Core Team Academy 18 th and 19 th September NHS England and NHS - - PowerPoint PPT Presentation

Population Health Management

Core Team Academy

18th and 19th September

Population Health Management

Welcome to Day 1

Peter Spilsbury and Fraser Battye

Brief re-cap on the PHM Academy

Core Teams Analysts Leaders

• Improve knowledge, skills,

enthusiasm and practice on PHM

• Support application - learn by

doing

• Build legacy, products and

networks

• Midlands region as a

trailblazer

Engagement and design Launch event for leaders First Core Team and Analyst events Core Team and Analyst events Analyst event Core Team and Analyst events Analyst event Core Team and Analyst events

Plus ‘open events’ and celebration

Webinars April - June July – September October – December January – March

midlandsphmacademy.nhs.uk

After July’s session, we asked you to:

• 1. Get together as a team
• 2. Understand your po

popu pula lation tion su sub-gr group

• up (engagement and analysis)
• 3. Set ou
• utco

tcomes mes you want to achieve (early measures)

• 4. Map st

stak akeholders eholders and plan engagement

Expectation of work between Academy sessions We can guide, inspire and provoke: on

• nly you
• u can do

• 1. Refine your understanding of the population sub-group
• 2. Articulate primary outcomes you want to achieve
• 3. Know how to ‘measure what matters’ and learn from results
• 4. Be equipped with approaches to design an effective response / intervention
• 5. Understand what is meant by ‘a culture of stewardship’, know why it matters and

how it applies to your project

• 6. Describe the value of your project to different stakeholders
• 7. Develop as a Core Team and plan next steps for implementation

Objectives for these two days

Agenda for today

10:00 Learning from each other’s projects 11:00 Break 11:15 Learning from each other’s projects 12:15 Team planning 12:45 Lunch 13:30 Measuring what matters 15:30 Break 15:45 Sir Muir Gray Award for Failure! 16:30 Refreshments 17:00-18:30 Evening session: Population and Personal Value: Competing approaches or two sides of the same coin?

(Gartner tner Hy Hype pe Cycle cle) )

www.sli .sli.do .do

Even ent t co code de: : W6 W678 78

Enter ‘W678’ pres ess s joi

• in

Population Health Management

Learning from each other’s projects

Karen Bradley

1) Find your STP/ICS pairing (next slide) 2) The first Core Team presents on their progress so far (15 minutes) 3) The other team formulates questions or observations:

• 1 minute on your own
• 2 minutes as a pair

4) Questions and observations are fed back to the presenting team 5) Presenting team responds to questions 6) Debrief and – in the next session - swap

Task

Grou

• up

STP / / IC ICS Roo

• om

1 Black Country and West Birmingham Coventry and Warwickshire Main Room 2 Derbyshire Nottingham and Nottinghamshire Edgbaston 3 Birmingham and Solihull Herefordshire and Worcestershire Sutton 4 Shropshire, Telford and Wrekin Staffordshire and Stoke-on-Trent Chamberlain

Population Health Management

Team Time

Belinda Weir

Th The P e Prof

• fesso

essor r Sir Sir Mu Muir ir Gra ray y ‘Award for Failure’

You are innovating; you must make mistakes and fail sometimes in order to learn We will champion this and recognise you for it

2-3 minute ‘pitch’ on what you’ve failed at and learnt from so far

Prepare your pitch for….

Population Health Management

Lunch

12:45-13:30

Population Health Management

Measuring what matters…

Mohammed A Mohammed, Simon Bourne, Al Mulley

• Al Mulley
• Mohammed A Mohammed
• Simon Bourne

Your session facilitators…

What have we heard? …and what haven’t we heard yet?

Reflecting on this morning…

By the he end nd of

• f th

the se session, ssion, you

• u wil

ill l be be able ble to to:

• Understand how theory leads to a measurement framework for

learning

• Describe the concept of person-centred intelligence (PCI)
• Understand the importance of decision quality
• Describe practical steps to support implementation
• Outline actions to progress this aspect of your projects
• Know where to access further resources

Learning objectives

Population Health Management

Measuring what matters

Mohammed A Mohammed

Outline

• Theory, learning and the measurement framework
• Run Charts
• Evaluation
• Targets (+incentives)
• Personalisation
• Measuring quality of shared decision making

Staff ☺ ☺… ☺

A Theory

“An apple a day keeps the doctor away”

https://en.wikipedia.org/wiki/An_apple_a_day_keeps_the_doctor_away

Program Theory in ‘Real’ World

Ap Appl ples es Deliv liver ered ed Ap Appl ples es Eaten n Vita tamin min Levels els Ra Rais ised ed Health lth Out utcomes

• mes

Impr mproved ed Int nterpr rpreta tati tion

• n

❌ ❌ ❌ ❌ Implementation Failure ☑ ❌ ❌ ❌ Engagement Failure (first causal link) ☑ ☑ ❌ ❌ Theory Failure (early causal link) ☑ ☑ ☑ ☑ Consistent with theory ☑ ☑ ☑/❌ ☑ Theory Failure (later causal link) ☑ ☑ ☑/❌ ☑/❌ Partial Theory Failure Works in some contexts ☑ ☑ ❌ ☑ Theory Failure (different causal path)

“An apple a day...” (Ref: Funnell & Rogers, 2013)

Theory + Intervention + Evaluation

• Improvement Effort
• Theory
• If A

then B

• If not A

then not B

• Won’t make anything else worse (balancing measure : C)
• Measurement – ideally with a control group
• A (fidelity)
• B (outcome)
• C (balancing measure)
• Simple statistical analysis
• Run charts

Knowledge Generation - The Scientific Method

Eval alua uation tion

Challenges of evaluation in complex dynamic contexts (Patton, 2014)

Challenges of evaluation in complex dynamic contexts (Patton, 2014)

24

Challenges of evaluation in complex dynamic contexts (Patton, 2014)

Developmenta elopmental l Evaluatio uation (Learning rning Parad radigm) igm)

• 3. Fidelity

Intervention Implementation 4 . Quality Improvement Methodology

• 5. Theory-

based behavior change

• 6. Human Sensor

Network

• 7. Evaluation ‘Dress

Rehearsals’

• 1. Purposeful

Programme Theory

• 2. Robust

Measurement Framework

Adaptive, Proportionate Pragmatic Stakeholder Engagement Patient Public Involvement Shared Learning Events Ethics and Governance

"The most helpful form of evaluation I have ever experienced. It allows the implementation of any intervention to be adjusted in a timely way. Means at the end of a project you aren’t left with regrets; “if only we had……” There’s an opportunity to test your theories very quickly. Quite energising. A regular objective viewpoint removes the emotion of implementing an intervention. I genuinely didn’t find anything negative even though I didn’t enjoy the nagging……" Alison Lovatt - Clinical Network Director Yorkshire & Humberside Improvement Academy

Target + £

• 1. Successfully Change the underlying system
• 2. Distort the data
• 3. Distort the system

“Drive out fear, so that everyone may work effectively for the company” - W. Edwards Deming

https://towardsdatascience.com/unintended-consequences-and-goodharts-law-68d60a94705c

• Describe your theory (version 1.0)
• Draft out your measurement framework (version 1.0)

Group Activity

Population Health Management

Person-Centred Intelligence

Simon Bourne

Based on the concepts that underpin pe pers rson

• n-cent

centred ed car are

Person-centred intelligence

An Any da y data ta we col e collec lect t wh whic ich is h is: : ✓Holistic ✓Focuses on the needs of people before systems/orgs ✓Involves them in the process of deciding what to measure and how to measure it ✓Focuses on their outcomes and experiences

• Moving away from paternal clinician-patient rel’ship
• Reflecting care beyond the NHS
• Recognising carers, staff and the wider population
• Encouraging a whole person perspective (not role-

focused)

Person…not patient?

• Implementing person-centred measures is a hi

high h pr prio iorit rity

• Desire to move towards funding/monitoring based
• n ou
• utco

comes mes

• Aspiration to take responsibility for op
• pti

timising mising he health alth and d care e resour sources ces on behalf of their pop’n

Why does this matter?

Frequently…

• ↓ thought/ effort on ‘what really matters’ to pop’n
• ↓ understanding of available data/lessons to be learned

from elsewhere

• Collecting data +++ but --- a clearly articulated purpose
• Lack of direction causing projects to stall

Surely we’re already doing it…?

(i.e. self-reported, completed via qs/surveys)

• Ou

Outcom come e me measur sures es – (e.g. QoL, mobility, wellbeing)

• Ex

Exper perience ience me measur sures es – objective (e.g. appt wait) vs subjective (e.g. satisfaction)

‘Standard’ lists? (ICHOCM – multidisciplinary) Carers? Staff?

Focusing on person-reported measures…

Do you real eally y know what matters to your population of interest? What are you basing that on? How confident are you? Questions to consider…

Do you reall eally y know what matters to your population of interest? What are you basing that on? How confident are you? In your groups…

Be ch e chall allen enging! ging!

What are you going to do about it? Assuming there’s room to improve…

Could follow a structured process e.g.

What’s the purpose? How will we use our findings? How will we measure it? Who are the population? What will we measure? Reviewing, incorporating and producing evidence Building capability through training and development Evaluating change

Could follow a structured process e.g.

What’s the purpose? How will we use our findings? How will we measure it? Who are the population? What will we measure?

Aka ka.. ..

• Why are we doing this?
• Who are we doing this with - an

and d how ar are w e we i e involvin

• lving

g th them em?

• What’s our chosen measure(s)? (hierarchy of measures/decision

criteria)

• How will we practically do this? (sample/methodology/collection)
• How will we analyse/learn/continue to improve?

Making it meaningful…

What’s the purpose? How will we use our findings? How will we measure it? Who are the population? What will we measure?

So So y you

• u can:

n: ✓(Know who your data relates to, select a sample accurately) ✓Und ndersta rstand nd wh what at mat atters ers to to the hem ✓In Involv

• lve

e the hem m in in the he de deci cisio sions ns to to co come Cha hall llenge enge: Are we underestimating capability? Or assuming a desire to be involved?

As a group…

What’s the purpose? How will we use our findings? How will we measure it? Who are the population? What will we measure?

• What could you do to bet

better er un unde derstand stand wh what at mat atter ers s to your pop’n of interest?

• How (and when) could you in

invol

• lve

e them hem in the decision- making process as you progress? What are the options? Then let’s get SMART…

Making it meaningful…

What’s the purpose? How will we use our findings? How will we measure it? Who are the population? What will we measure?

• Focus groups?
• Surveys?
• Events/workshops?
• (Previous work)?

Im Imagi gine ne its its all all go gone ne wr wron

• ng!

g!

• There’s no way you can describe any of the measures as

really ‘person-centred’…

• The population weren’t involved in decision-making

process at all…

• We’ve no idea what matters to them…

Just another ‘box-ticking’, window-dressing exercise…

What’s going to de-rail you?

What’s going to de-rail you?

“A pre-mortem may be the best way to circumvent any need for a painful post-mortem” Klein (2007)

Wha hat t wen ent t wr wron

• ng?

g? (1-2-table)

• List them
• Which are ‘show-stoppers’? (not in the bake-off sense)
• Which are most likely?
• Which do you have no control over?

In your groups…

Then… And what could you do to prevent it? Foc

• cus

us on

• n the

the one

• nes in

in y you

• ur

r co cont ntrol!

• l!

What are your actions? Who will take responsibility?

In your groups…

Population Health Management

Measuring What Matters for PHM

Understanding complexity, context, and competencies Al Mulley

Learning from Variation for PHM: Conceptual and Operational Barriers

Learn from Variation Deliver What is Valued System Leadership at all Levels Measure What Matters Deliver with Teams Organise for Innovation

Learning from Variation for PHM: Conceptual and Operational Barriers

Learn from Variation Deliver What is Valued System Leadership at all Levels Measure What Matters Deliver with Teams Organise for Innovation

Context Sensitivity Complexity Competencies 1 2 3

Learning from Variation for PHM: Conceptual and Operational Barriers

Learn from Variation Deliver What is Valued System Leadership at all Levels Measure What Matters Deliver with Teams Organise for Innovation

Context Sensitivity Complexity Competencies 1 2 3

Learning from Variation for PHM: Conceptual and Operational Barriers

System Leadership at all Levels Measure What Matters Deliver with Teams

Context Sensitivity Complexity Competencies 1 2 3

Learning from Variation for PHM: Conceptual and Operational Barriers

Learn from Variation Deliver What is Valued System Leadership at all Levels Measure What Matters Deliver with Teams Organise for Innovation

Context Sensitivity Complexity Competencies 1 2 3

Uncertainty about Outcomes Disagreement about Value

High High Low Low

Control Chaos Complexity

Evidence-Based

Respecting Complexity at the Level of the System and the Individual

The Need for Simple Rules:

• 1. Meeting needs and wants; no less but no more
• 2. No decisions made with avoidable ignorance
• 3. Showing manifest respect for the individual

Modified from Stacey, Plsek, IOM, 2001

Level of competence Difficulty of the task

High High Low Low

Inefficient Ineffective

Complementary Competencies for PHM: Technical and Relational

Relational Competence Relational Difficulty

High High Low Low

Inefficient Ineffective

Complementary Competencies for PHM: Technical and Relational

Level of competence Difficulty of the task

High High Low Low

Inefficient Ineffective

Measuring Teamwork as Relational Coordination (Gittel)

• Shared Goals
• Shared Knowledge
• Mutual Respect
• Communication that is…
• Frequent
• Timely
• Problem- solving
• Accurate

Measuring Teamwork as Patient Experience

Complementary Competencies for PHM: Technical and Relational

Context-Sensitivity

High High Low Low

Measurement-Subjectivity

Measuring What Matters for PHM Making People’s Choices Matter Control Personal Value

Preferences Matter: Measuring Decision Quality for PHM

We’re here to support you!

• Microsite (PHM + PCI - forthcoming)
• Detailed guides
• Wider offer of support (advisory, analytics,

evaluation/evidence expertise, implementation partners) To be shared…

Person-centred intelligence

By the he end nd of

• f th

the se session, ssion, pa participants ticipants wil ill l be be able ble to to:

• Understand how theory leads to a measurement framework for

learning

• Describe the concept of person-centred intelligence (PCI)
• Understand the importance of decision quality
• Describe practical steps to support implementation
• Outline a set of actions to progress this aspect of their projects
• Know where to access further resources to support this process

Learning objectives

Population Health Management

Break

Population Health Management

The Professor Sir Muir Gray Award for Failure

Population Health Management

Population and Personal Value: Competing approaches

• r two sides of the same

coin?

Value in kidney care

Dr Clara Day Consultant Nephrologist and Assistant Medical Director for Finance and Value University Hospitals Birmingham

Chronic kidney disease

• Gradual and

irreversible decline in kidney function

• General population 5-

6%. Much greater in elderly

• Guidelines are for

referral at certain level; huge numbers

• f elderly
• Very few symptoms or

clinical relevance in elderly

Treatment for kidney failure: dialysis

Haemodialysis: hospital, satellite unit or home?

Uses lining of abdominal cavity (peritoneum) as a membrane to facilitate removal of toxins

Peritoneal dialysis

What does the patient actually want?

• Not what you think they should want
• Some difference in price but cannot

perform home therapy if don’t want to

Ensure equity of treatment for all; not just those who shout the loudest

Barriers to live donor kidney transplantation: ATTOM

Less likely to have a live donor kidney if:

• Non-white
• Not married
• Not as well educated
• Not as wealthy

Not from Northern Ireland

Wu et al Nephrol Dial Transplant 2017 32 890-900

Population Health Management

Core Team Academy

18th and 19th September

Population Health Management

Welcome to Day 2

Fraser Battye

09:30-10:50 Teaming and leading for a culture of stewardship 10:50-11:00 Break 11:00-12:45 Design thinking: how to approach planning 12:45-13:30 Lunch 13:30-15:30 Theory of change and project planning 15:30-16:00 Wrap up and next steps 16:00 Close

Population Health Management

Teaming and leading for a culture of stewardship

Dr Tim Wilson, Margaret Mulley and Belinda Weir

Culture

Process

Structure Culture

Process

Structure

Where efforts are focussed Where the impact is

Is this what we are doing? Is this right?

• Building a common purpose for your teams
• Team exercise
• Behaviours to drive a new culture
• Personal actions

Session Outline

Population Health Management

Building a common purpose for your team

Culture is not something you are – it is something that you do

Building a Strong Team Culture

95

Create safety Share vulnerability Establish purpose

Three Areas for Action

Share the answers to these questions with your team:

• 1. The one thing that excites me about this particular
• pportunity is_____________
• 2. I confess, the one thing I’m not so excited about with this

particular opportunity is___________

• 3. On this project, I would like to get better at____________

Team Exercise

Think about during the rest of the day and share some thoughts before the end of the day

Des esign ign a f a few simpl ple, , for

• rthrig

thright ht sen entences ences th that wi t will l make a significant difference to your group’s be beha haviour viour.

Population Health Management

Lost at Sea

You have chartered a yacht with three friends, for the holiday trip of a lifetime across the Atlantic

• Ocean. Because none of you have any previous sailing experience, you have hired an

experienced skipper and two-person crew. Unfortunately in mid Atlantic a fierce fire breaks out in the ship’s galley and the skipper and crew have been lost whilst trying to fight the blaze. Much of the yacht is destroyed and is slowly sinking. Your location is unclear because vital navigational and radio equipment have been damaged in the fire. Your best estimate is that you are many hundreds of miles from the nearest landfall. You and your friends have managed to save 15 items, undamaged and intact after the fire. In addition, you have salvaged a four-person rubber life craft and a box of matches. Your task is to rank the 15 items in terms of their importance for you, as you wait to be rescued. Plac Place e the number r 1 b by the most t impor

• rtant

tant item, , the number r 2 b by the secon

• nd

d most t impor

• rta

tant nt and so forth th until l you have e ranked ed all 15 i items s in the first column. mn.

Background

Get into your teams to discuss your individual choices and work together to agree on a collaborative list. Rec ecor

• rd

d th the e grou

• up

p ran ankings kings in th the e sec econd

• nd col
• lumn

umn

Team Ranking

For r each h item, m, mark the number er

• f points

nts that t your r score e diff ffers rs from

• m the Coast

t Guard ranking ng and then n add up the points. ints. Disregar egard plus or minu nus s diff ffer erences. ences.

0 – 25 25 EX EXCEL ELLEN LENT Grea eat survi vival al skill ills s RES ESCUED ED 26-32 GOOD Above average survival skills RESCUED 33-45 AVERAGE Seasick, hungry and tired RESCUED 46-55 FAIR Dehydrated and barely

• alive. It was tough, but

RESCUED 56-70 POOR Rescued, but only just in time! 71 - VERY POOR OH DEAR

Compare your answers to the Correct Answer

Discuss the following:

• Why were the scores different?
• What changed your mind?
• Was this enough to survive?
• What actions might you take going forward to assure effective team

discussions and decision? Share with the room:

• Score of the best and the worst individual results
• Your team results
• A key insight

Team Discussion

Population Health Management

Behaviours

What behaviours should you:

• Stop

Stop?

• Do

Do mor more e of

• ften?

en?

• St

Star art? t? Think about each of these individually and then seek feedback from at least one

• f your team members for their suggestions to you.

With what you have learnt in the last exercise, and bearing in mind your common purpose…

At the last PHM Academy session in January what can you demonstrate in terms of culture change? List t 2-3 act 3 actions

• ns you
• u will

l pe pers rsonall

• nally

y ta take List t 2-3 acti 3 actions

• ns you
• u will

l do do a as a t a tea eam List t 1 a 1 act ctio ion n you

• u wou
• uld

ld like e you

• ur

r lea eaders ders to do

• do

Commitments

Population Health Management

Break

Population Health Management

Design thinking: how to approach planning

Fraser Battye

Evidence from engagement Evidence from mapping the problem Evidence from the literature Each is necessary; none are sufficient

Literature Engagement Problem mapping Best bet

Useful resource: Public lic He Health lth England land (Jul July y 20 2019 19) He Health lth inequa equalities ities: : place ace-ba base sed d appr proaches

• aches to

to reduce uce inequalities qualities

Three presentations designed to help you design your project’s activities:

• Using evidence from research - Red

d card, , Ma Main in Room

• Understanding population needs - Yello

low w card, , Edgba bast ston

• n
• Mapping the problem - Gree

een n card, , Chamberlain amberlain You have 30 minutes with each presenter. Then back in main room for summing up.

Population Health Management

Evidence from research

Shiona Aldridge, Gillian Cope and Alison Turner

…or How To Avoid Getting Stuck Stuck in in an Evid idence ence Jungle le

Photo credit: Paxson Woelber CC BY 2.0 https://www.flickr.com/photos/paxson_woelber/5425787897

Learning objectives

• To bust some myths about using evidence;
• To share some benefits of using evidence;
• To give you tips to tackle some of the main barriers to using evidence;
• To signpost where to find evidence;
• To help you sort the good from the bad.

Why use evidence?

116

• Developing bids for funding
• Making the case for change
• Generating options
• Stopping overuse of harmful or low value activities
• Designing programmes and innovations
• Scaling up proven practice
• Challenging assumptions and building consensus
• Demonstrating accountability and transparency
• Learning from success and failure
• Informing continuous improvement

So, what do you think we mean by “evidence”?

117

Evidence by Nick Youngson CC BY-SA 3.0 Alpha Stock Images

Putting evidence into context

118

Evidence from research Expertise and experience Population needs, characteristics and perspectives

Context: social, political, environmental, economic, technological, legal

Adapte pted d fro rom: m: Spring, , B. & Hitc tchcock, , K. (200 009) 9) Evidence-based practice in psychology. In I.B. Weiner & W.E. Craighead (Eds.) Corsini’s Encyclopedia of Psychology, 4th edition (pp. 603-607). New York:Wiley

For each programme, decide if the intervention had:

• a positive effect
• a negative effect
• no effect
• n the intended outcome/s

Can you guess…?

119

Acknowledgements: 80,000 Hours

Scare Scared S d Straigh traight Restorative Restorative Justice Justice Preventat Preventative ive Home Visits Home Visits

Public Domain Pictures

Can you guess…?

Preventa ntati tive home vis isit its

Preventative home visits try to reduce various health risks of independent older adults, such as illness, injuries from falling, and early

• death. The intervention involves a

health professional visiting an adult

• ver 65 living alone and assisting

them with medical and social issues, such as health checkups, balance training to reduce the risk of falls, or a recommendation to specific services. Several countries have incorporated preventive home visits into national policy, such as Denmark and Australia. Do home e visit sits s reduce e risk of prematur ure deat ath (as as measur asured d by how many partici icipan pants ts died during their respect ctiv ive e studies, s, comp

• mpar

ared to contr trols)

• ls)?

Pre reventi enting ng juvenile enile delinq nquency: uency: Scar ared ed Strai aight ht

Scared Straight is a program designed to discourage at-risk kids from committing crimes. The first program featured aggressive ‘rap sessions’ depicting life in prison, and received extensive media attention including a documentary. Following the documentary, over 30 prisons across the US adopted similar ‘juvenile awareness’ programs. All interventions in the Campbell review feature a prison visit, and most include a presentation by the prisoners which range from graphic to educational. Programs sometimes include tours and extended orientation sessions, such as living as a prisoner for 8 hours. Do Scared Straight ht and other r ‘juvenile awareness’ programs reduce e the rate ate that at partici icipan pants ts comm

• mmit

it crimes

mes in the future? e?

Restora torativ tive justi tice ce conferen enci cing ng

A restorative justice conference brings together offenders, victims, and others involved (e.g. families and communities) to discuss the impact

• f the crime and how the offender

should repair the harm done. All conferences in the Campbell review were planned face-to-face conferences with a trained moderator, where all parties involved consented to participate. Offenders had committed violent crime or property crime, and conferences were offered as an alternative or supplement to prosecution in court. Does s participa icipation tion in restor

• rativ

tive e justice ice confer eren enci cing ng reduce ce the frequen ency cy of crime me in offender nders, s, comp

• mpared

ed to to those se wh who were only ly prosecut ecuted in court? t?

https://80000hours.org/articles/can-you-guess/

Can you guess…?

Preventa entativ tive e home me visits ts Resul sult t - No effect ct

The Campbell review was able to use 55 studies with 24,198 participants to determine if home visits affected death

• risk. There was high quality evidence

that home visits had no effect, meaning that over the course of the studies (3 years maximum), death rates were equal among participants and controls.

Preventing enting juvenile nile delinq nquenc uency – Scar ared ed Strai raight ht Resul sult t - Negativ ive e effect ect

Nine randomized trials covering a 25-year period in eight different prisons demonstrated that Scared Straight programs increase the odds that participants will commit crimes in the

• future. The results are the same whether

the program is aggressive or passive. Despite the evidence, Scared Straight programs are still in use, and people continue to believe it's effective.

Rest stora

• rativ

tive e justic ice confer eren enci cing ng Resul sult t - Positiv tive e effect ect

10 randomized controlled trials involving a total of 1,879 offenders were reviewed. The researchers described their results as “clear and compelling”, showing a reduction in future crime and a higher level of satisfaction for victims. Many of the studies also found restorative justice conferences to be cost-effective. In

• ne striking example, a study in London

found that they provided “up to 14 times as much benefit in costs of the crimes prevented”, meaning for every £1 spent

• n delivering Restorative justice

conferences, £14 was saved in preventing the costs of future crime.

Welcome to the jungle

122

What is my question? What type of evidence is best for this question and where can I find it?

What evidence is relevant to my situation?

What findings and lessons are transferable to this context? How do I make sense of and connect all this evidence together?

Usefulness* = relevance x validity work

* Slawson, Shaughnessy & Bennett. Becoming a medical information master: feeling good about not knowing

• everything. J Fam Pract 1994;38:505-13.

Image by bere von awstburg from Pixabay

Take time to think about the question you’re trying to address:

• What specifically would you like to know?
• What seems to be missing in your understanding?
• How are you planning to use this information?

Know where you’re going!

123

Artem Beliaiken, CC0, https://www.flickr.com/photos/artembali/28784444928

What intervention

• r

innovation? In relation to which impacts or

• utcomes?

For which population groups? In which settings?

Wha hat t typ ype of e e of evi viden dence ce is is mos most t ap appr propria

• priate

e for

• r you
• ur

r qu ques estio tion? n? Plan a route

124

Wikimedia Commons, CC BY-SA 3.0

Desig ign Impact Lessons sons / reflecti lections

• ns

To unders derstand tand curr rrent ent trend nds To unders derstand tand the economi nomic/ c/ social cial value e of change ge

To identif tify y and as assess ss optio ions To understa stand nd the feas asibil bility y of change ge To as assess s implic licatio tions To apply ly learnin rning g from m experi rience ence Syst Systema ematic tic revi views ws; ; experi rimental ental resear arch ch studie ies; ; econ

• nomi
• mic

c evaluatio tion; ; innovatio tion cas ase e stud udie ies Cochrane chrane Library brary, , NIHR Themed Revie iews, ws, Medline ine; ; Goog

• gle Schol
• lar

ar; ; organ ganisati isations

• ns involv
• lved

in change ge and r resea earch e.g. . Jose seph h Rowntr tree Founda dati tion;

• n; NIHR Health

lth Servi vices s and Deli livery ery Research; ; CLAHR AHRCs Cs; ; AHSNs; ; Strategi

gic c Clin inical al Network

• rks;

; DoP

• PHER

ER; ; Socia cial l Ca Care e Online line

Mixed d methods s evaluatio tions s (quantitati titative e and qualita itati tive) ) of projects ects, , initia itiati tives es and progr gramme ammes; ; lesson sons s learn rned ed repor

• rts

ts; ; impact act as assessme ssment nts; ; inquiri iries s and a audit t repor

• rts

ts HMIC dat atabas ase, , arms s length gth bodie ies, s, Health th Select ect Commit mittee ee, , Nat ationa

• nal

l Audit t Offic ice; ; Nesta; ; NH NHS Hori rizon zons; ; NH NHS Conf nfedera erati tion

• n

Does s x work rk (better ter than y)? )? What at pote tenti tial al harms/r s/risks isks exist st? What at are the enablers, ers, challenge llenges s and trig iggers gers for cha hange? nge? How w does x work? rk? Does s it offer r bette ter r value? e? What at are the ne needs ds and nd priorit iorities? ies? Where e are the gaps? Feedback/c ck/con

• nsu

sulta ltati tion

• ns

s (e.g.

• g. surveys)

s); ; needs as assessme ssment nts s (JSNA); ; Atlases es of Vari riati ation;

• n;

gui uidance dance; ; mo mode delli lling; ng; ho horizo zon n scanning nning NHS Eng Engla land nd, , Publi lic c Health th Eng Englan land, , NICE, Royal l Colle lleges ges & pro professional essional bodie ies; ; charit rities s & pat atie ient t bodies es; ; think k tanks

126

FINISH 63 62 61 60 59 58 57 49 50 51 52 53 54 55 56 48 47 46 45 44 43 42 41 33 34 35 36 37 38 39 40 32 31 30 29 28 27 26 25 17 18 19 20 21 22 23 24 16 15 14 13 12 11 10 9 START 2 3 4 5 6 7 8

Approp

• priat

riate shor

• rtcuts

tcuts:

• Existing reviews or

summaries

• Try an aggregated search if

you’re not sure where to start e.g. NICE Evidence,

TRIP Database

• Has anyone shared their

searches? e.g. Kings Fund,

HSMC Library Avoi

• id

d the da e danger ers:

• Don’t accept evidence at

face value

• Beware of cognitive bias
• Beware of your own filter

bubble

To find out about the journals and databases accessible to NHS staff: https://www.nice.org.uk/about/what-we-do/evidence-services/journals-and-databases To register for access to licensed databases and journals: https://openathens.nice.org.uk/ For help with searching databases: https://www.nice.org.uk/about/nice-communities/library-and-knowledge-services- staff/training-materials To practice your critical review of research evidence: https://www.understandinghealthresearch.org/

Accessing the evidence base

127 Jurgen Appelo, CC BY 2.0

https://thatsaclaim.org/health/wp-content/uploads/sites/14/2019/08/KC- Poster_Health_EN_download.pdf

Mythbusters

(Source: Rob Briner, Centre for Evidence-Based Management)

129

Evidence means quantitative ‘scientific’ evidence Collecting valid and relevant evidence gives you The Answer to The Problem. Evidence-based practice means practitioners should use their professional expertise. Evidence tells you the truth about things. Evidence can prove things. Experts (e.g., consultants, experts and academics) know all about the evidence so you just need to ask them Evidence based practice is not solely based on the research evidence If you don’t have the evidence you can’t do anything

130

“I believe in evidence. I believe in observation, measurement, and reasoning, confirmed by independent observers. I'll believe anything, no matter how wild and ridiculous, if there is evidence for it. The wilder and more ridiculous something is, however, the firmer and more solid the evidence will have to be.” ― Isaac Asimov, The Roving Mind

Our approach in the Strategy Unit is to help you to naviga igate, fil ilter, , in interpr rpret t and apply evid idence nce to t thei eir r lo local l con

• ntex

ext. We publish a regular newsletter, called Evid idence ence In Insig ights hts, highlighting important new evidence which may be of interest. Find out more and sign up for Evidence Insights (free of charge) via our website: http://strategyunitwm.nhs.uk/

Getting help

131

Population Health Management

Designing a service response – Mapping the problem and drawing on experience

Simon Bourne & Abeda Mulla

• Simon Bourne
• Abeda Mulla

Your facilitators

Par artic ticipant ipants s wi will b ll be able e able t to:

• Describe the value in focusing on the problem and

drawing on a breadth of experiences

• Use a structured tool to consider a problem in more detail
• Know how to access further resources to support problem

solving in a group setting

Session objectives

What are we exploring here?

Evi vidence dence from

• m

resea search ch Evidence dence from

• m

enga gage gement ment Evi vidence dence from

• m

experience perience

What are we exploring here?

Evidence from research Evidence from engagement Evi vidence dence from

• m

experience perience

It’s all too easy to jump straight into ‘solution mode’! Being honest… …who’s already got an intervention in mind?

Designing a service response…

Have you rea eall lly understood the problem?

Working with stakeholders from a ra range nge of backgrounds… To get the benefit of their exp xper ertise tise and nd di diff ffer erent ent perspec rspectiv tives es…

Designing a service response…

If we come up with something on our own? If we rely on a pre-existing solution or rush to decide on something?

What’s the risk?

Designing a service response…

Supply driven thinking! (aka solutions in search of a problem…) Advocacy - ‘pet projects’ get pushed to the front, which may not address the key issues Implementation failure, loss of potential learning etc. etc. …sound familiar?

What’s the risk?

Take the time to wor

• rk

k on

• n un

understanding derstanding th the e pr problem

• blem...

... …with stakeholders from a range of backgrounds …to get the benefit of their expertise and different perspectives

So what’s our suggestion?

Invest the time up front… …or pay for it later!

Then use your learning to design the solutions… And test the solutions rigorously (in theory) by putting your th theory eory to scrutiny!

(You touched on this yesterday and you’ll be learning more about this later! It’s a lot cheaper than testing a bunch of ideas in real life…)

So what’s our suggestion?

We think this works best when you use st stru ruct ctur ured ed too

• ols!

ls! Capturing the input of everyone… Seeing things in a different way… Helping you to reflect before you progress…

So what’s our suggestion?

145

• Breaking the

rules/different points of view

• Thinking hats
• Pr

Problem blem/s /solutio ution trees es

• Driver diagrams
• Process mapping
• Five whys
• Fishbone diagrams
• Prioritisation matrices
• Logic models
• Planning data collection
• Project proposal/business case

development

• Quantifying the impact of

proposed changes

• Project/ programme

management tools

• Stakeholder mapping
• Planning

communication & engagement

• Plan-do-study-act

cycles

• Project/programme

evaluation tools

• Quantitative/ qualitative

evaluation methods

• Evidence ‘hacks’
• Using evidence

effectively

Com

• ming up

with an an i idea ea Devel elop

• ping

a a prop

• pos
• sal

al Mak aking chan anges es Evalu aluati ating ng Mak aking dec ecision

• ns

Revi viewing, g, incor

• rporati

porating ng an and d prod

• duci

cing ng evi viden dence ce

A selection of tools we’ve developed to support the problem-solving process and developing solutions…

Using e.g. pr prob

• blem

lem tr trees ees…

We can start to reflect on cause and effect relationships

Problem trees can help us understand causes and effects…

Problem trees can help us understand causes and effects…

• They can give us a guide to the co

comp mplexit lexity y of

• f a

pr problem

• blem…
• They can support us to identify po

potential ential in inter erventio entions ns and d th their ir eff ffects ects…

• They can also help us to pl

plan n pr projects jects…

The problem tree….

149

Core problem

Direct cause 1 Direct cause 2 Direct cause 3 Direct cause 4

Secondary cause 1 Secondary cause 2 Secondary cause 3

Effect 1 Effect 2 Effect 3 Effect 4

Secondary effect 3 Secondary effect 2 Secondary effect 1

Core problem TH THEN → Primary (direct) causes → Secondary causes (causes of causes!) TH THEN → Primary (direct) effects → Secondary effects (effects of effects!)

150

The problem tree….

Not enough GP appointments

Not enough GPs Patient list size increasing High proportion

• f unnecessary

appointments

GP retirement Shortage of GP trainees Patients not aware

• f alternative

services

Long waiting times Increased use of urgent care Increased GP disruptions

Increased costs to the system Angry patients Receptionists not aware of alternative services to signpost patients to

151

The problem tree….

Questions to consider…

• Nat

Natur ure: : what is the essence of this problem? You might think about the harm(s) caused, who / which groups suffer.

• Sc

Scale le: how many (e.g. people) does this affect?

• Dy

Dyna namics mics: is the problem getting bigger / smaller / staying the same? If you did nothing, what is likely to happen?

• Ca

Causes uses: : this is closely related to the nature, but what seems to lead the problem that you are defining? If you are struggling with this, keep asking why?

152

Give it a go!

153

How was that?

Solution trees… 5 whys… Articulating unwritten rules… Thinking hats… Fishbone (ishikawa)…

Also try…

154

If you would like access to other tools, or want something else to support your problem solving… …Let us know!

We’ve uploaded a sample of tools and templates to

• ur innovation & evaluation microsite...

155

Par artic ticipant ipants s wi will b ll be able e able t to:

• Describe the value in focusing on the problem and

drawing on a breadth of experiences

• Use a structured tool to consider a problem in more detail
• Know how to access further resources to support problem

solving in a group setting

Session objectives

Any more reflections?

Population Health Management

Lunch

Population Health Management

Theory of change and project planning

• Prof. Robin Miller and Karen Bradley

Theory of change and project planning

• Implementation – why is it so difficult and what do you need to

think about?

• Theory of Change
• Project Planning

Population Health Management

Implementation: why is it so difficult and what do we need to think about?

• Prof. Robin Miller

“Multiple ill-coordinated small-scale projects may, accordingly, degrade rather than improve the ability to achieve improvements across healthcare as a

• whole. Moreover, as attention shifts from
• ne project to another, the gains

achieved in the first project may attenuate, a phenomenon that has been termed the ‘improvement evaporation effect’.”

Professor Mary Dixon Woods

Dixon-Woods, M., & Martin, G. P. (2016). Does quality improvement improve quality?. Future Hospital Journal, 3(3), 191-194.

Shared care for Diabetes Pinnacle Midlands Health Network Achieving Clinical Excellence Consorci Castelldefels Agents Salut Wellbeing Enterprises Maison de Sante NAPC Medical Homes BHF House of Care Ontario Community Health Centres MacMillan Cancer Partnership

facili ilita tating ting leading ding learnin rning engag gaging ing funding ding eval aluati uating ng

Miller et al (2018) "Transforming primary care: scoping review of research and practice", Journal of Integrated Care, Volume 26, Issue 3 (Primary Care Special Edition)

Population Health Management

Theory of change: an introduction to the process

Karen Bradley

Theory of Change

If I eat healthier and go to the gym… then I will be healthier by Christmas…

Describe your theory of change

We need a logical description that connects what we are trying to achieve with a set of activities… …that will lead to an outcome… …that can be measured Working this through and writing it down, means you can:

• Test it with other people
• Inform your project planning…red

educe uce scope

• pe for magic

agical al thinking! ing!

Example theory of change for end of life care

“If If we deliver er our trainin ning g packa kage ge, , then we will improve the skills of care homes staff... If staff are more skilled, then they will be more able to cope in the event of a crisis... If staff are more able to cope in a crisis, then there will be fewer unplanned admissions to hospital.... If there are fewer unplanned admissions, then more e people ple will l die in a se setting ing of their ir choice.”

Setting thinking out this way helps you see where the theory might stutter

• Th

The pr prob

• blem

lem I a I am tryin ing g to to so solv lve: I have put on (a lot) of weight this year (too many nice holidays) and I'm feeling very unfit. I know this because my clothes don’t fit - and I'm out of breath by floor 3 walking up the stairs to our 5th floor office.

• Th

The ou

• utc

tcomes

• mes I’d like to achieve: to fit my old clothes and feel

healthier by Christmas (I have another holiday to go on…)

The acti tivities ities I n I need d to d

• do t
• to a
• achie

ieve e my ou

• utcomes
• mes are:

(As many ‘if x, then y’ statements as are required)

The resou

• urces

es I w I wil ill u l use for

• r

these se activi iviti ties es are: To t

• track

ck prog

• gress,

ess, I w I wil ill l measur ure:

To see whether I’m achieving my outcomes: To monitor progress with my activities:

The acti tivities ities I n I need d to d

• do t
• to a
• achie

ieve e my ou

• utcomes
• mes are:

If I plan a 12 week food diary then I will make healthy meals If I eat healthy meals then I will be more energetic If I am more energetic then I will go to the gym - and take the dog out for a walk If I go to the gym and walk the dog then I will burn calories and feel good If I feel good then I am more likely to continue eating healthily and exercising If I continue eating healthily and exercising then I will have lost weight and be fitter by Christmas

The resou

• urces

es I w I wil ill u l use for

• r

these se activi iviti ties es are:

• Recipes
• Time to plan recipes and do

shopping

• Money to pay for shopping and

gym

• An app to track this on
• A dog
• Will power

To t

• track

ck prog

• gress,

ess, I w I wil ill l measur ure:

To see whether I’m achieving my outcomes:

• Measure of weight loss
• Measure of breathlessness climbing stairs
• Old clothes fitting

To monitor progress with my activities:

• Production of food diary
• Record of food eaten /gym sessions / dog walks

completed against goals set

Beware unintended consequences…

Difference between our if, then statements

• Importance of talking to your stakeholders
• Different needs of different people

Anyone say save money?

• Highly unlikely – feeling good is likely to increase my online clothes shopping!

Theory of Change template

Resour source ces To carry out these activities we use the following: Activitie tivities To achieve these outcomes we will: Outcomes tcomes We aim to achieve the following:- Rat atio ionale le: When learning about (and from) our population sub-group, the problems we have uncovered are:- Measur asures s - We will know if we have achieved our outcomes/ or are on the way to achieving our outcomes because we will see:

Theory of Change template

Resour source ces To carry out these activities we use the following: Activitie tivities To achieve these outcomes we will: Outcomes tcomes We aim to achieve the following:- Rat atio ionale le: When learning about (and from) our population sub-group, the problems we have uncovered are:- Measur asures s - We will know if we have achieved our outcomes/ or are on the way to achieving our outcomes because we will see:

St Start he here

Outc utcomes

• mes 2n

2nd Res esour urces ces 4t 4th Activities vities 3r 3rd

Meas asur urements ements last last

Test your theory of change with another table

1. Give your theory of change to another table to review

• Look for gaps
• Do all outcomes have an activity that will relate to it?
• Do all activities lead to a stated outcome?
• Are any resources missing?
• Do the measures track both activities and outcomes?

2. Come back together

• Ask questions / give feedback

3. Teams revise and update your theory of change

Population Health Management

Project planning

Karen Bradley

Project planning

Two stages to your planning 1. Medium to long term

a) What do you expect to have achieved by the end of March? b) And beyond this?

2. Short term – a detailed plan on what needs to be done between now and 19th Nov

a) Describe the theory of change underpinning their project (and set this out in the template). b) Set out a measurement framework and a process for learning. c) Design the service change / intervention to achieve the intended outcome(s).

We’re working through the PHM Project cycle

Aft fter er 2nd Ju July ly you u set t out to to get to to know w eac ach h other her as as a team; team; Further her unde dersta stand nd the pop

• pula

ulatio tion n you will ll serve ; the outco tcomes mes you u want nt to to achie hieve e and d measu easures s you might t use; ; and d map p your ur Stak akehol holde ders s and enga

gage e with them..

We’ve now looked at fu further her understa erstand nding ing the pop

• pula

ulatio tion n need eds; ; how w to to use e evi vide dence nce fro from resear search; h; stak akehol holder ders; and d clinic inical al exper xperience ience to to make decisions cisions; ; and d star arting ting to to plan lan the next t steps teps for their ir project ject But there is still ill a lot t of f work rk going ing on here! e!

And then n in Novembe ember movi ving ng on to to Impl pleme ementa tatio tion n and d Evalua uatio tion

Ja January uary – celebra lebrating ting what t you u have e lea earne ned, , achie hieved ed and d have e plan lanne ned

March h – shar aring ing wha hat you u have e learned earned and d achie hieved ed

A few pointers…

It might include:

• How do we identify the necessary resources, and then can we secure these resources?
• What are the major risks to the project and how can we mitigate against these?
• Who has influence, and how do we get them on board?
• How will we coordinate our activities? What meetings do we need to stay on track?
• Who needs to know about the project, and how can we share relevant information?
• How can we easily measure progress so that we can review regularly?
• Will we cope with failure, and how do we use this to improve our approach?
• Who is able to unblock our barriers? Who is able to unblock our thinking?
• Are there potential changes to our local context that we need to keep an eye on?

Project plan – medium to long term

Descri ription tion of what at you antic icipa pate e achie ieving ing at at each h stage age of the programme e and beyond

• nd

Nov √ Jan √ Mar √

Left blank so you can draw your own timescales

Project plan – short term

Tas ask Person

• n

responsible

• nsible

Sept wk wk 1 Oct wk wk 2 Oct wk wk 3 Oct wk wk 4 Oct wk wk 5 Oct wk wk 6 Nov wk wk 7 Nov wk wk 8 Nov wk wk 9 Nov wk wk 10 10

Week 9 is the Nov PHM workshop

Test your theory of change with another table

1. Give your theory of change to another table to review

• Look for gaps
• Do all outcomes have an activity that will relate to it?
• Do all activities lead to a stated outcome?
• Are any resources missing?
• Do the measures track both activities and outcomes?

2. Come back together

• Ask questions / give feedback

3. Teams revise and update your theory of change

Population Health Management

Next steps

• 1. Complete the work you have started to understand your population sub-group, set a

project aim, etc (see Workbook). Once you have done so, then:

• 2. Start to design the service change / intervention to achieve your intended outcomes
• 3. Describe the theory of change underpinning this intervention - and set this out in a

logic model

• 4. Set a measurement framework and a process for learning from results

Next steps: simple to express, difficult to do…

www.sli .sli.do .do

Even ent t co code de: : W6 W678 78

Enter ‘W678’ pres ess s joi

• in

Population Health Management

Many thanks for your participation!