Nursing leadership can feel challenging, with the constant drive for improved performance in health and social care, and a top-down performance management culture in which we typically operate. Having recently visited an acute trust, the leadership and feedback from teams felt more upbeat, with colleagues’ commitment to embedding a change and continuous improvement model coupled with a set of behaviours and actions to set the culture. Their approach to all that they did was: ‘Does it make our patients and our staff lives better?’
This inspired me to refresh my knowledge of continuous improvement models. I revisited at Kotter's 8-Step Model, continuous improvement using the Toyota Production System (TPS) – often called ‘lean’ – and the NHS England Change Model Guide. What I saw in common across these models were the key themes for success:
- Importance of people
- Leadership is key
- Systematic approach
- Continuous improvement
- Data-driven decision-making
- Culture is paramount.
According to Kotter (2018), the change process starts by identifying critical opportunities or risks that demand immediate action, then progressing through the next steps:
- Urgency: creating and sustaining a sense of urgency is about concentrating on a window of opportunity that is ‘open today but may close tomorrow’
- Guiding coalition: building a diverse and accountable guiding coalition is the ‘linchpin’ of transformation, it should encompass diverse perspectives
- Volunteer army: the goal is to create a ‘want to’ rather than a ‘has to’ mentality
- Strategic vision and initiatives: a clear, communicable and motivating strategic vision is crucial for aligning actions
- Remove barriers: the identification and removal of barriers (silos, outdated processes) that hinder progress is essential
- Generate short-term wins: collecting, categorising and communicating these helps track progress and energise volunteers
- Sustain acceleration: press harder after initial successes to solidify changes within systems, structures and policies
- Institute change: embed changes into the organisation's culture to make them stick.
Chandrasekaran and Toussaint (2019) set out key components for the lean or TPS approach:
- Active involvement of the board is vital for sustaining continuous improvement efforts, especially during leadership transitions.
- Instil lean behaviours in managers at all levels
- Engage frontline staff in identifying and solving problems
- Be sensitive to potential resistance to a system developed for car production and its relevance to health care, and focus on solving specific problems within teams to demonstrate the value of the approach
- Make TPS a way of life that can endure after the champion who established it has moved on.
The Change Model Guide from the NHS England Sustainable Improvement Team (2018) is positioned for anyone who wants to make a difference – in a clinical or a support role, at any level of an organisation. Some key points:
- Framework, not methodology: the Change Model provides ideas, prompts, tools and resources that can be adapted in any a given situation
- Eight interconnected components: these should all be considered when planning and implementing change
- Shared purpose: the starting point, defining the ‘why’ of the change
- Spread and adoption: planning for the dissemination and uptake of changes
- Improvement tools: employing evidence-based methodologies to structure change
- Project and performance management: establishing clear plans and ongoing review processes
- Measurement: measuring the outcomes of change to provide evidence of progress
- System drivers: aligning incentives and standards to support change
- Motivate and mobilise: engaging staff and stakeholders and encouraging them to act
- Leadership by all: fostering leadership at all levels of the organisation.
The outcomes I recently observed included improved staff engagement, reports of reduced hierarchy, a feeling of empowerment, and improvements in patient care. When the pressure mounts, it's easy to fall back into old-style performance management, but sustainable change comes from a more considered style of leadership towards a common goal.
Nurse leaders play a critical role in advocating for and implementing continuous improvement initiatives. They serve as the bridge between frontline staff and senior management, ensuring that the voices of nurses are heard and that their insights inform policy and practice changes. By focusing on data-driven decision-making, empowering team members, and standardising best practices, nurse leaders can create an environment where continuous improvement thrives.