Scaling Up Improvement
InS:PIRE: Intensive Care Syndrome – Promoting Independence and return to employment
NHS Greater Glasgow and Clyde
- In partnership with: University of Glasgow, Healthcare Improvement Scotland, Scottish Government Health and Social Care Quality Unit, and Scottish Intensive Care Society.
Many patients have poor quality of life following an intensive care discharge. Reduced mobility, dependence on family members and continuing health issues can lead to depression, anxiety and low self-esteem. This can impede the recovery process, increase health care costs, and cause significant burden to individuals, their caregivers and society.
Glasgow Royal Infirmary has successfully prototyped a rehabilitation intervention for intensive care unit survivors: InS:PIRE (Intensive Care Syndrome: Promoting Independence and Return to Employment). This unique five-week recovery programme focuses on patient education, peer support and facilitating self-management.
InS:PIRE was co-produced with service users and is the first intensive care rehabilitation model to include caregivers and encompass health and social support, which is key for optimal recovery.
Weekly sessions with health professionals aim to help patients improve their health and participation in society, including return to work. Individualised goals help to measure improvements and help patients to make meaningful changes, which increases how in control they feel about their health and wellbeing.
By scaling up InS:PIRE to five further centres (Crosshouse Hospital, Monklands Hospital, Wishaw General Hospital, Golden Jubilee National Hospital, Victoria Hospital) across four health boards (NHS Lanarkshire, NHS Fife, NHS Ayrshire & Arran, Golden Jubilee National Hospital) in Scotland, this project aims to demonstrate that improvement can be successfully implemented across the NHS.
- Summary of progress since your last report
InS:PIRE has made significant progress in its first 6 months of implementation. The project is on track and we have not needed to make any changes to planned milestones
October 16 – Programme Manager came into post
Programme driver diagram and logic model updated
Programme plan including Gannt chart completed
Programme risk issue log created and maintained
Programme stakeholder listing created
Programme communication strategy and plan created
Programme chronology recorded and materials secured
Team contact list created and published
Engagement tracker created and implemented
National Learning Session hosts, venues and dates agreed & secured to end programme
Website completed and launched – with formal launch and participant celebration held 30/3/17
Website evaluation form drafted and data collection underway
Programme twitter account created and launched
Analytics across website and twitter implemented, and reported on monthly basis
Monthly programme report initiated
Monthly site progress /learning reports with budget tracking implemented
Monthly programme newsletter implemented for teams
Programme promotional materials designed and printed –cards and pop up banner
Staff profiles created and published on website and twitter
Programme viewpoint blogs initiated with first blog due end March 17
All sites have completed their first cohorts and local learning sessions
Cohort dates for all sites planned and published for 2017
Programme QI Lead has engaged with local site QI lead network
The second national InS:PIRE Learning Session was held on 17 March
Custom insomnia masterclass developed and delivered to all sites
Volunteer co-ordinators at sites linked and supported to develop service
Volunteer process, job descriptions, training and risk assessment updated&shared across sites
Evaluation Advisory Group implemented
Ethical approval received for evaluation of scaling up
Health economics input to evaluation agreed – provided by Healthcare Improvement Scotland
Evaluability assessment and evaluation plan updated
Evaluation team has contacted programme sites to begin engagement
Programme Board terms of reference drafted and membership agreed
RCT not undertaken – reverted to planned historical control trial for intervention efficacy
InS:PIRE presented in main plenary sessions at Scottish Intensive Care Society Conf Jan 17
InS:PIRE case study included in CMO ‘Realising Realistic Medicine Annual Report’
InS:PIRE programme won St Mungo medal for pioneering research and was featured on Scottish television news with interview
InS:PIRE won NHSGGC Chairman’s Award for Improving Health
Site Visit planned- Scottish Government Minister and Chief Medical Officer
InS:PIRE published in Thorax, Healthmanagement.org, anaesthesia news, critical connections
Programme clinical co-leads part of international Society of Critical Care's THIRVE peer support collaborative- ongoing shared learning
All sites encouraged and supported to engage with local stakeholders, senior management to raise awareness of the work and plan for sustainability.
Programme leads met with Chief Executive and Senior managers re service development
Increased engagement with third sector – regular partners include Health and Social Care Alliance Scotland, Citizens Advice, Carers organisations.
Engagement with criticalcarerecovery.com project – University of Edinburgh.
Engagement with health board non participating sites
We are most proud of the way the teams have come together and successfully implemented their first cohorts while remaining open to sharing their highs and lows across sites.
The programme was considering implementing an RCT towards the end of 2016, but decided against this and reverted to the original planned historical control trial.
The driver diagram was updated to reflect all the programme activity that we felt would underpin our theory of change – this had evolved since the original submission. This produced with and agreed by all teams.
We needed to address issues arising from absence due to sick or planned leave. We obtained cover for the sick leave with the help of our sponsor and using our networks. The planned leave has been covered by planning backfill for core tasks.
It took longer than we anticipated to move forward with our evaluation. We have implemented a structure around this with an Evaluation Advisory Group meeting fortnightly to support.
What, if anything, has taken you by surprise?
We know that the implementation of large and complex programmes can be very anxiety provoking. Having been through the set up and then initial 6 months of implementation, can you tell us how confident of success are you feeling right now, on a scale of one to eleven? (please answer this as honestly as you can so we can learn where you all are as a group)
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11
*Please bold or highlight the relevant score in the table above.
- Next steps
Delivery of further cohorts at each site and subsequent tests of change
Ministerial and Chief Medical Officer Site Visit – Crosshouse 9 May 2017
Third National InS:PIRE Learning Session: 28 August 2017
Implementation of site visits by evaluation team
Website evaluation report – June 2017
Outline service proposal paper with indicative costs for NHSGGC CEO
Implementation of historical control study
Attendance at Holyrood Royal Garden Party -July 2017
Site stakeholder engagement activity
Publication of new participant films
Presentations at events / conferences
Consideration of further participant involvement – programme board and service design
Publication of staff profiles, viewpoints, monthly newsletters
Explore joint event with Health & Social Care Alliance Health and Social Care Academy
Wider staff training and engagement sessions
Maintaining and increasing twitter profile, engagement and followers
Continuing to collate learning and materials into formal record
Ongoing support for site QI Leads by programme QI Lead
- Learningsince your last report
We found producing the website challenging. We were required by the lead health board policy to make use of the corporate platform to produce the site. This platform could not provide for all our planned functionality, without additional cost that we could not meet within budget. We compromised on some of the features – but it did mean we had to do without planned chat forums that we felt might be important for sharing learning across sites. It also meant that the website was delivered to teams later than we had hoped for. In addition, production of the website on the corporate platform required development by a member of lead Health Board staff. Fortunately the programme manager had these skills and was able to produce the website and content. However, this may prove a hurdle for others or incur significant extra cost. It was / is also a time consuming process. We are currently collecting feedback on the website – from the team responses thus far, this does not seem to have been an impediment to communication and progress. Working to scale up across traditional organisational and sector boundaries is difficult where historic structures and cultures implemented prior to health and social care integration legislation have not as yet evolved sufficiently to support new ways of working.
Distributed leadership and resilience in teams
We were aware of the need to avoid reliance on individuals for the delivery of cohorts – to prevent bottlenecks and failure should that individual be no longer available.
In addition, for our intervention to spread and be sustainable we believe we need to develop a multi-nodal, multi-disciplinary network, with distributed leadership and resilience in terms of staffing.
We have needed to ensure there are a number of staff who can fulfil the core tasks and these staff rotate through cohorts.
We have found that the model of distributed leadership does challenge traditional roles and hierarchies and takes some time for staff to adjust and work in new ways. We are still working on encouraging those in roles with traditionally less visibility or a ‘voice’ to take on a joint leadership role. This includes encouraging all members of the teams to become involved in speaking engagements, writing programme viewpoints, publishing papers, using social media, meeting stakeholders etc. For some members of the teams, this is a personal challenge but also a development opportunity. We have begun to see some team members progress from having no public speaking experience to networking across senior levels of local health and social care partnerships, politicians and the media – raising the profile of the entire programme in the process.
The importance of reflective space
In the early days of implementation, much of the focus can be on ‘getting it right’ in terms of delivering the intervention. Teams are stretched in terms of capacity – with each holding ‘day jobs’ also and ensuring time and space is held for reflection can be difficult. Yet it is only with that reflection that we learn and improve. We feel there is a need to robustly protect that reflective space.
A much used word in health and social care, we’ve been grappling with what this means within our context and to what extent the InS:PIRE programme and emerging service can be designed, delivered and managed with those it is intended to serve. Some ideas that we have tried have included a patient and family council, seeking feedback during every cohort and feeding this into learning sessions, focus groups prior to implementation, peer support volunteers with prior experience of the programme contributing to the delivery of cohorts, and former participants sitting on the programme board. Some challenges we have encountered within our own context include: a concern about encouraging participant dependence rather than independence; concern about the use and appropriateness of the limited time available for staff for reflection and the participation of others in this; and the view that being in intensive care is not a long term condition and it isn’t helpful to view it as such. As we enter into the service design phase this will become a key consideration.
Programme / project methodology
The majority of public sector projects and programmes utilise some or all of Prince 2, Managing Successful Programmes, Agile methodology and Lean Six Sigma / the IHI model for improvement. Driver diagrams and logic models are frequently used to articulate an underpinning theory of change.
Through the scaling up implementation, the core principles of project and programme management have been applied – with thought to stakeholder management, a communication strategy and planning, detailed programme planning with milestones, budget management, dependencies, scope, and regular reporting. More stringent governance arrangements have been implemented with an Evaluation Advisory Group and Programme Board.
However, some deviations from strict adherence to these methodologies has been required.
Structures and roles normally in place in organisations to support the delivery of Prince 2 projects for example are not in place in the current programme organisational context
In addition, the model of continuous improvement of the intervention at sites presents some challenges for forward planning. The programme does not involve a simple roll out of an established and fixed intervention.
Having to deliver the programme across traditional health board boundaries, has demanded flexibility in approach and willingness to compromise – and the courage to challenge the status quo.
Because the programme is innovative, working across traditional boundaries and structures, and challenging to established cultures, there can be a natural resistance to change. This we have anticipated and have chosen to approach sympathetically – focussing on the benefits to participants and to staff.
We have found that the impact on staff of participating cannot be underestimated. Individuals have been transformed – and through the teams communicating their experience and enthusiasm, we hope to engage others via a form of peer movement, rather than a ‘top down’ change that requires ‘change management’ – (something that is done to people rather than something they choose to do.) We observe teams needing to do this in their own time and in their own ways. We do not see this as needing centrally managed or planned for as such – rather, encouraged and supported. We have worked to create the containing environment and allowed this to grow organically.
We observe teams being motivated by distributed leadership and autonomy to implement and test change in their own areas as required. That motivation and enthusiasm is then conveyed to their contemporaries in the course of day to day work, and more formal stakeholder engagement work.
Overall, we have witnessed a growing confidence and independence in the teams as well as continued enthusiasm and passion for the work. This was evident in our second national learning session on 17 March 2017 – where teams shared their learning, swapped ideas, further developed cross-site relationships and set out their learning points and tests of change for the coming months.
- Evaluation(input from the evaluation partner)
The evaluation is on track and we are well into the formative assessment stage, meeting regularly with the project team and providing ongoing feedback. This has led to adjustments being made to the driver diagram and logic model for InS:PIRE and we are continually reviewing this and documenting its refinement along a project timeline. Insights from the formative phase have also highlighted the impact of the intervention on staff (e.g. in terms of improved communication, teamwork, morale) and we now plan to explore this dimension more formally in the fieldwork stage.
As stated in our end of set up phase report, we have had to seek ethical approval to undertake our evaluation research. We have received a favourable opinion from the NHS Research Ethics Service for the qualitative component (the evaluation fieldwork including interviews/focus groups with stakeholders) and are progressing NHS Research and Development (R&D) for individual site approvals.
We are working closely with the project team to finalise plans for the quantitative component (the quantitative exploration of the theorised mechanisms of change). We will seek ethical approval for this as a next step, once specific data requirements are finalised.
We presented our detailed evaluation plans at the InS:PIRE national learning session on 17 March 2017 and we are looking forward to beginning our qualitative evaluation fieldwork at scaling up sites over three phases (to track the scaling up over time): spring/summer 2017; autumn/winter 2017; and spring/summer 2018.
The InS:PIRE programme manager has now convened an Evaluation Advisory Group comprising membership from the project and evaluation teams, as well as the Health Foundation and Healthcare Improvement Scotland. We have fortnightly to monthly meetings scheduled. Informal communications (email, Twitter) continue in between.
Emerging lessons learned so far include: regular and open communications between evaluation and project teams to ensure mutual understanding of each other’s work and to facilitate regular two-way feedback is crucial; evaluation design relies on the good knowledge of, and clarity around, the intervention itself and its proposed and emerging scaling up, and the project team’s understanding the function(s) of, and deriving practical benefits from, the evaluation team’s insights; the need to be flexible and adapt the evaluation in light of emergent insights (e.g. expansion to include effect on staff); preparation of applications for ethics and R&D approvals requires considerable work and creation of documents (please see attached package of documents) and cooperation (including document sharing and transparency) between project and evaluation teams.
- We do not consider there to be any changes to our Risk Register or budget.
- The need for ethics and R&D approvals has been the main challenge, however, through the process of preparing the applications, we have gained more clarity about the InS:PIRE intervention, which have helped us to shape and rework evaluation components to ensure that our study design is fit for purpose to enable a comprehensive, independent report to be prepared.
- We are on track to deliver key outputs (namely interim report in September 2017) over the next six months.
- Resources/outputs to share
All our resources are available on our website. Logins to team areas can be obtained from the programme manager. We attach a visual learning record for the past 6 months – highlighting the developments referred to in this report, with links.
- Finance update
End of Health Board financial year – update to follow
8. Additional information and feedback to the Health Foundation