This report is based on:

Independent Evaluation of the Flow Coaching Academy Programme

RAND Europe, Final Report, August 2019. Where quotes in this report are credited as evaluation interview or evaluation report, these refer to the RAND Europe evaluation report.

Authors: Miriam Broeks, Eleftheria Iakovidou, Jack Pollard, Rachael Finn, Sarah Ball, Joanna Hofman and Tom Ling.

Interviews

The RAND Europe evaluation findings were supplemented and brought up to date by a series of interviews with the programme leads at the Central Flow Coaching Academy (FCA) and with leads from several local FCAs. Many thanks to all the interviewees who found time to contribute at the point when services were responding to the COVID-19 pandemic. Interviewees were open and frank in their discussion of the programme, providing insights from experience to date and thoughts for future development of the FCA.

Tom Downes FCA Clinical Lead

Nick Miller FCA Programme Manager

Richard Curless FCA Northumbria

Ailsa Brotherton FCA Lancashire

Catherine McDonnell FCA Northern Ireland

Athinyaa Thiraviaraj FCA Northern Ireland

Simon Dallas FCA Devon

Anna Burhouse RUBIS.Qi

Thanks to:

Central FCA Team: We would like to thank the Central FCA for their valuable comments and suggestions on this learning report.

Steve Harrison, FCA Strategic Lead

Tom Downes, FCA Clinical Lead

Nick Miller, FCA Programme Manager

Jen Draper, National FCA Communications Manager

When referencing this publication please use the following URL: https://doi.org/10.37829/HF-2020-I04

What is the FCA programme and its rationale?

Over the past 10 years the Health Foundation has supported the testing, development and evaluation of approaches to improving patient flow along care pathways. The most ambitious application of the approach is the FCA programme led by the Sheffield Teaching Hospitals NHS Foundation Trust, which aims to build a network of local FCAs across the UK that share a common purpose, language and method for improvement. The programme trains health and care staff in the team coaching, technical and relationship skills required to deliver continuous and sustainable improvement. It has a core programme team, the Central FCA, which is responsible for developing the content and approach for the FCA programme and overseeing the formation of local FCAs. The rationale for the programme is that patients typically experience care in condition-based pathways, and how they move along these pathways has considerable implications for patient experience, care outcomes and pressure on staff.

What are the key components of the FCA programme?

The FCA programme is based on a co-coaching model combined with elements of improvement science. Cohorts of 30 paired flow coaches are trained on a 1-year course. Coaching pairs comprise a clinical coach, who works in the pathway, and a flow coach whose day-to-day job role in the organisation is external to the pathway. The course curriculum has been successfully transferred for delivery by local FCAs and continues to be improved through iterative co-design with the FCA faculty. The paired coaches put their skills into practice while training, by jointly leading weekly Big Room meetings that bring together staff along the care pathway, enabling them to focus on the patient experience and assess, diagnose and iteratively test changes to improve patient flow. The views and experience of patients are central to the FCA model, with coaches using a range of skills and techniques to support meaningful input from patients in the improvement work. The Big Room meetings seek to make sure that each person in the room has a voice and is an equal partner in the improvement process, regardless of status or experience. This approach to flattening hierarchy, and the focus on jointly developing change ideas rather than imposing a predetermined solution, is unusual in health care improvement.

Who is involved in the FCA programme?

The aim of the FCA programme is to support the establishment of multiple FCAs across the UK, to scale up the approach and to build a networked community of practice to share learning. The local FCAs train further flow coaches in their organisation and surrounding area, and coordinate and support the work of local flow coaching pathway teams. In its first 5 years, the programme has scaled up to create a UK network of 10 local FCAs running flow improvements for a range of care pathways, with another three ready to start. Nearly 400 coaches, from over 30 NHS trusts and health boards, covering hospital, community and mental health services are trained and over 150 Big Rooms have been set up for over 85 care pathways, with several FCAs working on the same pathways, such as frailty, sepsis, cancer and diabetes.

What does the flow coaching training involve?

Flow coaches report consistently high levels of satisfaction with their training and almost unanimously feel well prepared to be a flow coach. The course includes:

• technical quality improvement (QI) methods
• measurement through statistical process control (SPC) charts
• coaching skills, such as active listening
• giving and receiving feedback
• facilitation methods
• time management.

An outstanding feature of the FCA programme has been the ability of the flow coaches to put the learning into practice by setting up Big Rooms to support continuous improvement across a range of care pathways, and sustaining this beyond the course.

Where has the flow coaching approach been applied?

A great strength of the FCA programme is the applicability of the approach across multiple clinical settings and sectors.

Flow pathway teams have reported reductions in waiting times from referral to appointment, less waiting time in clinics, reduced delays in discharge and a reduction in unnecessary procedures through the introduction of multi-professional assessments. They have also delivered better communication along the pathway and improved team culture. In addition, the emphasis on putting the patient at the centre makes sure that improvement is focused on issues that are important to patients, with greater understanding of the patients’ experience of the service. The programme effectively achieves QI where disruption of patient flow is responsible for poor patient experience, poor outcomes or inefficient use of resources.

The programme has also demonstrated its value in enabling services to adapt in response to COVID-19, which has required the development of new care pathways and improvements in the efficiency of existing pathways to tackle the waiting lists that have grown due to re-deployment of resources for COVID-19 care. Although flow pathway teams have helped to keep pathways running during COVID-19, many flow coaches have used their skills effectively to support wider organisational efforts to restart and redesign services after the first wave.

Developing and implementing a curriculum for flow coaches

In devising the flow coaching curriculum, the Central FCA team aimed to create a course that gives sufficient weight to the relational skills needed to drive improvement. It also allows participants to put their skills into practice and can be refined over time in response to learning.

Creating a curriculum that reflects the fact that improvement requires both technical and relational skills is essential. As well as focusing on technical skills, such as how to create process maps and use plan, do, study, act (PDSA) cycles, the coaching curriculum teaches relational skills, such as how to give feedback and facilitate discussions and how to listen effectively.

Treating the curriculum as a living document is important. Developing and designing the course iteratively in response to learning and feedback helps to make sure the curriculum and training materials remain fit for purpose for both coaches and local FCAs.

Providing training participants with the opportunity to put their knowledge into practice is key to recruiting and motivating participants. The impact of many improvement training programmes is constrained by a failure to offer trainees the chance to implement their learning. This programme allows participants, while they are still being trained, to coach flow pathway teams and work with them to design, deliver and embed improvements across the care pathway.

Training multiple coaches in one organisation, each of whom goes on to coach a flow pathway team allows a critical mass of improvement expertise to emerge and increases the chances of the programme delivering a tangible impact on care. A compelling feature of the FCA programme is that it creates a network of people in an organisation with experience of coaching and delivering flow improvement. These individuals can support and challenge each other and influence others.

Ensuring that the people delivering the coaching curriculum have themselves completed the course builds participants’ confidence in the training. Creating a faculty of experienced trainers who can pass on their own experience of completing the training and coaching flow pathway teams is a key strength of the training programme in the eyes of participants. It has also helped the programme to spread.

Enabling training participants to learn with people from other organisations broadens their knowledge and understanding. Bringing together people from multiple organisations allows fresh insights and ideas to emerge and encourages people to think critically about established ways of working in their own organisations. Regular programme-wide events have also helped to strengthen inter-organisational connections and promote the exchange of knowledge and ideas.

Ensuring flow coaches have the permission, time and support to complete their training and facilitate Big Rooms is key to embedding local FCAs. Coaches’ participation in the programme often relies on them being able to secure back-fill to cover their posts while in training or to make sure they have protected time to facilitate Big Rooms. Having supportive managers and sufficient resources to allow coaches to take time away from their day job is essential.

Selecting local FCAs

When selecting local FCAs, the Central FCA team focuses on identifying flow-ready organisations with an established improvement strategy and a clear sense of the role that their local FCA would play in it.

Identifying flow-ready organisations where there is a deep commitment to improvement at every level, from the board downwards, is critical. Organisations with a clear, organisation-wide approach to improvement, with senior leaders and managers at all levels committed to improvement and a well-resourced approach to improvement capability building, are best placed to host a local FCA.

Ensuring that organisations have a clear understanding of how flow coaching fits into its existing improvement capability building strategy is vital. Organisations looking to host an FCA need to be able to articulate how flow coaching will add value to their existing improvement capability building offers and other key strategies. These organisations should also have a clear idea of where and how flow coaching will be used to drive improvement, and to make sure it is aligned with and complementary to the other improvement approaches used in the organisation.

Selecting care pathways for improvement

In selecting care pathways for improvement, local FCAs are encouraged to take their time and focus on identifying stable pathways where there are clear care challenges that are amenable to improvement, as well as engaged senior clinical leaders.

Taking time to make the right choice is key. Spending as much time as possible getting to know each potential pathway and its wider context, and working with staff and patients at each step of the pathway to understand the scope for improvement and the risks involved, will help to make sure there is a robust and evidence-based rationale behind the selection of each pathway.

Identifying pathways that are stable, clearly demarcated and well understood is important. A key advantage of the Big Room approach is that it can be applied equally effectively in any care setting or across multiple settings. However, in choosing which pathways to improve, it is important to focus on those that are coherent and well established, and those that are not affected by structural changes that could destabilise the pathway.

Striking the right balance between ambition and pragmatism is essential. Finding pathways where there are well-recognised care challenges, which are amenable to improvement within the time and resources available, is important. The presence of senior clinical leaders keen to drive improvement is also necessary. In large, complex pathways it may be appropriate to start by focusing on one specific area and building gradually as confidence and knowledge increases.

Recognising that not every quality challenge is amenable to improvement through the flow coaching approach is important. The flow coaching approach is a versatile and flexible one, but it cannot address all quality challenges on its own. Some challenges require a range of methods and an integrated organisational or system-wide response. A strength of the flow coaching approach is that it complements other improvement approaches and can be used effectively alongside other methods.

Improving the flow of care pathways

To make sure that flow pathway teams have the best chance of delivering sustained improvement, the teams meet regularly and, supported by coaches with a range of experiences and knowledge, are encouraged to work collaboratively alongside patients in an open, honest and non-hierarchical way.

Creating an open, honest and collaborative environment for improvement in which each participant feels able to contribute fully, regardless of their experience or place in the organisational hierarchy, is vital. The Big Room approach that allows flow pathway improvement team members to ‘see together, learn together and act together’ on an equal footing, has played a crucial role in galvanising teams and helped them to stay focused over time.

Enabling staff and patients from each part of a care pathway to meet regularly is critical in building a shared understanding of the priorities for improvement and fostering a culture of improvement. In bringing teams together at the same time and place each week, the Big Room approach enables new relationships across the care pathway to develop, allows questions that have never been asked to emerge, and encourages a consensus view on where improvement is most needed. It also fosters a shared ownership across the pathway of the eventual solution to the improvement problem.

Using a co-coaching model brings a valuable blend of perspectives, experience and knowledge to flow coaching pathway teams. The co-coaching partnership between a clinician with specialist knowledge of the pathway who has credibility among professionals in the team, and a coach from outside the pathway who gives a fresh perspective and ideas, is a key strength of the programme.

Involving patients from the start as equal partners in the improvement process is essential. A key ambition of the programme is to make sure that the improvement led by flow coaching pathway teams is co-produced with patients. While patients have been closely involved in a number of Big Rooms, it is far from universal and there is an awareness that more needs to be done to make this the norm.

Finding a suitable space for flow coaching pathway teams to meet is a major challenge for some local FCAs. A shortage of available space has made it difficult for some academies to find regular homes for their Big Room meetings. Switching to virtual meetings during the COVID-19 pandemic has alleviated this pressure and made it easier for some staff and patients to participate, but it has also posed new questions, such as how to build effective virtual relationships.

Building effective relationships between local FCAs and the Central FCA

Creating balanced, reciprocal and mutually beneficial relationships between the Central and local FCAs, as well as opportunities for flow coaches across the UK to connect and share learning, is seen by the FCA programme as vital to its long-term sustainability.

Seeing local FCAs as ‘co-innovators’ has helped to make sure there is a balanced and equitable relationship between them and the central academy. As ‘learning generators’ with valuable insights about the local implementation of the programme, local FCAs are seen as having a vital role to play in the ongoing adaptation and spread of the programme. This encourages a balanced flow of ideas, advice and feedback between the local FCAs and the Central FCA and fosters a sense of parity between the programme adopters and the originator. Events such as curriculum co-design sessions help to reinforce this parity.

Knowing when and how to maintain fidelity to the core programme model and when to tailor it to local needs is vital. An effective relationship between originator and adopter relies on there being clarity on when to customise content and when to follow the core model. For example, in this programme, local FCAs have the scope to include local improvement examples and data in the curriculum to increase its relevance to local participants. However, the Central FCA also arranges regular support calls, guidance notes and on-the-ground observers to help local FCAs deliver the curriculum in a standardised way.

Developing an infrastructure to support the growing network of flow coaches is a priority. The focus of the Central FCA has shifted from developing and delivering a curriculum to finding ways for flow coaches to connect and share learning and ideas. Setting up this infrastructure is vital to the long-term sustainability of the programme.

Achieving measurable and sustained impact

A clear understanding of the time required to deliver meaningful improvement in the flow of care pathways, coupled with sufficient support and resources for flow pathway teams, is seen as critical if the FCA programme is to deliver sustained improvement in care processes and outcomes.

Recognising that it takes time to identify, plan and deliver improvement in complex care pathways is vital. The Big Room is a slow burn approach that relies on repeated tests of change and sees meaningful dialogue between stakeholders along the pathway as being key to the delivery of sustained improvement. It is not an approach that can deliver quick fixes to problems.

Accessing appropriate data and data analysis support and identifying ways of measuring impact along a complex care pathway is a challenge. As is often the case in improvement programmes in the NHS, many Big Rooms have found it difficult to secure regular input from a data analyst. Another challenge is finding a suitable mechanism, or suite of tools, capable of capturing and analysing the scale of change across multiple services that flow coaching pathway teams are delivering.

Introduction

Over the past 10 years the Health Foundation has supported the testing, development and evaluation of approaches to improving patient flow, which it defines as ‘the progressive movement of people, equipment and information through a sequence of processes… along a care pathway’. The FCA programme, led by a team based at Sheffield Teaching Hospitals NHS Foundation Trust, is the most ambitious application of patient flow yet supported by the Health Foundation. The team built on work they originally carried out in the Flow Cost Quality programme to improve flow along the urgent and emergency care pathway, bringing this together with elements from the team coaching model and improvement science approaches.

The rationale for the programme is that patients typically experience care in condition-based pathways, and how they move along these pathways has considerable implications for patient experience, care outcomes and pressure on staff. The programme approach is to train health and care staff in the team coaching, technical and relationship skills required to deliver sustainable improvement. The programme is designed to be replicable, with both a curriculum and training materials that can easily transfer to a UK wide network of local FCAs (Figure 1).

Figure 1: Growth of local FCAs through the programme cycles

Disrupted flow has implications for poorer outcomes

In common with many health systems, the NHS is facing pressures of growing demand for services and workforce shortages in a period of constrained funding and this is not keeping pace with rising costs. The Health Foundation analysis shows the number of urgent admissions to hospital has increased by 42% over the past 10 years, with patients having high morbidity and a higher prevalence of long-term conditions. Meanwhile, people living in disadvantaged areas are at greatest risk of having multiple conditions. The harmful and costly effects of delays in patient flow for older patients are well established, including higher mortality, higher risk of health care-acquired infections, depression, reductions in patients’ mobility and their ability to manage daily activities. These are recognised as major challenges in the NHS long term plan, with a number of national initiatives seeking to improve patient flow. The COVID-19 pandemic has made unprecedented demands on health and care services in the short term and continues to have an impact on the delivery of services and the need to redesign these services. In this context, improving the flow of patients, information and resources in and between health and care organisations is crucial to improving efficiency of services and the quality of care experienced by patients. Common disruptors of patient flow, such as disjointed IT and waits between stages of care, have been described in previous reports by the Health Foundation.,

Research shows that not all approaches to flow improvements in health care have resulted in measurable improvements. Beyond small case studies, some of the larger programmes have had disappointing results., Flow projects have mostly focused on a small segment of the patients’ care, due in part to the challenge of working collaboratively across multiple teams, services and organisations. A survey of US acute hospitals showed the challenge of scaling up improvement from micro and meso level to organisational level: while over 60% of respondents were using lean improvement approaches, only 12% reported this as hospital-wide implementation.

Much research focuses on process results from improvement, but the social factors contributing to improvement also need to be considered, such as encouraging and enabling supportive behaviours, team dynamics and culture. These factors help create high-performing services, sustainably achieving excellent safety and quality outcomes., A range of professions, grades, middle managers and data analysts need to be involved with a stake in the intervention. The extent to which clinical and managerial interests align is a key determinant of success in QI interventions.

Several major programmes in the NHS have focused on patient flow.

• Scotland: In 2013 NHS Scotland set up a Whole System Patient Flow improvement delivery programme.
• Wales: In Wales, 1000 Lives Improvement ran the national Patient Flow programme from 2013 to 2015 across all six health boards providing emergency care.
• England: NHS England and NHS Improvement are supporting a 5-year programme from 2016 to 2021, in which the Virginia Mason Institute – that adapted the Toyota Production System and applied it across the Virginia Mason health care system – is working with five NHS trusts to develop a culture of continuous improvement based on lean principles. The Health Foundation in partnership with NHS England and NHS Improvement has commissioned an independent evaluation of the programme, which is due to be published in 2021.

FCA coaching, technical and relationship skills

The course curriculum takes account of the idea that improvement is 80% relational and 20% technical. Expert faculty members teach flow concepts, coaching skills, data skills, patient experience and improvement approaches (Figure 2). Flow coaches also meet in smaller subgroups throughout the course, facilitated by an assigned FCA faculty member.

Figure 2: The flow coaching curriculum

A core element in the ‘flow’ part of the curriculum is the pathway assessment tool, The 5 Vs. This framework is used to assess and understand a pathway, through a focus on the following.

• Value: considering what is important for patients and families.
• Involve: how the Big Room will involve staff and patients from across the pathway.
• Evidence: the metrics that matter – data that helps to understand the system.
• Visualisation: making the evidence visual and accessible to help connect people and data.
• Vision: how the improvement work can shape the future.

The Big Room

The paired coaches support improvement on their pathway through weekly Big Room meetings (run in the same physical or virtual space at the same time each week) where health and care staff and in some cases patients, from the pathway work together to assess, diagnose and iteratively test changes to improve the flow of care. Stakeholders in pathways include all professional and support groups who have an impact on patient care and experience.

In the Big Rooms coaches aim to create an open, honest and collaborative atmosphere where each participant, regardless of seniority, feels empowered to contribute on an equal footing (Figure 3). A key principle is the flattening of traditional hierarchies and the inclusion of staff from a wide range of roles and professions. The Big Room is set up to allow participants to ‘see together, learn together and act together’.

‘Hierarchy is suspended when you go into the Big Room. It gives more junior staff or staff who have a quiet voice the chance to express their views and that’s helped everybody make progress together.’

(Infection prevention and control manager, Big Room participant)

‘There’s great enthusiasm in the room, great atmosphere and it brings together lots of disciplines in one room, with one voice, to make improvements to patient care.’

(Pharmacist, Big Room participant)

‘We kicked off our antenatal Big Room with 20 people from around the trust, setting the ground rules for how we will work together and are committed to keeping women’s voices at the heart of all we do.’

(Improvement lead, Big Room participant)

Figure 3: The Big Room approach

Flow coaches facilitate the care pathway group to share understanding about the patient experience of care, apply the techniques and methods to test out change ideas and monitor the data to evidence progress in achieving their aim. If a change leads to measured improvement, it needs to be incorporated as standard practice. The FCA roadmap for improvement offers a flexible set of steps for the pathway team to follow (Figure 4).

Figure 4: The FCA roadmap for improvement

The co-coaching model

The co-coaching model is a core element of the FCA programme. A lead clinician with detailed knowledge of the care pathway is identified as the clinical coach together with an external coach – a manager or a clinician from outside the pathway – to offer a complementary view. Coaches must be motivated to deliver improvement, with attributes necessary for team coaching. The co-coaching model brings a varied skill set into the partnership and helps build resilience into the programme, reducing the risks of unsustainability through loss of a coach (Figure 5).

Figure 5: Paired flow coaches for each care pathway

‘I am a clinician and [my co-coach] is not … having clinical and non-clinical is better because you bring different things ... [my co-coach] has a greater understanding of the operational-organisational side of the trust: pathways, CCGs, those types of things and I’ve got the clinical knowledge to back that up … if we were both clinical, it might be more difficult to engage some people that aren’t clinical.’

(Flow coach, evaluation interview)

Recruiting and setting up local FCAs

One of the great strengths of the FCA programme is the adaptability of the approach across multiple clinical settings and sectors. The approach has been applied across community and acute pathways, such as a cross-sectoral frailty pathway and a mental health pathway spanning an accident and emergency department, police and community mental health. Initially, pathways tended to be in the acute sector, as hospital infrastructure facilitated the set up of big rooms and, in theory, access to the pathway data. With experience and the shift to virtual meetings, the pathway work is spreading across community and mental health sectors.

NHS provider organisations are invited to express interest to participate and to identify condition-based pathways where the approach can be applied for a specific condition, such as diabetes, skin cancer, frailty or a discrete area of cross-system care, such as end-of-life care or sepsis. The pathway is viewed from the patient perspective, covering different clinical departments and other health and social care providers.

The Central FCA selects organisations to host local FCAs through a rigorous application process. Selection is based on perceived readiness for the programme. The organisation must be committed to improvement, with leadership support at all levels and organisational development, improvement or transformation functions to indicate they are ‘flow ready’.

Iterative learning by the Central FCA has deepened understanding of what contributes to flow readiness, such as identification of a suite of pathways with clear rationale for their selection and initial ideas about how flow coaching might enable improvement. However, it is understood that flow coaching is not a panacea for every quality issue or organisational challenge.

‘A single methodology is unlikely to succeed across a whole trust. We look to use flow coaching when there are flow issues. We also use lean methodology as appropriate and small-scale improvement projects. A Big Room is quite an investment and not necessary for every improvement effort. It is best for tackling thornier issues, where all the stakeholders need to be involved to make improvement happen.’

(Local FCA lead)

Figure 6: The FCA network (November 2020)

Local FCAs deliver the 1-year training programme and deliver ongoing support to their local community of flow coaches. The Central FCA worked with an agency specialising in social franchising to formalise key aspects of the relationship between the Central FCA and local FCAs. Achieving the balance between fidelity to the model and necessary local adaptation is a well-documented challenge in spreading successful improvement from the originating organisation to adopter sites. Local FCA faculties customise the training, using local examples, adding local videos and including data from their Big Rooms. This helps participants understand the content in their context.

Figure 7: Overview – setting up a local FCA

A local FCA initially identifies a minimum of six coaches for three care pathways. The Central FCA recommends that at least four of these coaches should be chosen with the expectation that they will become the teaching faculty and deliver the course locally. To join the teaching faculty all coaches need to complete their training and be coaching a Big Room. Currently the faculty for local FCAs have all been trained by the Central FCA. However, there is a desire to involve local FCAs in the delivery of training once they have become more established, in order to allow greater flexibility for scheduling courses and to free up development capacity at the Central FCA.

As the local FCA faculty delivers flow coach training for the first time, the Central FCA gives advisory support, all training materials, guidance notes and regular support calls over the first year. Before COVID-19 restrictions the Central FCA was committed to providing on-site support to every session during the first year of delivery. This made sure that local FCAs were supported while providing assurance that the curriculum was being delivered as expected and new learning was brought into the network.

Due to COVID-19, the Central FCA are developing e-learning packages and digital resources so the training can be delivered remotely. This will also help reduce the need for travel to different areas across the UK and will open up opportunities to develop shared faculty models across the network.

‘We were quite nervous when we ran the first local cohort, but we had support from the Central FCA at most of the sessions and we feel we’re trusted to deliver it now. It is effectively a franchise model and it needs to ensure the same focus and content, not deviating from the curriculum … We have the script and the template, but we run it in our own personal style.’

(Local FCA lead)

Curriculum co-design sessions with Central FCA and local FCA faculty members identify areas for improvement and highlight why certain elements of the programme are crucial and how these need to be taught.

‘There is a temptation to tweak and adjust the content, especially if you don’t quite ‘get it’. The fact that the Central FCA are so available means you can have that conversation to ensure you fully understand the module before you teach it, rather than change things.’

(Local FCA lead)

The level of support that local FCAs need reduces over time as confidence grows and there is more familiarity with the materials and approach, as well as the experience of running their Big Room pathways.

‘Central FCA are amazing! They’re very supportive and share all their knowledge and materials, and the things they’re developing … It’s very different from a lot of NHS competition culture.’

(Local FCA lead)

Local FCAs can experiment with changes to the format, as long as learning is shared across the programme. One local FCA wanted to have 2-day, rather than 3-day, modules to help clinicians attend without needing formal approval for study leave. However, experience showed that attendance dropped because without the formality of requesting leave it was harder to protect the time.

Successive cohorts of trainees have been able to make better progress with their pathways due to the build-up of collective experience across the FCA programme.

‘So, I think it’s a bit about the fact that the faculty have all done the course. You can teach them to avoid some of the pitfalls that you fell into so that, each time round, the next group of coaches can avoid the pitfalls a bit more easily.’

(Local FCA faculty member, evaluation interview)

‘I’ve gained just as much from teaching the course as participating in it, after two rounds you start to see the issues through a different lens ... we’ve talked about this as a cohort of coaches on faculty now and how we’re just learning more to apply to our own pathways as we teach.’

(Local FCA faculty member, evaluation interview)

Aligning FCAs with organisational strategies for improvement

Local FCAs need to understand how the programme fits with, and can enhance the delivery of, existing organisational strategies for improvement. FCA Devon is unique to date in England as a joint application by the acute hospital trust and the mental health trust, which has enabled work on pathways extending beyond organisational boundaries. However, FCA Devon is also conscious of the need to make sure its activities are aligned with organisational priorities. For example, when a new electronic patient record (EPR) system was the focus of trust level strategic attention in FCA Devon, the flow coaches supported the digital roll out. Their heightened understanding of pathway information flows and interactions between services helped to avoid some of the common pitfalls of EPR introduction.

FCA Lancashire, meanwhile, positioned the FCA programme as an opportunity for clinical leadership development. Getting clinical leaders together in a ‘programmed’ approach has unlocked ways to solve problems that seemed intractable. The FCA programme has brought acute and community teams together, who previously did little joint working. Their frailty pathway now has a shared assessment for older people, whereas in the past each team carried out their own (different) assessment.

‘A medical engagement programme was really important to get the medics on board – you have to be realistic and devote more time and energy to that. Of course, we want nurses and other staff on board, but they are relatively easy – very keen from the outset; medics are the harder nut to crack and it’s vital to get real traction in clinical areas.’

(Local FCA lead)

In contexts where the FCA is strategically positioned in an organisation-wide approach, support and buy-in from senior leaders can facilitate progress and stability for the approach. For example, at Lancashire Teaching Hospitals, the FCA is firmly embedded into the organisation’s improvement strategy as the primary means of driving improvement at the meso level. The trust has responded to the drive from the Care Quality Commission (CQC) and NHS England and NHS Improvement for trust-level commitment and a planned approach to QI. Flow coaching is closely aligned with the overarching capability building approach for the trust and therefore more likely to sustain and develop. Selecting organisations with the right conditions to support the programme is recognised as being crucial.

‘We built our application around our strategic approach with the CEO, medical director and director of quality working together on a vision for delivery of the FCA. We realised success depended on investment in learning about flow coaching as our chosen approach and a commitment to engage with staff, particularly getting the medics on board and getting sufficient numbers trained in the approach.’

(Local FCA lead)

However, in many local FCAs flow coaching is one of several QI programmes operating across the trust and competing for executive attention and organisational resources. Nonetheless, several local FCA leads described how the FCA programme model has helped them to develop a more coherent strategy for QI capability at an organisational level.

‘Although as a trust we have a long history of improvement work and investment in clinical leadership prior to the FCA, I don’t think we had a mental model for what we were doing. This [FCA] gave us a focus for our high-level capability and capacity building, linking pathway development with service transformation ... It gives us the top tier of training to complement the half-day QI introduction session and 3-day QI Leaders’ course that we were already running.’

(Local FCA lead)

Several local FCAs also described how the flow coach training fits into a tiered model of QI training, complementing the Introduction to QI sessions and other shorter courses.

‘We recognised that starting an FCA would complement the QI training we were already doing at a less intensive level and help us get to a critical mass of QI informed, QI trained and, through a local FCA, QI leaders across the trust. But the FCA is more than capability building – it gives us a better way to use the skills of the dedicated central transformation team to support improvement owned by the clinical teams; not to run in and “do unto” the service teams.’

(Local FCA lead)

FCAs with a nationwide reach

The approach for FCA Scotland has been more nationally oriented from the outset, sitting in the NHS Education for Scotland national QI training offers. Recognising the level of existing QI skills and experience across the NHS in Scotland, the delivery pace for FCA Scotland was accelerated. In 1 year, the first cohort of Scottish flow coaches were trained and delivering training to coaches from the Scottish health boards.

FCA Northern Ireland is also working to position the programme as a national initiative. While the drive has initially come from the Western Health and Social Care Trust, the first local training cohort involved coaches from all six health and social care trusts. The logistics of where to hold course sessions has been important, running these in Belfast rather than their Londonderry base to facilitate travel across the country. The development and testing of e-learning resources (such as videos, online seminars, sub-group time and supported Workplace activity) and delivery of virtual training is currently underway and will facilitate national access. For example, FCA Northumbria, FCA Birmingham, FCA Northern Ireland, FCA Scotland and FCA Imperial have completed, or are in the process of completing, training online for their current cohorts.

Strengthening the profile and reach of FCAs

Local FCAs are encouraged to recruit and charge for flow coaching trainees from outside their organisation to increase impact and generate a local revenue stream. The available training slots have been eagerly taken up.

‘The wider clinical management team are now appreciating the power of this. We have seen the skills in action and now we want to work like this across the trust.’

(Local FCA lead)

Local FCAs are keen to develop their academies and to initiate more pathway improvement across their trusts, with a sense of urgency to rapidly train more people to the skill level of flow coaches in the wake of COVID-19.

‘We can’t wait around for a year for this to happen. Services have been deconstructed and we need to reconstruct along the pathways, not purely along existing service lines. We need FCA expertise for this and we need it more speedily than the traditional model.’

(Local FCA lead)

This challenge is being met through the development of an online modular flow coaching course, which will enable local FCAs to train more than the current total of 30 flow coaches per year, and to accelerate the delivery of the programme so it can be completed in less than a year.

This report does not aim to examine the impact of the overall FCA programme. We will be in a better position to explore the overall impact once the findings of the summative evaluation of the programme, which has been commissioned by the Health Foundation, are known. However, some important learning points have emerged from the earlier formative evaluation regarding the steps required to enable the FCA programme to maximise its chances of delivering sustained improvements in care processes and outcomes. As well as discussing these learning points, this section includes local case studies illustrating the impact already achieved by flow coaching pathway teams. These case studies illustrate the potential contribution that the FCA programme stands to make to health and care across the UK.

Allowing time to achieve impact is vital

For many pathways, it is too soon to assess the impact on measurable outcomes immediately after the training. Flow improvements on care pathways need to be sustained beyond the first year to enable the delivery of measurable results. It also takes time for flow coaching pathway teams to identify, test and refine improvements, something that some organisations have found difficult to accept. Several interviewees described how organisations still tend to look for quick fixes for service improvement. They were confident that while the slow burn nature of the FCA intervention takes longer to deliver results, these are more likely to be sustained improvement outcomes and that the coaching relationship is what enables a sustainable improvement.

‘Flow isn’t about very quick turnaround. [It’s] repeated PDSA cycles and … a drip effect that leads to success rather than doing things in a big way very quickly. So that’s been a bit of a culture change that we’ve had to work on explaining. And it’s why it’s important to … take our time and to really understand the problem before we come up with solutions.’

(Flow coach, evaluation report)

‘You have to let the emergent work mature and keep people with you over the 2 years. After 2 years’ investment, you then start to see results. In my experience, it’s worth far more than 8 years of piecemeal QI projects with patchy results.’

(Local FCA lead)

There are challenges in measuring impact across complex care pathways

The FCA programme needs to take a broader view on how impact is measured across the programme. In many ways the pathway work is going beyond what can be measured on SPC charts in response to PDSA tests of change. When communication and cooperation improve between teams along a pathway, all sorts of profound changes in performance can happen. This reduces delays and improves coordination of care, but not in ways that can be clearly linked to a PDSA cycle.

The focus on meso-level improvement across the whole pathway compounds the difficulty, as data need to be collated and integrated from different organisations, which NHS IT systems are not well set up to do, requiring multiple data permissions from different organisations. FCA improvement work is sometimes the first attempt to collect data along the whole pathway.

The Central FCA insights and analysis workstream coordinates the collation and analysis of quantitative and qualitative data on the programme’s impact, including relevant contextual information. This enables assessment of whether observed changes or improvements are a result of flow coaching activities.

The Health Foundation has commissioned Ipsos MORI (in partnership with The Strategy Unit) to undertake a summative evaluation of the FCA. This evaluation will seek to understand the overall impact of the programme during its 5 years of operation.

The capacity and capability to access, collect and analyse impact data is scarce

It is a challenge for flow coaches to identify, access, collect and analyse the data to show improvement and research shows it is a common barrier to health care improvement., The scarcity of data analytical support across the NHS is also well documented. The curriculum co-design meetings have explored how coaches can best be supported to set measures and access the data required, including knowing who to ask for help with data and how this relies on building relationships.

Some local FCAs have a depth of data expertise to call upon and have produced robust data to show pathway improvement. In other organisations, there are only a few Big Rooms that can secure regular input from a data analyst. All flow coaches are now offered a software programme to help with appropriate data analysis. With each cycle of the programme the production of data from the pathways is more robust.

‘The measurement and data modules are the most important QI technical skills for flow coaching. This has traditionally been the weakest area of QI implementation. The whole time series measurement, run charts and SPC approach is new to most clinicians and it’s a revelation. Doctors like data and revel in the robustness of the SPC data – once they ‘get it’.’

(Local FCA lead)

More pathway teams are robustly charting improvement data as the programme develops. The FCA network are encouraged to add their case studies to each local FCA’s dedicated pages on the programme website.

Placing the patient at the centre of the FCA programme is key

Patients are central to the FCA programme, ensuring a focus on improvements that matter to service users. Organisations are actively encouraged to develop ways in which patients can be meaningfully represented in the work, and ultimately where care can be co-produced.

‘We’ve definitely moved up the ‘ladder of engagement’ through the FCA. In the past we used to think we were ‘involving’ patients when we told them about improvement work we were doing, now patients feed into the design of services. It’s all part of flipping the parent/child dynamic of doctor/patient relationships. There’s no doubt that Big Rooms have accelerated this.’

(Local FCA lead)

Some Big Rooms have patient representatives as regular attendees at meetings, although this is more common for long-term condition pathways. It requires a confident patient to become a member of a Big Room. However, there is already evidence that virtual Big Rooms are including patients more frequently than in-person Big Rooms, possibly because (for some people) the logistics of joining are easier. Patients joining virtual Big Room meetings from home feel an equal partner when others are joining from their home, clinic or office.

Patient experience can be highlighted through patient stories, often linked to poor care outcomes. The patient may attend a meeting that is focused on their story, or do a filmed interview. Another technique is to build up a representative patient profile using social and clinical information. This gives a rounded picture of a ‘typical’ patient, so the patient is then central to considerations of tests of change. Other FCAs have used patient shadowing, which follows a patient through all the stages of an outpatient visit. Another technique is the patient diary, where patients record their experience and reflect on it, and share their diaries with the Big Room.

‘We’re using the approach of coaching for existing patient leads to supervise new patients getting involved. It’s all about thinking more deeply about the relationships and expectations, helping people in a new role.’

(Local FCA lead)

Focusing on patient experience helps translate insights from one area of care to others along the pathway who are less aware of the impact either upstream or downstream of these aspects of care. For example, a frailty Big Room drove improvement by highlighting how each day of hospital immobility can reduce patients’ muscle strength, so early mobilisation became a patient-focused goal. Coaches identified the use of patient mobility surveys and analysis of mobility outcomes as a facilitator in increasing patients’ mobility. There was a measured increase in weekly discharges.

While there are some good examples of patient voice in FCAs, these are not universal and realising greater patient involvement is recognised as a major challenge. The ongoing aim is for learning to be shared through the network, so that FCAs, including the Central FCA, can learn from those who are further ahead. By engaging with patient involvement experts in the network, the FCA programme will further develop its model for routes of engagement with patients, service users and the wider public.

Some Big Rooms have carried out advanced patient involvement leading to coproduction of improvement. In FCA Northern Ireland work on the gestational diabetes pathway has involved women at every stage, so the service reflects and responds to their care needs (Box 3).

The FCA programme has had positive impacts on care

While it is too soon to understand the impact of the FCA programme as a whole, a number of flow coaching pathway teams have reported some positive impacts on care. Case studies examining the impact of the work of two teams, the Sheffield skin cancer pathway team and the Imperial sepsis pathway team are described below (see the Appendix for a longer list of example care pathways).

FCA Sheffield skin cancer pathway

Skin cancers have a higher overall incidence than other types of cancer and a wide range of severity, from extremely good prognosis to life threatening. It is often possible to detect skin cancers at an early stage and therefore offer effective treatment for patients. The waiting time target for a specialist appointment after an urgent referral for people with suspected malignant melanoma is 2 weeks or less.

The skin cancer pathway aimed to increase the number of cancer target referrals seen by reducing the waiting time from referral to being seen in the clinic. National targets were being achieved, but the team believed they could improve. Figure 8 shows data for the period from September 2015 to October 2017 that covers a change in practice of collaborative working between consultant dermatologists and consultant plastic surgeons working in a joint clinic. This was introduced in October 2016 and the SPC chart indicates a step-change increase in the number of cancer target referrals seen on the skin cancer pathway, following this change. In addition, the reliability of the process was improved, with less variation in the range of patient numbers attending. After being trialled for several months, this clinic became a permanent fixture of the service.

The pathway improvement had further impact in reducing the number of attendances for patients, reducing time patients waited with a known diagnosis of skin cancer before treatment, from 29 to 9 days and reducing the associated administrative and clinic staffing costs. However, these are harder to show with a classic SPC chart. Subsequent developments have included further joint clinics for complex cancers and the Big Room has been influential in the development of a shared minor operations facility, releasing capacity in main theatres for other essential surgery. The skin cancer Big Room continues to meet weekly and is part of core business for the staff who attend.

Figure 8: FCA Sheffield skin cancer SPC chart

FCA Imperial sepsis pathway

The Imperial sepsis Big Room aimed to improve management of sepsis across the trust to ensure the earliest possible identification and treatment. There were already plans for an EPR alert and it was recognised that processes needed to be developed to give information on the treatment required and to trigger that care to occur quickly and effectively.

The EPR system captures patient observations, such as pulse rate and blood pressure and laboratory results. Certain combinations of observations and laboratory results can indicate sepsis. Using this data, the EPR system produces an alert if there is the possibility the patient has sepsis. The alert prompts an immediate review of the patient and, if they have sepsis, the diagnosis is recorded on the EPR. This prompts the launch of sepsis power plans, detailing the investigations and treatments required. The combination of the alert and the power plans help to make sure the patient receives the right antibiotic treatment.

The Big Room piloted the alert at the acute medical unit at St Mary’s Hospital in London. The alert revealed that several improvements were needed: not just technical aspects of the alert, but also a range of issues around effective communication between staff and departments. The Big Room tested changes to improve the alert system, then rolled it out in the emergency departments at St Mary’s Hospital and Charing Cross Hospital and the haematology service. Improvements have been made to how the alert function works in the EPR and the team constantly refine data collection and feedback to facilitate improvements.

The digital sepsis alert has made a significant impact. The team initially improved identification of sepsis and increased patients coded with a diagnosis of sepsis by 85%, that is, from an average of 26 cases per week to 48 cases per week. They then implemented interventions that decreased sepsis mortality by 23%. Retrospective analysis of the introduction of the alert was associated with:

• lower odds of death (OR:0.76; 95%CI:(0.70, 0.84) n=21,183)
• lower odds of hospital stay ≥7 days (OR:0.93; 95%CI:(0.88, 0.99) n=9988)
• in-patients who required antibiotics, increased odds of receiving timely antibiotics in 60 minutes (OR:1.71; 95%CI:(1.57, 1.87) n=4622).

In short, more patients are correctly diagnosed with sepsis and, of these, more are surviving sepsis too. Research evidence shows that the effectiveness of digital sepsis alerts is mixed. An alert system in the EPR alone may not lead to such a level of improved outcomes. At Imperial, the introduction of the alert was a driver for QI initiatives to make sure there were effective treatment responses to the alert.

In the 5 years from 2015 to 2020, the FCA programme has evolved from an emergent initiative into an evidence-based, replicable approach to improvement at scale and has been adopted at a strategic level by NHS organisations. The training has engaged clinicians and managers as flow coaches and enabled them to successfully apply the approach in their care pathways. The practical support from Central FCA facilitates robust implementation, reinforcing fidelity to programme principles and reducing the chances of poor implementation. The Central FCA and local FCAs are accumulating a growing body of evidence of impact to show that flow coaching can improve care outcomes and efficiency.

The FCA approach has direct implications for patient experience, patient outcomes and pressure on staff. All of these are crucial as services redesign to adapt to the impact of COVID-19 on the delivery of health care. The FCA programme is notable for its flexibility in application across a variety of pathways. The programme is not limited to one improvement intervention or clinical setting. It can support genuine continuous QI along any care pathway. The ability of flow coaches to rapidly respond to the challenges posed by COVID-19 and implement workable solutions has been noted and adds to the programme’s impressive contribution to date.

The curriculum and training style are consistently highly rated by flow coaches, who go on to confidently apply the learning in their services. They have demonstrated an ability to run Big Rooms as a mechanism to improve patient flow. The programme has also shown resilience in the face of COVID-19, moving to virtual platforms to continue the work. A high proportion of flow coaches are remaining engaged over time and are committed to continued learning and growing the approach. The flow coaches use quantitative metrics, improvement science methods and coaching skills to create medium- to long-term improvement, based on understanding the whole care pathway.

The FCA approach is also an effective form of staff engagement. The many positive references to flattening hierarchies and ensuring that all voices that need to be heard are included indicate a wider context, outside the FCA approach, in which staff are often not engaged and not all voices are being heard. The programme shows the creation of working environments, where improvement is jointly produced and owned with the care team and becomes a regular part of the working week.

The programme is showing qualitative impact on care pathways, such as improved information flows through which staff gain better understanding of patients’ concerns and more knowledge of other professionals’ roles. However, these gains are hard to illustrate with purely quantitative measures, so the qualitative data and experience of the care pathway improvement also need to be rigorously reported. In common with many improvement programmes in the NHS, the lack of access to data and analytical expertise to reveal evidence of clinical impact is a challenge. While rigorous data collection and analysis is not yet consistent across FCA programme, the iterative changes to the curriculum and the growing expertise among flow coaches and the FCA faculty is leading to more robust evidence of its impact on clinical outcomes.

An active community of practice among FCA faculty and flow coaches is being built through the FCA network. This will support sustainability and further growth, reducing reliance on the personal engagement of the Central FCA faculty. The growing FCA community are committed to continuing to co-design the programme, sharing experience and co-innovating as the programme adapts to the changing context of health care.

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Big Room care pathway examples	Focus of improvement work
	Aim	Outcome
Abdominal pain	Improve results for abdominal laparoscopic surgery. The trust knew they could improve on national audit data.	Mortality reduced to well below the national average.
Acute frailty	Improve completion of frailty assessment pro forma. Increased to two-thirds of patients having a form completed. Improve direct access to consultants and clerking of falls. Increase the use of a recognised frailty scale to assess patients.	Data showed a decrease in number of patients staying more than 72 hours. Data showed a reduction in average length of stay. Reduced number of emergency visits to inpatient admissions.
Acute paediatric care	Changes in clinical practice to reduce discharge delays.	Changed timings of ward rounds, introduced preparation of discharge summaries on the ward and multidisciplinary working, resulted in reduced length of stay.
Acute respiratory	Reduce patients receiving non-invasive ventilation (NIV) dying in hospital.	Regular training was introduced for accident and emergency staff in the use of NIV and acute respiratory care; use of NIV dashboard to engage MDT staff on NIV bundle.
Antenatal care	Improved experience of care	Reduce length of stay in the maternity triage/day assessment units
Colorectal	Reduce the waiting time for clinic. Reduce the length of inpatient stay. Increase the percentage of patients undergoing laparoscopic resection.	PDSA on allocation of time slots for the clinic was associated with a reduction in the median wait time from 15 to 3 minutes. PDSA on ‘enhanced recovery after surgery’ was associated with a reduction in median length of stay by 1 day, with benefits lost after the scheme ended. There was a significant increase in the proportion of patients undergoing elective laparoscopic resection.
Community dementia	Introduce individualised folders for patients with dementia, to include key service information and contact details, kept at patients’ homes.	Reduced unnecessary visits to hospital across a large rural community.
Diabetes foot care	To improve the quality of care for patients with diabetic foot problems.	The team achieved a 25% reduction in length of stay, with comparison to national trend data. Big Room activity scaled across all diabetes care.
Elective vascular care	To improve the efficiency, patient experience and length of stay for patients receiving elective vascular surgery	Reduction in average length of stay of two days for elective patients.
Emergency care	Improve performance against the accident and emergency department 4-hour target by redesigning the department, room-by-room considering capacity and demand.	From ‘failing’ against the target, the department routinely achieve 96% compliance.
Gastroenterology	Reduce unnecessary procedures associated with unexplained symptoms.	Changes included introducing a permanent part-time health psychologist to work on the pathway and talks by mental health professionals to the gastroenterology multidisciplinary team.
Inflammatory bowel disease	Reduce waiting time for outpatient consultations.	Set up system for virtual consultations.
Lower urinary tract symptoms (LUTS)	Increase the proportion of patients either discharged or listed for surgery.	Changes included physiotherapy for Male LUTS patients, multidisciplinary teaching with over 40 GPs, refreshed pre-clinic preparation, introduction of a urology one-stop clinic.
Mental health (accident and emergency department)	Improve patient experience in the accident and emergency department with a mental health need.	Multiagency Big Room, collaboration between accident and emergency staff, mental health staff and the police.
Orthopaedic surgery	Reduce waiting list times for surgery.	Average length of stay reduced by 2 days, decreased use of blood for transfusions and improved patient experience.
Surgical recovery	Reduce the average total time for patients in recovery room post-surgery.	Changes included development of a recovery standard operating procedure and recovery discharge criteria. Re-design of the day-case recovery pathway.