NIHR_SDO_Lean_Propos.. - Durham University

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Nov 16, 2013 (3 years and 6 months ago)

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Research
o
utline


Introduction, aims and objectives


In the North East of England t
here is a
regional paradox of having high quality, high
performing health services but relatively poor population health

(Department of
Health
and APHO
2008)
. The
North
East Transformation System (
NETS) aims to
promote
continuous improv
ement
to

improve processes and clinical outcomes.

The
aim
s of this research proposal are

threefold: i)
to provide a comprehensive evaluation
of NETS
;

ii)
to identify
lessons for the adoptio
n of lean management in the NHS
;

and

iii)
to
build on

the evidence base on lean management in public services.



The NETS initiative

to bring about change and reduce waste

comprises

three elements
known

as the ‘three
-
legged stool’: vision, compact and met
hod
.

NHS North East
regards

t
he three elements
as
mutually reinforcing and
their alignment as essential for
the success of

the transformation process



a key issue for the proposed evaluation to
explore
.

The vision of NHS North East
,
set out in the 10 year strategy arising from
the
NHS
next stage review (NHS North East SHA 2008)
,

i
s to be a leader in
excellence in health improvement and health care service
s
.
It

has seven aims: i) no
barriers to health and well being; ii) no avoidable d
eaths, injury or illness; iii) no
avoidable suffering or pain; iv) no helplessness; v) no unnecessary waiting or delays;
vi) no waste; and vii) no inequality.


The

objective of the
second element


the

compact



is to
shape

the
psychological
contract bet
ween clinicians and the institutions in which they work

to facilitate
transformational change
.

Change

occurs within the context of

the
organisatio
n’s

culture

(artefacts, values and basic assumptions)
, processes, systems and structure.


The final element is

the method


the Toyota
P
roduction
S
ystem (TPS) and Lean


which seeks to

improve processes, quality and efficiency through standardisation,
eliminating waste,
and
reducing variance
.

The research will

address the two levels of
evaluation identified in the

call:

(i)

evaluate

the

effectiveness of the

change strategy
(the ‘three legged stool’
); and

(ii) investigate the impact of the introduction of the

TPS
in the NHS North East

on clinical behaviour

and outcomes,
assessed

in the context of
the vision

and drawing on evidence from both the health service and manufacturing
sectors
.


This initiative is
of
national and
inter
national importance

because
NHS North East

is
the first
Strategic Health Authority (SHA) to
adopt a region
-
wide strategy that aims to
transform an
entire healthcare system
.

Th
e

initiative is ambitious because the

SHA

serves

a population of
2.6
million

people

and
the
NHS

in the region

employs

72,000
staff.
Previous
ly,

implementation of
L
ean
in the NHS
ha
s involved

relatively small
scale
interventions, for example applying Lean tools within a particular hospital.
NHS
North East is committed to addressing

more complex
system wide
issues
,

including

culture and the relationship between clinicians and managers
. This is

in keeping with
the NHS
next stage review conclusions
about how to ensure successful service
redesign
(Department of Health 2008).

The results of the evaluation
will

therefore
be
of national and international significance
.



2

The NETS

started with
seven

P
athfinder
s

that

represe
nt
a

wide
range of NHS
organisations
,

including

the SHA, P
rimary
C
are
T
rusts
,

acute trusts and

mental health
trust
s
.

The initiative
is

based on the Virginia Mason Production System (VMPS),
which is a form of the TPS applied to healthcare.

Lean
is being

impleme
nted through
a series of Rapid Process Improvement Workshops (RPIWs) supported by
the
NETS
and
staff from
Virginia Mason
Medical Center in Seattle
that has pioneered the
application of Lean in healthcare
.

NHS North East commissioned a six month scoping
stu
dy
of this initiative
by

the applicants

to capture initial developments
.

A draft

report
was completed in July

2008
and provides a platform for this

propos
al

to

evaluate
fully
the NETS initiative.

It has guided the research questions and issues to be explo
red
and, as a result of the knowledge acquired and contacts made, will enable the research
to begin without delay.


The
proposed
research

is centred on

a

longitudinal study that

utilises
a mix of
qualitative and quantitative methods. It will be conducted
by a multidisciplinary team
with extensive knowledge of healthcare policy and practice
,

health management
,

the
NHS in the North

East region
,

and the implementation of Lean in the North

East
.




The research will
:



evaluate
the
impact of the
NETS

and how
pro
cesses and outcomes

change
over time




assess

the receptiveness of Pathfinders to transformational change
, including
the adoption of the TPS



determine
, on the basis of macro and micro level analyses,
how

NETS and
RPIWs
improve the quality and efficiency of
care

in terms of

technical
quality, safety, patient experience, access,
and
equity



evaluate

h
ow

RPIWs
work

or what
stops
them

from working
, identifying
f
actors that facilitate
,

or hinder
,

the intervention from
succeeding



e
valuate

t
he role of the NETS
proje
ct
team in coordinating progress and
supporting the transfer of learning



provide mechanism
s

for identifying and disseminating best practice.





T
he

research has
six

objectives:

I.

review the evidence in three
key
areas: change
management
in health
systems
;

the
adoption of
TPS/
Lean (and related) thinking in health care organisations
; and
learning from Lean in the

manufacturing sector wh
ere it has been widely adopted.


A preliminary

literature review

in respect of each of these areas
was completed as
part of the scoping study

II.

ascertain how far
the
NETS has
improved performance
(
eg reduced waiting times
and waste
,

reduced variation across specialties, departments and hospitals
)

III.

evaluate

how far
, and in what ways,

the

compact


has
helped to change

the c
ulture
in NHS organisations

to facilitate the transformation process
; in p
articular
, what is
the nature of the

commitment of clinicians t
o the
NHS North East

vision and how
do
the
y

participate in
its

management
?


IV.

establish
the extent to which

staff feel empowered and enabled to take control of
their work

V.

evaluate

the extent to which

the changes have become embedded
in order to

ensure
sustainable change

VI.

evaluate

the effect of

the transformation process

on service users

(eg

patients or
carers an
d/or family and friends
)
.






3


Relevance to SDO call for proposals

The focus of the proposed evaluation is on the NETS



vision
, compact and method



and its role in achieving transformational change within a region
-
wide healthcare
system.
The resea
rch strategy is based on the set of drivers for change identified in the
call for proposals. These are intended to:




reduce variation across specialities, departments and hospitals



free up professionals to use their skills and knowledge to focus on diffic
ult cases



achieve better work
-
life balance for staff, reducing work
-
related stress



make a reality of the compact with doctors in order to secure their commitment
to the purposes of the NHS in the North East



empower staff to take control of their work



sus
tainably embed new ways of working.


The proposal is directly relevant to the call

because

the team assembled for the
research undertook the

scoping study
which prepared the way for this call. The team
is therefore

uniquely
well
-
placed to conduct the full evaluation.


Background, including NHS context and relevant literature

A wide
and diverse
body of literature is relevant to the call, notably, the professional
and managerial interface in health systems
;

organisational culture
;

managing
and
leading
with power
;

complex adaptive systems
;

and the evolution of TPS/Lean
thinking in both the wider
public sector and
industrial and manufacturing context
.



The distribution and exercise of power between health car
e professionals, notably
clinicians and managers
,

and its interplay with politics
is a long
-
standing and central
feature of

UK
health policy (Hunter 1980; 1992; 2002;
2006;
Harrison et al 1992;
Degeling et al 2001;
Davies and Harrison 2003;
Blackler 2006;
Sheaff 2008). The
tension between managerial and professional values underpins the rationale for a
compact which is a core element of
the
NETS.
A g
rowing dissonance over what
professionalism stands for in the NHS
,

and over what clinicians and others expec
t
from their work
,

is evident from successive reforms over the past 30
plus

years. The

psychological contract


or

compact


is a useful concept both to explain the problem
and to begin to tackle it (Edwards et al 2002; Silversin and Kornacki 2000 and 2002
).
Research
at Durham University
by Degeling and colleagues, including one of the co
-
applicants (Maxwell), on NHS modernisation highlights the need for a management
approach that is

congruent with professionalism
rather than running counter to it
(Degeling

et al 2006a and b).



Schein (1985)
acknowledged the impact of culture on organisational behaviour and
performance.
Mannion
et al
(2005)

confirmed this in the NHS context.

Culture
constitutes the informal social aspects of an organisation that influen
ces how people
think, what they regard as important, and how they behave and interact at work

(Mannion et al 2005)
. However, there is no simple cultural prescription for the ills of
the NHS. What works is contingent upon context ‘and on how and by whom e
fforts
targeted at culture reform are evaluated and assessed’

(p.
214
). Culture has
implications for leadership styles with West
er
n (2008:

33
) arguing that much w
ork

on
leadership ignores context when in fact ‘the experience on the ground may be that
there

is little room for
seizing the future

and
empowering others
when the context

4

feels disempowering due to a production
-
line atmosphere where success is measured
against meeting targets and deadlines’.

S
ituational leadership is therefore a more
useful concep
t in the context of complex adaptive systems of which
the
NETS is a
good

example.


There is a growing literature on the value of Lean systems in the NHS (eg McNulty
and Ferlie 2002; Jones and Mitchell 2006; Fillingham 2007; Green 2007; Esa
i
n

et al

2008;
Papadopoulos and Merali 2008; Lodge and Bamford 2008; Proudlove
et al
2008).
These examples
demonstrate that
success
or failure is

context
-
dependent
. A
strategic approach and leadership commitment as well as effective communication
and realistic timescale
s
are needed
to bring about change.

T
hese studies have
examined the impact of Lean on a hospital
,

department or service

and therefore none
approximates to the scale or ambition of the NETS
.



Evaluating organisational innovations in the NHS to establish ‘
what works’
and what
may prove suboptimal in their impact
is fraught with difficulties (Pope 2008).

Capturing
the ‘dynamics and effects of time, process, discontinuity and context’
to
understand the impact of complex interventions poses a particular challenge to
researchers
(Pettigrew 2001: 697).

It may be that
the notion of path dependency
prove
s

to be a more accurate determinant of the fate of organisational change in the
NHS than
theories of change. Wilsford (1994) argues that

inertia
stemming
from

previous decisions
,

and existing institutional arrangements dominated by powerful
structural forces
,

result in
policy
changes that

are typically incremental
and partial
.
They require str
ong pressures to succeed which

might
take

the form of what
Pettigrew

et al
(1992)
,

in their model of
‘receptive contexts for change’
(see

below
)
,

term

environmental pressures


or what Gould (1990
)

calls the concept of ‘punctu
ated

equilibrium’
.







Plan of investigation

The re
search will
comprise a three year

longitudinal case
study
design to evaluate the
transformation process

and assess the degree to which
either path dependenc
y

holds

or
the
NETS
is a

product of ‘punctuated equilibrium’ in the NHS
’s evolution
.

Seven

case

studies

will be selected from the
seven
Pathfinders. Qualitative and
quantitative

data collection methods will be used to analyse processes and outcomes. These will
include
:

semi
-
struc
tured interviews,
focus groups,

document analysis,
process
mapping
,

and interrupted time series.

The data obtained using these multiple methods
will be analysed within and between cases. This will allow the research to identify the
impact of the transform
ation on processes and outcomes. The research will utilise
Pet
t
igrew et al
’s

(1992) model of

receptive contexts for change

developed in
a study
of strategic change in the NHS
. Systems models will provide a
link between the
qualitative and quantitative me
thods. They will create a
framework for
understanding
and analysing

multi
-
level processes and their relationships to
outcomes.
The results
will be
critically
compared with evidence from the literature.
D
etail
s

of this research
strategy are
provided

in the
next sub
-
section
.

Through the scoping study, the research
team has already established contact with key personnel in each of the Pathfinders and
the NETS project team at the SHA.


Methodology

The
research will adopt a longitudinal comparative case

design
.

Case studies will be
conducted
in

each of the Pathfinders

(n=7)
,
build
ing

on and
extend
ing

the preliminary

5

analysis undertaken during the scoping study.

Q
ualitative

and quantitative

methods

will be used to evaluate context,
content
, processes
,

outcomes an
d changes over time.

As Berwick (2008: 1183) argues, many assessment techniques developed in
engineering and used in quality improvement, including statistical process control and
time series analysis, ‘have more power to inform about mechanisms and contex
ts than
do RCTs, as do ethnography, anthropology, and other qualitative methods’.
Quantitative data
are

useful for triangulating the findings obtained using qualitative
methods. The qualitative data are useful for understanding the relationships and trends

identified by quantitative data.
The qualitative methods will focus upon process,
whereas the quantitative methods will be outcome based.


Process evaluation

Qualitative d
ata will be collected through
a combination of
semi
-
structured interviews

and

focus
groups

involving each of the 7 Pathfinders. A content analysis of key
policy and other relevant documents will also be undertaken.


Data sources

and collection

The interviews

will be conducted
with various stakeholders including managers,
human resources, the NETS team, clinicians, administrators,
health improvement
staff
,

Virginia Mason
Medical Center
,

and Amicus
consultants.

This
component
will
include interviews before, during and after sele
cted interventions.
The strategic
choices made by

the
P
athfinders will be compared during the pre
-
implementation and
implementation stages. A comparison will be made of the initial conditions, resources,
capabilities, and culture in each of the
P
athfinders
.
We anticipate conducting around
70 semi
-
structured interviews in total in Year 1. They will be repeated in each of the
following two years. The interviews will be recorded, transcribed and subjected to
thematic analysis
using NVivo and
based on a combina
tion of grounded theory and
Pettigrew et al’s framework (see below).
To supplement the interview

data
, staff will
be invited to keep a diary
,

ideally

in a web
-
based format.


Such blogs would take the
form of reflective accounts regarding impressions and i
mportant events as they occur.



We envisage focus groups serving two purposes. First, one focus group per
Pathfinder

(n=7)
,

comprising a maximum of 10 participants

per group,

will be held in
year one
. The
se focus groups

would
be aimed at

staff not spec
ifically tasked with
change responsibilities and not selected for interview.
T
hey would allow the research
to capture the views of ‘followers’ as well as change ‘leaders’. Late in the second or
early in the third year, depending on progress with the case studies, focus groups
would be held in each Pathfinder
(
n=7
) as

a means of feed
ing back interim findings
and checking on their robustness. A second purpose for focus groups is to

evaluate
the impact of the NETS on service users
.


In years one and two, we

will conduct up
two
focus groups
(n=4)
with relevant
user and
patient and carer

groups

from across
the region in order to gather their views on the impact of service delivery and
outcomes rather than the NETS initiative itself since it is unlikely that users will know
what it is.



The policies developed in order to adopt TPS
,

such a
s the
selection of
clinical and
non
-
clinical processes for the RPIWs, the selection of staff for training, the level of
training, and decisions on the redesign of processes
,

will be compared and contrasted.
Any impediments to the adoption of TPS, such as
lack of absorptive capacity

(Cohen

6

and Levinthal 1990)
, lack of management and/or employee commitment, inadequate
staff
training
,

will be identified.


In addition to

interviews and focus groups, a

range of documents will be analysed

relating to each case s
tudy
,

including
relevant national and regional
policy documents,
local strategies
,
and
NETS training materials
. H
istorical and current statistical data
will be collected
for

interrupted time series analys
e
s.
Secondary data used by the staff
engaged in the RPIWs will be collected and analysed.
Th
ese

will typically include:
information on standard work, flow diagrams to identify the movement of people and
materials, lead time observations, value stream maps (pre

and post intervention);
measures of performance used, together with associated historic
al

data. Th
ese

data
will provide the information required to understand the change in the processes
resulting from the RPIW, together with preli
mi
nary information on th
e outcomes

(see
below)
.


Analysis

The Pettigrew et al (1992) model of the

receptive context of change
’, derived from a
study of strategic change in the NHS,

will underpin the

evaluation of the ‘three legged
stool’
. It comprises eight factors: i)

quality
and coherence of policy; ii)
availability of
key people leading change;
iii) long
-
term environmental pressure to trigger change;
iv)
supportive organisational culture; v) effective
managerial
-
clinical relations; v
i
)
cooperative inter
-
organisation
al

network
s; vi
i
) simplicity and clarity of goals and
priorities;
and
vii
i
)
fit between
change agenda and its locale.

The approach considers a
pattern of association rather than direct causation between independent and dependent
variables (Pettigrew 1990). The model

considers receptive and non
-
receptive
conditions for change which are dynamic and reversible through changes in personnel
o
r

management action. The approach identifies patterns in processes and recognises
emergence, possibility, precariousness and iterati
on.
The model is based on the
following principles: i) change is studied over time in the context of interconnected
levels of analysis; ii) change is considered in terms of the past, present and future; iii)
the relationship between context and action

is e
xplored
; iv) change is considered to be
neither linear or singular.

The model will be used as an analytical tool to evaluate the
transformation process and outcomes in the Pathfinders.



The evaluation will identify the issues and problems arising from the

transformation
process.

For instance, t
he scoping study revealed that
some Pathfinders had

emphasised different aspects of the ‘three legged stool’

with s
ome

concentrat
ing on

methods, wh
ile

others had focused on leadership, compact and vision.

Language was
also an issue.
T
hose interviewed used the same terms
but
it was evident that t
hey

attached different meanings to

them.
The multiple case study approach
proposed
will
adopt a
pluralistic evaluation (Smith and Cantley 1985)
framework to

capture

these
variations
.



The analysis of qualitative data in terms of the Pettigrew
et al
mod
el

will consider a
range of ‘soft’ issues relating to standardisation, organisational culture, change
management, barriers to change, required changes in policy, leade
rship style, medical
practice, employment conditions, the role of line management and consultants in
implementation and so on.



7

At the implementation stage, comparisons will be made
with

how TPS has been
adopted and its impact on the service process. This
will include the training of staff to
monitor the process and to experiment and solve problems. The next task will be to
investigate how TPS has been consolidated in each
P
athfinder. This will include the
impact of TPS on the performance of the respective

services and the development of
new competencies. The extent of roll
-
out of TPS across clinical and non
-
clinical
services in each of the
P
athfinders will be investigated.
The success of the TPS will be
established in terms of
: i)

avoidable deaths, injury
and illness; ii) unnecessary waiting
and delays; i
ii
)
the level of standardisation of practices,
i
v
)
the reduction of waste
,

mea
sured using value stream maps
; v
) reduction in lead
-
times a
nd process
t
im
e
s; v
i
)
other measures such as occupancy, use of
surgery rooms, readmission rates and length
of stay.


Outcome evaluation

Q
uantitative approaches
will be used
for evaluating data from the case studies.
The
potentially quantifiable benefits of
the
NETS include: quality of care (covering
technical quality,

safety, patient experience, access, and equity, mapping to the
ii, iii
and iv

aims of the NHS North East vision); and improvements to individual processes,
e
.
g
.

timeliness, cost, and other efficiency indicators of the ‘removal of waste’
(mapping to
aims v

and vi
).
Q
uantitative data
will be collected
at
the
macro
-
level
,

including comparisons of routinely available data with non
-
NETS organisations
.

A
t
the micro
-
level,
the impact of
the
RPIWs

will be evaluated

using a controlled
Interrupted
T
ime
S
eries (ITS)
design.


ITS designs utilise multiple observations
over time
that are ‘interrupted’ usually by an
intervention or treatment (Cook
and

Campbell 1979). They are used to improve
before
-
and
-
after designs (Campbell
and Stanley
1966) which cannot answer important
questions such as: did a trend in a parameter exist before the intervention? Did
external factors such as policy changes introduced during the same time period as the
intervention influence the findings? Were the changes

sustained after the intervention
or did they begin to return to the original level? ITSs are further strengthened by the
inclusion of one or more control groups. ITS designs allow for the statistical
investigation of potential biases (as above) in the es
timate of the effect of the
intervention (Draper 1981; Box
and

Jenkins 1976).
Short time series need to have at
least three observation points in

each of the pre
-

and post
-
intervention phases
(Crosbie
1995). Therefore
,

data will be collected retrospectivel
y for at least three time points
pre
-
intervention
,

and prospectively for at least three time points post
-
intervention.


Data and data sources

At the macro

level routinely available measures

of
the
potential benefits

will be
examined
.
Using data such as inc
ident reports by type, waiting times and Hospital
Episode Statistics t
he performance of
P
athfinder organisations will be compared with
other organisations regionally and nationally.


We aim to evaluate a
t least one RPIW within each case study using ITS (i
e
7
).
The
research will focus on RPIWs which commence after the onset of the research.
The
RPIW studies will consist of multiple observations
over time

that are ‘interrupted’ by
the RPIW intervention
, with the time point
specif
ied

as the RPIW week.
Outcome
measures (clinical measures, such as percentage compliance with a standard; or
efficiency measures) will include: i) the outcome of the targeted change; ii) ‘halo

8

effect’ indicators (indicators of change that could be hypothesised to also occur if
the
targeted change is successful); and iii) indicators of unintended consequences. For (i),
at a minimum the performance metrics identified by the RPIW will be available but
the number of time points may not be sufficient even for a short series. Most of
the
RPIWs observed as part of the scoping study collected new data to
develop n
ew
performance measures. Routinely available data are problematic for measuring
clinical quality
at a micro
-
level
(Sheldon et al 2004). It is therefore assumed that it
will be
necessary to collect new data to evaluate the RPIWs. The number of
observations may be increased either by collecting data more frequently or by
increasing the monitoring period.


Data collection

The relevant routinely available regional
and national
data
will be obtained from the
SHA Performance and Patient Safety Teams
.
All data will be available on a quarterly
basis

and

electronically
. Their

collection is something the applicants have past
experience in doing. For the RPIWs at the case study sites t
he re
searchers will

engage
with the staff responsible for planning and conducting
the RPIWs
to facilitate the
collection of appropriate data.

Where possible the data will be collected by the staff
undertaking the RPIW, using a framework developed by the researc
h team. If
necessary,
data collection
will be supplemented by the Research Associates.

For
controls, data collection for internal control units will be carried out as for study unit
s;
external control units
will be selected from
NETS o
rganisations

of the s
ame type
, for
which
the
special collection of data will also need to be undertaken

by the research
team
.

The multiple ITSs mean that data collection will be spread over the life of the
project.


Analysis

Sample size
: The RPIWs will each be implemented in
one or more units

(eg

a ward or
clinic)
. In each case a number of comparator units

will be identified
. The same
outcomes will be collected in all units at repeated points before and after
each
RPIW
.
We wish to be able to detect an interaction between a

be
tween unit


effect (the
difference between units that implement the RPIW and the comparator units) and a

within unit


effect (the difference between the measures made prior to the RPIW and
those made after the RPIW). Using th
e program

G*Power

(version 3)

(Faul 2007) we
can investigate the power of alternative designs to detect such an interaction. It can be
shown that if we aim for a minimum of six units

(ie 5 control units)

per ITS
, a
minimum of three measurements prior to the RPIW and three measurements
post
RPIW we will have 83% power to detect an effect size of 0.5 assuming a type 1 error
rate of 5% and th
e

correlation between the repeated measures is 0.5.


Data analysis
:
The primary hypothesis to be tested is that there will be a significant
interactio
n between time (the difference between the measurements made pre/post the
RPIW) and groups (the difference between units in which the RPIW is implemented
and other units).
As it is very unlikely that we will have enough data points to
undertake a classical

ITS analysis, t
he short time series will be analysed using
repeated measures analysis of variance

(Box
and

Jenkins 1976).
Internal and external
controls will be used. For example, the comparison of similar wards within the same
organisation would be an i
nternal control, whilst a comparison with a ward in another
regional organisation of the same type would be an external control.



9

Benefits of research to the NHS

The
NETS and its three elements

is predicated on the assumption that its application
will resu
lt in more efficient and effective care services which will benefit both
patients and staff.

In the manufacturing sector,

the
adoption of
TPS has reduced waste
and unnecessary waiting and delays. Standardisation of products and processes has
led to
improved quality and reduced variance in outcomes.

In
a health context
proponents anticipate that the TPS will
:



enhance patient safety



increase capacity without increasing resources by making better use of
existing resources



make full use of the potential
skills and strengths of all the members of the
team



increase patient satisfaction



increase staff satisfaction



shorten the patient pathway from first point of contact to completion of
treatment



stimulate continuous improvement as a formative process for gre
atest health
gain and a new cultural approach to clinical care.


The evaluation is designed to:



demonstrate the effectiveness
(or otherwise)
of the NETS initiative in
achieving the above benefits and improvements and in adding value to the
health of patien
ts, their carers and the public



demonstrate the applicability
(or not)
of the Lean method to health care more
generally



inform thinking as to which approaches to changing complex systems
appear
to
work best in disparate areas of health care.


Plans for the

involvement of stakeholders

As we have done throughout the
NETS
scoping study
,

we will work closely with the
NETS project team based at the SHA.

We will also meet regularly with the Coalition
group comprising representatives from the Pathfinders
. Lastly,
we will

ensure that
patient
s

and
the
public

are

involve
d through
the focus groups mentioned above under
Methodology
.




Plans for dissemination of results

The evaluation of

the

NETS and associated methods and tools will focus on
documenting the proce
sses involved in order to support subsequent dissemination and
learning; understanding barriers to implementation
;

how they can be resolved; and
identifying outcomes and track
ing methods
.


The evaluation will take the form of applied research in order th
at findings to inform
learning can be fed back to

the NETS
Coalition
,

policy
-
makers and practitioners as
the project proceeds and evolves. Dissemination will therefore be ongoing over the
duration of the evaluation. It is envisaged that this will include the
following:

workshops around the region, Master
c
lasses on implemen
tation, and providing
support to those seeking to replicate
culture change and adopt
Lean processes in other
parts of the NHS in the region. In addition, there will be wider dissemination at the
end of the evaluation to the NHS throughout the rest of the
UK. This will be through

10

presentati
ons at national conferences and articles published in practitioner outlets as
well as through peer reviewed academic journals.
A

project website will be a source
of information on the evaluation as it unfolds.