© PROMISE 2016 - All Rights Reserved | Em@il:promise@cpft.nhs.uk

PROMISE.global

PROactive Management of Integrated

Services & Environments

PROGRESS PROCESS PROMOTE PROTECT

PROMOTE (PROactive Modelling Of Therapeutic Environments)


Framework to Transform Ideas into Initiatives


Objective:

To provide an easy to use framework for reflection in order to develop and test out new ideas which challenge the status quo and facilitate positive change.

To promote innovation as everyone’s business and to recognise that we should all strive for improvement in everything that we do.


Concept:

Reflection is a process of thinking back over events to enable and facilitate critical inquiry into one’s own actions with a focus on continuous improvement and innovation. Guided Reflection is a facilitated process where one person facilitates another or group of others to think deeply about their practice; an intervention, process or system, with a view to establishing any room for improvement and suggestions for new or different approaches or ways of working. This process ensures that we constantly question ourselves in relation to our actions and interventions and seek to improve what we do in service of our overall purpose. This will not only improve our ability to be more helpful helpers, but also improve the overall experience for the person who may be in considerable distress. Additionally, this will ensure that vital resources can be released or used differently to better effect.


It is all too easy in a busy, pressured environment, to focus on the everyday demands being placed upon us, especially in the context of stretched resources and performance management. We also perhaps sometimes think about change only on a macro level and find ourselves paralysed by inertia when the change might feel too big or too difficult to ever make a start on. However, failing to reflect on what we do, how we do it, and how it serves the person towards their own self-mastery simply perpetuates the status quo and does nothing to interrupt the relentless ‘busyness’ that professionals often experience. The challenge is to create breathing space and engage staff in a process of guided discovery so that any changes are ‘owned’ by frontline staff. Guided Reflection helps us to establish where things could be improved and might also allow us to think about alternatives or solutions.  


PROMOTE involves breaking a process down into bite size pieces and putting each piece under the virtual microscope of Guided Reflection in order to ask whether there is a better way to serve the overall goal or purpose. We might ask ‘what is the smallest thing that we could change that would make a positive impact here?’

This is not to suggest change simply for change’s sake. Drawing on Appreciative Enquiry we also need to ask:

 What are we doing well that we should continue and build on?

 What should we stop doing? and

 What should we start doing or do differently?  


Pragmatics:


Provide a reflective space for the team and facilitate them to select a specific process or a particular part of the therapeutic day or patient’s journey that could be improved. A good way to choose what to focus on is to use feedback from patients and/or carers. This could be as simple as the appointment letter or how a patient is woken up in the morning or more complex procedures in which there are many variables like the ward admission or discharge process.


While it’s important to value the patient voice and reflect on their feedback there’s also a great opportunity for staff and patients to work together. In order identify good and bad experiences patients and carers need to tell their stories and staff need to tell theirs. Having an honest dialogue will open up the way for coproduction of innovative solutions and it will help to catalyse the process of continuous improvement. Many patients have the passion and empathy to work with others and can suggest new ways of doing things. They bring insight and a unique perspective which enables them to come up with the kind of creative ideas that can make a big difference. Seeing patients as partners and actively engaging them in the reflective process will support them on their recovery journey and helps to mitigate against a ‘them and us’ culture.


Using techniques like process mapping list out the sequence of events that take place. Use the 80-20 rule, the goal is to capture what happens most of the time rather than every possible eventuality. Be forensic about how each step is adding value and whether this is the best we can do.

List out all the simple change ideas in the format of stop, start and continue. Encourage individual staff to take ownership of specific changes. Prompt and support them to think through short and medium term goals. The hope of this stage is to generate proof of concept, i.e. the idea makes a difference. We recommend following the 333 approach.


3 days: what do I need to do get it off the ground, develop clarity around what success would look like and seek guidance from fellow colleagues to shape the idea.

3 weeks: implement the changes and keep a close eye on any unintended consequences, discuss with the team any challenges that one is facing.

3 months: evaluate against set outcomes to decide whether the idea is a runner or not. If successful an initial pilot would test the readiness of the concept to be scaled up.


Ask yourselves with a fly on the wall approach ‘is the idea ready or does the initiative need further fine tuning before you can go from proof of concept to proof of feasibility?’ Again a simple red, amber, green rating system could be applied to break the initiative down further for fine tuning. It is important not to get too attached to the idea as this can make one resistant to suggestions and the ethos of continuous improvement which lies at the heart of PROMOTE.


It is also important to remember that change will bring forth resistance in some shape or form. Resistance is energy and using the leadership framework described in PROCESS every effort should made to harness the energy and transform it into propulsion. A genuine effort to understand the basis for the resistance and openness to change course goes a long way in achieving this.


Top Tip:


Try to focus all of the small changes into one specific process. This will ensure that the changes will be more noticeable to both patients and staff, and sustainable in the longer term. One must not lose sight of the delicate balance that needs to be struck as sustainability today is resistance tomorrow.


Example:


Bed Tea: On Mulberry 2, staff chose to review how they wake patients up in the morning. They decided to gently wake people at around 8am for their medication. A nurse suggested that would it be much nicer if they could wake the patients up with a cup of tea 10 minutes earlier to allow people time to get ready.  They were also ked whether they wanted the medication brought to them or whether they would prefer to go to the clinic room. This might seem quite simple and intuitive as an idea but even this was met with a degree of resistance. However, once staff saw the positive effect this had on patients and how it improved the start of their day, the idea was adopted by every member of the team. It not only provided better engagement with patients but also decreased incidents overall.


Getting past Tabula Rasa: Patients are often asked a myriad of questions and yet mental health professionals are trained to avoid or deflect personal questions themselves. Given the recovery literature emphasising the importance of establishing strong relationships, Dr Kar Ray started to question whether this distancing gets in the way of genuine human interaction. So, whilst assessing patients, he started explaining that he was going to ask them questions about themselves and invited them to return the favour if they wished. It was a small shift but has had a profound impact on the power dynamics in the interactions and the relationships. This does not negate the need to use clinical judgement as to what is appropriate to answer and how, and, of course, the clinician, just like a patient, can choose to politely decline answering a question. Some patients were surprised, some just nodded and chose not to. However, some did and it considerably helped in establishing rapport and common ground. In one rather frosty clinical interaction, a conversation about an upcoming holiday helped to break the ice. Both had been to the same ski resort and the patient advised Dr Kar Ray to go back in winter. Dr Kar Ray then shared a funny story about his skiing incompetence. This helped to melt the tension and establish the relationship achieved a shared decision-making process with an acceptable outcome. Having continued to practice this approach for 3 months he now shares his experience with his colleagues with the intention of scaling up the approach.


PROMOTE - Innovations Framework

(Exec Summary - Download PDF )