The Q Improvement Lab (Q Lab) is working with people in health and care across the UK, developing new ways to make progress on problems that are not straightforward; they involve and affect lots of people, are impacted by a number of factors and there is no single answer to them.
Any darn fool can make something complex; it takes a genius to make something simple.
The motivation for setting up the Lab was based on a recognition that there are countless complex issues facing the health and care system. For example, we know that one third of patients admitted to hospital today will have three or four conditions such as heart disease, diabetes or high blood pressure, and will arrive at A&E with an urgent medical problem such as a stroke.1 Often these patients need to stay in hospital for a long time. With so little spare capacity available, this can result in hospitals cancelling planned admissions and treatments while these patients are being cared for in an environment that is not best suited to meet their health and care needs. There are dozens, maybe hundreds, of issues, challenges and indeed opportunities to take action in response to this, but if you are responsible for leading change, where do you begin? What thread do you start to pull at? At what level do you tackle the problem – the GP, the hospital, the individual, the government, society at large?
Although it would be understandable, the health and care sector is not in paralysis in response to complexity; great work is happening right across the UK led by innovators and improvers from all backgrounds. The Q Lab seeks to bring something new and complementary to this busy world of improving health and care, and this essay sets out how the Lab seeks to support people and help catalyse change.
At the end of our first year there have been some early signs that the Lab is well-placed to make a difference, accelerating promising work and kick-starting new collaborations and ideas. However, it is with humility that this essay describes the work the Lab does and the impact we aim for. The Lab is not yet a finished product and as it moves into its second project we will develop the Lab approach and continue to share our learning with openness and transparency.
What is the Lab trying to achieve?
The Q Lab is part of Q – a growing community of over 2500 members with experience and expertise in improving health and care. It is an initiative led by the Health Foundation, co-funded by NHS Improvement and supported by partner organisations across the UK.
The Lab provides a mechanism to bring Q members and others together to work on a specific challenge over the course of approximately 12 months. For the Lab’s pilot project we looked at what it would take to make peer support available to everyone who wants it to help manage their long-term health and wellbeing needs. The What is the Q Improvement Lab? essay provides an outline of what the Lab is, and its key features. You can read about our findings on this topic in our essays Learning and insights on peer support and How do people make decisions in peer support?.
During year one the Lab developed an impact model which identifies four direct areas of impact that we aim to achieve:
- Build a rounded understanding of the issue
- Generate and test ideas for improvement
- Develop skills for action
- Disseminate learning widely
The impact model also outlines some wider changes the Lab aims to contribute to. Flowing from this, metrics and evaluation approaches will be developed to measure these outcomes, as well as descriptive accounts of the process and stories that bring to life the work in practice. This essay shares learning about each of the four key impact areas.
Build a rounded understanding
However, in times of scarce resources and high pressure, it is understandably tempting to move quickly to conclusions and solutions. Sometimes the problem can appear blindingly obvious, and the solution follows logically and quickly from that. But in our enthusiasm to get things done it can be easy to misdiagnose the issue or see it only from one angle, thus skewing our understanding of what is happening. This can lead to organisations wasting time and resources on initiatives that may start quickly but unravel as they encounter broader issues that have not been recognised.
While it may never be possible to see or understand every single element of a complex challenge, there are steps that can be taken to develop a rounded understanding in a time-efficient way.
The Lab brings together people who, through lived experience and expertise, can contribute different and multiple perspectives of the issue. During the pilot project, the Lab convened a diverse group of people and through workshops and online collaboration, insight on the topic was developed jointly to build a picture of what was happening.
We use a range of methods2 to probe and seek answers to questions such as:
- Who is this a problem for? How do different people see this problem, and what effect does it have on them?
- Is the problem being caused by other problems, or is the problem causing other problems?
- What is it about the circumstances in which the problem occurs that gets in the way of it being addressed?
- Where have people failed or made progress in the past to address this problem and what can we learn from that?
This process serves two important roles. Firstly, it provides an opportunity to test and refine the diagnosis and understanding of the issue, making clear the assumptions that might be underneath the surface, and driving work towards the most important aspects of the problem.
Secondly, it creates the conditions in which open conversations can be held. People are encouraged and supported to be curious about their own and others’ experiences, and to surface differences and disagreements. We create spaces where disagreements can be aired and biases can be rooted out safely, in the knowledge of a shared commitment from the group to use the Lab process as a platform for making progress on a topic everyone involved cares about.
Of course even trying to find the ‘starting point’ – the topic or problem to focus on solving – can be challenging. Many problems are inter-connected and any single issue is likely to connect upwards to more systemic issues, as well as downwards to more granular issues. For example, the challenge ‘what would it take for peer support to be more widely available’ is a broad, ambitious topic area. During the 12 months the Lab identified large systemic issues (such as the development and use of evaluation approaches to build the evidence base for peer support) as well as more granular barriers (such as using stories in a more targeted way to bring services to life).
While it is important to understand these connected problems, it’s also important to not get lost in the maze of problems. We think the Lab can get better at identifying a more specific start point; an anchoring problem that feels strategically important as well as tractable. As we move into our second year we will start with a more tightly defined challenge. Drawing on the double diamond approach3 we will expand our research from this stage, and then narrow our focus to identify specific areas of opportunity to take forward to testing.
Generate and test ideas
Having spent some time deliberately ‘slowing down’ thinking to develop a deep understanding of the problem, those involved in the Lab then move into a phase of developing and testing ideas, often acting at some pace to prototype or test things that appear to be well placed to make a difference. Through online and offline collaborations, such as workshops or webinars, the Lab works with participants to identify opportunities and explore ideas for improvement and innovation.
Key to this part of the Lab’s work is supporting people to generate ideas at multiple levels. At the Health Foundation’s 2018 annual event Matthew Taylor stated that organisations that want to thrive should learn to ‘think like a system and act like an entrepreneur’. This phrase resonates with the Lab’s approach which seeks to understand, map and take account of the system in which we are operating and the changes that we may wish to enact at a system level, while simultaneously supporting people to generate ideas that can be quickly tested and iterated in local contexts.
Our work in this area has been influenced by the Three Horizons Framework, a tool to help conceptualise the different sorts of change that is possible over different timeframes.
In this model, horizon one represents the current system and processes. At the other end of the spectrum horizon three represents the future, recognising that some pockets of innovation that will influence or be present in the future, exist now. Horizon two represents the bridge between current ways of working, and how we might operate in the future. With some of the right people in the room this framework provides a structured approach to thinking about an issue in a way that goes beyond an individual or an organisation, but then allows people to develop specific ideas to test in their current context which take account of emerging ideas and trends.
Part of the ethos of the Lab’s testing approach is that when addressing complex challenges, the likelihood is that there is no single or best way to intervene, so instead of trying to develop a silver bullet answer and then finding that it doesn’t work or scale, we encourage Lab participants to create a range of responses. These prototypes can then be tested in practice, tweaked, improved, or rejected with learning extracted.
We have learned a lot about this phase of work during our pilot year and it is the area in which we are likely to make the most changes in the Lab methodology as we move into the second project. We have seen some success this year but there is more work for us to do to identify the scale and type of testing that is most meaningful as part of the Lab process, to be clear with participants about the time commitment that may be needed, and support people to move from workshop prototyping, to in-situ testing.
Develop skills for action
Generating and testing ideas in practice is a key part of what the Lab aims to do. But that on its own is not enough. Any single idea, no matter how successful, will only be relevant, or work well, for so long. As the context changes, services and processes need to be continuously improved and developed.
As such, supporting people to take action isn’t merely about idea generation and implementation; it’s supporting people to create the conditions for new ideas and insights to emerge in their own contexts and organisations, as well as supporting them to develop the skills required to drive change and be able to connect the dots in a constantly shifting context.
We use creative approaches, tools and techniques to support people to engage with and tackle challenges, not simply because they can be enjoyable (although we should not underestimate the role of fun and joy in work),4 but because creative approaches can unlock new ways of looking at problems. When exploring a problem across professional boundaries a ‘certain mindset is crucial: framed by inquiry not certitude, one that embraces paradoxes and tolerates multiple perspectives’.5 The Lab provides safe spaces for people to nurture this mindset, and apply it in very practical ways on a specific challenge, offering a developmental experience for those involved.
We know that breaking out of professional and conceptual silos can be difficult. But, as we look to the challenges of 21st century health care, for example the need to support people with multiple long-term conditions over many decades of their life,6 or the need to support number of young people who experience a mental health problem,7 we see that increasingly people are required to work across professional or sector boundaries, balancing the need to work with multiple stakeholders, with the need to make progress at pace. We think that more can be done to help nurture the skills and expertise needed to work multiple sources of data and insight, supporting people to build confidence about when to expand thinking and seek input, and when to narrow focus and move forward.
We have more work to do to understand whether a certain commonality in skill set or approach will help accelerate implementation and change in practice and how to best support this. As we move into our second year the Lab will explore a capability framework, drawing on what we know about the skills needed for innovation and improvement,8 and helping those involved in the Lab to understand what these are and how they can be further developed.
Disseminate learning widely
Spreading innovation and good practice in health and care is no easy task, and the challenges that are associated with it are often a source of frustration. In addition, new practice can be difficult to sustain once the initial innovation has occurred. There are many stories in health and care about a heroic battle to make a change, which then fails to be sustained after the initial burst of energy.
The reasons that spread and sustainability can fall short of our expectations are multi-faceted. They may in part relate to the funding that is available, as a number of sources suggest that funding for innovation far outweighs funding available for adoption.9 10
There is a compelling case for investing differently and a recent Health Foundation and Innovation Unit report makes a number of recommendations about funding, as well as other conditions needed for spread. Borrowing concepts from this report, the Q Lab focuses on building ‘receptivity’ and ‘readiness’ to take forward new ideas, seeking to socialise them throughout the process and consider the implications at multiple levels in the system.
The Q community provides a unique opportunity to channel new thinking and ideas through the health and care system and build readiness for change. Q has grown to over 2,500 members in just three years, and looks set to grow further over the months and years ahead. It is also growing in maturity in terms of the mechanisms and relationships through which learning can be shared. Fostering productive and creative connections is core to Q, informed by evidence that flexible networks support innovation and spread.11
In terms of receptivity, it is human nature to feel more strongly about something you have helped create, than something someone else has created12 13 , and while this emotional connection alone is unlikely to be enough to secure the successful spread of an idea, it can help to create the condition in which new approaches are taken up. By ensuring the Lab is a highly collaborative and participatory process our hypothesis is that more people have a stake in the ideas and insights generated through the Lab than might normally be the case and are better placed to take them forward.
We are mindful of over-simplifying the complex, uncertain issue of spreading ideas that many hundreds of people and billions of pounds have been committed to. There is much more for us to do and learn about how to design with scale in mind, know when to focus on replicating ideas, when to push towards reaching a ‘tipping point’ where the willingness to change gathers momentum, and when to focus on the skills and resilience people need to make change happen. Broadly however, we see an argument for increasingly focusing on scaling the environment or conditions for innovation, including leveraging the power of networks and investing in people’s capability, rather than solely thinking about spread through the uptake or rollout of a specific change.
The impact model sets out, at a high level, the four outcomes the Lab focuses on, which have been explored within this essay.
In addition to these four outcomes, it describes wider changes the Lab will seek to contribute to. These wider changes guide much of our thinking about how the Lab operates, both in terms of what it should look and feel like to be part of a Lab, but also in recognition that the Lab is positioned to catalyse and boost existing work and energy within the health and care system, rather than falling into the trap of seeing the Lab project as ‘the end goal’.
The wider changes that we hope to see are:
- Increased use of participatory design methods
- More people with capability and confidence to lead change in complex environments
- Thriving communities that allow cross-pollination of learning across health and social care
- New approaches to spreading learning and ideas, which focus on adopters and adapters as well as innovators
Measurement of these outcomes is challenging and the Q Lab’s contribution will inevitably be partial. We recognise that activity in this area is hard to formulate in terms of SMART objectives, and we may not be able to build a complete picture of delivery against them, but we will continue to work with our evaluation partners to track progress where possible.
Evaluation and a learning mindset is a key part of what the Lab is, and developing our approach to learning is a key focus for the Lab going forward. It is important that, as a new initiative, we are able to really understand how and in what ways we might have the biggest impact, and objectively be clear about the limitations.
I shall therefore end with some wisdom that I have tried to hold close during our first year – the caution of the Stockdale Paradox.14 James Stockdale was a United States vice admiral awarded the Medal of Honour in the Vietnam War, during which he was an American prisoner of war for over seven years. He famously talked about remaining optimistic whilst also realistic: you must never confuse faith that you will prevail in the end—which you can never afford to lose—with the discipline to confront the most brutal facts of your current reality, whatever they might be. It takes courage to look at whether you are on the right path but if we can all learn to prefer failure to delusion, the long-term prospects could be worth it.