CASE STUDY – Starting with a series of pilot sites, the NHS is hoping to engage the Kata coaching approach to really spread an improvement culture to staff and patients.  

Words: Ann Hill, Improvement Practice Consultant, NHS Improvement

The Health Foundation describes an organizational approach to improvement as one that “aims to embed a culture of continuous improvement and learning, along with the means to make it a reality”. The arguments as to why improvement is necessary are well rehearsed: the need to reduce variation in patient outcomes, improve patient, carer and staff experience, and effective stewardship of resources.

There have been a number of improvement approaches and methodologies used within the NHS. Lean has featured regularly, and lean-based activities are cited frequently in many NHS Trust board reports. However, systematic and sustained implementation is not common.

In 2015, NHS Improvement (NHSI) – the national body that regulates delivery of healthcare – announced a five-year partnership with Virginia Mason to work with five NHS Trusts to develop a lean culture of continuous improvement. Following the success of the Virginia Mason Partnership, in 2018 NHSI started the Vital Signs program, whose vision is for every NHS staff member to “know what their team improved last month, what they and their team is striving to achieve this month and the next” and to enjoy the improvement work and learn every day from it. The program focuses on delivering transformation through improvement, creating a learning culture and developing the right management behaviors.

Vital Signs is working with a number of health and social care providers to support their lean transformations. Each of the organizations within the Vital Signs program has been given the opportunity to test the Toyota Kata methodology and incorporate it in their approach to improvement.

Mike Rother describes Toyota Kata as a tried-and-trusted way to develop a test-learn-adapt, “growth” mindset. The significance for the NHS is that this approach can help us to develop new ways of working and enable our staff to improve, adapt and innovate as part of their job – which is critical in the ever-changing and often unpredictable world of healthcare. (We are grateful to Mike and Beth Carrington who have been very generous in sharing their knowledge and providing advice, challenging and coaching us.)

The first step was to develop an understanding of Kata within the Vital Signs team, so that we could consider the approach going forward. My colleague Dr. Joy Furnival (Practice Consultant) and I attended the Kata for Daily Improvement workshop offered by the University of Michigan, which proved invaluable in helping us to understand. A visit to Zingerman's Mail Order enabled us to see both familiar traditional lean production and Kata working seamlessly side by side. We have also developed a fruitful relationship with Maurene Stock at Mercy Health in Muskegon.

Working with Beth and Mike, we created a series of four short modules to guide the development of the kata “advance party” in each site. Joy and I delivered these in November 2018, with a second coaching session from Beth. Each delegate was then to practice the Starter Kata (the first step in our deployment of the Kata methodology) themselves, identify their own “advance party” i.e. begin their own deployment of the Starter Kata.

Development block workshops have been attended by executives, management staff, senior and junior clinical staff across medical, nursing and Allied Health Professional groups.

We are learning how to deploy kata, using it to create the conditions for daily experimentation in the workplace. We now have some insight into how much practice is needed to acquire scientific thinking skills.

EARLY LEARNING

Our initial aim is for learners to practice both starter learner and coaching kata. As we develop proficient learner and coaching capability, the intention is then to formally align kata challenges to delivery of organizational True North objectives.

Our learners have chosen a mix of personal and professional challenges. Personal challenges have ranged from acquiring new skills, improving fitness and creating a morning routine to ensuring there is time for breakfast (not always a given). Early professional challenges focus on areas we know are pivotal to the provision of successful care – quality and delivery of services, safety improvement and contract management. Examples include the timely and consistent triage of patients on arrival in the Emergency Department, improving the compliance with hand hygiene standards or HIV screening of patients on admission with Community Acquired Pneumonia.

Dr Aklak Choudhury, Consultant Respiratory Physician, University Hospitals of Derby and Burton Foundation NHS Trust, provides a patient story demonstrating the impact of his kata practice. A patient told him: “Looking back, it explained why I had been so ill recently. I wondered however why none of the doctors before offered me a HIV test. If I was detected earlier, I could have been commenced on treatment earlier. I might not have had deteriorated so badly.”

Practicing kata provides a mechanism to directly influence individual patient’s lives. From a clinical perspective, this is often underplayed in lean programs in which we talk about value vs waste, and the perception is that the focus is on efficiency rather than care. In the face of this perception, clinical staff is often skeptical about lean thinking: they see it as non-sustaining and managerially led, with clinical staff following after.

As we began to tackle these challenges, we realized we can indeed delivery improvement. But what else did we learn?

To begin with, our teams are telling us that the hardest part is to get started. Initially, Kata feels like an alien way to work compared with how we currently approach our problems. For example, one organization is struggling to ensure consistency of practice among their advance party due to the impact of differing shift patterns. (This is both an obstacle to overcome and an important learning in how we choose our advance party.)

In the early days, discipline is key. Both learner practice and coaching sessions are essential. Rhian Slattery, Executive Lead at Livewell Southwest, systematically scheduled daily sessions across her organization. Rhian says: “When I didn’t practice, I didn’t berate myself; instead I did a learning cycle and learned from the experience understanding what the obstacle was that prevented me from practicing. This proved motivational to carry on.” Sarah Pearce, Community Urgent Care Service Manager at Livewell Southwest, now begins her day with Kata – before even “switching on her computer”.

Learners had said it has taken between 10 and 30 coaching cycles to feel comfortable in practicing. They have quickly gained confidence to experiment and they are developing new target conditions. In some cases, they are even asking for new challenges. Charlotte Power, a QI Facilitator East Lancashire Hospitals NHS Trust, told me: “I feel that Kata helps to make improvements more manageable. Practicing Kata has helped me to focus on a specific improvement aim and allows me to conduct tests related to this aim on a daily basis.”

There has been a much more systematic approach to achieving goals. A regular reflection is that people have experimented with ideas they would not have considered previously.

Reflecting on her experience with Kata, Julie Pearson, a therapist at East Lancashire Hospitals NHS Trust, said: “It’s great to be able to learn with someone, and break down the task into bite size chunks, try to resolve it, learn from what you have done, and try something else. To reflect on what happened is also great, rather than just do it and change it.”

Feedback from management has also been positive. They tell us that through practicing Kata, they are moving from knee-jerk reactions to problems to scientific problem solving and engaging their staff at the gemba. As managers, we are learning to be quiet and let our learners do the talking!

The structure provided by the kata storyboard guides learners to use data systematically.  This is beneficial in that it not only demonstrates evidence of progress, but also teaches learners to be understanding of improvement data in other areas of their working life.

We need to consistently work to maintain the integrity of the kata: we have experienced the reaction of staff wanting “to be a coach” without having developed the discipline and understanding that comes from being a learner. We know, for example, that if Kata is seen as a tool, the five coaching questions are seen as a “miracle cure”. Creating an environment for learners and learning to improve through practicing scientific thinking isn’t an attractive marketing ploy for executives who short on time and high in demand, which has taught us we need to improve our messaging.

There is also a sense that ultimately the burden of assurance reporting will be reduced. Managers coaching at the front line are seeing real-time progress, whereas previously they would have asked for a report to be presented at a committee.

Relationships have improved and the rigor and safety of the coaching questions means security and predictability are provided through the coaching conversation. Dr Choudhury commented: “Traditionally, the NHS is used to command and control (as can be seen in the way managerial hierarchies are split into divisions in most NHS trusts). The learner-coacher dynamic in Kata is different: the coach supports the learners through their learning by experimentation and provides mentorship rather than giving the learner direct commands to carry out. The Kata coaching is more aligned to the relationship between the learner pupil and Mr Miyagi in Karate Kid than to Darth Vader and the Emperor in Star Wars!”

It is the close relationship people are creating with their line managers, enabled by coaching, that is making it safe to experiment. Interestingly, there has been reflection on the impact that scientific experimentation and coaching may have on the clinical educator and student relationship. Could kata also enable better relationships and understanding of the often differing perspectives of medical staff and management teams?

Using the starter kata model, we have been able to practice the coaching kata to support current learner practice. Our current experiments aim to understand how to spread the practice. Our first learners are now taking on their own learners.

High-quality coaching is key to success, which is why it is our next major development priority: we are planning a coaching development block in September. To access the coaching block our current learners will have to demonstrate basic competency with the Improvement Kata pattern, through their story boards.

There is so much we don’t know still, but through experimentation we will understand more and more.  We know that conditions for success are different in each of our organizations.

A question we have been asking ourselves is whether or not a strong background of quality improvement or lean improvement skills and knowledge are critical to success with Kata. Early indications seem to suggest that this is not the case, and that diligent and systematic practice is much more important.

So will the kata be the breakthrough enabling the NHS to develop that “learning culture” that so many programs – even the “successful” ones – have failed to deliver in the past?

Our early experiments have demonstrated the potential of kata to unlock the creativity and potential of all of our staff. With demand for care going up every year, the NHS is constantly struggling with staff capacity. This means that taking people away from their daily work to participate in improvement events is not always an option; we hope that Kata will help build the improvement into our every-day work. We certainly see it as a great way to engage staff and patients.

Using kata is enabling us to learn to learn the conditions for success, thus enabling the Vital Signs vision to become a reality.

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