Organisation : Review of a Positive Deviance project for referrals in Hertfordshire Adult Care Services
Hertfordshire Adult Care Services: Positive Deviance Project Review - Jane Lewis
Positive deviance (PD) is a technique to deliver quick improvements for communities or groups, within existing resources. Its underpinning principle is that in every community, there are a few people who cope better than others with the problems that beset the community. The community itself works to define the problem, find the positive deviants and discover in detail what they do, then shares these effective coping strategies.
The recent PD project has delivered measurable improvements in the referrals process in the North Hertfordshire area teams:
- Time savings of at least one hour (for locality team members) and 2.5 hours (for Referrals Management Team) per person per week. This equates to between £50,000 and £110,400 a year, for a team of 60 social workers (based on a social worker salary of £34,000 and no on-costs)
- Time savings for Referrals Management team of about 5 – 30 minutes for each equipment list.
- Time savings for social workers of between 5% and 30% of a day in dealing with incoming phone calls– and identification of the need for a new approach which is now being implemented.
- Increased flexibility enabling a higher level of referrals to be dealt with in spite of a flu epidemic amongst the teams.
- A step in the procedure for adaptations has been removed for Council tenants, cutting out the need for them to be put on one of three waiting lists
Qualitative improvements included:
- A more positive approach to challenging how the teams work which enabled a very constructive approach to the new BPR project. People felt able to contribute to improvements, regardless of status, and front-line opinions were seen as important. Taking part in the inquiry process opened people up to learning and development, and they became more used to working with data.
- A laminated sheet that helped people understand the information flow within IRIS and Hyperwave case recording systems, and how to complete the screens.
- Better use of time, for travelling, and use of touchdown centres.
PD differs from the simple sharing of good practice as follows:
- Practices are discovered by the “community” through a systematic process that is “bathed in data”, to use Jerry Sternin’s words
- the whole process is co-created with the community (“don’t decide about me without me”)
- Impact is measured by the “community”, which reinforces change
- The detailed “hows” of the PD practices are identified so they can be taught and learned by anyone (“acting your way into a new way of thinking”)
- People learn by doing, not by reading or telling
- The practices are accessible to all
- People are given time and space to discover and learn, and activity happens quickly
The referrals exercise required a total of eight consulting days’ support and was to my knowledge the first positive deviance project to be undertaken in the UK, and one of few done to date without the direct involvement of the late Jerry Sternin, the co-founder of the organisational approach to PD, who kindly ran workshops for us and mentored me before he passed away.
Original Project Objective
Following briefings from the Director of Social Care, the Assistant Director of Older People and Physical Disability (E&PD), and the former Assistant Director of Performance, the formal objectives for the pilot project was agreed. These were to engage people in completing IRIS to increase the proportion of properly completed and closed care records, and to increase throughput of referrals. The project had to be completed without changes to the system.
The project brief was to review referrals within North Hertfordshire, Stevenage and Welwyn and Hatfield (NHSWH). The project was set up on the basis of a series of half-day workshops for the project team.
The team was a representative cross section of six people from the area. The deputy Manager of North Hertfordshire was involved with each group, to keep an eye on progress and to act as a focal point for project management and liaison with Jane Lewis. The role of the teams was:
- to work with their colleagues to define their problems in their own terms
- to carry out observation and enquiry exercises to find out if there were positive deviants and what they did
- to facilitate team meetings to share discovery and agree action
- to design ways of spreading what was learned
The team started by creating a picture of how they saw the main issues that prevented them from delivering a good service to service users. The referrals project team produced the diagram below, and problems are identified in the pink call-out boxes, as follows:
Step 1 – Define the problem
It was clear from preparatory meetings that the objective of completing care records was owned more by managers than social workers and occupational therapists. We needed the teams to define in their own terms what they saw as the problem to focus on. The feedback from the social work teams indicated that they saw completing the records as being the most time-consuming part of their job, and that staff thought it was a cumbersome and unfriendly system. It was a “given” of the project that this system would not be replaced for at least two years.
Staff perceptions were that they spent between 50% and 80% of their time on completing records. A review of closed cases indicated that 80% did not have IRIS completed properly.
The referrals project covered the locality teams and referrals management team, a total of 63 workers and about 18 administration staff. The first step was to define how much time staff were generally spending on completing care records, (the norm) and whether any staff spent less (the positive deviants). We agreed that a timesheet for one day taken at random would be sufficient and not too invasive. The data was collected by the team and analysed by them, on the basis of total hours spent on the target day. The review indicated that staff spent on average about 25% of their day on completing records but with large variations between individuals. The exercise also identified that another big part of “unproductive” (as they saw it) time, about 5% of the day, was spent fielding phone calls from people enquiring about the progress of their case, as shown below, either directly with the user or through calls from other workers. Some workers spent up to 30% of the sample day on this.
At this early stage, the referrals team were able to develop “latent solutions” to some of the issues – to get admin to field the users’ calls, thusfreeing up social workers, which has been implemented and is reported to be working effectively. Another idea was to develop a diagram showing the process to go out with an acknowledgement letter. It was ultimately agreed not to send the diagram as there were concerns that users would not understand it – however, until the system is replaced I think the idea merits reconsideration and trial with some service users.
Step 2 – Determine if there are any Positive Deviants
At team meetings, or working with pairs, the referrals project team members facilitated discussions about how people got the most from their time and how they worked with the system. They used team meetings to discuss specific practices and collated their findings in the next PD meeting.
Step 3 – Discover what the Positive Deviants actually do
The referrals project team’s observation and enquiry exercise identified that some people were better able to cope with care recording than others. The team found that some just cross-referenced the care plan pages to those on Hyperwave rather than duplicating them or leaving IRIS blank, which enabled these positive deviants to get through the recording process much more quickly than their peers.
It was agreed that the procedure would change, so that everyone cross-referenced the care plan to Hyperwave to prevent duplication and speed up the process. The referrals project team believe that this saves about 5 minutes per care plan item. There is an average of three items per care plan. The referral management team deal with between six to ten care plans per team member per week, and the locality management team with three to four. The referrals management team also found that they could hyperlink equipment requests – this also saved about five minutes per item and there are usually about six items per request.
Since the change in procedure at the end of November, it appears that the throughput of new allocations a month increased in North Hertfordshire, despite a high level of sickness absence due to the flu “epidemic” that hit the teams over both December and January:
Step 4 – Design a way of spreading the PD practices
Very little design was required to train others in how to update and link care plan items. The data quality officer designed a laminated sheet to help people complete the right screens on the system which has been successful, from project team feedback. This has now been reinforced by a new data check that prevents records being closed when incomplete, introduced by the new Assistant Director of Performance.
Further work was being done to identify the details of other good practices on IRIS and to get team members to try out new ways of completing IRIS in a practical way, including setting time aside.
Benefits delivered by the referrals project
Significant time savings were delivered – of between about one hour per person per week for locality team members and 2.5 hours per person per week in the referrals management team, in speeding up completion of care plans, and up to 30% of a day for social workers by transferring call handling to administration. Further time savings were made in the Referrals Management team, who were able to cut down the time on equipment requests by 5 minutes per item.
Further to discussions at team meetings, more effective use of travel time and touch-down centres were identified, and it was decided to put time aside for IRIS completion each day.
One of the team devised a route-map guide through IRIS, which helped completion of care plans prior to the introduction of the data-checking process.
The PD review also cut out a step for Council tenants who needed adaptations made to their homes.
Although the project was slow to get started, which is usual (“start slow to go fast”), the PD practices were discovered and implemented in three months.
It was suggested that we got feedback from project team members on their experiences in PD. Cmments at team meetings were positive – team members enjoyed the chance to make a difference and have time to consider how to improve the job in a practical way. “the drip, drip, drip of solutions helped to make for much more positivity” – Hatfield team manager.
“Although it has been time consuming I have found the PD experience very stimulating and it has provided a good opportunity to step back and consider a whole range of practice issues that we do not usually have time to think about and discuss. Ican certainly see the benefit of the PD approach; the main difficulty being the reality of implementation within the constraints of our structure.” – team member.
The deputy manager of North Hertfordshire commented that it has helped all the teams, not just the PD project team members, to reflect on what they do and to think about better ways of working. She said that as a result, the business process review currently in progress is moving forward in a constructive way, with people challenging how things are done. People felt they had contributed regardless of status, and that front-line opinions were important and taking part in inquiry process opened people up to learning. The assistant Director, E&PD, observed that PD had fulfilled its role in identifying effective solutions based on the practices of non-conformists.
Key learning points
We found the following learning points which are now incorporated into later projects:
- In organisations, the PD teams will come up with a range of “latent solutions”, ideas that are not currently practised, but which have been at the back of people’s minds for some time. We found that teams will only focus on the detail of current practices once these latent solutions are discovered, discussed and tried out.
- Managers are useful to have in the team, to focus effort and ensure actions are seen through. However, they have to bite their tongues when the team discover solutions managers think are either obvious, or that are things they should already know. The managers at Hertfordshire managed this very well.
- The PD team needs to have its own internal team leader to ensure tasks are carried out. This can be an empowering opportunity for middle manager or first line supervisor.
- Although PD itself is a very democratic and egalitarian approach, senior management backing is essential for it to happen, and this helped the project to work in Hertfordshire. Use of unofficial power is important as well – hence it helps for the facilitator to spend time in the organisation before the project starts to identify communications flows and influencers
- The willingness for things to emerge, and to keep coming up with new areas to address in new iterations, means that the scope of the work can creep, but that in the end important issues are uncovered and addressed.
The aspects of PD that worked particularly well were that:
- That the team members were the prime movers in refining and defining the problem, collecting data and engaging people in observation and enquiry – this created interest and ownership, and enabled progress to be tracked, and the data was helpful in getting a shared view of the issues
- Working through the team honoured the existing culture and avoided the resistance to management initiatives
- The energy created rippled out and got people thinking more widely about how to improve their roles
- The solutions identified were straightforward and easy to copy, and were examples of where people had thought outside the normal procedure in a constructive way.
Although the project had a number of learning points, it was able to deliver a significant range of quantifiable improvements that can now be spread more widely to other teams. It also helped to deliver a positive culture shift. It also demonstrated that there is a sound methodology behind Positive Deviance that can be replicated, and which is cost-effective.
I received the following e-mail recently:
Thank you for thinking of me, this is very interesting. I continue to use elements of Positive Deviance in my team management post and find it very useful particularly when undergoing transformational change programmes.
Kim Kattenhorn- Manager
Referral Management Team. NHerts/Stev/Welwyn Hatfield. SFAR206
Hertfordshire County Council
We are now rolling out the PD approach in Children’s and Adult Care Services and also in the community. We have delivered successful projects funded by the Home Office and the Workers Educational Association on behalf of the Community Development Fund and Department of Communities and Local Government, to use PD as the basis of community coaching events, to address issues such as domestic violence, anti-social behaviour, community development on a deprived housing estate and children’s safety.
PD is now an explicit part of the NHS Change Model and is being reviewed for its policy implications by the senior management team in the Department of Health. We are working with other authorities on domestic violence applications and as part of the Troubled Families Initiative.
Our strategy is now to train practitioners to engage, coach and facilitate community groups and work teams in finding their own solutions to these issues and to spread them in their community or organisation. We have developed a three-level programme, to deal with increasing levels of complexity.
Copyright Jane Lewis 2012