HEALTH SERVICES AND DELIVERY RESEARCH

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1 HEALTH SERVICES AND DELIVERY RESEARCH VOLUME 2 ISSUE 47 NOVEMBER 2014 ISSN A mixed-methods evauation of transformationa change in NHS North East David J Hunter, Jonathan Erskine, Chris Hicks, Tom McGovern, Adrian Sma, Ed Lugsden, Paua Whitty, Ian Nick Steen and Martin Ecces DOI /hsdr02470

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3 A mixed-methods evauation of transformationa change in NHS North East David J Hunter, 1 * Jonathan Erskine, 1 Chris Hicks, 2 Tom McGovern, 2 Adrian Sma, 2 Ed Lugsden, 2 Paua Whitty, 3 Ian Nick Steen 3 and Martin Ecces 3 1 Centre for Pubic Poicy and Heath, Durham University, Durham, UK 2 Newcaste University Business Schoo, Newcaste upon Tyne, UK 3 Institute of Heath & Society, Newcaste University, Newcaste upon Tyne, UK *Corresponding author Decared competing interests of authors: Paua Whitty has been empoyed as Director of Research, Innovation and Cinica Effectiveness at one of the research study s menta heath trust study sites since Apri 2011 (and by the trust s predecessors as Consutant in Medica Care Epidemioogy since 1998). David Hunter is an appointed governor of one of the acute foundation trust hospita study sites invoved in this research project and was a member of the commissioning board for the Nationa Institute for Heath Research (NIHR) Service Deivery and Organisation programme between 2009 and 2012, and the NIHR Heath Services and Deivery Research programme between 2012 and Jonathan Erskine was a non-executive director of one of the primary care trust study sites unti October Martin Ecces received a saary one day a month as a senior mentor for the Nationa Institute for Heath and Care Exceence Feows and Schoars programme. Pubished November 2014 DOI: /hsdr02470 This report shoud be referenced as foows: Hunter DJ, Erskine J, Hicks C, McGovern T, Sma A, Lugsden E, et a. A mixed-methods evauation of transformationa change in NHS North East. Heath Serv Deiv Res 2014;2(47).

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5 Heath Services and Deivery Research ISSN (Print) ISSN (Onine) This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: nihredit@southampton.ac.uk The fu HS&DR archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Services and Deivery Research journa Reports are pubished in Heath Services and Deivery Research (HS&DR) if (1) they have resuted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. HS&DR programme The Heath Services and Deivery Research (HS&DR) programme, part of the Nationa Institute for Heath Research (NIHR), was estabished to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Heath Services Research (HSR) programme and the Service Deivery and Organisation (SDO) programme, which were merged in January The HS&DR programme aims to produce rigorous and reevant evidence on the quaity, access and organisation of heath services incuding costs and outcomes, as we as research on impementation. The programme wi enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evauative research to improve heath services. For more information about the HS&DR programme pease visit the website: This report The research reported in this issue of the journa was funded by the HS&DR programme or one of its proceeding programmes as project number 08/1809/255. The contractua start date was in December The fina report began editoria review in Juy 2013 and was accepted for pubication in February The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the fina report document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

6 Heath Services and Deivery Research Editor-in-Chief Professor Ray Fitzpatrick Professor of Pubic Heath and Primary Care, University of Oxford, UK NIHR Journas Library Editor-in-Chief Professor Tom Waey Director, NIHR Evauation, Trias and Studies and Director of the HTA Programme, UK NIHR Journas Library Editors Professor Ken Stein Chair of HTA Editoria Board and Professor of Pubic Heath, University of Exeter Medica Schoo, UK Professor Andree Le May Chair of NIHR Journas Library Editoria Group (EME, HS&DR, PGfAR, PHR journas) Dr Martin Ashton-Key Consutant in Pubic Heath Medicine/Consutant Advisor, NETSCC, UK Professor Matthias Beck Chair in Pubic Sector Management and Subject Leader (Management Group), Queen s University Management Schoo, Queen s University Befast, UK Professor Aieen Carke Professor of Pubic Heath and Heath Services Research, Warwick Medica Schoo, University of Warwick, UK Dr Tessa Criy Director, Crysta Bue Consuting Ltd, UK Dr Peter Davidson Director of NETSCC, HTA, UK Ms Tara Lamont Scientific Advisor, NETSCC, UK Professor Eaine McCo Director, Newcaste Cinica Trias Unit, Institute of Heath and Society, Newcaste University, UK Professor Wiiam McGuire Professor of Chid Heath, Hu York Medica Schoo, University of York, UK Professor Geoffrey Meads Professor of Heath Sciences Research, Facuty of Education, University of Winchester, UK Professor Jane Norman Professor of Materna and Feta Heath, University of Edinburgh, UK Professor John Powe Consutant Cinica Adviser, Nationa Institute for Heath and Care Exceence (NICE), UK Professor James Raftery Professor of Heath Technoogy Assessment, Wessex Institute, Facuty of Medicine, University of Southampton, UK Dr Rob Riemsma Reviews Manager, Keijnen Systematic Reviews Ltd, UK Professor Heen Roberts Professor of Chid Heath Research, UCL Institute of Chid Heath, UK Professor Heen Snooks Professor of Heath Services Research, Institute of Life Science, Coege of Medicine, Swansea University, UK Pease visit the website for a ist of members of the NIHR Journas Library Board: Editoria contact: nihredit@southampton.ac.uk NIHR Journas Library

7 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Abstract A mixed-methods evauation of transformationa change in NHS North East David J Hunter, 1* Jonathan Erskine, 1 Chris Hicks, 2 Tom McGovern, 2 Adrian Sma, 2 Ed Lugsden, 2 Paua Whitty, 3 Ian Nick Steen 3 and Martin Ecces 3 1 Centre for Pubic Poicy and Heath, Durham University, Durham, UK 2 Newcaste University Business Schoo, Newcaste upon Tyne, UK 3 Institute of Heath & Society, Newcaste University, Newcaste upon Tyne, UK *Corresponding author d.j.hunter@durham.ac.uk Background: The North East Transformation System (NETS) was conceived as an experiment in adopting arge-scae transformationa change across a NHS region in Engand. Athough the NHS in the North East performs we, the heath of the popuation ranks among the poorest in the country. The NETS was viewed as a means of addressing this conundrum. It comprised three components: Vision, Compact and Method. Objectives: The evauation study comprised six eements: a iterature review; an evauation of the evoution and impact of the NETS; an identification of the factors faciitating, and/or acting as barriers to, successfu change; an assessment of the roe of the NETS project team; estabishing how far the changes introduced through the NETS became embedded and sustained; and an evauation of the impact of the NETS on end users. Design: The research comprised a ongitudina mixed-methods study conducted over 3.5 years. Research methods incuded 68 semistructured interviews, observation, two focus groups, documentary anaysis and interrupted time series (ITS) anaysis. The ITS component comprised anaysis of five rapid process improvement workshops in two of the sites. Setting: The research setting was the NHS North East region unti its aboition in Apri 2013 foowing the UK government s NHS changes. Fourteen sites were seected for the study, comprising primary care trusts as commissioners, and provider trusts incuding menta heath, community, acute care and ambuance services. Participants: The study respondents were members of staff in the 14 sites drawn from different eves of their organisations. Interventions: The NETS comprised a compex set of interventions aimed at improving the efficiency and effectiveness of care pathways for staff and patients. Main outcome measures: The receptive contexts for change framework was used to evauate the transformationa change process and its outcomes. Data sources: Quaitative parts of the study drew on semistructured interviews, focus groups, observation and documents. Quantitative parts of the study used routiney coected NHS data. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. v

8 ABSTRACT Resuts: Transformationa change in a compex system takes time and demands consistency, constancy of purpose and organisationa stabiity. The NETS was seriousy disrupted by the NHS changes announced in Juy Progress was sustained at four of the study sites, but sowed or ceased at the other sites. Leadership stye was found to be critica to the success of transformationa change. Concusions: The NETS was a bod and ambitious initiative which succeeded in bringing about rea and asting change in some parts of the North East. However, it was unabe to fuy reaise its vision and purpose party because of the widespread reorganisation of the NHS by the new coaition government. Future work: There is a need to deveop new methods to understand how change occurs, or fais, in compex settings ike the NHS. There is a need for more in-depth studies in those sites that were abe to impement and sustain change. This woud inform future poicy and practice. The resuts of the quantitative anayses were ess concusive than those obtained by quaitative methods. Further deveopment of mixed-methods approaches woud provide additiona support for evidence-based decision-making. Funding: The Nationa Institute for Heath Research Heath Services and Deivery Research programme. vi NIHR Journas Library

9 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Contents List of tabes List of figures List of boxes Gossary List of abbreviations Pain Engish summary Scientific summary xi xiii xv xvii xix xxi xxiii Chapter 1 Poicy context and background 1 The North East Transformation System: key features, research aims and objectives 3 Research aims and objectives 4 Conducting the North East Transformation System study 4 Chapter 2 Literature review 5 Management profession interface 5 Organisationa cuture and eadership styes in heath care 7 Compexity and heath 8 The evoution of ean 9 Fordism 10 Toyota Production System 10 Lean in the UK 10 Lean phiosophy and strategies 11 Lean initiatives in the North East of Engand 12 Lean in the pubic sector 12 Lean in heath care 14 Chapter 3 The origins and evoution of the North East Transformation System 17 Why the North East Transformation System? 17 Vision 18 Compact 19 Method 21 Concusions 22 Chapter 4 Study design and methods 23 Research design 24 Study sites 24 Longitudina research design, incuding timetabe 26 Year 1 26 Year 2 28 Year 3 28 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. vii

10 CONTENTS Methods 28 Literature review 28 Interviews 28 Observations 29 Focus groups 29 Dissemination of eary research findings 29 Documentary materias 29 Quaitative data anaysis 30 Interrupted time series 35 Data and data sources 35 Quantitative data anaysis: interrupted time series 36 Chapter 5 Perspectives on the North East Transformation System 45 The deveopment of the Vision 45 Compact deveopment 46 Perceptions of the roe of the Compact 47 How the Compact was deveoped 48 How trusts are integrating the concept of the Compact with existing manageria practices 49 The adoption and use of the Method 50 The vaue of visua management 51 Lean toos 52 Waste 53 Standardisation 53 Training 55 Undertaking improvements and sustainabiity 56 Summary 57 Chapter 6 Case studies 59 Case study 1: purposefu inpatient admission rapid process improvement workshop 59 Rapid process improvement workshop support 61 Pre-rapid process improvement workshop work 62 Outputs and outcomes 62 Interrupted time series anaysis 64 Case study 2: community psychosis superfow rapid process improvement workshop 65 Rapid process improvement workshop support 65 Pre-rapid process improvement workshop work 65 Rapid process improvement workshop outputs and outcomes 67 Interrupted time series anaysis 68 Case study 3: surgica pathways assessment area (abdomina pain) rapid process improvement workshop in an acute hospita 70 Rapid process improvement workshop support 70 Pre-rapid process improvement workshop work 71 Outputs and outcomes 71 Interrupted time series anaysis 72 Case study 4: other North East Transformation System environments 72 The North East Transformation System in a wave 2 organisation 73 The North East Transformation System in a commissioning organisation 75 Non-Virginia Mason Production System North East Transformation System: study site Non-Virginia Mason Production System North East Transformation System: study site Summary 81 viii NIHR Journas Library

11 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Chapter 7 The impact of the North East Transformation System 83 Impact on performance 83 Patient safety 83 North East Transformation System and the quaity of care 86 The roe and deveopment of the North East Transformation System Coaition 87 Communication via visua management in the North East Transformation System organisations 87 The North East Transformation System and patient invovement 91 Interrupted time series anaysis of seected rapid process improvement workshops 93 Summary of findings for the rapid process improvement workshops incuded in the interrupted time series 93 Site 09 surgica pathway (abdomina pain) 93 Site 10 purposefu inpatient admission rapid process improvement workshop 104 Site 10 community psychosis rapid process improvement workshops (referra, treatment, discharge) 110 Factors that promoted or inhibited the adoption, impementation and sustainabiity of the North East Transformation System 126 Key peope eading change 126 Quaity and coherence of poicy 127 Environmenta pressure 129 Change agenda and its ocae 131 Manageria cinica reations 132 Share-and-spread activities 133 Cost-effectiveness 134 Summary 136 Chapter 8 Discussion and key themes 137 The impementation and sustainabiity of transformationa change in a compex and changing poicy and organisationa context 137 The importance of eadership and its effectiveness 139 Differences between ean in the manufacturing and heath sectors respectivey, and the nature of compexity in the two sectors 140 Differences between study sites in terms of their receptiveness to the North East Transformation System and ean thinking, as we as their reative success in impementing the North East Transformation System s founding principes 141 Refections on the interrupted time series 143 Genera messages from the study 144 Chapter 9 Concusions and impications 147 Potentia benefits of the research for the wider NHS 147 Chaenges of conducting research in compex systems 148 Key impications 149 Importance of eadership and eadership stye 149 Importance of the Compact 149 Importance of training and deveopment 149 Avoid becoming fixated on the Method 150 A ong hau, not a quick fix 150 Importance of ocaism 150 The nature and roe of data 150 Impications for future research 151 Concusion 151 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. ix

12 CONTENTS Acknowedgements 153 References 155 Appendix 1 Membership of the externa advisory group and terms of reference 163 Appendix 2 Management feow 165 Appendix 3 Interview question schedue 167 Appendix 4 North East Transformation System Coaition-reported training rapid process improvement workshops, November 2007 to June x NIHR Journas Library

13 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 List of tabes TABLE 1 The od compact 19 TABLE 2 Mixed-methods research design 24 TABLE 3 Study site context 25 TABLE 4 The coding framework 32 TABLE 5 The NETS three-egged stoo coding framework 34 TABLE 6 Outcome measures and data sources for the RPIWs incuded in the ITS 37 TABLE 7 Outcomes measures for ITS: measure definitions and issues encountered 40 TABLE 8 Case study overview 59 TABLE 9 Study site 10 PIPA RPIW (Apri 2008) 60 TABLE 10 Study site 10 community psychosis superfow RPIW, panned for November 2010 and carried out in January TABLE 11 Output documents from psychosis superfow RPIW 67 TABLE 12 Interrupted time series metrics for community psychosis RPIW 69 TABLE 13 Study site 09 surgica pathways (abdomina pain) RPIW (October 2011) 70 TABLE 14 Interrupted time series resuts for metrics concerning time 72 TABLE 15 Study site 07 trust main stores RPIW (October 2010) 73 TABLE 16 Study site muti-agency hospita discharge RPIW (Juy 2010) 76 TABLE 17 Key NETS Coaition deveopments as reported by the NETS Coaition Board, TABLE 18 Key NETS Coaition deveopments as reported by the NETS Coaition Board, TABLE 19 Summary tabe by RPIW of findings for variabes incuded in the ITS 94 TABLE 20 Proportion of occasions on which target was achieved, by day of the week 103 TABLE 21 Number of patients admitted directy on to the ward 108 TABLE 22 Time in days from referra to discharge 123 TABLE 23 The NETS as described in SHA annua reports, Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xi

14 LIST OF TABLES TABLE 24 References to ean, QI programmes and the NETS in seected study site annua reports 128 TABLE 25 Views of the NETS and QIPP (numbers refer to study sites) 132 TABLE 26 Notes on the study sites receptiveness to the NETS 142 xii NIHR Journas Library

15 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 List of figures FIGURE 1 The Leadership for Heath Improvement framework 22 FIGURE 2 Research design 27 FIGURE 3 The receptive contexts for change framework 31 FIGURE 4 Psychosis superfow overview: the standardised post-rpiw care pathway 68 FIGURE 5 Attendees at A&E presenting with abdomina pain from 2009 to FIGURE 6 Proportion of patients admitted who went on to have a surgica procedure 96 FIGURE 7 Distribution of time to surgica procedure (n = 518) 97 FIGURE 8 Distribution of time to surgica procedure (n = 524) 98 FIGURE 9 Log-time to procedure by month of foow-up 99 FIGURE 10 Proportion of admissions who had an utrasound scan by caendar month 100 FIGURE 11 Geometric mean time to utrasound by caendar month 101 FIGURE 12 Distribution of og-transformed time to utrasound scan (n = 1201) 102 FIGURE 13 Proportion of days with procedures starting before and finishing before 20.30, by month 103 FIGURE 14 Length of stay in days in hospita and on the ward 105 FIGURE 15 Admissions and transfers to hospita wards by caendar month 107 FIGURE 16 Distribution of og-transformed ength of stay with superimposed norma curve (n = 186) 108 FIGURE 17 Geometric mean ength of spe on ward, in days, by month of admission by sex 109 FIGURE 18 Time in days from referra received to first aocation 111 FIGURE 19 Proportion of patients aocated on the day that the referra was received 112 FIGURE 20 Mean time to aocation for those patients who did not receive an aocation on the day that the referra was received 112 FIGURE 21 Frequency distribution of time in days to first contact 115 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xiii

16 LIST OF FIGURES FIGURE 22 Proportion of patients with face-to-face contact on day of receipt of the referra by caendar month 116 FIGURE 23 Mean time to first face-to-face contact for patients whose contact was not on the day that the referra was received, by caendar month 116 FIGURE 24 Proportion of DNAs at first contact by caendar month 117 FIGURE 25 Distribution of time in days from referra received to assessment 119 FIGURE 26 Proportion of cases where assessment was recorded on day of receipt of referra by caendar month 120 FIGURE 27 Mean time in days to assessment for patients not assessed on day referra was received by caendar month 120 FIGURE 28 Mean time to diagnostic formuation by caendar month 121 FIGURE 29 Proportion of referras with a recorded date of discharge by caendar month 123 FIGURE 30 Time to discharge in days 124 FIGURE 31 Frequency distribution of og-transformed time to discharge (n = 1169) 125 FIGURE 32 Log-transformed time to discharge by caendar month 125 xiv NIHR Journas Library

17 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 List of boxes BOX 1 The new compact 20 BOX 2 Extract from site 10 staff Compact: the psychoogica or cutura reationship that exists between staff and the trust 49 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xv

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19 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Gossary Jidoka A Japanese word meaning autonomation ; may be described as inteigent automation or automation with a human touch. Kaizen Japanese word for improvement, or change for the better. Kanban Japanese word for visua board, used to indicate a means of visua scheduing of a production system. Takt time Derived from German; transates as cyce time. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xvii

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21 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 List of abbreviations 3P 5C 5S Production Preparation Process cear out, configure, cean and check, conformity, custom and practice sorting, set in order, systematic ceaning, standardising and sustaining NIHR NPM ONE PCT PI Nationa Institute for Heath Research new pubic management One North East primary care trust principa investigator A&E accident and emergency PIPA purposefu inpatient admission BPR business process re-engineering PPI patient and pubic invovement CCG Cinica Commissioning Group QI quaity improvement CEO CI CQC DNA EAG ERIP FT GP HR ITS KPO KSL LES MF NEPA NETS NHS NE chief executive officer confidence interva Care Quaity Commission did not attend externa advisory group European Regions for Innovative Productivity foundation trust genera practitioner human resources interrupted time series Kaizen Promotion Office knowedge sharing and earning oca enhanced service management feow North East Productivity Aiance North East Transformation System NHS North East QIPP QIS RDA RIE RPIW SDO SHA SME SMED SPD SUI TPS TQM VMMC VMPS VSM Quaity, Innovation, Productivity and Prevention quaity improvement system regiona deveopment agency rapid improvement event rapid process improvement workshop Service Deivery and Organisation Strategic Heath Authority sma- and medium-sized enterprise Singe-Minute Exchange of Dies standard process description serious untoward incident Toyota Production System tota quaity management Virginia Mason Medica Center Virginia Mason Production System vaue stream mapping Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xix

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23 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Pain Engish summary Improving the quaity of service provision and care for patients is of centra importance in the NHS. The North East of Engand enjoys good, we-performing heath-care provision but the heath of the popuation remains generay poor. The North East Transformation System (NETS) was introduced to encourage a new approach to the provision of heath-care services throughout the region and to improve their efficiency and effectiveness. It adopted best practice from the USA, Japan, the UK and Europe. The NETS was an ambitious and compex project and was the first attempt to transform an entire heath-care system. The research aimed to evauate the impact of the NETS using a range of methods in 14 seected NHS organisations. The NETS stimuated change and new ways of working. Positive impacts and asting change were achieved in severa of the study sites. However, oss of the North East Strategic Heath Authority in Apri 2013, foowing the government s NHS changes, made embedding and sustaining the improvements more difficut. It had been the main inspiration and driver behind the NETS. Leadership was found to be particuary important in promoting change and improvement, especiay the reationship between cinicians and managers, which has not aways been an easy one. Given the compexity of the NHS environment and the range of infuences on it, it was difficut to say with compete certainty whether or not any changes identified were the resut of the NETS and not due to other factors, either in part or in their entirety. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxi

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25 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Scientific summary Background The North East Transformation System (NETS) was conceived as an experiment in the adoption of arge-scae transformationa change across a NHS region in Engand. Athough the NHS in the North East performs we, exceeding required targets and performance measures, the heath of the popuation within the region ranks among the poorest in the country. The NETS was viewed as a means of addressing this paradox by instigating a programme of change which aimed to transform the way services were provided with a view to improving their efficiency and effectiveness. It comprised three components Vision, Compact and Method which were a features of a successfu approach to heath system change deveoped by the Virginia Mason Medica Center (VMMC) in Seatte, WA. Vision The Vision was for NHS North East (NHS NE) to achieve exceence in heath-care services and to sustain continuous improvement. This was to be accompished by a zero-toerance approach which was underpinned by the seven no s : no barriers to heath and we-being no avoidabe deaths, injury or iness no avoidabe suffering or pain no hepessness no unnecessary waiting or deays no waste no inequaity. A staff were encouraged to engage with the Vision. It was intended to inspire, co-ordinate and inform the deveopment of the Visions of each NHS organisation in the region. These were taiored to suit individua circumstances so as to avoid any charge of one size fits a, top-down imposition of the Vision. Compact The Compact emerged to address the deep-seated and enduring tensions between manageria and professiona vaues which have been a ong-term feature of the NHS. These have persisted since the first major reorganisation of the NHS in 1974, when the rise of manageriaism in heath care started in earnest and began to chaenge professiona cinica autonomy. The Compact aimed to estabish a psychoogica contract between managers and heath-care professionas by ceary articuating the gives and the gets. Method The Method was derived from the Virginia Mason Production System (VMPS) which, in turn, was based on the Toyota Production System (TPS). The VMMC was one of the first hospitas to appy ean production (often referred to simpy as ean ) to a heath-care faciity. In manufacturing, ean production has been shown to improve processes, quaity and efficiency through standardisation, the eimination of waste and the reduction of variance. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxiii

26 SCIENTIFIC SUMMARY Research questions The research questions, as described in the study protoco, were as foows: How have the various manifestations of the NETS and non-nets approaches evoved over time? How receptive have NHS organisations in the North East been to transformationa change, incuding the adoption of VMPS, TPS and other ean toos? What has the impact of the different NETS approaches been on the quaity and efficiency of heath care in respect of technica quaity, safety, patient experience, access and equity? How far has variation been reduced across speciaties, departments and hospitas? How far has work-reated stress been reduced? How far has the Compact with cinicians, to secure their commitment to the NETS approaches, been made a reaity? How far have staff been empowered to take contro of their work? What are the factors faciitating, and/or acting as barriers to, successfu change? Objectives The research objectives were to: review the iterature reating to change management in heath systems; ean and its appication in the manufacturing sector; and the adoption of TPS/ean in heath-care organisations evauate the impact of the NETS and its evoution over the time of the study, incuding its infuence on NHS organisationa and cinica cutures (such as staff engagement and empowerment); the quaity and efficiency of heath care in terms of technica quaity, safety, patient experience, access and equity; reduced waiting times and waste; and reduced variation across speciaties, departments and hospitas identify the factors faciitating and/or acting as barriers to successfu change, incuding evauating how rapid process improvement workshops (RPIWs) function and/or what woud inhibit their take up and impact evauate the roe of the NETS project team in co-ordinating progress and supporting the transfer of earning, incuding mechanisms for identifying and disseminating best practice evauate the extent to which the changes introduced through the NETS (and through other means in the case of non-nets study sites) have become embedded and been sustained evauate the impact of the NETS on service users, for exampe patients or carers and/or famiy and friends. Research design The research comprised a ongitudina, 3.5-year study. The study sites were 14 NHS trusts in North East Engand, comprising two custers of primary care trusts, two menta heath and earning disabiity trusts, three hospita trusts, an ambuance trust and a community services trust. These sites were chosen to provide geographica coverage of the whoe region, and to refect the scae, scope and variety of the NHS organisations that were part of the NETS programme. The research design adopted a mixed-methods approach that expored transformationa change in terms of content, context, process and outcomes, in order to address the research questions set out in the study protoco. The quaitative eement of the research made use of semistructured interviews, observation, documentary anaysis, focus groups, and attendance at trust meetings and presentations. The quantitative eement used interrupted time series (ITS) anaysis. xxiv NIHR Journas Library

27 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The research was panned to remain responsive to changes in NHS organisations at oca, regiona and nationa eves. This fexibiity of approach aowed research activities to proceed mosty as originay envisaged: in three phases that corresponded to years 1, 2 and 3 of the study. Methods The research empoyed a iterature review, quaitative and quantitative investigations and feedback to the study sites through reguar dissemination of emerging findings. The iterature review took pace throughout the duration of the project, and buit on and extended an earier scoping study. It provided the theoretica background to the research. Quaitative research progressed through three phases, corresponding to years 1, 2 and 3 of the study. It empoyed semistructured interviews (n = 68), fied observation, focus groups (n = 2), and document gathering and anaysis. The anaysis of the quaitative data made use of both deductive and inductive frameworks. The deductive framework adopted Pettigrew et a. s receptive contexts for change framework (Pettigrew AM, Ferie E, McKee L. Shaping Strategic Change: Making Change in Large Organizations The Case of the Nationa Heath Service. London: Sage; 1992) to evauate transformationa change in NHS NE. The framework comprises eight factors: quaity and coherence of poicy avaiabiity of key peope eading change ong-term environmenta pressure to trigger change supportive organisationa cuture effective manageria cinica reations co-operative interorganisationa networks simpicity and carity of goas and priorities fit between change agenda and its ocae. The inductive frameworks, which were iterativey updated during the duration of the study, were derived from issues and topics that arose during cose reading of interview and focus group transcripts, and from anaysis of documentary materias. Quantitative research focused on a sma number of RPIWs, and made use of ITS anayses to evauate the impact of these. The ITS approach was adopted owing to the strength of controed ITS design and the short period over which RPIW interventions took pace. The research team iaised with the trusts information staff to identify and obtain extracts of the appropriate anonymous data. Ethica review Ethica approva for the study was obtained from the ethics committee of Durham University s Schoo for Medicine, Pharmacy and Heath in August Ethica review was aso sought from the Nationa Research Ethics Service Committee North East County Durham and Tees Vaey. Ethica approva was obtained from this committee on 19 October Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxv

28 SCIENTIFIC SUMMARY Resuts Undertaking successfu transformationa change in a compex system takes time and demands consistency, constancy of purpose and organisationa stabiity. The NHS continuay experiences changes in its context in terms of poicy, organisation, funding and externa environment, which creates particuar chaenges when it comes to embedding transformationa change. The NETS was seriousy disrupted by the NHS changes announced in Juy 2010 as it was overseen and co-ordinated by the Strategic Heath Authority, which was subsequenty aboished. In addition, there are numerous compexities within any heath-care setting. When combined, these issues make it extremey difficut to arrive at any fina concusions about the impact of any change programme on services or the pubic s heath. Even where there may be evidence of change and improvement, it is important to exercise caution in attributing these soey to the NETS. Estabishing strong causa inks, as distinct from strong associations and/or correations, has not proved possibe. Notwithstanding the impact of the changes on the overa NETS programme, four of the study sites demonstrated positive impacts. Progress in the other study sites was sowed, hated or seriousy disrupted by the NHS upheava, which resuted in oca impementation of the NETS osing momentum. Leadership stye is critica to the success of any transformationa change initiative, wherever it is pursued. Athough this was ceary a factor in the progression of the NETS overa, it was aso critica in respect of each of the participating organisations. The four sites which made progress in impementing the NETS a had cear, visibe and reativey stabe eadership. Despite this, the commitment to embedding deep cutura change proved chaenging and fragie. Arguaby, none of the sites coud match what had been achieved by, or the degree of embeddedness to be found in, the VMMC. Most of the attention of managers and other practitioners was devoted to the ean toos rather than to the more difficut issues around vaues and cuture which the Vision and Compact sought to address. Some of those invoved in the NETS regretted the imbaance and fet that they shoud have spent ess time on the Method. Compared with its use in the manufacturing sector, the appication of ean to the NHS invoved a far greater degree of being abe to manage compexity and numerous competing objectives. Perhaps four, maybe five, of the study sites remained truy committed to the NETS. Other sites tended to adopt a pick-and-mix approach that combined eements of the NETS with other approaches which were perceived to be more appropriate. The absence of adoption of a pure NETS approach did not precude some sites from achieving success in quaity improvement and patient safety. Anaysis of the ITS component of this study produced mixed findings when evauating the outcomes of RPIWs. A sma number of statisticay significant improvements were observed. However, some resuts were ambiguous and others showed no evidence of impact. There were aso some counter-expectation findings. Cear improvements incuded: a reduction in time from the arriva of patients with abdomina pain in accident and emergency to their being X-rayed (surgica pathway RPIW) a reduction in ength of stay on the ward for women (purposefu inpatient admission RPIW). Counter-expectation findings incuded an increase in the time to discharge (community psychosis discharge RPIW). Overa, for 9 out of 19 variabes anaysed, the resuts tended to be ambiguous without cear evidence of a positive or negative impact of the RPIWs. It is difficut to draw definitive concusions from the ITS anaysis, which may have missed significant changes owing to a reiance on routine administrative data and the absence of data on a range of cinica outcomes. xxvi NIHR Journas Library

29 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Concusions The NETS was a bod and ambitious initiative. It may have succeeded in bringing about rea and asting change in some parts of the heath-care system in the North East of Engand. However, it was unabe fuy to reaise its vision and purpose party as a resut of dramatic change in the NHS andscape. Positive and encouraging deveopments and changes were identified but their utimate fate became ess certain as the NETS programme itsef underwent radica change from mid Our recommendations for research are derived from a need to deveop new methods to understand how change occurs, or fais, in compex settings ike the NHS. There is a need for more in-depth studies in those sites that were abe to impement and sustain change. The findings woud inform future poicy and practice. The resuts of the quantitative anayses were ess concusive than those obtained by quaitative methods. Further deveopment of mixed-methods approaches woud provide additiona support for evidence-based decision-making. Athough our study was concerned with adopting a broad sweep across a number of organisations as this whoe-system approach was at the centre of the NETS, this inevitaby meant some sacrifice in terms of depth. This is the reason for our support for studies aimed at exporing the organisations engaged in the NETS in greater depth and eiciting the factors that contributed to success or, conversey, to faiure. Finay, there were imitations with the ITS part of the study, in particuar with getting access to NHS data retrospectivey. There might be merit in considering a we-designed prospective study to evauate the effectiveness of RPIW-type interventions. Funding Funding for this study was provided by the Heath Services and Deivery Research programme of the Nationa Institute for Heath Research. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. xxvii

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31 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Chapter 1 Poicy context and background The North East Transformation System (NETS) was a unique experiment in the adoption of transformationa change in a compex system, namey the NHS in North East Engand. If the initiative had been aowed to evove and mature, it might have become a bueprint for other regions to copy. However, it was unexpectedy interrupted and required to take a different direction foowing the UK coaition government s proposas to reorganise the NHS, announced in Juy In this scene-setting introductory chapter, we ocate the NETS in its broader poicy context. Launched in 2007, the NETS was both pioneering and nove in terms of its purpose and scope. However, it did not exist in isoation from other quaity initiatives that aso sought to improve service deivery and quaity of care, whie aso reducing waste and variation. Government poicy during this period was infuenced by severa factors. First was the eection of a Labour government that sought to distance itsef from its predecessor s heath-care reforms, which emphasised interna markets and competition as a mechanism to stimuate heath service improvements. In addition, the appointment in 1999 of Liam Donadson as Chief Medica Officer for Engand proved both timey and significant. Donadson had been a major proponent of patient safety in his previous roe as Regiona Genera Manager of the former Northern and Yorkshire Regiona Heath Authority. He was aso a principa architect of cinica governance arrangements. Cinica governance has been defined as a framework through which NHS organisations are accountabe for continuousy improving the quaity of their services and safeguarding high standards of care by creating an environment in which exceence in cinica care wi fourish. 2 Many of the concerns and concepts embraced by cinica governance were encompassed in the NETS. The NETS therefore evoved and took root within a poicy context that was sympathetic and receptive to its overa aims, purpose and approach. This introductory chapter sets out the key eements of the government s focus on quaity improvement (QI) which formed the broad poicy context for, and background to, the NETS. Chapter 3 provides a brief history of the origins and evoution of the NETS, which formed the backdrop to the evauation of its evoution and its impact over the period of the study. A focus on quaity and QI has been a centra feature of NHS poicy since 1997, athough the interest in quaity goes much further back. The Labour government, eected in May 1997, invested heaviy in a range of initiatives intended to improve quaity. In a White Paper pubished in 1997 (The New NHS: Modern, Dependabe), it stated: The new NHS wi have quaity at its heart... Every part of the NHS, and everyone who works in it, shoud take responsibiity for working to improve quaity 3 [ Crown copyright 1997, contains pubic sector information icensed under the Open Government Licence v2.0 ( The government expressed concern about the unacceptabe variations in performance and practice. It sought to address the probem by putting quaity at the top of the NHS agenda. The objective was to aign oca cinica judgements with cear nationa standards that incorporated best practice. This was described in detai in an important consutation document pubished by the Department of Heath in 1998, A First Cass Service: Quaity in the new NHS. 4 The pan was for nationa standards to be set through nationa service frameworks and through the estabishment of a new body, the Nationa Institute for Cinica Exceence (NICE) (in Apri 2013 this became the Nationa Institute for Heath and Care Exceence). At oca eve, standards were to be deivered by a cinica governance system that was informed by the atest evidence and guidance on what worked best for patients. The approach was aso supported by ifeong earning for staff and modernised professiona sef-reguation. Cinica governance is the process by which each part of the NHS assures its quaity and ensures that cinica decisions are aigned with its principes. The intention was to introduce a system of continuous improvement into the operations of the whoe NHS. Quaity was to be everybody s business and was based upon partnerships within heath-care teams comprising heath professionas and managers. The new emphasis on quaity was to be estabished Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 1

32 POLICY CONTEXT AND BACKGROUND at a eves of the NHS. It was stressed that the drive to pace quaity uppermost on the NHS agenda was concerned with changing thinking, rather than merey ticking checkists. Centra to the government s focus on quaity was the cinica governance framework which incuded a comprehensive programme of QI activity and processes for monitoring cinica care. Deveoping a structured and coherent approach to cinica quaity was centra to the whoe endeavour. This incuded an emphasis on attracting, deveoping, motivating and retaining high-caibre heath-care professionas, managers and staff. Continuing professiona deveopment was viewed as centra to continuous QI, which was termed action for quaity. The 10-year strategy acknowedged that the issues were compex and coud not be tacked overnight. The vision for quaity aimed to create a NHS cuture that encouraged innovation and success, and one that fostered a earning cuture which made good use of best practice exempars. This was seen as the bedrock of continuous improvement, as we as a focus on partnership working rather than competiton. 4 The drive to improve quaity was considered to invove major cutura change for a. Part of supporting such a change in cuture entais deveoping organisations to deiver change. 4 The crucia eements to achieve success were exceent eadership and the invovement of staff. These were important because, in some QI work, there has tended to be a separate focus on either cinicay ed improvement or improvement ed from a management perspective. The resut was discrete, parae activities within organisations with misaigned objectives, dupication of effort and a ack of focus. 5 The chaenge for heath-care organisations is to improve both cinica and manageria quaity, as in practice they interact or shoud do. The government acknowedged this in When the NETS was conceived neary 10 years ater, it was simiary informed by such an approach. Many of the ideas set out in the government s 1998 consutation document were ost in the subsequent series of NHS reforms that started with the NHS Pan in Further waves of structura and other changes to various NHS organisations proved both disruptive and distracting. Quaity and patient safety ony came back into vogue as a resut of two particuar deveopments. First, the period of increased investment in the NHS came to an end in 2007 owing to the goba economic sowdown and the subsequent coapse of the banking system. Attention therefore focused on using resources more efficienty and effectivey. The Quaity Innovation Productivity and Prevention (QIPP) initiative was introduced specificay with this aim in mind. It was intended to avoid a retrenchment response to spending pressures through adopting a more inteigent approach to commissioning decisions that avoided putting quaity at risk. Initiatives ike the NETS were seen by some NHS eaders at the Department of Heath as being especiay important for the whoe NHS, and were being ooked to as pioneers providing essons for the rest of the system. This was because they offered the potentia to improve services without sacrificing staff or osing any of the gains resuting from previous additiona investment stemming from the Waness report. 7 The second factor which reinstated QI as a centra objective of government poicy was Lord Darzi s next stage review of the NHS. 8 Commissioned by the then prime minister, QI was given particuar prominence by Darzi, an eminent cardiac surgeon. In his view, one of the core eements of eadership was a focus on continuous improvement. Aigning cinica and manageria approaches to quaity was seen as critica. A review of QI in heath care pubished in 2008 concuded that having an improvement method is important to achieve outcomes, but the particuar method adopted is not important. 9 Faiures are usuay due to intractabe probems in reationships or eadership rather than in the toos or methods adopted. These concusions are supported by our research. The architects of the NETS approach saw it as a transformationa change initiative that sought to achieve a change in overa cuture. It specificay addressed the issues of eadership and reationships through the Vision and Compact. The evidence demonstrates that it is important for eaders to adopt and commit to whichever too or method is chosen for as ong as it takes to deiver the resuts for patients 8 (Our NHS Our Future: NHS Next Stage Review Leading Loca Change, Crown copyright 2008). Øvretveit provided evidence that eadership is associated with, and infuences, successfu improvement and is a factor contributing to sow, partia or faied improvement. 10 However, the highy contextua nature of change makes generaisation difficut. 2 NIHR Journas Library

33 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The eary deveopment of the NETS initiative was informed by these findings, athough how far this was expicit or impicit is uncear. The origins of the NETS are described in Chapter 3, drawing on a scoping review conducted in 2008 which formed the basis for the main study. 11 Before doing so, however, we set out why the NETS was important, its particuar features which set it apart from other QI initiatives, and our research aims and objectives. The generaisation of resuts is an important, if often contested, issue in research that investigates compex adaptive systems of the type to be found in the NHS. 12 Washe 13 commented that with QI research the aim is not to find out whether it works, as the answer to that question is amost aways yes, sometimes. The purpose is to estabish when, how and why the intervention works and to unpick the compex reationship between context, content, appication and outcomes. Having undertaken these tasks, the issue remains one of how far it is reasonabe to offer generaisabe findings, as the precise combination of factors making for success may be particuar to that setting and not possibe to repicate esewhere. On the other hand, it is ikey that the presence of some features wi serve as generic drivers of change which can be usefuy highighted and disseminated more widey. Of course, how they are then appied in practice in varying settings wi determine their precise configuration and impact. The Heath Foundation s work on spreading improvement demonstrates that with the right earning and support systems, the NHS has the potentia to spread good practice across the system to the universa benefit of staff and patients. However, reaising this potentia is far from straightforward. 14 The North East Transformation System: key features, research aims and objectives The NETS is of nationa and internationa importance because NHS North East (NHS NE), unti its demise in March 2013, was the first Strategic Heath Authority (SHA) to adopt a region-wide strategy that aimed to transform an entire heath-care system. The initiative was bod and ambitious because the SHA served a popuation of 2.4 miion peope and the NHS in the region empoyed 77,000 staff. Up unti that time, the impementation of ean and simiar toos and methods in the NHS had invoved reativey sma-scae interventions confined to particuar hospita departments and support services. 15 However, NHS NE was committed to addressing more compex system-wide issues, incuding addressing transformationa change, cuture and the reationship between cinicians and managers. Many aspects of the NETS were aigned with Darzi s NHS next stage review concusions about how best to ensure service redesign. 16 The NETS started with seven pathfinders that represented a wide range of NHS organisations, incuding the SHA, primary care trusts (PCTs), acute trusts and menta heath trusts. These pathfinders constituted wave 1 of the NETS initiative. Subsequent waves incuded other NHS NE organisations that were programmed to undertake NETS training at reguar intervas of around 12 months. The NETS took much of its inspiration and guidance from the Virginia Mason Production System (VMPS) whose ean method was derived from the Toyota Production System (TPS). Athough NHS NE was committed to supporting a fu evauation of the NETS, it was anxious to capture the earning from its eary experiences. To this end, a 6-month scoping study of the background and initia steps was commissioned from Durham and Newcaste Universities. 11 The scoping study took pace between January and Juy 2008 and investigated the NETS, its aims and objectives and the initia deveopments that had occurred in the seven first-wave pathfinder organisations. It prepared the ground for the main study, whose aims and objectives are described beow. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 3

34 POLICY CONTEXT AND BACKGROUND Research aims and objectives This research has: Produced a iterature review that focused upon change management in heath systems; the adoption of TPS/ean in heath-care organisations; and earning from ean in manufacturing. This buids on the iterature review undertaken for the scoping study. 11 Evauated the impact of the NETS (comprising Vision, Compact, Method) and its evoution over time, incuding the impact on NHS organisationa and cinica cutures (incuding staff engagement and empowerment); the quaity and efficiency of heath care in respect of technica quaity, safety, patient experience, access and equity; reduced waiting times and waste; and reduced variation across speciaties, departments and hospitas. Identified the factors faciitating (or acting as barriers to) successfu change, incuding an evauation of rapid process improvement workshops (RPIWs). Evauated the roe of the NETS project team in co-ordinating progress and supporting the transfer of earning, incuding the mechanisms used for identifying and disseminating best practice. Investigated the extent to which the changes introduced through the NETS (and through other means in the case of non-nets study sites) have become embedded and sustained. Assessed the impact of the NETS on service users, for exampe patients or carers and/or famiy and friends. Conducting the North East Transformation System study The NETS research team was drawn from Durham and Newcaste Universities. Members of the team incuded heath professionas, and academics who were speciaists in heath poicy, human resource management, operations management, strategy and statistics. Project management was provided by one of the co-investigators (Erskine) who was ocated with the principa investigator (PI) at Durham University. Part of this important roe was to organise and support team meetings. These occurred frequenty and rotated between Durham s Queen s Campus on Teesside and Newcaste University Business Schoo. In addition, and apart from reguar e-mais and teephone cas, the team set up a password-protected virtua research environment on a secure server for sharing key documents and managing communications. Second, an externa advisory group (EAG) was estabished to guide and support the study throughout its duration. Membership of the group and its terms of reference are provided in Appendix 1. Between them, EAG members possessed a weath of experience of managing and researching heath-care services and of improvement science methods. The EAG met approximatey every 6 months and members provided usefu guidance and advice on various aspects of the study during its data gathering and writing-up stages. The third feature to note was that the study was aocated a Management Feowship. The Management Feowship scheme was estabished by the former Service Deivery and Organisation (SDO) programme to address concerns about transating research into practice. A part-time management feow (MF) was seconded from the NHS and commenced work in Apri A report on her activities, and the way the roe evoved during the course of the study, is incuded in Appendix 2. 4 NIHR Journas Library

35 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Chapter 2 Literature review A iterature review was undertaken for the scoping study. This invoved searching a wide body of pubished work that incuded professiona and manageria tribaism in heath systems, organisationa cuture, eadership styes and the evoution of ean thinking in manufacturing, pubic services and the NHS. 11 The review of iterature on professiona manageria reations, organisationa cuture, eadership styes and compex adaptive systems is ony briefy reported here. The review focuses on the evoution of ean and its appication to the NHS and how this can reate to the NETS. The section Lean in heath care has been updated to refect how this particuar area has deveoped since the origina scoping study was produced. Management profession interface The tension between manageria and professiona vaues is we documented in the iterature and underpins the rationae for a Compact. A BMJ editoria in 2001 posed the question: why are doctors unhappy? 17 It suggested that the causes were mutipe, athough one in particuar was highighted: the mismatch between what doctors were trained for and what they are required to do. 17 Trained in some speciaty or fied of medicine, doctors find themseves spending more time thinking about issues ike management, improvement, finance, aw, ethics, and communication. 17 In an artice in the BMJ the foowing year, Edwards et a. suggested that the cause of doctors unhappiness is a breakdown in the impicit compact between doctors and society: the individua orientation that doctors were trained for does not fit with the demands of current heathcare systems. 18 They described the od compact and why it is no onger regarded as egitimate, and outined what a new compact might ook ike. The od compact comprised two aspects: what doctors give and what they get in return (see ists beow). The mismatch between these has been the cause of dissonance over what doctors might have reasonaby expected the job to be and how it now is. Some commentators have suggested that the psychoogica contract or compact is a usefu concept to expain this probem What doctors give: sacrifice eary earnings and study hard see patients provide good care as the doctor defines it. What doctors get in return: reasonabe remuneration reasonabe work/ife baance ater autonomy job security deference and respect. A new and more sustainabe Compact is required because the od promise to doctors is either no onger vaid or can act as a barrier to modernisation. Among the new imperatives to be addressed in a revised Compact are the foowing: 18 greater accountabiity (e.g. guideines) patient-centred care becoming more avaiabe to patients, providing a personaised service working coectivey with other doctors and staff to improve quaity Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 5

36 LITERATURE REVIEW evauation by non-technica criteria and patients perceptions a growing bame cuture. Edwards et a. asserted that it was not possibe to return to the od compact and that cinica eaders and managers must create a new compact that improves care for patients, improves the effectiveness of the heathcare organisation, and heps create a happier workforce. 18 The foowing year, once again in the BMJ, Davies and Harrison returned to the theme of the discontented doctor and argued that a principa reason for the dissatisfaction doctors experienced was their reationship with managers. 21 This manifests itsef in a perceived sense of diminished autonomy and reduced dominance. The authors argued for better aignment between doctors and the organisations in which they provide services whie noting that the extent of cutura divergence between managers, doctors, and other professiona groups suggests that such a reaignment wi be far from easy. 21 They concuded by insisting that there is no practicabe aternative to doctors engaging with management. Yet, despite such cas, the unease fet by many doctors and their ack of being vaued has persisted. 22 This was a major reason for inviting a surgeon, Ari Darzi, to ead the next stage review of the NHS, which had cinicians and other front-ine staff at the heart of the change process change that is ocay-ed, patient-centred and cinicay driven 16 (High Quaity Care For A: NHS Next Stage Review Fina Report, Crown copyright 2008). For their part, managers are aso unhappy with their ot. They can appear beeaguered functionaries in a system that is more poiticised than ever and whose poitica heads regard themseves as its eaders. 23 A major exponent of ean in the UK, Seddon, considered that distortions in the heath system ensure that the patient is not put first. 24 The resut is an eaborate set of manageria poys which are, in effect, forms of cheating or gaming to arrive at the resuts desired by their poitica masters. But it is a further contributor to the unhappiness fet on both sides of the management medicine divide. The awkward and often dysfunctiona reationship between managers and professions is far from being a new phenomenon. In their study of hospita organisation in 1973, Rowbottom et a. 25 noted that the position of doctors... presents a fascinating, and possiby unique, situation to any student of organisation. Never have so many highy infuentia figures been found in such an equivoca position neither whoy of, nor whoy divorced from, the organisation which they effectivey dominate. The work of Degeing et a. 26,27 demonstrated the importance of getting professionas and managers to: recognise interconnections between the cinica and financia dimensions of care participate in processes that wi increase the systematisation and integration of cinica work and bring it within the ambit of work process contro accept the mutidiscipinary and team-based nature of cinica service provision and accept the need to estabish structures and practices capabe of supporting this adopt a perspective which baances cinica autonomy with transparent accountabiity. 27,28 The findings from Degeing s work pointed to significant profession-based differences on each of the four eements of the reform agenda They aso demonstrated the barriers that face those seeking to introduce changes in the deivery of heath care. For those changes to happen there needs to be a common sense of purpose and a set of core vaues shared by the key stakehoders. These prior conditions do not exist. Degeing s work showed that a attempts to impose manageria contros on cinica work are doomed to faiure uness a different approach to managing change and engaging with cinicians and other heath-care staff is adopted. 26,27 6 NIHR Journas Library

37 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Organisationa cuture and eadership styes in heath care Cuture is something of a wease word that may simpy be empty rhetoric. It is often invoked too readiy and simpisticay in a heath-care context, the beief being that if cuture change can occur then issues of organisationa performance wi be resoved. Despite this, cuture does matter. Many commentators such as Schein 29 and Mannion et a. 28 have emphasised the importance of cuture in shaping organisationa behaviour and hence achieving improved performance. However, change can be stifed by cuture. As Mannion et a. stated, cuture constitutes the informa socia aspects of an organisation that infuence how peope think, what they regard as important, and how they behave and interact at work. 28 Organisationa cuture has been defined by Schein 29 as: the pattern of shared basic assumptions invented, discovered or deveoped by a given group as it earns to cope with its probems of externa adaptation and interna integration that has worked we enough to be considered vaid and, therefore, to be taught to new members as the correct way to perceive, think, and fee in reation to those probems. Cuture is therefore not merey that which is observabe in socia ife but aso the shared cognitive and symboic context within which a society or institution can be understood. 28 But Mannion et a. 28 resisted the temptation of searching for a magic buet or simpe cutura prescription for the is of the NHS (pp ). In their view, what works is contingent upon context and on how and by whom efforts targeted at cuture reform are evauated and assessed (pp ). They counseed against the adoption of a one size fits a approach to cuture management in the NHS and encourage[d] the adoption of more nuanced strategies which seek to depoy a judicious mix of instruments and supporting tactics depending on setting and appication (pp ). One of the principa components of effective cuture management reates to eadership styes. 30 Much has been written about eadership and hundreds of definitions offered but, as Goodwin observed, it is principay oca context that argey determines the eadership approach to be adopted, meaning oca chaenges, the history and reative strength of oca reationships, oca resource issues and oca ways of doing things (p. 330). 31 Some writers on eadership subscribe to a trait or competency approach, i.e. one size fits a, which ignores context. The NHS competency framework is an exampe of this. Competencies have been criticised for being overy reductionist, overy universaistic or generic, focusing on past or current performance, focusing on measurabe behaviours and outcomes, and resuting in a imited and mechanistic approach to deveopment. 32 Critics aso beieve that such frameworks reinforce the underying assumption that eadership resides in the individua (pp. 32 3). 33 They are regarded as too generic and ignore the context of a situation and the compexity of running very chaenging and diverse workpaces (pp. 32 3). As Western argued, the experience on the ground may be that there is itte room for seizing the future and empowering others when the context fees disempowering due to a production-ine atmosphere where success is measured against meeting targets and deadines (pp. 32 3). 33 Situationa eadership is therefore regarded as more appropriate in the context of compex adaptive systems. In their study of the impact of eadership on successfu change in the NHS, Aban-Metcafe and Aimo-Metcafe found that competencies did not predict effectiveness but that engaging eadership styes significanty predicted motivation, satisfaction, commitment, reduced stress and emotiona exhaustion, and team effectiveness/productivity. 34 For them, eadership was viewed as a shared or distributed process and one that was embedded in the cuture. Like other writers on eadership, Goodwin 30,31 aso noted that eadership is not a characteristic of one person but rather is a process payed out between eaders and foowers, without whom eadership cannot exist (p. 330). 31 Not a commentators beieve that eadership and management are entirey separate entities, but those who do consider that eaders are different from managers because they view peope from an emotiona perspective, seeing them as individuas. 33 But managers can demonstrate eadership and a eader can have manageria skis. Bennis defined eaders as those who master the Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 7

38 LITERATURE REVIEW context whereas managers surrender to it (p. 45). 35 Leadership is about passion, vision, inspiration, creativity and co-operation, rather than contro, which is the hamark of management. 33 A variant on this view is that a eader creates change whereas a manager creates stabiity. Running through a these definitions is the derogatory assumption that management is the other to eadership; a view of the manager as an outdated mechanistic functionaist. Leadership is very ceary in vogue and sexy ; whereas managers are regarded as transactiona in their approach, eaders are seen as transformationa. In keeping with this view of eadership as being about emotions and meaning rather than contro, Goodwin caimed that eadership is a dynamic, reationship-based process that uses a twofod approach: creating an agenda for change using a strong vision; and buiding a strong impementation network to get things done through other peope. 30 In their Leadership for Heath Improvement framework, Hannaway et a. 36 appied improvement science thinking, which borrowed many of its ideas and principes from ean. The approach has been appied in the NHS as a resut of the work of the former NHS Modernisation Agency and its successor, the NHS Institute for Innovation and Improvement, which has been superseded by the NHS Leadership Academy. The 10 High Impact Changes for Service Improvement Deivery incudes the optimisation of fow and the reduction of bottenecks, the appication of systematic approaches, improved access and roe redesign. 37 Compexity and heath It is generay accepted that eading and managing a heath system is a compex business where there are few certainties and where ambiguity and paradox are often present. These need to be managed rather than denied or obscured by an inappropriate manageria mode. Faiure in pubic poicy and pubic services occurs, according to Chapman, because assumptions of separabiity, inearity, simpe causation and predictabiity are no onger vaid (p. 65). 38 Under such conditions of growing compexity, it is essentia that those responsibe for managing and governing take on a wider, more hoistic perspective, one that incudes compexity, uncertainty and ambiguity (p. 65). 38 Systems thinking marks a shift away from regarding the entities being managed as if they were inear, mechanica systems. As Psek (Pau E. Psek & Associates, Inc., 2003) commented in materias distributed at a Leadership for Heath Improvement workshop hed in York in 2006, existing principes of management and eadership are based on od metaphors that fai to describe adequatey or accuratey compex situations ( 2003 Pau E. Psek & Associates, Inc.; reproduced with permission from Psek P. An Organisation is not a Machine! Principes for Managing Compex Adaptive Systems. Materias prepared for Leadership for Heath Improvement programme. York: Unpubished; 2006). In a compex system, the compex adaptive manager and/or eader: manages context and reationships creates conditions that favour emergence and sef-organisation ets go of figuring it a out reies on good enough anaysis of the probem and its soution requires minimum specifications to act rather than prescribing actions in advance. Psek, in the workshop materias referred to above, defined a compex adaptive system as [a] coection of individua agents with freedom to act in ways that are not aways totay predictabe, and whose actions are interconnected so that one agent s actions changes the context for other agents ( 2003 Pau E. Psek & Associates, Inc.; reproduced with permission from Psek P. An Organisation is not a Machine! Principes for Managing Compex Adaptive Systems. Materias prepared for Leadership for Heath Improvement programme. York: Unpubished; 2006). 8 NIHR Journas Library

39 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The remainder of the iterature review presented beow focuses on ean thinking and toos, as these have been centra to the NETS initiative and, in particuar, in demonstrating that successfu change is possibe and motivationa for staff. The sections The evoution of ean, Fordism and Toyota Production System focus on the origins and evoution of ean in the manufacturing sector, incuding its impact in the North East region of Engand. Lean in the UK examines the recent take-up of ean thinking in the UK NHS as we as the pubic services sector more widey. The evoution of ean Lean production evoved from estabished production management approaches. These incude the concept of interchangeabe parts devised by Ei Whitney, scientific management deveoped by Tayor, Henry Ford s mass production and the TPS Tayor found that in craft systems, skis and knowedge were transferred through the apprentice mode. 39 Braverman considered that management was buying knowedge which was the workers capita. 42 There were variations in the voume and quaity of work performed by different individuas as they had different ways of performing tasks. Tayor used the term sodiering to describe workers who deiberatey did work sowy. 40 He noted that there was confict between management and workers fighting over the contro of work and pay. There was a ack of standardised working methods and training. The end resut was that there was waste, which was to the detriment of both the workforce and management. 43 The scientific management movement was very infuentia in the deveopment of modern institutions which carry out abour processes. 42 Tayor stated that: the principa object of management shoud be to secure the maximum prosperity for the empoyer, couped with the maximum prosperity for each empoyee (p. 9). 39 Tayor beieved that this required each individua to maximise efficiency by producing the greatest possibe daiy output. Tayorism is based upon four principes: 1. It is necessary to systematicay anayse work through time and motion studies to deveop standardised methods. 2. Organisations shoud train empoyees in best practice approaches rather than eaving them to train themseves. 3. Workers shoud be provided with detaied instructions that prescribe how to undertake standardised tasks. 4. There shoud be a separation between panning, undertaken by managers using scientific management principes, and doing, performed by workers. 44,45 The core eements of Tayorism are (1) that operations shoud be standardised and optimised scientificay using time and motion studies and (2) the division of abour between managers and workers. 46 Tayor highighted the importance of training as a mechanism for ensuring that individuas were abe to work at maximum efficiency. 39 Tayorism has severa imitations. 45 It creates non-vaue-adding supervisors and other indirect workers, which increases costs. Fexibiity is reduced by the reiance on semiskied workers and high eves of demarcation. However, new workers can be integrated quicky into the production process, which increases numerica fexibiity. It becomes unattractive to work on the shop foor. Tayorism is widey considered to be anti-worker. 42 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 9

40 LITERATURE REVIEW Fordism Ford deveoped mass production at the Highand Park pant in His approach incorporated many aspects of Tayorism. He automated the production of standard parts using repetitive processes and introduced a continuousy moving assemby ine. 40 The pace of work and the voume of production were determined by the ine speed. The combination of Tayorist approaches and assemby ines, together with a rigorousy controed and we-paid workforce, became known as Fordism, 43 which achieved economies of scae through the division of abour. The objective was to minimise the unit cost through high-voume manufacturing. Production workers were not responsibe for quaity; there were speciaist inspectors and repair staff. There was aso a strict separation between the panning and execution of work, and a high division of abour. 46 Toyota Production System The TPS was deveoped by Taiichi Ohno. 41 He identified severa barriers to impementing mass production approaches in Japan. After the Second Word War there was imited domestic demand. Furthermore, customers required a arge variety of vehices, so there was a requirement for ow voume and high variety. Workers were reuctant to work in a system that considered them to be a variabe cost, owing to egisation that strengthened workers rights during the period of American occupation. Japanese companies were starved of capita and foreign exchange; therefore, companies were unabe to purchase expensive Western equipment. There was intense competition from overseas manufacturers that were keen to enter the Japanese market whie defending their estabished markets. 47 Toyota coud not afford to fund the working capita required to maintain the buffers that woud be needed to maintain the high utiisation of production ines that were subject to ine imbaances, quaity probems and other sources of variabiity. Toyota therefore deveoped an aternative soution, which was to operate with minimum inventory whie simutaneousy maintaining high resource utiization. 48 The TPS is based upon two concepts. First, costs are reduced through the eimination of a forms of waste (those things that do not add vaue to the product). Second, there is a need to fuy utiise workers capabiities. 49 The TPS may be viewed as a set of toos for reducing waste or as the set of principes that ed to the deveopment of the toos. 50 Liker 51 identified 14 principes associated with four themes: (1) ong-term phiosophy; (2) the right process wi produce the right resuts; (3) add vaue to the organisation by deveoping peope; and (4) continuousy soving route probems drives organisationa earning. Lean in the UK In the 1980s and 90s inward investment by Japanese automotive companies exposed the uncompetitiveness of many UK automotive components suppiers. 52,53 The Society of Motor Manufacturers and Traders coaborated with the Department of Trade and Industry to form the Industry Forum in ,55 This initiative was supported by major automotive companies. They seconded staff with expertise in improving manufacturing processes, who became master engineers. 56,57 Their roe was to train UK engineers in the use of best practice manufacturing toos and techniques in order to increase the competitiveness of the UK suppiers. The Industry Forum deveoped training programmes that used a Common Approach Tookit. The buiding bocks incuded cear out, configure, cean and check, conformity, custom and practice (5C)/sorting, set in order, systematic ceaning, standardising and sustaining (5S), 58 the seven wastes, 59 standardised work and visua management. The workshops aso incuded training in data anaysis, probem soving, set-up improvement and ine baance. 56 Skis, knowedge and deivery techniques were disseminated through Master Casses, 60,61 which incuded training and practica, shop foor-based process improvement activities. The aim of the Master Cass is to introduce staff to best practice approaches and to improve performance in terms of quaity, cost and deivery NIHR Journas Library

41 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The superior performance of Japanese exempars encouraged the dissemination of ean principes and toos to other contexts, incuding service industries and heath care. However, Western organisations have often been abe to adopt specific ean toos but have found it difficut to change the organisationa cuture and mindset. The impact of ean interventions is often ocaised. Organisations often fai to achieve the desired improvements to the overa system. 62 Lean phiosophy and strategies The TPS was deveoped in Japan by Ohno and Shingo and forms the basis of ean manufacturing. 63 Vomann et a. 64 considered the goa of ean to be zero inventories, zero defects, zero disturbances, zero set-up time, zero ead time, zero transactions and routine operations that operate consistenty day to day. Transactions consist of (1) ogistica transactions (ordering, execution and confirmation of materia movement); (2) baancing transactions, associated with panning that generates ogistica transactions (production contro, purchasing, scheduing); (3) quaity transactions (specification and certification); and (4) change transactions (engineering changes, etc.). In ean manufacturing, waste may be viewed as any activity that creates cost without producing vaue. 65,66 Ohno outined seven forms of waste: Overproduction, i.e. making too many items or making items before they are required. The resut is extended ead times and increased inventory, which incurs carrying costs. 2. The waste of waiting, i.e. time when materias or components are not having vaue added to them. 3. The waste of transportation, i.e. the movement of materias within the factory, which adds cost but not vaue. 4. The waste of inappropriate processing describes the use of a arge, expensive machine instead of severa sma ones eads to pressure to run the machine as much as possibe rather than ony when needed. 5. The waste of unnecessary inventory, which increases ead times, reduces fexibiity and makes it difficut to identify probems. This form of waste increases carrying costs and may cause waste through obsoescence. 6. The waste of unnecessary motions reates to ergonomics. If operators become physicay tired it is ikey to ead to quaity and productivity probems. 7. The cost of defects is caused by interna faiures within the factory, incuding scrap, rework and deay, as we as externa faiures that occur outside the manufacturing system (repairs, warranty cost and ost custom). Bicheno 59 identified additiona new wastes: untapped human potentia; inappropriate systems that add cost without adding vaue; wasted energy and water; wasted materias; wasted customer time; and the waste of defecting customers it may cost many more times to acquire a customer than it does to retain one. Lean comprises a phiosophy, a way of thinking that focuses upon vaue. Often this is considered in terms of cost reduction: 62 This migration from a mere waste reduction focus to a customer vaue focus opens essentiay a second avenue of vaue creation... Vaue is created if interna waste is reduced, as the wastefu activities and the associated costs are reduced, increasing the overa vaue proposition for the customer... The other main emphasis is on continuous improvement that is usuay based upon teamwork undertaken by empowered empoyees. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 11

42 LITERATURE REVIEW Lean initiatives in the North East of Engand In 2000, the eve of productivity (measured in terms of gross vaue added, i.e. the vaue of outputs minus the vaue of inputs) in the North East was 25% ower than the nationa average. 68 This situation had made the support of manufacturing companies a major poicy objective of One North East (ONE), the regiona deveopment agency (RDA) (RDAs were aboished in 2012 as part of the government s deficit reduction programme). In 2002, ONE funded the North East Productivity Aiance (NEPA), which aimed to improve the productivity of regiona companies by training empoyees in ean toos using the Master Cass approach. The NEPA Master Casses seectivey trained empoyees in the foowing toos: (1) 5S/5C; (2) standard operations; (3) ski contro; (4) Kaizen; (5) visua management; (6) process fow; (7) probem soving; (8) Singe-Minute Exchange of Dies (SMED); (9) production-ed maintenance; (10) work measurement; (11) faiure mode effect anaysis; (12) poka-yoke (mistake-proofing); (13) vaue stream mapping (VSM); and (14) advanced probem soving. 69 The NEPA approach was further deveoped in 2008 through the European Regions for Innovative Productivity (ERIP) project. Research ed by Newcaste University deveoped an improved ean impementation approach for sma business that aimed to standardise processes and reduce costs whie improving quaity and deivery performance. 70 This approach was appied in 25 sma- and medium-sized enterprises (SMEs) across the North Sea Region of Europe. Poicies for improving the productivity and efficiency of SMEs had not been fuy resoved by any of the European member states. Therefore, a transnationa approach was advocated to deveop a transferabe soution. Buiding on the research highighted above, a grant was awarded by the European Regiona Deveopment Fund (Interreg funding) to support the transfer of ean into SMEs across the North Sea Region. The objective of the ERIP project was to deveop a methodoogy, using the knowedge deveoped in the North East of Engand (buiding on the NEPA work), which coud be used by SMEs across the North Sea Region of Europe to impement ean to become more competitive. A key chaenge identified through the research was that SMEs found it difficut to aocate the necessary time and resource to undertake the improvement activities. To address this, a new approach was deveoped through the research, caed bite-sized ean. 70 This demonstrated that whie ean coud be appied in various contexts, it needed to be taiored. The next sections review research reating to ean in the pubic and heath-care sectors respectivey. Lean in the pubic sector McNuty and Ferie 71 argued that the UK s new pubic management (NPM) reforms, which began in the eary 1980s, eventuay evoved, by the mid-1990s, into what they termed NPM 4. NPM 4 is characterised by a meange of private and pubic sector management ideas, emphasising a vaue-driven approach, concerned with the quaity of service, and a continuing commitment to a distinctive pubic sector ethos of coective provision. Athough McNuty and Ferie had reservations about the appication of private sector modes such as business process re-engineering (BPR) to pubic sector settings (within the context of NPM 4), they concuded that the shift to a NPM mode has made the pubic sector more receptive to ideas of process redesign. Lean is focused on process rather than product, and to this extent McNuty and Ferie s observations are highy reevant. For exampe, they found that a number of pubic sector organisations experience a probem over organising their work with regards to process and functiona principes. 71 This is precisey the tension described by Seddon 72 when he criticised oca government for setting up front office/back office ca centres to process the various requests and demands from oca citizens. Athough BPR and tota quaity management (TQM) have certainy attracted considerabe attention in the pubic sector incuding heath care there is evidence from recent iterature that ean management and the TPS are currenty more in vogue in a variety of pubic service settings. 73 For exampe, Hines and Lethbridge 74 reviewed a project that impemented a ean vaue system in a university. 12 NIHR Journas Library

43 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The authors found a number of case studies reating to ean initiatives in academic settings, and they engaged in a 3-year initiative to embed ean methods and thinking in a cient university. 74 Radnor and Bucci 75 investigated the use of ean in UK business schoos and universities. They found that the appication of ean in UK universities was sti reativey new and primariy appied in support and administrative functions. Hines et a. 76 expored the use of ean in the Portuguese and Wesh ega pubic sectors, particuary in court services. McQuade 77 discussed the organisationa transformation brought about by ean thinking in a UK socia housing group. Erridge and Murray 78 reported on the appication of ean principes to oca government procurement processes, using the exampe of procurement contracts drawn up by Befast City Counci. The authors concuded that ean suppy was compatibe with the best vaue approach to procurement, as ong as characteristics of ean that are most cosey aigned to manufacturing are adapted to fit the cuture of oca government. Scorsone 79 considered the impementation of ean by the city government of Grand Rapids, MI, USA, in the face of fisca restrictions and a dwinding workforce. Radnor and Bucci 80 evauated a ean programme undertaken in Her Majesty s Court Services. The programme sought to focus on administrative functions as part of the operationa aspects of court services. The underying chaenge of the project was to improve the deivery of service through a waste eimination programme, as we as simpify processes and free up capacity to be abe to do more work. The outcome of the evauation found that the programme had created impact within the court services. Leadership payed a key roe aong with the dedicated project team. Other findings identified the understanding of why there is a need to change, changing and updating practices which had not been revisited, and engaging with the workforce in a manner that promotes a desire to change. Radnor and Bucci provided a framework to support the impementation of ean in pubic services. This framework requires an understanding of an organisation s processes, customer requirements and types of demand. These factors are identified as key to ensuring that any ean programme can be successfu. 80 One of the most wide-ranging evauations of ean in the pubic sector in terms of the scope of the research undertaken is the report tited Evauation of the Lean Approach to Business Management and Its Use in the Pubic Sector. 81 This document aimed to provide a comprehensive assessment of the success of the ean phiosophy and toos in transforming a number of pubic sector organisations in Scotand. The report, commissioned by the Scottish Executive, covered eight case studies and three piot sites, incuding oca authorities, heath agencies and a government (Roya Air Force) agency. It described a range of eves of engagement with ean, from fu impementation (acceptance of ean thinking across a eves of an organisation, and use of ean toos and techniques, together with some ikeihood of sustainabe transformation) to ight-touch ean [adoption of a quick win, tookit approach, usuay based on rapid improvement events (RIEs)]. These case studies coectivey warn against a ean impementation approach that reies too heaviy on the ean/tps toobox without a compementary commitment to ean thinking at a eves of the organisation. The impication is that the toos of ean/tps (RIEs, 5S, Kaizen bitz, etc.) are ess ikey to become embedded and have sustainabe vaue uness they are part of a wider package of organisationa reform. Furthermore, Radnor and Waey 82 suggested that many pubic sector organisations ack an understanding of process management. Organisations that ony gain quick wins, usuay via RIEs [or rapid process improvement workshops (RPIWs) in VMPS parance], find it difficut to sustain improvement in the ong term. In a number of cases, the authors found a ack of aignment between the ean/tps impementation and the organisations strategic objectives. An over-reiance on the ean/tps toobox can make it difficut to embed process-oriented thinking. Radnor et a. 81 found that a common pubic sector response has been to avoid specific, transformationa, quick win toos, beieving these to be unwecome imports from a manufacturing environment and inappropriate for use in pubic service. The message here is that baance is required. The case studies showed that the success of ean/tps impementation was context dependent, and reied to a arge degree on a number of organisationa and cutura factors. When ean is not fuy aigned with the strategy of a pubic sector organisation, there is a risk that it wi not be sustainabe in the ong term. Having a critica mass of peope who are trained in ean and accepting of it as a transformationa agent is aso essentia. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 13

44 LITERATURE REVIEW As a brief summary, Radnor et a. 81 identified the foowing critica success factors for impementing ean in pubic service organisations: organisationa cuture and deveopment organisationa readiness management commitment and capabiity externa support from consutants (at east initiay) having a strategic approach to service improvement teamwork and whoe-systems thinking timing setting reaistic timescaes and making effective use of staff commitment and enthusiasm effective communication channes across the whoe organisation. These points were reinforced by a range of papers in a specia issue of Pubic Money & Management (February 2008). These considered the reevance of ean in improving pubic sector services; aspects of ean thinking that fit pubic service organisations; the transfer of ean experience from other sectors; and the extent to which ean is a distraction or a panacea. Lean in heath care Most of the research on ean in heath care has focused on hospitas. Spear 83 highighted a series of avoidabe medica errors and patient safety issues in the US hospita sector. He advocated the use of the TPS to remove ambiguities in processes and to empower heath-care workers to sove probems as they arise, rather than opting for work-around soutions. Spear pointed out that No organisation has fuy institutionaised to Toyota s eve the abiity to design work as experiments, improve work through experiments, share the resuting knowedge through coaborative experimentation, and deveop peope as experimentaists. 83 Radnor et a. 84 investigated the introduction of ean in four UK NHS hospita trusts. They found a widespread use of ean toos that ed to sma-scae and ocaised productivity gains and highighted significant contextua differences between heath care and manufacturing that made it difficut to move towards a more system-wide approach. In particuar, some of the principes proposed by Womack et a. 47 do not appy. Customer vaue in heath care is different to manufacturing because the patient is normay a recipient of treatment and does not commission or pay for the service. The provision of heath care is often subject to budgetary constraints that make it capacity ed; there is imited abiity to infuence demand or reaocate resources saved by improvement measures. Fiingham 15 described the use of the TPS for improving patient care at the Roya Boton Hospita in the UK, which has been widey considered to be an exempar case. He reported a 42% reduction in paperwork, better mutidiscipinary teamworking, a reduction in ength of stay by 33% and a 36% reduction in mortaity. Baé and Régnier 85 reported on the use of ean to reduce medication distribution errors, nosocomia infection rates and catheter infections in a French hospita. Athough the initiative was deemed successfu, the authors identified resistance to the standardisation of cinica and nursing practices. Gowen et a. 86 investigated the appication of continuous QI, Six Sigma and ean in US hospitas. They concuded that ean was significant in reducing the sources of errors, but that it did not improve organisationa effectiveness. Chiarini 87 researched an improvement project utiising ean and Six Sigma toos to reduce safety and heath risks to nurses and physicians who managed cancer drugs in an Itaian hospita. The author identified that the toos heped improve heath and safety and reduced pharmaceutica inventory. Yeh et a. 88 ooked at the appication of ean thinking and Six Sigma and how they coud be used to improve processes in treating an acute myocardia infarction. The outcome was that the medica quaity improved, as did market competitiveness. Esain and Rich 89 focused on improving patient fow through hospitas to reduce waiting times. 14 NIHR Journas Library

45 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Outside the hospita sector, Boaden and Zokiewski 90 conducted a process study of the non-cinica aspects of a UK genera practice, with particuar attention to the reationship between the patient and the manageria and administrative aspects of the organisation. Endsey et a. 91 considered process and fow issues in famiy medica practice in the USA. They focused upon understanding patient needs and administrative procedures, which ed to reduced waste. Endsey et a. made a good case that, from the patient s perspective, many of the frustrations invoved in accessing genera practitioner (GP) services arise not from direct contact with the physician, but from missing paperwork, unacceptaby ong waiting times, and poory managed hand-offs between doctor, practice nurse and receptionist. 91 One of the most frequenty cited exempars of ean in heath care is the Virginia Mason Medica Center (VMMC). It adopted the TPS to create the VMPS. The research on VMMC has incuded work by Weber, 92 who investigated how improved ogistics and productivity reduced costs and defects; Furman and Capan, 93 who outined the patient safety aert system; Neson-Peterson and Leppa, 94 who described the eimination of waste in nursing procedures; McCarthy 95 on the appication of the TPS; Bush 96 on eiminating waste; Kowaski et a. 97 on nurse retention and eadership deveopment; and Pham et a. 98 on the redesign of care processes. The next chapter considers the origins and evoution of the NETS, which was supported by consutancy from VMMC and Amicus. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 15

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47 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Chapter 3 The origins and evoution of the North East Transformation System In this chapter, the key infuences and factors that ed to the introduction of the NETS and the pivota roe of NHS NE are considered. The NETS comprised three principa components: Vision, Compact and Method. It drew heaviy on the semina infuence of the VMPS which was derived from the TPS and from Amicus. Why the North East Transformation System? In the North East of Engand the NHS performs we in terms of meeting targets and performance measures, but the popuation has poor heath due to the region s industria heritage and socioeconomic factors. 99 Athough this might seem to be a paradox at first gance, it is not reay, as good heath is determined by factors that ie outside the heath-care system. 100 The socia and economic circumstances in which peope ive and work can have a significant impact on their state of heath, as Marmot s work on the socia determinants of heath and the ife course ampy demonstrates. 101,102 Nevertheess, whie in existence, NHS NE beieved that the NHS coud do much better by focusing on quaity and patient safety and adopting a whoe-systems approach to an individua s and community s heath state. 11 The NETS was instigated as a resut of the SHA board s conviction that a new approach to the way in which it conducted its business was both required and essentia. At a meeting hed to share information about ean activities across trusts in the North East of Engand in February 2011, the SHA s medica director, one of the chief champions of the NETS, commented that the soution was no onger simpy doing the same thing but harder, but doing it smarter. Merey doing what had aways been done woud deiver exacty the same resut. To shift the paradigm or do something genuiney different required changing the rues of the game and transforming the cuture of the system. This is something Don Berwick and his coeagues at the Boston-based Institute for Heathcare Improvement in the USA had known for a ong time. 103 It was a centra theme in his report to the coaition government on the essons to be earned from the faiures at Mid Staffordshire hospitas. 104 NHS NE sought to achieve system-wide rather than ocaised transformation through a major change programme that woud engage a parts of the heath system in the North East, incuding commissioners as we as providers of services. There was an eary intention to encourage GPs to undertake training in the principes of the NETS, but it was recognised that GP practices were unikey to form part of the vanguard, as they acked the required resources to do so. Throughout the NHS there was considerabe interest in organisationa change and the toos avaiabe to embed and sustain it. These were reviewed in a Nationa Institute for Heath Research (NIHR)-funded study by Ises and Sutherand, 105 intended for heath-care managers, professionas and researchers. The study concuded that change in the NHS wi not be straightforward. The NHS was an exampe of a compex adaptive system, which Psek and Greenhagh defined as a coection of individua agents with freedom to act in ways that are not aways predictabe, and whose actions are interconnected so that one agent s actions changes [sic] the context for other agents. 12 Compex adaptive systems invariaby have fuzzy boundaries, with changing membership and members who simutaneousy beong to severa other systems or subsystems. In such contexts, tension, paradox, uncertainty and ambiguity are natura phenomena and cannot necessariy or aways be resoved or avoided. Instead, they need to be embraced by the various stakehoders and harnessed in such a way that they resut in sustainabe soutions to compex probems. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 17

48 THE ORIGINS AND EVOLUTION OF THE NORTH EAST TRANSFORMATION SYSTEM Arising from such concerns, the term whoe-systems thinking is now routiney used by managers and cinicians to capture the particuar features of a compex heath-care system and refect the foowing features: an awareness of the mutifactoria nature of heath care and an acknowedgement that compex heath probems often termed wicked probems because they have no simpe or easy soutions ie beyond the abiity or capacity of any one practitioner, team or agency to fix 106 an interest in designing and managing organisations as dynamic interdependent systems committed to providing safe, integrated care for patients. 105 The NETS and its evauation was informed by systems thinking. A system cannot be considered in isoation from its context and overa environment, 107 nor do systems constitute neat chains of inear cause-and-effect reationships which can be isoated and understood in their own terms. In heath-care systems, compex networks of inter-reationships are the norm. 108 Ises and Sutherand s 2001 review noted that the probems and situations that occur cannot be resoved through the use of a singe too or strategy. 105 Consequenty, NHS managers had to acquire the abiity to diagnose different situations, as we as the ski to find the right too to use in the particuar circumstances that they face. NHS NE s choice of the NETS and its three main components was certainy informed by such a diagnosis as we as exposure to the VMMC s adoption of a change programme. The VMPS was derived from TPS principes and methods that were subsequenty adapted to suit the North East context. The NETS comprises three components, famiiary known as the three-egged stoo : Vision, Compact and Method. These components are not individuay pioneering. It is the combination that constitutes the NETS approach to transformationa change and ends it particuar novety as far as the NHS is concerned. Vision The Vision adopted by NHS NE was for it to be a eader in exceence in heath improvement and heath-care services. To achieve this, the SHA adopted a zero toerance approach and proceeded to articuate a powerfu, uncompromising vision for heath-care services in the North East, underpinned by the seven no s : 99 no barriers to heath and we being no avoidabe deaths, injury or iness no avoidabe suffering or pain no hepessness no unnecessary waiting or deays no waste no inequaity. The sheer bravura of such a ist had an immediate impact which made staff in the NHS take stock. The NETS was seen as one of the piars for impementing the Vision set out in NHS NE s strategy, Our Vision, Our Future. 99 Of course, achieving the Vision was to prove immensey chaenging, but the SHA board, ed by its chairman, wanted to set the bar high. The Vision set out the fundamenta objectives and direction of the NHS in the region and it was intended to be a iving document with which a staff coud engage. It was shared with other pubic bodies, embedded in a suite of oca strategy documents, promoted by oca managers and cascaded down to front-ine staff. The architects of the NETS intended each NHS trust in the North East to draw on the regiona Vision for inspiration, but aso to create their own Vision, reevant to their organisation s purpose and vaues and owned by their staff. Otherwise, the Vision risked being imposed from on high, which coud have resuted in resistance from front-ine staff. 18 NIHR Journas Library

49 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Compact The Compact arose from the enduring tension between manageria and professiona vaues and the attempt to find some accommodation between the two groups with their differing cutures. It was infuenced by the Physician Compact introduced by the VMMC at an eary stage of its change journey. The concept of a compact was simpe enough: an expicit dea between two parties which, in the case of the VMMC, comprised the cinicians and the VMMC organisation. 109 The intention was to move from an impicit compact to a new expicit one which refected changes in heath care and its management. Such tensions were not confined to the VMMC or even the USA. In the UK, successive governments have sought to change the way the NHS operates and is managed. Centra to these efforts has been shifting the frontier between medicine and management in favour of the atter. It was a deveopment that began in earnest with the first major reorganisation of the NHS in 1974 and has been an enduring theme ever since. However, the effect of a growing manageria encroachment into medicine was not unanimousy wecomed by cinicians. Many were suspicious of such deveopments and opposed to what they perceived to be an erosion of their cinica freedom. An editoria in the BMJ in 2001 posed the question: why are doctors unhappy? 17 It suggested the causes were mutipe, but highighted one in particuar, which concerned the training doctors received and the nature of the work they were subsequenty required to perform. Despite their medica training in a particuar speciaty, the reaity of ife on the front ine required doctors to think about other matters, incuding management, finance, ethics and communication. 17 Edwards et a. 18 suggested that the cause of doctors unhappiness ay in a breakdown between them and society at arge. Doctors were trained to function as individuas with a fair degree of autonomy, but the demands of modern heath-care systems required them to be accountabe for their actions and to operate as members of a team. They described the od compact which underpinned the NHS and why it was no onger regarded as egitimate, and outined what a new compact might ook ike. The od compact comprised two aspects: what doctors gave and what they got in return (Tabe 1). The mismatch between these was the cause of the dissonance over what doctors might have reasonaby expected the job to be and what it now was. Some commentators have suggested that the psychoogica contract or compact is a usefu concept to expain this probem Jack Siversin from Amicus, an internationa consutancy speciaising in heath-care system improvement, was an infuentia figure during this period on both sides of the Atantic. His contribution to the debate was significant because he had worked on the Physician Compact at VMMC and subsequenty provided an input into the NETS and its deveopment of the Compact. A new and more sustainabe compact was required because the od promise to doctors was either no onger vaid or coud act as a barrier to modernisation. Among the new imperatives to be addressed in a new compact were those isted in Box 1. Edwards et a. 18 were of a view that returning to the od compact was not possibe and that doctors and managers shoud work together to devise a new compact that: was fit for modern heath-care systems, sought to improve patient care and the effectiveness in which they worked, and woud resut in a happier workforce. Apart from the issues with patients and their care, a principa reason for the discontent among doctors was the dissatisfaction they experienced in their reationship with managers. It manifested itsef in a perceived sense of diminished autonomy and reduced dominance. To address these concerns, TABLE 1 The od compact 18 What doctors give Sacrifice eary evenings and study hard See patients Provide good care as the doctor defines it What doctors get in return Reasonabe remuneration Reasonabe work/ife baance ater Autonomy Job security Deference and respect Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 19

50 THE ORIGINS AND EVOLUTION OF THE NORTH EAST TRANSFORMATION SYSTEM BOX 1 The new compact 18 New imperatives Greater accountabiity (e.g. guideines). Patient-centred care. More avaiabe to patients, providing a personaised service. Work coectivey with other doctors and staff to improve quaity. Evauation by non-technica criteria and patients perceptions. A growing bame cuture. Davies and Harrison 21 argued in favour of a better aignment between doctors and the organisations in which they worked. However, given the tensions and cutura differences that existed between doctors, managers and their professiona groups, they were under no iusions that such a task woud be easy or straightforward. They concuded by insisting that there was no practicabe aternative to doctors engaging with management. Despite such cas, there was sti unease fet by many doctors who perceived that they were not vaued. 22 This was a major reason for Ari Darzi being invited by the government to ead the next stage review of the NHS. As noted in Chapter 1, this was an attempt to re-engage cinicians in the reform effort together with other front-ine staff so that they were at the heart of the change process change that was ocay-ed, patient-centred and cinicay driven. 16 However, the unhappiness fet was, and is, not confined to cinicians. Managers are aso unhappy with their ot, a situation that has arguaby, and for many, deteriorated further in recent years as a resut of being subjected to continuous organisationa change whose precise purpose is often uncear and whose impact often fas short of expectations. Combined with a cuture of fear and terror by targets, 110 the outcome is an environment which, as the Berwick report put it, is toxic to both safety and improvement. 104 The harvest of fear evident at Mid Staffordshire resuted in a vicious cyce of over-riding goas, misaocation of resources, distracted attention, consequent faiures and hazards, reproach for goas not met... A symptom of this cyce is the gaming of data and goas; if the system is unabe to be better, because its peope ack the capacity or capabiity to improve, the aim becomes above a to ook better, even when truth is the casuaty. Berwick [A Promise to Learn A Commitment to Act: Improving the Safety of Patients in Engand, Crown copyright 2013, contains pubic sector information icensed under the Open Government Licence v2.0 ( Managers in such a dysfunctiona environment can appear beeaguered functionaries in a system that seems more poiticised than ever and whose poitica heads regard themseves as its true eaders. 23 Indeed, critics of the waves of reform under the Labour government between 1997 and 2010 hod that the terror by targets regime was argey responsibe for distortions in the heath system which, unintentionay, ensured that the patient was not put first. 110 The resut, as Berwick noted, is an eaborate set of manageria poys, often abeed gaming, to arrive at the resuts desired by their poitica masters and mistresses. The term cuture is often invoked too readiy and simpisticay in a heath-care context, especiay in the aftermath of the Francis report into the events at Mid Staffordshire Hospita between 2005 and It is assumed that cuture change wi address issues of organisationa performance. Cuture is important in terms of shaping organisationa behaviour and improving performance. 28 Change can aso be stifed by 20 NIHR Journas Library

51 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 cuture. Mannion et a. 28 commented that cuture comprises the informa socia aspects of an organisation that infuence how peope think, what they regard as important, and how they behave and interact at work. Organisationa cuture has been defined as 29 the pattern of shared basic assumptions invented, discovered or deveoped by a given group as it earns to cope with its probems of externa adaptation and interna integration that has worked we enough to be considered vaid and, therefore, to be taught to new members as the correct way to perceive, think, and fee in reation to those probems. Cuture is therefore not merey that which is observabe but aso the shared cognitive and symboic context within which a society or institution can be understood. 28 But Mannion et a. counseed against the adoption of a one size fits a approach to cuture management in the NHS and encouraged the adoption of more nuanced strategies which seek to depoy a judicious mix of instruments and supporting tactics depending on setting and appication (pp ). 28 These issues were very much at the heart of the NETS and how it sought to win hearts and minds across the North East region. Those eading the initiative recognised the importance of estabishing shared goas, cutura change and coaborative working. As the iterature review in Chapter 2 reveaed, a principa component of effective cuture management is eadership stye. 30 Perhaps the key factor to note is that eadership entais much more than the actions or behaviour of an individua, as such a focus ignores the importance of both context and compexity. Situationa eadership is therefore regarded as more appropriate in the context of compex adaptive systems. Aban-Metcafe and Aimo-Metcafe, 34 in their study of eadership and successfu change in the NHS, found that a cuture of engaging eadership significanty predicted motivation, satisfaction, commitment, reduced stress and emotiona exhaustion, and team effectiveness/productivity. Leadership, then, is not about contro but about co-operation and creating an agenda for change using a strong vision. In their Leadership for Heath Improvement framework (Figure 1), Hannaway et a. 36 empoyed a mix of improvement science concepts together with softer notions of emotiona inteigence and poitica astuteness. Method We now turn to the third eg of the stoo the Method. The particuar method used within the NETS approach was considered ess important than the commitment to QI. It is important to adopt a contingency approach to achieve fit between the oca context, the needs of the organisation and the Method. However, the VMPS was by far the preferred approach and was strongy supported by the SHA, which invested resources in it to encourage wider engagement and commitment. The NHS NE s desire was to deveop and ro out across the region a NE Production System modeed on the VMPS. The SHA anticipated that the VMPS woud enhance patient safety and increase capacity through making better use of existing resources. The objective was to increase patient and staff satisfaction, shorten the patient pathway, stimuate continuous improvement and encourage a new cuture of cinica care. 11 This was to be achieved by making fu use of the potentia skis and strengths of a team members. The impementation of the NETS began in mid-2007 and was ed by a sma project team based at the SHA. This team of enthusiasts activey promoted the approach and provided a ink with the consutants engaged in deivering eements of the initiative, notaby Amicus (Compact work in its eary stages) and VMMC (ean method training). The SHA aso hosted meetings, acted as a repository of information about ean and other aspects of the NETS, and maintained communication channes with NETS organisations that were not empoying VMPS as their method of choice. Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 21

52 THE ORIGINS AND EVOLUTION OF THE NORTH EAST TRANSFORMATION SYSTEM The Leadership for Heath Improvement Programme Framework Successfu Heath Improvement Systems Promote and protect the popuation s heath and we-being Deveop heath programmes and services and reduce inequaities Proactivey buid on surveiance and assessment of the popuations heath & we-being Encourage and impement evidence based practice Operationaise a strategic vision of the future Promote seamess partnership working across boundaries for the benefit of staff and communities Earn and retain the confidence of poiticians and the pubic Prioritise and focus on key issues and everage points in the heath improvement system Continuousy increase capacity to deiver the heath improvement agenda Engage operationa staff and others in activey deivering heath improvement Nurture organisationa cutures that are receptive and positive environments for change A Successfu Leader... Communicates cear vision, direction & roes Strategicay infuences and engages others Buids reationships and works coaborativey across organisationa boundaries Chaenges thinking and encourages fexibiity, creativity and innovation Drives for resuts and improvement Practices poitica astuteness Dispays sef-awareness and emotiona inteigence Manages persona and organisationa power and vaues diversity Nurtures a cuture in which eadership can be deveoped and enabed in others Ethicay manages sef, peope and resources Commits with passion to vaues and mission Demonstrates mastery of management skis Leadership Heath Improvement Systems Leadership of Heath Improvement Leadership for Improvement Improvement of Leadership A Successfu Improvement Leader Sees whoe systems and any counter-intuitive inkages within them Brings in the experiences and voice of staff and the community Seeks to create new evidence and to transate evidence into practice Improvement Knowedge & Skis Exposes processes to mapping, anaysis and redesign Encourages fexibe, innovative rethinking of processes and systems Sets up measurement to demonstrate impact and gain insight into variation Faciitates refective practice Deveops quaity and risk management within an evauation cuture Works constructivey with the human dimension (psychoogy) of change Sustains and embeds past improvement and drives for continuous improvement Spreads improvement ideas and knowedge widey and quicky FIGURE 1 The Leadership for Heath Improvement framework (reproduced with permission from Figure 7.2 in Hunter DJ, editor. Managing for Heath. London: Routedge; p. 158). 36 Concusions In ater chapters, we describe and assess the journey taken by the NETS from its inception to the present time. Large-scae transformationa change is chaenging and often probematic in any compex adaptive system. This is especiay so when considering a arge region s entire heath-care system. 71 There are mutipe reasons for this. Constituent organisations have conficting aims, different cutures and varying ski mix. These issues were evident in the NHS organisations participating directy in, or more oosey associated with, the NETS. Externa forces, often unforeseen and unexpected, can aso have a decisive impact on what happens regionay and ocay. This occurred to the NETS in mid-2010, when the coaition government eected in May 2010 announced a major restructuring of the NHS in Engand. The research reports on the impact of the NETS within the North East region and how it adapted to a changing environment. 22 NIHR Journas Library

53 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Chapter 4 Study design and methods The research comprised a ongitudina evauation of the NETS conducted over 3.5 years, from 1 December 2009 to 31 May The NETS comprises three principa components: Vision, 99 Compact 18 and Method, 51 the three-egged stoo with patients at the centre. 18,51,99 The study design aimed to answer the research questions set out in the proposa, which are of significance to practitioners, poicy-makers and researchers studying transformationa change in heath systems. The research questions were as foows: How have the various manifestations of the NETS and non-nets approaches evoved over time? How receptive have NHS organisations in the North East been to transformationa change, incuding the adoption of either VMPS, TPS or other ean toos? What has the impact of the different NETS approaches been on the quaity and efficiency of heath care in respect of technica quaity, safety, patient experience, access and equity? How far has variation been reduced across speciaties, departments and hospitas? How far has work-reated stress been reduced? How far has the Compact with cinicians, to secure their commitment to the NETS approaches, been made a reaity? How far have staff been empowered to take contro of their work? What are the factors faciitating, and/or acting as barriers to, successfu change? The research team drew on their mutidiscipinary skis and expertise in the areas of heath poicy and management, engineering, operations management, strategy, human resource management and statistics. Team members had first-hand and extensive experience of working, and researching, in an NHS environment. According to Eisenhardt: 112 Mutipe investigators... enhance the creative potentia of the study. Team members often have compementary insights which add to the richness of the data, and their different perspectives increase the ikeihood of capitaizing on any nove insights which may be in the data. The research environment was compex in terms of scae (the NHS in the North East empoyed approximatey 77,000 peope and served a popuation of 2.4 miion); scope (geographicay dispersed, primary and secondary care, commissioning, deivery and management); and orientation [poicy, organisation, eadership, human resources (HR) and operations]. Towards the end of the study, the research had unexpectedy to contend with a major reorganisation of the NHS. It foowed the UK genera eection in May 2010 which ushered in the coaition government, which pubished proposas for an extensive restructuring of the NHS within months of entering office. The study sites, which are referred to in this report in the form site xx, where xx is the interna project code, comprised two custers of PCTs, two menta heath and earning disabiity trusts, three hospita trusts, an ambuance trust and a community services trust. Furthermore, there were many actors at different eves in the organisations incuding managers, cinicians, nurses, anciary staff and administrative and operationa areas. Research on transformationa change benefits from a sociotechnica perspective that takes account of both the behavioura and cutura context, described in Chapter 3, as we as the technica chaenges invoved in bringing about change. This is because organisationa objectives are best met not by the optimisation of the technica system and the adoption of a socia system to it, but by the joint optimisation of the technica and socia system (p. 62). 113 Aternative aspects of reaity and different research questions require appropriate methods of enquiry. 114 It has been argued that the compexities of human phenomena require mixed-methods approaches to capture deep insights. 115 Furthermore, the purposes of using mixed-methods incude trianguation, to ensure the corroboration of data or convergent vaidation; compementarity to carify, expain or eaborate the resuts of anayses; and guiding additiona samping data coection and anaysis. 116 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 23

54 STUDY DESIGN AND METHODS Research design Transformationa change may be viewed in terms of content, context, process and outcomes. 117 Furthermore, there is a distinction between episodic and continuous change. 118 This ed to different types of research questions that needed to be addressed through quaitative and/or quantitative methods. 119 Various typoogies of mixed-methods research have been proposed that consider sequence, priority, purpose, etc. 120 The research methods incuded semistructured interviews, observation, documentary anaysis, focus groups, attendance at meetings and presentations and interrupted time series (ITS) anaysis. The research approach is shown in Tabe 2, which identifies the sources of quaitative and quantitative data that were used to evauate processes and outcomes. The priority and sequence of the data coection and methods varied according to the quadrant and aso the research question being addressed. Initiay, a deductive approach was adopted and empoyed to aid the anaysis of quaitative data at the end of the first year of the study, and to assist in identifying key issues associated with transformationa change. As the study progressed, emerging themes were anaysed inductivey to compement the deductive approach. 121,122 The research methods aso took into account mutipe eves of anaysis; for exampe, at the eve of specific interventions the stakehoders incuded a sponsor, a process owner, a workshop eader, a team eader, a subteam eader, an advisory group and participants. 123 The NETS incuded forma evauations of the impact of the interventions after 30, 60 and 90 days. Study sites Stratified purposive samping is an approach where certain cases are seected to ensure that they vary according to preseected parameters. 115 This approach was adopted so that the sampe of cases incuded organisations that were representative of the scae, scope and geographic ocation of the participating trusts. A simiar strategy was adopted within each case to ensure that the respondents seected for interview were representative of the various professiona groups, ski mix and band eve. The pan outined in the initia proposa was to conduct research in five pathfinders that had impemented the VMPS and two non-pathfinders as contros. The pathfinders were subdivided into two waves: the first wave started in 2008 and the second in This was intended to refect organisations at different stages of the NETS journey. The actua design was modified to refect the range of methods used to achieve transformationa change (incuding study sites not using the VMPS as their Method), as we as the changes to NHS organisations across the North East that occurred foowing the 2010 genera eection and came to be enshrined in the Heath and Socia Care Act TABLE 2 Mixed-methods research design Data type Quaitative Quantitative Process Interviews Documentary data Observation Focus groups Attended Coaition meetings Target progress sheet Vaue stream map Takt/cyce time Seven wastes categorisation Spider diagrams Outcome Interviews Documentary data (incuding sef-reported routiney coected data) Focus groups Routiney coected data for five RPIWs (ITS anaysis) Attended report-outs 24 NIHR Journas Library

55 DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 The research design (see Figure 2) incuded 14 study sites (Tabe 3) which formed the basis of nine case studies (as some organisations operated on mutipe sites). Four cases were wave 1 pathfinders, one was a wave 2 pathfinder and four were non-pathfinders. A stages of the research invoved mutipe investigators to aow for trianguation and to enabe different perspectives to be obtained from mutipe observers. 112 TABLE 3 Study site context Site Context and background NETS information Staff (approximate number) Annua budget ( M) 01 University teaching hospita NHS FT. Operates across two acute hospita sites, one arge and one smaer. Granted FT status in May Took over running oca community heath services in Apri 2011, incuding a number of smaer primary care and community hospitas A non-vmps NETS organisation, using a mix of different improvement methodoogies in This custer of four PCTs is treated as a singe entity for the purposes of the NETS evauation. The PCT custer operated under a singe CEO, but with four separate boards, during the evauation period A non-vmps NETS organisation Numbers varied over the period of the study, from many thousands in 2009 (incuding community heath service staff) to fewer than 300 in 2012/13. This decrease in staff numbers refected the major changes in the structure and governance of commissioning organisations in the NHS from 2010 onwards 1100 (2011/12 data) 06 This organisation provided NHS community services from its origina creation in 2007 to Apri 2011, when it became part of a NHS hospita FT. Its functions and services are now provided through one of the cinica divisions of site 01. The data beow refer to the study site pre This NHS ambuance trust was formed around Juy 2006 foowing the merger of the previous service and part of three other transportation services 08 This NHS acute menta heath and earning disabiity trust was formed in 2006, and became a FT in December 2009 A non-vmps NETS organisation, which made use of a variety of improvement methodoogies A VMPS NETS organisation, which joined the NETS training programme during its second wave A VMPS NETS organisation, which joined the first wave of NETS training 1000 (2010 figure) 44 (2010 data) Estabished as a NHS hospita FT in 2005 A VMPS NETS organisation, which joined the first wave of NETS training continued Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 25

56 STUDY DESIGN AND METHODS TABLE 3 Study site context (continued) Site Context and background NETS information Staff (approximate number) Annua budget ( M) 10 This NHS menta heath and earning disabiity trust was created in Apri 2006, foowing the merger of two other menta heath and earning disabiity trusts. FT status granted in mid This custer of three PCTs is treated as a singe entity for the purposes of the NETS evauation. A singe management team operated the day-to-day PCT activities during the evauation period A VMPS NETS organisation, which joined the first wave of NETS training A VMPS NETS organisation, which joined the first wave of NETS training (2011/12 data) 14 This trust, which manages hospita, community and adut socia care services, became a FT in 2006 CEO, chief executive officer; FT, foundation trust. A non-vmps NETS organisation, which uses a mix of different improvement methods. Invovement in structured QI activities predates the NETS programme by severa years Longitudina research design, incuding timetabe A representation of the research project is shown in Figure 2, which contains an overview of the work conducted during each year of the 3-year research study. Figure 2 is a schematic diagram intended to provide a visua reminder of the eements of the design; detais are expained in the remainder of this section. Year 1 The research used two frameworks to evauate the process of transformationa change: the Pettigrew et a. 125 framework of receptive contexts for change which was deveoped in a study of strategic change in the NHS in the 1980s; and the three-egged stoo (Vision, Compact and Method) that was adopted as the basis of the NETS. The research aims and objectives the study set out to address were derived from the scoping study and infuenced by the Pettigrew et a. framework. 125 In year 1, interviews were conducted with 55 key respondents at different eves throughout the study site organisations. The interviews were coded deductivey against the Pettigrew et a. framework and the three-egged stoo. Detaied observations were made during four RPIWs that sought to improve processes in two important pathways. Each RPIW was of a week s duration. Three of the RPIWs were part of the same cinica pathway (a superfow RPIW), which demonstrated a vaue stream approach. Secondary data, incuding standard NETS RPIW documents and training materias, fiedwork notes and photographs were coected and anaysed. The team reguary attended quartery meetings of the NETS Coaition Board which co-ordinated the NETS activities, and report-outs where the RPIW participants presented the resuts of their interventions. In addition, a piot ITS study was conducted in a menta heath trust. Once the deductive anaysis was competed, an inductive anaysis was undertaken, thereby aowing other themes and issues to emerge. Through a combination of deductive/inductive anaysis a ist of topics and issues were captured which were expored further and added to during years 2 and 3 of the study. 26 NIHR Journas Library

57 First year of study Second year of study Third year of study Observations trianguate with ITS anaysis RPIW secondary data anaysis trianguates with ITS anaysis Interrupted time series anaysis Interrupted time series anaysis Deductive coding scheme Codes identified not covered through interviews and observations RPIW 2010 secondary data anaysis Codes not Covered by the Interview NETS Framework N1.5_No Unnecessary Waiting or Deays N1.6_No Waste Typica intervention case study anaysis N1.7_No Inequaity N2.2_Od Compact N2.5_No Knowedge of Compact N3.1_Gemba Kanri (Standardisation 5S Visua Management) N3.10_7 Wastes KPO focus group N3.11_Production and Materia Contro (Kanban Pu) Pettigrew framework heps create question set In conjunction with Newcaste University Business Schoo Research Study: An Evauation of Transformationa Change in NHS North East Chief Investigator: Professor David J Hunter 4 detaied RPIW observations 55 Interviews What is NETS? N3.12_Inter-Company Lean (Singe Sourcing) N3.2_Ceuar or Line Layout (Fow) N3.3_Ergonomics N3.4_Singe Minute Exchange of Dies N3.5_Overa Equipment Effectiveness N3.6_Andon N3.7_Jidoka N3.8_Smaest Machine Concept HR interviews, n = 3 Further information: Topic Guides for Interviews with staff: nb probing may be required at each point Interviews confidentiaity of responses reinforced Introduction Topics to be covered Participants understanding of o the NETS initiative and its origins o Identify the reative focus on the various eements of NETS i.e. vision, compact, method N3.9_Foo Proofing o the aim(s) of the initiative? Specific objectives in terms of quaity and efficiency of patient care in terms of quaity, safety, patient experiences, access and equity o their organisation s forward pans o do you envisage any aternatives to NETS for your organisation in the future? What are the chances of success for any changes that might occur? Do you anticipate any risks to any other new initiatives? o the interventions that have taken pace o identify factors faciitating or acting as barriers to NETS The reevant activities being co-ordinated in your organisation? o What initiatives have you been personay invoved with? o Specificay, expand on your experience (if any) of working with RPIWs o What criteria were used for seecting RPIWs. o What initiatives are you aware of esewhere in the organisation (that you haven t been invoved with)? What are you perceptions of the success of these? Which KPIs are being used to measure the impact of NETS, how is the data coected, data sources, frequency of data coection, evidence of reiabiity etc. Who is evauating the data. What impacts are you aware of on other parts of the organisation? How widespread is NETs/NETs activities in the organisation? i.e how many RPIWs, how many certified eaders, how many team members trained etc. What quantitative evidence is there of impact of the interventions in terms of quaity and efficiency of patient care in terms of quaity, safety, patient experiences, access and equity. Has the impementation of NETS had any impact on ski mix, changing patterns of work, evauation/appraisa etc. Centre for Pubic Poicy and Heath Pettigrew framework receptive context for change Typ Name Memo Link Sources References Created On Created By P1_Quaity and coherence of poicy 0 AS P1.1_Bue print P1.10_Vision /08/ :57 05/08/ :57 Intervention case anaysis trianguates with ITS anaysis P1.11_Compact /08/ :57 P1.2_Coherent poicy /08/ :57 P1.3_Commitment buiding /08/ :57 P2_Key peope eading change P1.4_Fragmented poicy P1.5_Framing strategic issues P1.6_Nationa poicy P1.7_Regiona poicy P1.8_Shared word view P1.9_Trust poicy P2.1_Continuity /08/ :57 05/08/ :57 05/08/ :57 05/08/ :57 05/08/ :57 05/08/ :57 AS 05/08/ :57 1 detaied RPIW observation P2.2_Leadership /08/ :57 P2.3_Leading change /08/ :57 P2.4_Nationa eve /08/ :57 P2.5_Personay /08/ :57 P2.6_Regiona eve /08/ :57 P3_Environmenta pressure P2.7_Stabiity P2.8_Team buiding P2.9_Trust eve P3.1_Deay P3.2_Denia /08/ :57 05/08/ :57 05/08/ :57 AS 05/08/ :57 05/08/ :57 ITS RPIW foow-up interviews, n = 4 P3.3_Energy drain /08/ :57 P3.4_Low morae /08/ :57 P3.5_Radica change P3.6_Restructuring P3.7_Financia /08/ :57 05/08/ :57 05/08/ :57 Further issues to foow-up coming from second year data KPO Leads NETS as is focus KPO/OD/QI interviews, n = 6 NETS Three- Legged Stoo Framework Lean toos vs. methods Compete data set aows inductive anaysis of theoretica frameworks HR focus group FIGURE 2 Research design. KPO, Kaizen Promotion Office; OD, organisationa devovement DOI: /hsdr02470 HEALTH SERVICES AND DELIVERY RESEARCH 2014 VOL. 2 NO. 47 Queen s Printer and Controer of HMSO This work was produced by Hunter et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. 27