I wrote last time about the importance of developing ‘capability’ and how the Health Foundation’s Framework for Measurement and Monitoring of Safety can help us with that. Making care safer involves making decisions. Improvement results from making more good decisions and less bad ones. That can happen either deliberately or by chance. Sustaining improvement is harder and requires us to understand which were good decisions and which were bad. To do that we need to understand some of the basic statistical concepts that allow us to correctly interpret variation.
A lack of understanding of variation is harmful to individuals, teams and organisations on a number of levels. In essence if we don’t understand variation we don’t know whether we are getting better or worse. If we don’t know that, then we don’t know what to start or stop doing, what to do more of and what to do less of. We don’t know how and where to deploy finite resources. We risk making variation worse by changing the wrong things at the wrong time. We cause waste and harm by intervening when it would have been better to do nothing, or not intervening when it would have been timely to do so. We create perverse incentives by rewarding people for the wrong things. We demoralise staff by blaming them for things beyond their control. We waste time looking to explain perceived trends when nothing has changed.
Achieving meaningful improvement in the hullabaloo of frontline services is tough. Change is hard. Accumulating the theoretical knowledge and motivation is one thing. Having the tenacity to engage, challenge, overcome and sustain is a different and altogether more daunting (yet rewarding) challenge.
One of the more common phrases you will hear when seeking to engage others in change is ‘I haven’t got capacity’. ‘What would you like me to stop doing to allow me to focus on the change you wish me to make?’ To the early adopter or enthusiast it may come as a disappointment that your primary concern is trumped by multiple confounding or competing priorities.
The problem is that this philosophy presupposes that existing ‘capacity’ is entirely value adding and being used to maximum effect. Sadly we know that for a complex array of internal and external reasons, that is seldom the case. I would contend therefore that capability rather than capacity is the real issue.