Table 5

Illustrating the structural conditions for motivating change—a case example from NHS Highland

What change did we implement?How did we use the physical environment to motivate change?
NHS Highland introduced a weekly review of financial and performance information in a series of wards and teams, using information from the previous week, and leveraging this to produce change. Teams picked priorities, based on data from their own areas.We created a ‘box score’ showing metrics in five areas (safety, quality, patient experience, staff satisfaction, finance). These are displayed in a shared team area and a weekly huddle is held in front of the board. The linked improvement projects are shown on the same board, with their own metrics. Teams can see how their data align to their chosen priorities and current improvement projects.
What financial resource was available?How did we use incentives?
Staff could see the expenditure on their service, using contemporaneous data. This made it easier to link actions to costs. There was no direct incentive for staff to reduce costs, but by increasing efficiency, they could offer their service to more patients. In the pilot ward, a respiratory service, they reduced the number of ‘off service’ patients, and so focused on an improvement in quality of care. Staff found the line of sight between information, improvement and capacity motivating.The incentives were more direct control of the team’s own services, and ability to offer improved services. There were no financial rewards for staff. The focus on quality matched the intrinsic motivators of the majority of healthcare staff, who seemed to find work on quality more motivating than work on finance alone. Using a range of measures across staff and patient experience, quality and safety as well as finance reassured staff that money was not being considered to the exclusion of service quality. There was local recognition for the pilot services, but later services taking up the work were doing it as part of a roll-out plan, and this does not appear to have reduced the impact of the approach.
What was the impact of timing?How did our methodology support change?
Staff routinely undertake quality improvement activities in their own areas, so there was no additional time devoted to projects, although there was increased alignment with team priorities, and therefore greater impact. Weekly huddles lasted only 30 min.
The original pilot was in an area that had already conducted a Rapid Process Improvement Workshop (RPIW), and so had experience of Quality Improvement work at a larger scale. They had also standardised processes to some extent, so were a good starting place.
Later teams were selected because of their place in linked value streams, and then of geographical location, allowing a local QI Collaborative approach. They did not all have previous experience of QI work, but the opportunity to work at the same time as neighbouring teams was successful and motivating.
The methods were overtly Lean, using Lean Accounting, but with regular use of the IHI Model for Improvement. Staff from the Institute of Healthcare Improvement in USA offered telephone coaching, which helped staff to be reassured that there was no conflict between improvement approaches. We provided local coaches to work with teams for around 2 hours a week, who were trained in Lean methods, and familiar with the Model for Improvement.
Several teams had already taken part in RPIWs, and/or had staff who had undertaken the Intermediate Highland Quality Approach training, which is intended to support team leaders to coach improvement work in their own team. The existing experience was therefore a good fit. The previous exposure to QI methods seemed to be helpful to teams, and coaching helped to articulate the links between methods and approaches, to reduce potential confusion.
  • IHI, Institute for Healthcare Improvement; NHS, National Health Service; QI, Quality Improvement.