1. Establish a national improvement board to agree a small number of shared national priorities on which NHS England, with providers and systems, will focus our improvement-led delivery work
2. Launch a single, shared ‘NHS improvement approach’
3. Co-design and establish a Leadership for Improvement programme.

• solving problems together
• making time to understand

• Bringing people together around a common purpose is vital. 
• Including diverse voices, such as patients and service users, can challenge assumptions and help address issues of inclusion, power and paternalism in care. 
• Involving voluntary organisations can help to harness knowledge and skills in local communities. 
• Effective learning communities have trusting relationships and a culture that supports an open, honest and safe learning environment.

• acknowledge past breaches of trust 
• redress and close trust gaps in the present
• build systems to strengthen trust for the future

Guide notes the difference between individual people using improvement skills and having an improvement approach (system).

Section 3 - benefits to the workforce

• Improved workplace culture

• More job control and higher satisfaction

• Development of key professional skills

Section 4 - benefits to patients and society

• Improved access to appts and services

• Smoother flow between services

• Care avoidance through early diagnosis

• Improved safety & care experience

• Improved outcomes through reliable adoption of best practices (GIRFT)

Section 5 - benefits for organisations

• Consistent delivery of safe, high-quality care

• Effective focus of scarce resources

• Cost avoidance (due to improved safety, reduced waste and improved capacity utilisation)

• Delivering sustainable healthcare

• Productivity gains from faster technology adoption (Digital Transformation)

• Improved workforce capability, capacity, recruitment & retention

[read May 2024]

• elephant - emotional brain

• human rider - rational brain

• sell the idea to the human brain and provide clarity. unblock the path for the elephant.

[listened Nov 2023]

[accessed Nov 2023]

[read Dec 2021]

I didn't know what Gemba was or seeking to understand - but its what I was doing.

Go to where the work is done, listen to the people closest to the problem.

Needed teams who could:

• empower - bottom up decision making

• shared consciousness AND mindset

• high trust and clear purpose

• a sense of whole picture

Alternative to traditional Taylorism (foundations in industrial revolution, hierarchy focused, division of labour, standardisation), helps reduce the risk of hitting the target, but missing the point.

Decentralised teams are able to reconfigure quickly to changing needs. High level of psychological safety, permission to act / controlled risk taking etc (links to Amy Edmondson, Teaming etc).

[NHS elect webinar April 2024]

• Building a environment for improvement

• Avoid initiatives (move towards CI)

• Get the problem right (including co-design)

• Comms (right message to right people)

• Enable learning to occur (CI mindset)

• Contextual experience (adapt to the needs of the customer, apply lived experience)

[read May 2024]

Recap of sessions from Confed Expo

• hard versus soft side of improvement (science versus people)

• 'split screen thinking' - how we do things better and how we do better things

• ambition to reimagine healthcare (transformation). population approach, place based care etc

• NHS Impact and beyond (wider partners)

• Hierarchical change doesn't really work anymore - we need to reimagine leadership. Leaders move to the top to the centre of an ecology

[read May 2024]

10% Education through formal learning

20% Exposure through social learning

70% Experience through day-to-day tasks and practice

2: Learning - "Based on what I learnt this is what I plan to do differently"

3: Behaviour - "This is how I am working differently", Are learners able to teach their new knowledge and skills to others?

4: Results - demonstrate why this training was good business sense, what is the return on investment?

Lean leadership is about creating more value for ALL stakeholders (including team members, not just shareholders)

• Element 1: To Serve and Develop People

I believe this is the most crucial role of a leader. Development needs to be intentional, planned, and purposeful.

• Element 2: Through Human Interactions and Relationships

Leadership is a relationship. As Lean leaders, it’s easy to get caught up in the processes, but we have to keep in mind that organizations are made of people while work is made of process. 

• Element 3: Toward the Achievement of Goals that Support Purpose

Goals should support purpose, meaning we’re developing people through our relationships to achieve the goals that move us closer to True North. 

• Element 4: Creating More Value for All Stakeholders

This is Respect for People and Continuous Improvement.

"If you didn't have competing tasks or non-value add activities to do, and you could choose what to do, what would you do first? What would you do next? What do your team really need from how? How do you create and enrich value? How do you develop people so that they can better and more easily achieve the goals that support purpose?

What are the activities you would do if THAT was your role (developing people)?"

TPS master and Ohno disciple Nampachi Hayashi explained it this way:

“There is no magic method. Rather, a Total Management System is needed, that develops human capability to its fullest capacity to best enhance creativity and fruitfulness, to utilize facilities and machines well, and to eliminate all waste.”

The starting point is to take developing leadership seriously and recognize that short training courses or workshops or coaching leader standard work for a short time will not fundamentally change how your leaders think and act. At best, the people being coached will become more aware of certain things and develop a new vocabulary. But when faced with a real situation, especially under stress, they will likely revert to what comes naturally. 

-- When FHFT want changes NOW, how do we get them to see and commit to such a long and all encompassing programme of change?

[read July 2024]

• Capture change-in-flight – Understanding what’s changing as opposed to just the change.  

• Evaluate change over-time in as real-time as possible and with a rich blend of quantitative and qualitative methods 

• Use observational methods to generate the type of real-time processual change understanding which is needed 

• Be flexible in our evaluative designs 

• Broaden our perception of evaluation to focus on learning 

• Nurture a culture openness, trust, and being critical friends 

If your focus on process is combined with respect, humility and other guiding principles then we can cultivate true continuous improvement and accelerate our progress towards sustainable excellence.

Connect to the purpose is a key role of a leader - are you doing that?

You can set expectations but you cant set culture.

Culture = outcome

Climate = process (If it can be observed, it can be measures. If it can be measured, it can be improved)

[listened Aug 2024]

"Planning your training should include thoughtful approaches to engagement, learning, and actionability. Ask yourself: is your training built in a manner that will lead to meaningful participation? Is your training successfully going to bridge key knowledge or skill gaps? And last but certainly not least, is your training going to lead to the desired shifts in behavior in the long run?"

So here is a good new article about how to make workplace training work. Advice incudes:

1) Be clear about the purpose of the training & consider ways to reinforce learning from one-off sessions: continuous learning opportunities are needed to foster long-term change.

2) Omit content rather than condense it: too much information can keep participants from retaining any of it

3) Equip people to know what questions to ask, rather than assume the training will give them the answers

4) Acknowledge the wider benefits of training sessions, such as building rapport, creating collaborative opportunities, generating ideas & fostering a sense of community around specific topics or initiatives

[Read Sept 2024]

2) Discipline: everyone understands the strategies, objectives & deliverables of their peers so they can work together interdependently

3) Drive: the team prepares carefully, debates constructively & is industrious & resilient over the long term

4) Dynamism: they treat change as constant & positive

5) Collaboration: the team creates the psychological safety needed to give and take feedback, listen actively, brainstorm, solve problems & hold themselves accountable:

?? What incremental changes will shift the paradigm?

"Some transitions are more predictable than others, like an office or house move. Others involve an evolution into the unknown and an accompanying transformation, a dissolving of old identities. These are complex, and they can create a lot of anxiety and grasping for old certainties. It is in contexts like these that we are invited to let go of our maps and once again become wayfinders."

"But we cannot separate ourselves from our contexts. We are not independent agents observing, acting on, and changing the system. We are embedded in the context and co-evolving with processes of transition and transformation already happening at multiple scales."

"It is about becoming comfortable to know as you go, not before you go (Tim Ingold). Thinking and planning are helpful, but they are prone to create stuckness in uncertainty. We will never feel we know enough; only by moving and experimenting do we learn to find our way"

2.Build awareness of the interconnected elements that enable sustained improvement and the methods and tools that can drive success

3.Ensure meaningful opportunities for wide-scale collaboration and learning between those leading and those supporting improvement.

4.Focus improvement approaches and methods on the most promising and critical areas. 

5.Ensure organisation- and system-level change strategies have a simultaneous and sustained focus on improving quality and productivity.

• Valuation: Consider why a particular task is important to you. Think how your “future self” will feel when it is done.

• Specificity: Define a task in specific terms coupled with a specific day, time, and place it will be done.

• Externalize motivation: Use pictures, quotes, or other inspirations to reinforce your plan.

• Coping thoughts: Anticipate how you might rationalize task avoidance and develop task-oriented responses. Develop strength-based mindsets to promote follow-through, such as building endurance and recognizing which of your personal characteristics can be used.

• Normalize discomfort: Acknowledge that you won’t always “be in the mood” for a task but can still engage with it.

• Emotions as sensations and information: Just because the task (or its anticipation) feels uncomfortable does not mean that it is bad. Most, if not all, goals require facing some discomfort to achieve. You are investing your discomfort to achieve a goal.

• Initiation step: Define the smallest step that, when you do it, by definition will mean that you have started and did not procrastinate.

• Follow through with the implementation plan: Get started, see how it goes, and review the results.

• Learn from slip-ups and practice self-compassion: Modify your plan if it did not work. Be kind to yourself if you simply did not use your plan—the relapse rate for procrastination is 100 percent for everyone, so each time is a chance to learn and grow.

1. Lean Isn’t Just Tools: It’s a cultural transformation—a way of thinking that permeates every corner of your organization.

2. Engage Your People: Employees are your greatest assets. Involve them in problem-solving, innovation, and continuous improvement.

3. Leadership Matters: Leaders set the tone. Their commitment, adaptability, and vision drive Lean success.

4. Results Speak Louder: Real-world case studies—from Toyota to Starbucks—show that Lean isn’t theoretical; it’s practical and impactful.

10 point

3 - engage staff in improving their work on a daily basis to improve wellbeing and enhance joy and pride in work

4 - develop the skills and capability of NHS managers and leaders in improvement and system leadership

6 - build on the successes and expertise of NHS teams (GIRFT, ECIST etc) expanding their reach and aligning their impact

8 - engage patients and communities as full partners in ideas and decisions about the way care is delivered and received

• fully referenced

Consider FXIS as a social movement. Not too down or bottom up.

Links to further reading about behaviour models, change theory and communication (including kotter)

1. Leading with Faith (Leaders have to believe or at least show up)

2. Imbuing rituals with meaning (used to achieve strategy + planning, performance management, improving operations, learning, team engagement + relationship building) - these are the same ambitions of FXIS

3. Being religious about participations (make it just as important as other work duties)

4. Keeping the faith but adapting the practice (review every 6-12 months)

5. Spreading the word (preach! share with others) - like when previous waves come along to class

[read Jan 2025]

I like the use of plain English.

"encourage all staff to initiate and test small changes in a safe-to-fail environment" - dont need improvement teams permission

"track outcomes through local reporting systems" - dont need to tell improvement team what you are doing

• world uncertainty is here to stay (its not just covid, it was already trending)

• speed of change is also increasing (see power of super computers)this can feel overwhelming as an individual and as an organisation - the longer you wait the bigger the gap will get!

• kotters 8 steps are now a 'group' you can bounce around rather than linear.

• we are hardwired to fear some kinds of change and embrace other kinds

• Survive triggers for me - uncertainty, short deadlines, change in priority, ambiguity

• Thrive triggers for me- shared purpose, being valued/trusted, teamworking, permission to act

• What questions can you ask to activate Thrive and mitigate Survive? How do you reduce the noise from survive? (do you need to RAG/report all 150+ metrics etc)

• Fuel survive - celebrate progress!!

• [attended book club Feb 2025]

Focus on relationships and trust

Encourage experimentation

Value local insights and contextual knowledge

Strengthen systems to adapt and innovate in real-time

Anchor decisions in shared values

Connection to strategy. How does this link to application of FXIS.

*Key Takeaways:*

*Definition & Challenges:* Improvement huddles are a popular topic, but to have a lasting impact a cultural shift is essential, this is more than just a tool.

• Improvement team trains service-level teams in improvement methodologies beyond just PDSA cycles.

• Use a bespoke improvement board to help focus,

• Aim for daily huddles with ongoing visibility of improvements, even outside of meetings.

• Some have huddles taking place daily or twice weekly for 15 minutes. First 5mins to discuss the big problem they are trying to solve as a team. Then the following 10mins used to cover medium and small ticket items.

• Coaching support is crucial, and ensuring everyone’s voice is heard is key.

• Consider whether to capture names or not (by avoiding using individual names, prevents confidence issues and hierarchy barriers).

• Successes should be celebrated.

• Clinical teams tend to engage more than non-clinical teams.

• Plan for virtual options to support inclusivity.

• Covers operational aspects such as length of stay (LoS) and delays.

*Conclusion:*

The success of improvement huddles depends on cultural change, strong engagement, and adapting the approach to suit the needs of different teams.

Resources shared at the session have been uploaded to the NHS IMPACT Futures workspace and can be found here: https://future.nhs.uk/NHSIMPACT/view?objectID=61836592

"Leaders should not think of these as a tick-list of problems to be solved, rather as ongoing workplace realities to be navigated."

Discusses importance on focusing on improving processes rather than improving outcomes (mirrors my thinking about FXIS scorecards)

Encourage gemba after class - go see what you learnt about

Value of going to different sites and industries - similar issues and strategies cross cutting themes and learning "industry agnostic"

Gemba skills- Apply humble inquiry, what works in practice, where are the bottlenecks, give feedback, reinforces academic learning

Virtual gemba -

-‘dead ideas’ in change management persist because they align with simplified assumptions about human behaviour, overlooking the roles people inhabit, the heuristics they rely on, and the multiple identities they navigate in organizational life

--organizational change is a top-down, linear process, driven by leaders and implemented by followers..

--change can be ‘managed’ like a project through predictable phases and sets of deliverables..

--resistance to change is a default human response, and not the product of people’s rational experiences under conditions of threat rather than conditions that enhance their individual identities or the organizational identity..

--change management requires individual leaders rather than shared leadership and collective action among formal and informal leaders working with followers..

--change occurs within bounded organizations rather than through organizations, co-produced with wider social, political, and material shifts.

INSTEAD ... recognize the complexity of organizational life, honour the lived experiences of those navigating transformation, and call for collective agency.

[read Sept 2025]

"In practice, there is a tendency to give significant attention to Lean tools and techniques but reducing Lean to a toolbox risks reducing recognition of the need for the cultural change and leadership behaviours required to deliver improvement"

• cognitive overload is common - changing the experience, changes the performance

• leaders must find ways to build cultures of trust and experimentation (talking about application of AI)

• authenticity, vulnerability, resilience and courage - high accountability leadership

• also applicable to teaching improvement and huddle theory. Focus on principles and practice, allow learners to sit with the uncomfortable until it becomes natural.

• Principles instead of rules allow local adaptation without losing meaning

Might be helpful for writing up FXIS or case studies

[read Dec 2025]

• Attention

• Equality

• Ease

• Appreciation

• Encouragement

• Feelings

• Information

• Diversity

• Incisive questions (could replace with curiosity)

• Place