All organisations need systems, but too often the systems become more important than the human beings they are meant to serve. Over the last 18 months, the learning disability provider Three Cs have been developing a methodology and running a live project, Project 17, which is about reducing waste caused by systems and releasing time for supporting people. To date, they have re-designed, streamlined and piloted a new Health Action and Emergency system, and consigned 23 forms, templates and tools to the bin. CEO Jo Clare explains the thinking behind Project 17, how it works and the ‘people’ benefits envisaged.
A number of unhelpful beliefs and myths in our sector have been bugging me for some time now: the belief that compliance is other than quality and gets in the way of the job, the prejudice that people work and paper work are incompatible, and the total myth that managers know better than staff how best to do the job.
The combined effect is a neglected excess of the wrong stuff that takes staff away from direct support. Project 17 aims to change that by restoring human value to systems, integrating compliance, and releasing time for support.
The 17 in the project title refers to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which is there to “make sure that providers have systems and processes that ensure that they are able to meet other requirements in … the Health and Social Care Act” (1). Amongst other things, the Care Quality Commission (CQC) say those systems and processes must “drive improvement in the quality and safety of the services provided” and “assess, monitor and mitigate any risks relating to the health, safety and welfare of people using services and others”.
Nowhere does CQC say “create a parallel universe for compliance which has nothing to do with the real quality of life and safety of the people you are supporting” or “make a mountain out of a molehill”. Those, in my view, are provider-generated myths which, along with tick boxes and back covering, are unfairly ascribed to CQC, especially when we feel under pressure. Project 17 is based on a belief that compliance is a subset and servant of quality; if providers genuinely focus on quality and its bosom pal, safety, compliance will naturally follow.
One of the problems with providers coming to grips with this part of the job is that systems do not automatically speak human and system methodologies are unnecessarily mystifying. However, you don’t have to have been baptised in Total Quality Management or acquired a Black Belt in Six Sigma to understand the basics of efficiency and human value in systems. Project 17 aligns with Kaizen, the Japanese theory of ‘good change’, and the principle that staff who do the job are much better placed than consultants and senior managers to inform how the job can be done efficiently and effectively. After all, staff experience wasted human value directly; every hour spent on duplicated or poorly designed process wastes two human hours, one hour of their time and expertise and one hour of direct support to someone who needs it. As a result, and counter-intuitively given the nature of the subject, staff are also potentially highly motivated by system improvements which, as any change manager knows, is gold dust.
Underpinned
At the heart of Project 17 is a very simple matrix of human value and system value, underpinned by evaluation criteria, which is designed to guide the way we evaluate any part of any system, as well as help prioritise areas for attention. Things evaluated as currently high in both human and system value (the upper right box) are kept. Things evaluated as low in human value and low in system value are trashed (the lower left box), often with the epithet ‘what on earth were we thinking?’ (See below the Values Matrix).
Usually, it is the fear of losing something of small but important value which stops us from trashing otherwise low value elements of systems like poorly designed forms or templates or obsolete tools – and so we live with them, and their devaluing effect, for years. Under Project 17, the idea is that before anything is terminally trashed, it is re-examined for gems which can be restored to other more valuing parts of the system. This makes trashing wasteful stuff both safe and exhilarating. Anything that has landed in upper right or lower left boxes on the matrix, we can conserve or despatch quickly, which is satisfying for those involved and instantly shrinks the task mountain.
The slower and harder work starts with systems and processes that end up in the upper left and lower right boxes. Those evaluated as high human value but low in system value are lined up for improvement, and those low in human value and high in system value are lined up for replacement. This last box has priority. It is important to replace and not simply improve things with low human value because human value has to be the starting point in human services, and is rarely served well by tweaks or reforms to existing systems.
Take our (newly named) Health Action and Emergency system as a prime example. In good faith lots of alleged improvements had been made to elements of this previously sprawling system over many years, some generated by attention to compliance, some generated by commissioner-specific requirements, some generated by the tyranny of unbridled good ideas. The result? A dog’s dinner of documents with the full human value to a person’s daily health too often obscured by volume, duplication, deviation and poor navigation.
Simple is the new complex
We spent six months in a highly involved and iterative process guided by principles of ‘leading innovation and change’ (2) followed by a six month pilot to turn a 19 document non-standardised system into a simple four document one. The end product has extinguished a high risk associated with replication of health data, ie. failing to update in all places. When we roll it out, it will also do away with other emergency documents, like grab and run sheets, and missing persons. Staff previously labelled ‘stuck and resistant to change’ have embraced it wholeheartedly. Staff describe the main document as friendly, which for a system document is a real coup. Champing at the bit, some managers have pre-empted the end of the pilot and rolled out the changes in their services without authorisation. Although it is early days, managers’ feedback is that it will fulfil its promise to reduce waste and release time for support.
In all my years involvement in innovation and change I cannot remember being involved in a change so ordinary yet unexpectedly and emphatically popular.
The next big amber project is our person-centred planning and decision-making systems. Perhaps excited by our Project 17 gains, what started out as improvement is now a radical departure which, we hope, will make the person-centred approach a deeper part of Three Cs’ DNA.
Maybe you are a senior manager, have an ISO 9001 badge and/or a CEO who wears an ‘I love systems’ T-shirt and you are reading this thinking ,“That’s not us, we’re all sorted”. What I would say is think again, have a detailed look, and talk to your support staff. As it is with remote controls, black socks, cables and junk so it is with the paraphernalia of systems and processes in social care: things hide, disappear and reappear, things muddle and multiply. Systems are never parked where you last left them. In your absence, your cables have become knotted and your carefully designed mole hills have turned into mountains.
References
- Care Quality Commission – Regulation 17 Good Governance http://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance
- George Boak, (2011) MA, ‘Leading innovation and Change’, Course materials, York St John University.
If you are interested in finding out more about Project 17: Human Value in Systems, please contact Jo Clare at jo.clare@threecs.co.uk
