Implementing flow coaching in practice

 

Developing and implementing a flow coaching curriculum

Flow coaches highly rate the training course

Evaluation surveys completed by the first three cohorts of flow coaches as they started the training, at 6 months into the training and at 12 months when training was completed, gave consistently high satisfaction ratings for the training. The content was found to be useful and relevant. Flow coaches, almost unanimously, believed they were well prepared for the role.

Flow coaches valued learning technical QI methods such as process mapping, using PDSA cycles and measurement through SPC charts. They also valued the suite of coaching skills, such as active listening, giving and receiving feedback and time management. Evaluators observed high levels of engagement among flow coaches in training sessions, with supportive, engaged and knowledgeable faculty.

‘The trainers … were fantastically supportive. And they really … did a great job of delivering the content in a way that was meaningful and useful and it felt, in a lot of cases, that we were all learning together and that was a really positive learning environment. It felt very safe and supportive, so commendation to the people who delivered the content, as well as those people who developed the content in the first place.’

(Flow coach trainee, evaluation report)

Different trainees rated different aspects of the course most highly. Some particularly valued the powerful patients’ stories, others were motivated by examples of flow coaching in practice. One flow coach saw the use of statistics as the least useful aspect of the flow coaching training, while others found the data skills sessions essential to develop their data analytical ability.

‘I think the balance of content between the measurement and the team development stuff is probably about right, actually. So, I would have liked more of the measurement stuff and part of the group would have probably liked much more of the touchy-feely, but that’s just the spectrum of people you’re dealing with.’

(Flow coach trainee, evaluation report)

Flow coaches gain new skills from the training

The majority of flow coaches confirmed that they were using what they had learned from the training and were seeing positive results. A few flow coaches reported major personal impact from the training.

‘I’ve done lots of training before, including intensive QI and lean, as well as some management training, but this has transformed the way I think about working with people on improvement. It’s a fantastic journey and gives a different lens and way of being collaborative.’

(Local FCA lead)

My lightbulb moment came when I realised that before it had always been about getting staff buy-in to our vision, either as service leads or the organisation’s plans … Flow coaching is about the team owning their ideas for what needs to improve … that’s what makes it long term and sustainable.’

(Local FCA lead)

Flow coaches have gained and mastered new skills, including leadership, team management, active listening, reflecting on their own work, problem solving, facilitating effective discussions, engagement and developing mutual understanding. These skills have also had wider applicability.

‘Flow coaching is helpful to look at data … to get the best out of people. So, how to not give people answers, but let people come up with their own answers. It certainly helped in terms of some difficult decisions. I think it does help in terms of some kind of … difficult conversations when you have people that aren’t in agreement with what you’re doing and just how to move forward positively.’

(Flow coach trainee, evaluation report)

Participants reported becoming more confident in using flow coaching tools throughout their work, not just in Big Room meetings.

‘I feel much more confident, [the new skills] have really helped to empower me in my daily job … regarding the knowledge about data and charts. They always come to me and say “What would you think? How would you interpret this?”.’

(Flow coach trainee, evaluation report)

Flow coaches also reported increased confidence, coaching skills, expanded professional networks and increased competence to work with data. It was felt that professional development from flow coaching generated key skills that trainees could use throughout their career.

‘There’s definitely been development for me in terms of my personal confidence in dealing with quite senior people or clinicians that, you know, might otherwise in other forums be seen as quite powerful … So, I think in terms of having influence and credibility, confidence to deal with perhaps difficult situations or challenging circumstances, these have definitely all been things that I have got out of this.’

(Flow coach trainee, evaluation report)

Flow coaches can put what they learn into practice

An outstanding feature of the FCA programme has been the ability of flow coaches to put into practice what they are learning: to set up and coach a Big Room, to make improvements on their pathway and to sustain this beyond the 12 months of the course. Only four respondents out of 50, across the first three training cycles, reported not being able to apply any of the learning in practice

This ability to apply learning is not universally achieved by QI training. Several studies have illustrated the difficulty for staff in translating QI models and theories into action., Research shows that staff trained in QI can feel isolated without additional support and unable to secure priority for QI, given the pressures of day-to-day work. The QI-trained staff also find it hard to pass on learned technical methods, such as PDSA cycles, in a way that can be implemented effectively by others.

Flow coaching brings together different elements to achieve improvement

‘What’s really good about flow coaching is the way it bundles all of the [QI techniques] together and uses coaching methodology in order to work with … large groups in a pathway to deliver that service improvement. That’s the bit that’s different.’

(Trust senior leader, evaluation interview)

‘The fact that a team is trained is vital to [FCA] success – no matter how good an individual course is, one person going back into the trust is going to struggle to make an impact. When you start with a minimum of three teams involved, it immediately multiplies the effect. Each coach has their flow coach partner to work with on their improvement and the other flow coaches to relate to in the trust.’

(Local FCA lead)

Flow coach training has created additional organisational benefits

Trust senior leads reported changes in behaviour of coaches and other staff as a result of flow coaching.

‘We know that having done this course in itself will make you a better leader and build quality improvement and systems thinking into your way of working.’

(Senior FCA lead, evaluation interview)

‘It’s one of the best QI and leadership training courses out there. I saw [flow coaches] ‘growing’ in front of my eyes: in their confidence and relationship building. The greatest legacy is having these brilliantly trained people in the trust, who are able to tackle the really thorny issues.’

(Local FCA lead)

The benefits of flow coach training have been recognised as benefiting a local FCA trust more widely during the recent emergency response to COVID-19, as the quote below and Box 1 show.

‘The people who have had the [flow coaching] training have responded rapidly to COVID-19 challenges and got changes in place very quickly. The coaches have been very visible in their leadership in the trust and working to a rhythm of developing ideas, testing it out and engaging with people as they go.’

(Local FCA lead)

Box 1: Applying flow coaching skills during COVID-19: case studies from Sheffield and Devon

Sheffield's Anaesthesia and Operating Services department during COVID-19

Karl is Clinical Director for the Anaesthesia and Operating Services department at Sheffield Teaching Hospitals NHS Foundation Trust. In this leadership role during the pandemic, he describes his FCA coaching skills as being invaluable. At the height of the first wave he facilitated Big Room-style team huddles to flatten the hierarchy, use data objectively to inform decisions and collaborate as a team on key challenges – all fundamental aspects of FCA methodology. The collective ownership, performance and morale this engendered in his team helped the department navigate the biggest professional challenge they had faced to date.

Using flow coaching skills to manage COVID-19 supplies in Devon

At the start of the pandemic one of Devon FCA’s flow coaches was deployed to work with his trust’s stores, procurement and facilities team to help manage the organisation’s COVID-19 supplies. Using the skills developed as a coach, he facilitated daily meetings with a wide range of stakeholders with the aim of creating a collaborative working environment and highlighting the interconnectedness of the different systems in use. He is now leading the team through a series of PDSA cycles to make sure the trust has sufficient supplies during the second wave of the pandemic.

Coaches benefit from doing the course with flow coaches from other organisations, gaining fresh insights from their experience and their organisational context. The faculty from local FCAs have noticed the difference between running an internal course in the first year and then opening it up to other trusts for the second and subsequent years.

‘It’s very important to have six coaches from [neighbouring trusts] and understand their views. They can have a very different perspective; it refreshes our thinking.’

(Local FCA lead)

Identifying and setting up flow coaching pathway teams

Big Rooms facilitate engagement and relationship building

The Big Room meetings get stakeholders who are not usually in the same room to talk to each other, leading to better understanding of roles, breaking organisational barriers and facilitating collective work on problem solving.

‘The fact that two groups are talking to each other that never talked to each other before is pretty profound … community nurses are now talking to the acute hospital nurses. The fact that they’ve now got a set of skills to actually understand what their key issue is in their pathway and have started to do tests and make changes and got people ownership is quite profound.’

(Flow coach, evaluation interview)

Gathering staff along the pathway in a Big Room builds a shared perspective. New connections and new communication channels facilitate changes to improve flow.

‘The hospital and the community worked very separately … And I think one of the great things about flow coaching is that it’s brought us all together, and so staff are communicating well with each other in a way that they hadn’t before. A lot of phone calls go backwards and forwards now in a way that they weren’t ... it’s really had a great impact on relationships between us all, to the point where we can just ring up and say, “look, you know, this has been a bit of an issue”[…] That’s one of the best things about flow.’

(Flow coach, evaluation interview)

A key benefit of flow coaching is to flatten hierarchies, resulting in joint decision making. Flow coaches felt that changes tested by pathway teams, based on Big Room discussions, were implemented with less resistance than if they had been imposed top down.

‘Anyone can propose an idea and it’s not just entertained, it’s actively encouraged. So I think that’s a key strength of it … before my lean thinking was always based on tools, value stream mapping, PDSAs … I always read about cultural change as the most significant thing and it’s actually taken me by surprise, but I will honestly say in the last 3 months that’s really come to the fore.’

(Flow coach, evaluation interview)

By bringing pathway staff together, flow coaching opens a space for questions that have never been asked. Staff gain a better understanding of each other’s service and the pressures they face. It facilitates co-design among multi-professional groups and helps to nurture an appetite for change, fostering a flow coaching culture. Coaches described changes in mind-set or culture as a major success of the programme.

‘I think the biggest milestone for us has been a recognition … for something to be done differently. And that there is a high level of motivation for that to happen, so people recognise that not only does something need to be done differently, but they want to be part of doing things differently. So people are motivated to make change happen and now we just need to move to that point of better understanding of what that “doing things differently” looks like and making it happen.’

(Flow coach, evaluation interview)

Another key benefit of the Big Room approach is that it gives teams the chance to learn and reflect together.

‘Everyone in the Big Room has come out with another set of skills. Because it gives us, as a team, time for reflection, it means that it’s more likely to stick.’

(Local FCA lead)

As a result, many Big Rooms have been able to sustain the interest and enthusiasm of participants, according to flow coaches.

‘Everyone just comes along and gives up their time willingly … We can’t say how much we appreciate that and the fact that the directorate sees it as a priority too.’

(Flow coach, evaluation interview)

‘The ‘why’ is never forgotten in the Big Room and that just shoots [the work] up into the stratosphere, staff come because they care about patient outcomes and that is always the focus.’

(Local FCA lead)

Changes in organisational culture have also been observed, resulting from Big Room engagement and flow coaching activities.

‘Interestingly I thought that we might have more of a culture of resistance to change than we have. I thought that it would be hard to change the culture and actually I think the opposite has really been the case, I think people have been embracing change.’

(Flow coach, evaluation interview)

Box 2: Benefits ascribed to flow coaching implementation by coaches and Big Room participants

  • Bringing staff along the pathway together: people who do not usually work together join to focus on the care pathway in Big Room.
  • Patient perspective for improvement: focus on patient stories highlights important issues for improvement.
  • Flattening hierarchy: allowing any of the staff involved in the pathway to, for example, propose ideas and challenge data.
  • Better communication: between different professionals, different services and between teams from different organisations.
  • Improvement culture: increased willingness to try changes and do something differently.
  • Brings together QI tools and coaching: supports use of the tools in practice with supportive leadership.
  • Better flows of information: exchange of ideas and more accurate care information feeds into ideas for change.
  • More ownership of improvement interventions: Big Room participants discuss and agree which change ideas to attempt.
  • New skills brought into the pathway: presenting patients’ stories, running complete PDSA cycles on each test of change and the use of SPC charts.

Select care pathways for improvement carefully

The Central FCA has gained expertise in selecting appropriate care pathways amenable to flow coaching. Experience has shown that a successful Big Room can bring together staff from different services who support the same patients, for example, community mental health teams and accident and emergency departments supporting people in mental health crisis, or hospital and community teams working with frail, elderly people. Without the focus of a clear pathway, an early Big Room on chronic pain was not successful. The learning from this helped to shape the approach for cross-service pathways, such as sepsis. The initial sepsis Big Room tested changes in one defined area, making necessary tweaks while engaging stakeholders across the whole pathway, and ultimately gaining confidence for wider application of cross-service improvements to sepsis care.

The Central FCA has recognised the problem of selecting pathways too quickly, with insufficient analysis of the context, and advise trusts starting flow coaching on how to avoid common pitfalls. These pitfalls could include working on pathways that are unstable due to, for example, structural changes. Trusts are encouraged to select pathways with an appropriate balance between ambition, involving pathways where there are known quality of care issues and pragmatism, and selecting pathways with keen clinical leaders.

‘We opened up applications across the trust, and it was over-subscribed, so we chose two pathways to get ‘quick wins’: colorectal, as we had identified the pathway needed redesign to ‘work smarter’, and sepsis, as we were very impressed with the work at Imperial. The other pathways were frailty, where there had been intractable problems for a long time between acute and community teams, and inflammatory bowel disease, because the clinical team were just so keen to get involved.’

(Local FCA lead)

Big Rooms also need to balance their aspirations for improved patient outcomes with what is manageable and realistically achievable through QI approaches, by building up pathway level impact through a series of changes. Addressing what is manageable can lead to a micro-system focus (a small-scale QI project on a segment of the pathway, usually only involving one clinical team) rather than the desired meso-system approach, improving flow along the whole care pathway. In an example of micro-system improvement, a local FCA Big Room only focused on the discharge process for their pathway, which achieved worthwhile improvement but did not consider other parts of the pathway and therefore limited the overall impact.

Challenges in setting up and sustaining Big Rooms

Not all the Big Rooms have been successful. In a small minority of cases, slow progress led to the Big Room meetings being discontinued. For example, flow coaches reported lack of engagement from senior or middle managers to attend the Big Room as a barrier to progress. It can be hard to implement a flat hierarchy if some Big Room participants hold on to power and control, and resist new approaches.

‘Some people come but they’re like observers, they don’t share their information … We’ve also seen resistance to the new approaches we want to try ... not everyone gets that pathway idea, they’re only interested in their own area.’

(Evaluation case study)

Another challenge faced by some flow coaches has been in getting back-fill to cover the time they spend training or facilitating Big Rooms, or in earmarking protected time for their role in a formal job plan after the training.

Enacting the coaching role, such as delegating team roles and ensuring ownership in the Big Room, rather than leading and directing work, has also required a change in approach for some flow coaches. Tensions resulted from balancing an operational function in the pathway with the coaching role. Time and workload pressures made it hard to sustain the coaching role beyond the end of training (particularly for clinical coaches). Organisations need to consider the support that flow coaches need to sustain the Big Room approach.

‘We won’t have workshop days in the future, so we need to think how we can come together and support each other to keep it going. We need to actively keep skilling up, keep flow coaching with a high profile across the trust, or we’ll lose the edge we’ve gained from this fantastic experience.’

(Local FCA lead)

Some local FCAs have also found it difficult to set up Big Rooms due to a shortage of suitable spaces in NHS organisations to physically hold these meetings. Dealing with the time pressures that staff are under, when faced with a requirement for another weekly meeting, is also a concern.

‘We have to have a mobile Big Room venue due to the geographical distance between the sites involved. We’ve also had to think about how to cover participants’ travel expenses. The trust is covering these for now, but it will be a big barrier if that support doesn’t continue’.

(Local FCA lead)

‘It’s been really hard not having regular attendance [at Big Room meetings]. We have to keep going backwards to catch up on the rationale and the aims ... I know everyone’s busy, but we can’t make real progress if we don’t have the representation along the pathway.’

(Evaluation case study 1, evaluation report)

Some of these challenges have been addressed by meetings switching from in-person to virtual during the COVID-19 pandemic. The virtual format facilitates patient involvement on a more equitable basis as they can take part in their own space. It also benefits GP, community and social care attendance, as they no longer need to factor in travel time.

These benefits are balanced by virtual meetings being a harder medium to build the relational side of improvement. It is harder to hold a meaningful discussion if there has not already been a functioning face-to-face relationship. This suggests risk to the sustainability of Big Rooms set up during or post-COVID-19, which only meet virtually. The Central FCA team have learned that this can be mitigated by extra attention to relationship building with key staff, using a combination of engaging by video conference and in person (with appropriate social distancing).

The rapid shift to online consultations and meetings across the NHS in response to COVID-19 escalated work development of the training for online delivery, requiring innovative ways to facilitate connections between participants in a virtual setting. Online training has advantages in reducing the costs and time required to attend in-person training and enabling greater numbers of flow coaches to be trained, more quickly. The FCA programme can now to be delivered in-person, online or through a hybrid approach, combining the efficiencies and accessibility of virtual with the relational value of in-person training. For example, at Sheffield Teaching Hospitals NHS Foundation Trust, the frailty Big Room moved onto the Workplace online platform in June 2020, allowing the team to connect, even when working remotely. The platform enables everyone in the group to access the online discussions and to find the posts that are most relevant and helpful for them. Documents are uploaded to a shared space where everyone can edit and comment on them directly, with no need to wait until the next meeting.

‘It’s kept me connected to things I wouldn’t usually be connected to and has more of a sense of community. It allows people to contribute straight away and there’s more visibility of the conversations that are taking place.’

(Frailty Big Room coach)

Developing an FCA network

Local FCAs are co-innovators in the FCA network

Central FCA works with the teams at local FCAs as co-innovators in developing the programme. There is a clarity that the adopters are ‘learning generators’ with as much to contribute in understanding how the programme is working and how it needs to adapt as the originators. Local FCA leads recognise the benefit of regular communication and exchange of ideas with each other and see the development of the FCA network as key to this.

‘Local faculties can exchange ideas and material and stuff, and individual Big Rooms can say, “Hey, we did this really well” or “This is what we’ve achieved” or “Anybody know how to solve this problem?” The programme will gain more momentum and coaches and faculty will gain learning and knowledge by being able to share in that way.’

(Local FCA lead, evaluation comment)

During the programme’s implementation, the focus of the Central FCA has shifted from developing and delivering the curriculum, to designing and testing the operational model to grow and maintain the FCA network as a thriving community of practice. The growing community of flow coaches need the infrastructure to support ongoing engagement, exchange of ideas and communication for the sustainability of the programme.

‘Central FCA are great at receiving and responding to feedback … these feedback loops are really important and they are absolutely in place for the programme.’

(Local FCA faculty member)

The Central FCA engages with the local faculties to enable them to give local support to their coaching community and to collaboratively develop the national FCA network. Regular network events are hosted by different local FCAs showcasing their work and this is an opportunity for all FCAs to share learning at different stages in the programme. Each local FCA is expected to hold two local faculty events annually to develop coaches. The Central FCA runs curriculum co-design days, bringing together representatives from each local FCA faculty to discuss and refine the flow coaching curriculum.

‘The curriculum day was run very much in the FCA way, breaking down the hierarchy, not Central FCA and ‘the rest’. It’s very much ‘do as they do’, not ‘do as they say’ and that builds our trust in the Central FCA team.’

(Local FCA lead)

‘It’s important to keep in learning mode through these events. It stops the local programme getting stale as we keep learning from what others are doing. The Connect event that was run virtually was great, really successful and we want to keep this going. It’s very important to get everyone together. Virtual is good for now, but it will be important to ensure in-person meetings when these are possible. This is where the deep relationship building happens.’

(Local FCA lead)

Keeping members connected as the FCA network grows

The current scale of the FCA network means that personal contacts, although still important, are insufficient as the organising force. The network is using Workplace as a dynamic online platform to facilitate sharing comments, enquiries and contacts between local FCAs and individual flow coaches. Coaches can download materials, make connections and seek support from others working on similar issues on their pathway. Flow coaches working on sepsis and frailty across local FCAs run virtual groups to facilitate rapid knowledge transfer. Coaches connect on a range of flow coaching topics, not just pathway issues, where they are facing common issues. In addition, the dedicated website has pages for each of the local FCAs to upload their case studies and successes – https://flowcoaching.academy

‘The new website is great and will really help to raise the profile of the work and help connecting with other FCAs. It builds on the Twitter stream, which is a great way to stay in touch with what’s happening in the flow-coaching world.’

(Local FCA lead)

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