Crossing the Improvement Chasm: Models, an Improvement Faculty, and #ProjectA

I was minded last week to consider a phrase that a colleague of mine, Zoe Lord (Deputy Director – Horizons), has used on a couple of occasions recently:

“All models are wrong, but some are useful”.  

A quick Google, thank you George E.P. Box.

The context of my deliberations was based around the concept of co-creating a national improvement faculty for ambulance services.  A good idea on the face of it but one that also creates many questions of approach, design and practicalities. The UK ambulance services are undoubtedly interested but questions needed to be explored, opinions gathered and views listened to. 

On Friday, 2nd August 40 people came together to do exactly that – was there value to be gained in developing a national improvement faculty for ambulance services?

The setting for this event was Chapter Hall, Museum of the Order of St John. I must say I feel like I am on a tour of beautiful venues with recent ambulance service events having visited the Royal College of Surgeons in Edinburgh, the Grand Pavilion at Llandrindod Wells, and now the Grade 1 listed Chapter Hall in London. 

The tables in Chapter Hall were exquisite, priceless antiques, which meant we couldn’t use them. No matter we told ourselves – informality will shine through and a willingness to get on the floor with flipcharts would add an element of humour and team working.  

What has been noticeable over the course of the last 12 months is a rising impetus amongst ambulance services to focus on improvement. The Carter report, #ProjectA, Q Community and a significant focus locally within individual ambulances services are all contributing towards this. 

The question posed therefore was as much about the ‘What’ as about the ‘How’ and that if a National Improvement faculty was to be established what did this mean and what did it look like?

It was apparent through the design for the day that people had varying opinions as to what a national improvement faculty for ambulance services could actually be. There was broad agreement that support to improvement, sharing and supporting best practice, overviews of improvement methodologies and legacy to #ProjectA were all laudable aims. 

In the design team itself some people were very much at the conceptual phase whilst others were looking to take action and start to build the faculty in the form and function they could foresee.

The morning’s discussion used the Prochaska, DiClemente & Norcross (1992) model of behaviour change as a frame for the morning discussion. 

Attendees were asked to consider the model in light of their initial considerations on being invited to the day's discussion whilst also reflecting on an introduction by Anthony Marsh (CEO, West Midlands Ambulance Service) about the potential for a national improvement faculty for ambulance services. 

Each person placed a coloured dot sticker on a poster of the model that was displayed at the front of the hall. This created a visual of where the group found itself in relation to creating such a change. The results were interesting if not surprising, indeed they mirrored the discussion of the design team. 

People were not ready for action yet – there was still a lot of contemplative thinking to do and preparation if we were collectively to get the national ambulance improvement faculty off the ground. It was going to be an interesting day of discussion. Would people be able to move around the improvement wheel?

We used more models over the course of the day to advance our discussions – including some that will be familiar in the field of OD and Improvement. We discussed at length why we have good practical improvement initiatives and ideas in one service that don’t scale and spread to others and what could we do to bridge Geoffrey Moore’s innovation chasm, indeed asking directly could an ambulance improvement faculty help with this? We stayed practical in the afternoon looking at a faculty from different perspectives (De Bono’s six thinking hats anyone?) and action planning in an unconference style. The models used to stimulate discussion not to set the room down a pre-determined path.

Source of image:  @voinonen

What was particularly interesting was that at the end of the day we did not have a universally agreed way forward or an agreed practical solution formed in the minds of the attendees. There is an acknowledgement that more discussion and debate is needed but crucially there is also a real willingness to have this debate about how improvement is best curated nationally within ambulance services and where a faculty may or may not support. This is real and tangible progress and should not be underestimated. To have passionate and interested people connecting across their organisations and wanting to contribute is essential if progress is to be made. 

Perhaps therefore, we are slowly moving around the Prochaska, DiClemente & Norcross (1992) model of behaviour change as well as acknowledging that somehow we have to set the faculty up in such a way that it supports existing ambulance staff, QI leads and networks to “cross the chasm” with improvement ideas. 

A faculty that curates the context is not about assigning programmes of work or monitoring performance of projects but defines the improvement needed, facilitates idea sharing, links people together, accesses academic support and embeds/promotes an ambulance service approach to QI could be a possibility.  Is this truly going to work? We don't yet know – certainly more work is needed and everyone acknowledged that but reflecting on the feedback at the end of the day crystallised the view that everyone is keen to co-operate and connect their different networks for the greater good.

So what about the models then? Without them I am not sure that the debate would have flowed as well as it did and indeed in such an open subject matter, where we were largely starting from just context, they provided structure to the necessary conversations. In particular the behaviour change model allowed everyone to safely express where they were in relation to the idea of a national improvement faculty. 

Sometimes we feel the pressure to be at the pace of others, this was not the case during the morning and people could ask questions openly and with curiosity. Also the models not only helped us frame the discussion and kept the day moving but allowed the participants to not get caught up in the detail or become encumbered with the theory behind the models. They worked well for the day’s discussions.

Perhaps all models are wrong but some are definitely useful.