Creating a safe space for regional quality improvement

‘Improvement for the Curious’ is a series of network building events, co-created and supported by the South West AHSN, to enhance quality improvement in the South West.

For those intrigued or excited by the opportunities and complexities of improvement culture within health and care, they provide a safe space to explore new ideas with others keen to develop their improvement practice.

Kim Morrissey, Senior Partnerships Manager at the South West AHSN, shares insight gathered directly from coaches and network members on how creative structured networks can help individuals from all parts of the health and care sector to enhance each other’s improvement skills.

The ultimate ambition of this work was to co-create a self-sustaining, psychologically safe space that actively supported a culture of continuous learning in the region. Improvement for the Curious has been a very positive initial catalyst for this ambition. The events were designed to build a network of improvement focused peers, including Q members, in the South West. Using coaching, co-development and support, the events created the conditions to learn, support one another and problem solve, in order to optimise the impact from delivery of improvement projects and enable the spread and adoption of innovative practice.

The first series of Improvement for the Curious ran between November 2021 and June 2022. It consisted of seven facilitated sessions, with 70% of respondents in a survey reporting feeling better able to support improvement activities following the series. 90% of respondents felt that in the sessions, it was easy to discuss difficult issues and problems. 100% of respondents felt safe offering new ideas or experiences, even if they weren’t fully formed plans.

A ‘funnel’ format
The Improvement for the Curious programme adopted a different approach to other events in terms of its structure and co-design with participants.

Online sessions were held monthly, in the evening. The sessions followed a ‘funnel’ format where the coaching team introduced the session topic through a fireside chat (providing example and context). Members separated into virtual breakout rooms to discuss the question posed before returning to the main room to feedback and discuss together. This loop was then repeated for the next question. Tools and resources were shared via the chat function and feedback and suggestions for future session topics were requested from the members. These suggestions went into designing the next session.

Impact of COVID-19
In response to Covid-19, the sessions were delivered online rather than face-to-face, which heavily determined the format. In many ways the online format helped – regular, shorter sessions made them more accessible, and they provided an easy-to-leave space to support psychological safety.

As the pandemic continued, the sessions also provided an ‘out of work’ sanctuary for important improvement work to progress, despite the day-to-day pressure being faced by these frontline and management staff across the South West.

Highly positive participant feedback
A total of ten surveys were completed by session participants. As a result of their work with the Improvement for the Curious:

• 70% of respondents felt better able to support their own as well as other’s people improvement activities or efforts.
• 60% of respondents felt more aware of the wider challenges facing the health and care sector.
• 40% of respondents felt better able to cope with difficult situations or conversations because of their involvement with the Improvement for the Curious.
• 14 of 15 members that responded to a question about expectations felt that the sessions met or exceeded expectations.

The ambition of the Improvement for the Curious was to create a psychologically safe space for its members to share their challenges, thoughts and ideas and receive support from peers. The average score on Edmondson’s (1999) ‘Psychological safety and learning behavior in work teams’ survey was 45.5 out of 55, showing that members felt that the Improvement for the Curious was a psychologically safe space. The highest scoring items were:

“I won’t receive retaliation or criticism if I admit to something challenging or a mistake I have made.”
“In this network, it is easy to discuss difficult issues and problems.”
“I feel safe offering new ideas or experiences, even if they aren’t fully formed plans.”

The high scores for these items demonstrate how members felt safe to participate in the sessions, to offer their ideas and opinions without fear of criticism.

Members also had useful suggestions for future sessions. These were captured within a formal evaluation for the project which will be used to develop and enhance future improvement programmes and network development through Improvement for the Curious and, more broadly, by the South West AHSN team.

Barriers and enablers found to impact the success of building a successful network

Barriers

Timing of sessions – due to the evening scheduling members had other clashing commitments which meant many were not able to attend. “The evening time slot was really tricky for me, [it] would have been better in work hours.” 

Relevance of material – members had a mixed experience in terms of QI, which meant that some of the content was less relevant to those with more knowledge and skills. “Because we weren’t hearing from the two experts, we were hearing from the peers in the group, who I think were all at different levels. Some of the stuff that the people in the group were talking about, I already knew. I’d already done it and it was quite new for some of the others. I would say maybe they got more out of the programme than me because I was in a much more advanced stage.” 

Lack of professional recognition – when the programme was not recognised as CPD it provided less of an incentive for some members to attend. “It was not mandated as part of CPD or my role, it was definitely [an] optional extra.” 

Enablers

Personal interest – having a keen interest in QI work was a motivator for members to attend. “I’m interested in quality improvement, and I’m interested in service improvement.”

Professional role – QI work was a part of their role in their organisation. “Because [I’m] taking on a new role as director [of] transformation. It might be interesting because I’ve got to structure the whole transformation agenda for the newly voiced organisation, and I thought I might learn some stuff.” 

Knowledgeable and credible facilitators – members found the facilitators engaging and created a relaxed atmosphere which encouraged them to contribute to discussions. “The facilitators were very honest about what they were good at, what they were less than [good at], what was interesting, what was challenging them. You know what I mean? I think very quickly people opened up and shared stuff, made connections with people in groups.” 

Session structure – the structure of the sessions encouraged members to share and connect with each other. The use of breakout rooms for small groups to get to know each other better and discuss ideas in more detail before sharing insights back with the wider group, as well as giving members the opportunity to decide the topics for the next session, were appreciated by members. “It was that element of here’s two people talking about some stuff, sharing some thinking, talking heads, and then you’re invited to respond to that as a breakout, I thought what a very interesting way of going about it. I hadn’t experienced that before.”

Timing of sessions – by hosting the sessions in a time outside of normal working hours encouraged a more relaxed and informal atmosphere where members were willing to share. “I think the fact that they were in the evenings and things might make it difficult for some people to attend, but I think it made it feel quite conversational, quite relaxed. It had quite a different meeting to it or vibe to it, I think, than if it would have been during the working day. It was that informal, relaxed space that I think it was intending to be. I got a lot out some of the conversations that we had.” 

Flexibility – allowing members to attend the sessions when they could, but not commit them to every session increased overall attendance. “Even if you weren’t there, they didn’t say ‘Oh, you can’t come again because you didn’t come to the last one.’ You could add value [to the] session, which is flexible.” 

Recommendations and Learnings
Feedback from coaches and members suggests that the whole ‘team’ has enjoyed the opportunity to develop our learning about networking and learning communities. Key recommendations and learnings are summarised below:

• Creating a self-sustaining network takes time. This is especially the case when people have multiple priorities and are nervous about additional commitments. This was acerbated by COVID-19. Similarly, we gradually increased the size of the group. But it took time.  
• Some infrastructure and facilitation are required and are valued by members to ‘feed’ the network and keep it running. Members were generally too busy to prepare and organise the network’s events and resources, as well as participate in the sessions. We therefore focussed our efforts on providing infrastructure and a ‘template’ for how these sessions could be delivered by others.
• Learning about Quality Improvement can be fun for both coaches and members. Whilst we shared very personal and challenging stories in the session, we also shared funny and uplifting thoughts and ideas which enabled us to enjoy the time together and better appreciate the complexities of the work we all did outside of these sessions.
• Unconstrained organisational boundaries seem to be leading to psychologically safe spaces. Feedback from the coaches suggests that members were sharing more rapidly and more deeply than in other ‘forms’ of training and development they have experienced. This was happening between individuals at different points of their development, between different parts of the health sector and at different levels of seniority.
• We were learning as a coaching community. The coaching group developed together during this process and used this to build the confidence of the members to contribute and shape sessions: learning and listening to each other, sharing suggestions, receiving feedback. This is likely to be a key opportunity for us as we seek to move forward with sustaining the network.

From the learning outlined above, it is clear we are developing a learning culture which is specific to the Improvement for the Curious approach. From co-development of the programme, open challenging discussions on health equity topics, and galvanising around shared purpose of improvement (particularly in COVID-19), we have used numerous but simple tools and focused on creating the conditions to help effect change.

These recommendations and learnings are valuable not only for the South West AHSN as we look to integrate them into our Building Capability programmes which support the workforce in the region, but also for others seeking to find new and creative ways to convene people around a topic like quality improvement.

Improvement for the Curious has been run by South West AHSN and has been funded through Q by the Health Foundation and NHS England and NHS Improvement. Our thanks to our funders for their support of this exciting and important work, to all coaches who went on this curious journey and participants in the network that shared their individual experience in the spirit of collective learning so graciously.