The process used to select the high impact actions for nurses and midwives can be used by individuals and organisations to identify ideas to improve practice
Mark Mugglestone, PhD, MSc, is lead associate, innovation practice; Helen Baxter, MSc, MCSP, is associate, innovation practice; both at the NHS Institute for Innovation and Improvement.
Mugglestone M, Baxter H (2010) Using ideas management to identify ways to improve care in the NHS and in organisations. Nursing Times; 106: 3, early online publication.
Nurses and midwives have been asked to implement eight high impact actions, announced by the chief nursing officer for England Dame Christine Beasley in November 2009. Here we describe the process of ideas management that led to the actions being selected for the final list, and suggest ways in which nurses can use this process to implement changes in practice.
Keywords Ideas, Innovation, High impact actions, Ideas management process
- This article has been double-blind peer reviewed
There is a general perception that innovation is about new ideas and radical breakthroughs. However, often the innovations that make by far the biggest difference are not radical breakthroughs but the successful implementation of several less radical ideas.
While ideas are the driving force of innovation, they do not have to be radical or totally new; they just have to be different. The value of innovation is not in having ideas, but being able to successfully apply them (see Box 1).
Box 1. Successfully applying ideas
“When did you last use your Spengler?”
This question might well be greeted with a quizzical look. But if someone asked when you last used your “Hoover”, the answer would be fairly easy.
Yet it was not Hoover who invented the vacuum cleaner in the late nineteenth century but J. Murray Spengler. Hoover’s genius lay in taking that idea and making it into a commercial reality.
Source: Bessant and Tidd (2007)
Innovation in the NHS
The NHS does not suffer from a shortage of good ideas. What it needs to develop is successful application of the ideas produced.
The challenge of being able to spread ideas or good practice is one which many large, complex organisations share with the NHS. The health service can therefore learn from the best of other industries, and look at the processes they use for managing ideas.
The following are key components in an ideas management process which we used to develop the high impact actions for nursing and midwifery:
- Understand what you are trying to achieve;
- Engage people who have ideas;
- Collect the ideas;
- Assess them;
- Select them;
- Design the changes;
- Make these changes.
Background to the project
The HIA project is a joint initiative between strategic health authority chief nurses, the Department of Health, Royal College of Nursing, Royal College of Midwives, Nursing and Midwifery Council and NHS Institute for Innovation and Improvement.
Katherine Fenton, from South Central SHA who is leading this work on behalf of other SHAs, explained the aim of the project: “There are many examples of improvements made by individuals or teams of nurses and midwives and if these are replicated throughout the NHS, they could make a huge difference to improving the quality of patient care while at the same time significantly reducing costs.”
One of the main influences on the project was the 10 high impact changes for service improvement and delivery produced by the NHS Modernisation Agency (2004). Rather than focus on changes at an organisational level, the idea behind the HIA work was to focus specifically on improvement that individuals or teams of nurses and midwives could make (NHS Institute for Innovation and Improvement, 2009).
Understand what you are trying to achieve
In any innovation or improvement activity, understanding what you really want to achieve is important. This is even more so when asking people to submit their ideas or improvements made. Clarity about the challenge or area of focus ensures that people know what is expected of them and means they are more likely to take part.
Successful idea management schemes also need to be clear about the target group and time limits. Staff suggestion boxes or schemes, which are general and not time limited, produce a low number of responses that are also of poor quality. When campaigns focus on specific topic areas and are time limited, the quality of responses and number of submissions improves considerably.
For the HIA work, the focus ended up being on current practice rather than new ideas, and specifically on activities or changes that frontline nurses and midwives could lead. This is a good example of a key way of being innovative - transferring ideas that work in a different location into your area. This is a particularly important type of innovation for the NHS.
The question we posed was: What do you do as an individual, unit or department that if spread across the whole NHS would make the biggest difference to improving quality of care and patient experience while reducing costs?
Engage people who have ideas
The success of the HIA programme depends on engaging and working with those who really know the problems and have the solutions: the frontline staff who deliver care day in day out.
How the activity’s aim is stated can also have a substantial impact on how likely staff are to get involved. The natural tendency is to state improvement challenges in a technical way but often a more effective approach is to try to engage with people on a more emotional level.
To engage with potential participants on such a level, it was important to relate the HIA project to the reason most healthcare staff join their profession - to deliver the best care possible - rather than using policy language of cost, quality and productivity, which is less likely to engage them.
It was also important to make the project personal, not only by appealing to individuals but also by ensuring that communication about the project came from the individuals leading it.
To promote this engagement through “real” people known by those we wanted to engage, we decided to have champions for the HIA programme in each SHA. These were all senior nurses who had the time and motivation to fully engage in the whole process. It was the champions’ excellent work that was responsible for the number of submissions we received in the three weeks the website was open.
Collecting the ideas
Linus Pauling (twice a Nobel prize winner) said: “The best way to get a good idea is to get lots of ideas.”
Whether it is a suggestion box, an email address or a website, it is vital to have a way of collecting ideas and to ask for information that is related to the aim. The key is to make it as easy as possible for people to respond.
Within the HIA programme, we developed a simple website, launched in September 2009, which enabled people to submit their actions in a structured way.
We specifically asked about the impact the work had on quality, patient experience and cost, as well as getting some of the practical detail of what was important in making it a success. We had an amazing response of over 600 submissions from frontline nurses and midwives.
Assess the ideas
The famous Voltaire quote “the perfect is the enemy of the good” is important to remember when trying to work with or assess ideas.
There is a natural concern about promoting one’s own work; British culture does not encourage people to “blow their own trumpet”. There is also anxiety that someone may point out they have already done that, except better. This is a barrier to change and it is impossible to be completely certain that something excellent is not being missed when trying to filter and compare different ideas. A key concept behind any idea management approach is that all ideas are important and can usually be built on and made even better.
For the HIA work, we were clear that those ideas selected were some of the examples of good practice that should be spread more widely, but that they were not the only ones. There will undoubtedly be other things that individuals or teams are doing that should be spread much more widely. It is important that the selection process does not make those who have not been selected feel their ideas are bad; it is just that they may not be appropriate for the specific aim.
For the HIA work we sent groups of submissions to a wide variety of nurses and midwives from a range of different backgrounds and specialties as well as to improvement specialists. The submissions were scored against key criteria and a long list of the highest scoring ideas was taken forward.
Select the ideas
A workshop with over 70 nurses and midwives was held to decide on the final list. All the assessment information was examined by groups working in specialty areas. While the aim was to use the best possible evidence of good practice, it is also important to take into account the experience and expertise of frontline staff. Participants then voted on a shortlist to create a final list.
Whenever carrying out a selection process it is vital to have a degree of practicality and pragmatism. Areas or ideas often arise that are important and interesting but outside the programme’s aims. For our work two areas scored highly but did not fit one of the underlying principles, which was that frontline staff should be able to lead and make the improvements themselves. It was therefore not appropriate to include them in the final list.
When looking through all the submissions, it was clear there were hundreds of excellent initiatives that improved quality of care and patient experience. The weakest of the key criteria was around showing the impact on reducing costs. This is not just related to improvements made by nurses and midwives, but is common to a great deal of improvement work in the NHS. Given the increased pressure on public and NHS finances, this is something that everyone will need to improve.
We are currently in the process of designing a programme of support and material (see Changing Practice [direct link to article]) to help nurses and midwives to make changes in the eight HIA areas. This is being developed following the same guiding principles used throughout the process to date.
We know that simply telling people what to do will not achieve the results that everyone wants. It is critical that whatever is developed is relevant and appropriate to frontline staff, but also addresses how NHS organisations need to support and facilitate people who are passionate about improving patient care to make the necessary changes.
The process of developing the high impact actions has been about getting those who deliver excellent patient care every day to share what they are doing. The ultimate success of the programme depends on how well we can continue to do this and implement some of this excellent practice more widely across the NHS.
Bessant J, Tidd J (2007) Innovation and Entrepreneurship. London: Wiley.
NHS Institute for Innovation and Improvement (2009) High Impact Actions for Nursing and Midwifery. Coventry: NHS Institute for Innovation and Improvement.
NHS Modernisation Agency (2004) 10 High Impact Changes for Service Improvement and Delivery. London: DH.