With David Bell
Episode 96: “Managing a Transformation Program in the NHS”
David is an MBA graduate and has over 30 years experience of working in strategy and project management within the UK’s Health Service.
During David’s time with the NHS, he has had a particular focus on strategic planning, change management, and running large projects within NHS trusts. In this interview, David and I are going to discuss managing a transformation program in the NHS.
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Transcript: Managing a Transformation Program in the NHS
Could you tell us a little about your background and how you came to work in project management in the NHS?
Yes, I’m a mathematician by trade and when I graduated from University, I went into the NHS as a General Manager, working in a number of services before kind of focusing more on strategic planning and project management. For the past 30 years, I have worked in most parts of the NHS, either working on strategic planning or managing large projects within large NHS trusts.
What are the challenges of implementing a project or program with such a large number of people?
I think the issue for us is largely just our size. We’re a slightly above average size NHS trust in Leicestershire, which is in central England. We provide all the Community Mental Health Services across the country. We estimated at one point in time that we have 160,000 patients on our caseload, our stuff is trying to cover the patients in their own homes on over 830 square miles.
We got something like 6,400 staff, revenue turnover £250 million and to try and bring change around in large organization such as this is very, very complex and you need to kind of try and deploy consistent methodologies across the Trust to make things happen as quickly as you can.
What kind of methodologies did you employ? Can you tell us a little about how you rolled them out into a place like Leicestershire?
Back in 2015/16, the Trust had been given changing at a rapid pace, it needed to have a more consistent approach to project management. Also, we were trying to enhance the governance, also get a better insight into preparedness for the future. So, basically, what we did, we did three things. The brief I got was a very much a people approach to change.
The first thing that we did was a group of people came together to kind of co-design a change model for the organization. So, we have a consistent way of approaching change and improvements and what we did as a starting point was to take the NHS evidence base change model and adapted it for my organization. So, we took that model, found a group of 20 of us, we looked at all organizational values, the way we work and we then came up with the HLPT model which is branded, we improved it within the organization.
The second part was, we then handed that over to another group of people and they co-designed the one-day training program based on the 8-dimensional model. An idea was that over the three year period we would train about 500 colleagues in the use of the model. So, that when people sit down to work on the change project, either because they want to or they’ve been told to, everybody’s been schooled in the same way of working, so when the project team hits the ground, it runs faster, delivery deeper, all of those things.
And then, the final bit that we did was we then deploy project management program management software to bring all of our projects and programs into one place. So, that we could all see them, see what was going on, see progress, group things together, report better. We deployed some project management software to help us do that.
Previously, everybody’s projects were all over the place, on different servers, you couldn’t see things, people couldn’t self-service to, kind of, get the information they needed. So, if you needed something you had to trouble the colleague and take many minutes out of their day to service your information request.
Now, we got all of that in one place where you can just run reports on a touch of a button to get the information you need on a self-service basis. The way we’ve approached it over the past three or four years has been this kind of three-dimensional approach – develop a change model, implement a training program and then deploy software to kind of manage what you doing.
Is that three-way approach successful?
We will evaluate it at the end to see whether it is delivering what we’re expecting. We are investing about £100,000 a year and we will review it to see whether it is having an impact. I think for us and we did the thing I think we tried to get our people to go for it, we’re very much come from base to a process of continuous improvement to get to a new place is a much better way of getting there than you’re doing nothing for a long time and then having to go through a big bang approach to things.
The process is a continuous improvement, you get more by more support usually better outcomes, so we constantly trying to encourage our people to use the change model for continuous processes of improvements, using methods such as a PDSA.
That is the preferred method, but we do have to accept that every now and then we have to do big bang change projects either because there has been a national changing policy direction or something has gone terribly wrong which we need to sort out really quickly. So, we need to be agile enough and prepared to do a big bang change as well. All managers need to be equipped to do both things, continuous improvement and the large scale big bang challenge.
For this continuous improvement, within the Leicestershire Trust itself, do you have any way of measuring the interim on boarding success that you have at this stage?
We have some indicators, as I said, we are part way through project, so we haven’t got to the end point yet to see it but we do know, we are seeing it when our service teams come down, where they’re starting to manage their waiting list better, we are on our annual quality assessment we are seeing our kind of scores go slowly up every time the regulator come in to see us, we are seeing it in our financial position that is relatively constant, we balanced our books.
Those are all indicators that we are pointed in the right direction, that new things are working well and that we’re bringing change and improvement around at a rate that we need to prepare for the future. It has got the benefits that we expected for a £300,000 investment after 3 years, but we will do the evaluation at the end of the project. What we did was, there are many things going on in the large organization, you can’t put everything into your initiative all at once. So, we basically rolled the “We improve” approach out to the main projects enough, delivering our five-year plan.
We started with the 104 improved projects at the moment. Once people felt comfortable with that with, we then rolled out our cost improvement projects out into using the same methodology and we are just getting ready to roll on quality improvement projects out as well. We are slowly pushing more and more projects into this way of working and into the project and program management software.
Once that’s in that software then you really start to getting insight about your what’s working, what’s not working, which change methods seem to bring you the best results compared to others. There is a whole load of insights starting to emerge now that we kind of never had in the past because everything was spread all over the place, on different servers, different systems, some people using Word for project management other people use Excel for Gantt charts. Now we have everything in one place and that is really helping us.
What are the biggest challenges that you have met along the way in the whole of change management program?
We are very much in an organization which encourages co-design, so we get a group of the right people around the table to come up with things and that by its very nature is a slower process where this people just go off and do things on their own. It feels quite slow to start with but what then of course when you start your delivery, you get more buying because more people have been involved in the co-design, you get more people buying.
So, the overall time things take is probably a bit shorter. At the birth of this initiative, it did feel quite painful when you’re bringing a whole load of people together who approach things in very different ways and to try and get them to agree. We have some facilitation for that, so we did bring somebody in to help us with the co-design phase and when we turned the 8-dimensional model into a one-day training program we did bring in an external educator who helped us turn it into an educational package.
She was very helpful and that really brought in some expertise that we didn’t have internally. I think we are seeing a normal distribution of response really, we have some projects in the trust where we say the use of the 3-way model is mandatory, but for the majority of projects we will talk about it, to be encouraged and I think we’re seeing a normal distribution of response. We have an annual conference on the model so we like to encourage the community of users, creating like a social movement within the organization.
Then, we have got the followers in the middle and these are the kind of people that would say that they were using the same thing in the Word or Excel. We brought in a change model at the point where some projects were already underway and what we said was ”If your project is already underway after start date, you’ve got a choice, you can either move to the new system, we will help you to do the new way of working or you can finish your project off in whatever methodology way that you were doing it before” and some of those projects were two to three years long.
We do have some colleagues who are reluctant, individually or personally reluctant to use this way of working and they may feel that the way they do things is his better and at the moment the organization isn’t enforcing the use of the model because we want to build this kind of social movement within the organization. Hopefully, those people will come on board or they may just go through the rest of their working careers not with it, I think every large organization has these people.
And I think what has really helped was that the brief I got from our executive team when we started this. I really wanted people to approach this. The software system was put the last, but we could have quite easily just started with that system. What we did, we developed the change model, we developed the training program, we developed our internet resource centre which helps project managers to get all the resources they need to do their work. We get out and help people with methods of training.
So, if you want a whole day they’re finding out about PDSA or prints or Lean Six Sigma, you can now do that as soon as part of your personal development. And then we put software in right at the end and we deliberately chose a software package that allows us to adapt it to our change model so when the project managers open up their software they see the 8-dimensions in the software. So, it’s all inexplicably linked together. We really make sure that we picked a piece of software that was customizable to what the organization needed and that’s really helped.
Can you tell us a bit about the eight dimensions that you have in place?
So, what we say, for a project to increase its chances of success, you need eight things. The first one is that you need to understand the drivers, what is causing the need for the project and we do encourage people to use something like PESTLE to help them classify that. The second dimension is the purpose, so being absolutely clear and writing things down about what the definition of the project is, what the project is trying to achieve.
We do encourage people to use the smart methodology as a way of doing that. When you are defining the project you have to be able to do it in one sentence, in one breath. So, we basically said to people to just start with the very long project definitions and we were just saying “This is overly complex, you’ve got to be able to explain it simply to your team and other people, so let’s try to write our project descriptions in one sentence” and then knowing that some people can write very long sentences we added “Let’s do it in one breath, as well”.
That’s really helped people to focus so now we got really crisp project definitions. The next dimension is leadership, who’s leading, who’s the project manager, we do encourage co-leadership and who were the other members of the project team. The fourth dimension is the stakeholders, stakeholders’ analysis to determine who are internal and external holders that are involved in the project.
Then we move on to the methodology, which method are you going to use to bring about change and it may be something like PDSA, maybe Lean Six Sigma, it could be PRINCE2, it could be a model that somebody’s been using to their working career. So, this part is like an empty box to insert the method. We very much encourage people to use the method which is right for the job, so it is something that continuous improvement needs, a continuous improvement methodology, or if it is going to be big bang change, the appropriate big bang methodology.
Very much it’s to get the right tool for the job. The sixth dimension is what we call to learn and it really has two parts. The first part is research and we encourage people to do a whole load of research before they start about, what was going on before, who’s tried, what evidence is there about what they are doing, before they start so they learn lessons before they start making mistakes or covering ground or the people, both internal or external.
We have great research facilities in the NHS that we can tap into, internet resources, professional journals, all of those kinds of things, we could quite easily get into those areas of expertise, to do research before the project starts. We’ve not been very good at post projects write-ups and evaluation and went out trying to get people to, when they close the project to write it up so the other people when they look at the project they can say “Oh they did that, next time I am going to do the same” but on the different subject.
The seventh dimension is the measurement. If you’re going to bring about change or improvement, how are you going to detect it, what are the ways of measuring, where are going to get your data from? My Trust, as any large organization, has got a rich variety of systems, ranging from patient information systems through to the general ledger through to the stopping systems and there are a lot of data that people can access to measure what they’re doing.
At this point, the project hasn’t been started yet, so this will be worked out before the project start. And then finally, we get to the last dimension which is the delivery, and here is where we lay our project plan, Gantt charts, a work breakdown structures, those kinds of things. But, also, the trust has standard assessment that has to be done for every project and also we’ve replicated those assessments within the software, so that the project manager can do those assessments in the software rather than on paper.
That’s things like risk assessments, quality impact assessments, and those kinds of things. And that’s also where the project manager files the regular report and everything else. That’s our eight dimensions. We didn’t invent them, we took existing models and adapted them to our organization. It’s a framework it is not descriptive, and we encourage people to, what we call, “do the eight” if they want their project to be successful.
Connect with David on LinkedIn.