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# 4 What sustains the practice improvement?

Having ascertained what the service is, and having reflected on improvement criteria, we turn to the business of what sustains a practice improvement. How you address this question will depend on whether you are examining an improvement that is largely complete, ongoing, or an improvement that is planned or aspired to.

The reflections and discussions that you have completed so far may already have enabled you to develop a series of views on what principles help to sustain improvement. Among these may be:

- clarity as regards the service
- coherence of views on the improvement
- personal and colleague commitment
- open to investment (not just in terms of money, but practitioner time as well). Failing to accurately estimate what can be achieved by a given team or budget may undermine success.

For an improvement to move forward, it is necessary for the stakeholders to have the relevant skills. Skills are not only used by service providers, they are used by service recipients as well. The four short case study examples (below) make the point.

## Case study: Danielle

Daniel is a lecturer working in the healthcare faculty of a university and she teaches students a variety of practice-based skills. She is keen to make more use of practice simulations so that students can build their confidence in clinical matters, without competing for limited opportunities on placements in different healthcare settings.

Practice simulations, either computer, written case study, or role-play based are cost effective, minimise risk for others (such as patients) and will often enable students to conduct their studies at a time that suits them. But for Danielle’s vision of more simulated practice to operate, not only will she need to have skills of simulation design (some involving computers), but students will need skills associated with simulation-based learning. Working through the simulation, venturing responses and correcting mistakes is a different matter than attending lectures or reading handouts.

So, for this improvement to proceed, Danielle will need to attend to both her and the students’ current skills. All will need to evaluate their skills and improve some of them if the initiative is to succeed.

## Case study: Emmanuel

Emmanuel is a physiotherapist who is eager to help manage the considerable workload that he and colleagues in the department face. He realises that part of the problem is associated with the record system and the lengthy notes that he and others have to make and review in association with different patients. He therefore designs a different record system, one that involves checking off different questions about the patients’ condition, and selecting treatments from a menu of options. Only variations on the above most common questions and treatment options are recorded manually.

For this improvement to work Emmanuel has already exercised skills of design and consultation (his colleagues like the ideas put forward), but he now relies on the skill of a computer programmer to translate this into an electronic system that can be quickly and securely accessed.

## Case study: Adele

Adele works as a project officer in a healthcare charity and she is interested in the ways that storytelling might help patients suffering from chronic illness to manage their difficulties. She has read a lot about patient narratives and how these are used. But to make patient narratives a part of what she uses in group sessions with patients and their families, there is a need to develop a bank of illustrative narratives.

She will need skills associated with interviewing, helping the patients to tell their stories in a clear and coherent way. She may need to edit the audio tapes to enable the patient journey to be understood. But patients will have to develop their storytelling abilities, too. They have been used to sharing only brief observations on how they are getting on. Now, they must tell a story, putting events in an order to demonstrate their reasoning, insight and coping with a condition.

## Case study: Joel

Joel works voluntarily running a self-help group for mental health service users. He is interested in how the group can work better with formal services to ensure the best healthcare for people with mental health problems. Joel needs to be skillful in understanding the structures of formal services and the roles of professionals, as well as being able to engage with a range of people at a range of levels.

Skill is a fundamental support within service and service improvement (Stowe et al., 2010). Skill training and personal development become central when demands on service change or increase, when roles are altered and resources are updated. Investment in skills by individual practitioners and their employers is necessary if the service is to remain responsive and able to seize new opportunities.

## Activity 4

Make a note in the box below regarding how important skill is to service improvement in your own healthcare setting. Whose skill are you talking about? What sort of skills might be in action here?

Critical skills for service improvement

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### Discussion

As you think about service improvement in your own setting, you might realise that you have insufficient skills for this work. Alternatively, you may have the full array of skills that are relevant, but some are more developed than others. Other skills may seem well rehearsed, even polished and fully developed. Remember, skills may be clinical, managerial, educational, interpersonal, technical – what you need relates to the chosen service that you are working on.

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