement coach, I have learned that change often starts with a series of conversations.
For example, I was once coaching a team working on an inpatient hospital ward. When they looked at their data, they found that people were waiting a long time to be admitted to their ward. When people needed to be admitted, they often had no beds available. And, when people were admitted, their length of stay was long. The team was frustrated and wanted to make the situation better.
The first thing I did was have conversations with some of their leaders. I then spoke with the consultant psychiatrist, who was the clinical lead for the unit. I also talked with the modern matron, who is a senior nurse for that ward, and with other staff. I spoke with the families of their service users. I spoke with all of them to get their perspectives. I wanted to understand their context and help us get on the same page. I mostly asked questions and listened.
How do things work here?
What are some of the biggest challenges you face?
What is the impact of those challenges?
What does it look like when things work well?
As a coach who was coming from outside their team to support them, I asked questions to get to the heart of what was going on. They all felt they were letting their patients and the patients’ families down. Some of the conversations got emotional. The most heartening thing I heard was that everyone was motivated to solve the problems they were facing.
Notably, I learned during these conversations that there was a strained relationship between some of the disciplines. They did not feel they could count on each other. Each side felt the other side took too long to do their work. Each side felt they could not rely on the other.
W. Edwards Deming once said that “joy in work comes from understanding . . . Who depends on us? Whom do we depend on?” For this team, it was very clear that these problems were robbing them of joy in work.
With these insights in mind, I advised the team to create a flow chart. We used some flip charts and sticky notes to map out their current system. We also created swim lane diagrams. Each swim lane was a column for each of the different stakeholders in the system. Nurses, doctors, occupational therapists, social workers, and others all had a lane.
This exercise turned out to be very powerful because it helped them to see interconnections between their work. Each person saw how someone else depends on them and who they depend on in the system. And they were able to take a step back and see the opportunities for improvement. As a result, bed occupancy reduced from 90 percent to 58 percent and length of stay reduced from 70 days to 35 days.
Improvement Coaching Lessons Learned
Some people might assume that being an improvement coach must mean spending a lot of time talking with teams about tools and methods of improvement. Teaching about tools and methods is important, but here are some of the things I have found most important to do as an improvement coach:
- Focus on building relationships and developing psychological safety. When you are an improvement coach, you are usually working with teams wrestling with complex problems they have tried to solve for some time. When you come in from the outside, people can be very protective. From the outset, it can be helpful to say, “My role here is to help you and not to judge you. I’m here to develop solutions together.” When I meet with teams, we spend most of our time getting to understand the heart of the issue we are trying to work on. Building relationships is essential to this. Instead of focusing on the problem, you focus on the solution. But to get to the solution, you have to deeply understand the context. What is going on? How do things work? You may have to talk about some things that people do not often speak about.
- Go in knowing you do not have the answers. The answers come from the team or individual you are coaching. Your role is to facilitate them arriving at those answers. You can share your technical skills and help them ask key questions, but they have the solutions.
- Get the service user or patient perspective. I ask every team I meet to bring their patients or service users into our conversations. It is essential to get their perspective of the problem you are trying to solve. It is amazing how it accelerates progress to have the people most affected be part of the solution.
- Focus on testing. Whether we are meeting for 10 minutes every week or 15 minutes every fortnight, I focus on testing. What are you testing now? What are you planning to test? What have you learned from testing? Until a team starts to test and learn, they are not yet solving the problem, and they are not yet challenging their own perceptions of what the solution might be.
- Encourage good habits. One resource I always direct people to — and I use myself when I am meeting with teams — is the Health Foundation paper called “The habits of an improver.” It is brilliant because it helps an improver — not just a coach — think about the things that they need to pay attention to when it comes to improvement. The improvement habit is something that you can build, learn, and train.
Recently, I was asked about my proudest moment as an improvement coach. It was difficult to pick only one.
Just the other week, for example, I met with a team for about 30 minutes. They started with a concept of what they are trying to improve. It felt very complex. I could barely understand it.
But, by asking questions and probing with them, they were able to go from that initial concept to an aim, a set of measures, and a set of change ideas. After 30 minutes, they were ready to go back to the rest of the team with an idea they could start to develop. They were amazed that they were able to do so much.
As an improvement coach, I have had this experience multiple times. It brings me great satisfaction to help teams get from something that can seem overwhelming to something that is doable. Being an improvement coach means having many opportunities to make an impact on the services that we all use, that our loved ones use, and I absolutely love it.
Auzewell Chitewe is Associate Director of Quality Improvement, East London NHS Foundation Trust and faculty for the IHI Improvement Coach Professional Development Program.
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