Posted on: 15 March 2022
March 2022 
Welcome to our third Improvement Academy Newsletter for 2022.
In this edition, our feature article will be on the role of behaviour in leading change where we will be introducing the COM-B model with some useful top-tips and downloadable guides to support you and your teams with your improvement work. Our second improvement story of the year to share with you is from Amina Juma and the Preston Ward team at the Kingswood Centre in north west London. Each month we will be sharing great examples from across CNWL where individuals and teams are improving systems and processes to ensure that we deliver the best evidence-based service user and carer experience where ever teams are delivering care across the trust. We also have exciting updates from the Improvement Academy and share great educational opportunities that are coming up.
The role of behaviour in leading change:
An introduction to the COM-B Model
In this month’s newsletter we would like to highlight the major role that behaviour plays in leading change. The COM-B model and Behaviour Change Wheel can be used to unpick the role that behaviour plays in tackling some of our most stubborn service issues (see Figure 1) (Michie et al. 2011, 2014).
Figure 1 – The COM-B model and Behaviour Change Wheel
The COM-B model and Behaviour Change Wheel align perfectly with the Model for Improvement (the framework we use for structuring improvement projects at CNWL) and can be used to help us understand the messiness of our problems, map our systems, design change ideas in a systematic and evidence-based way and then communicate and share what works and why (see Figure 2).
Figure 2 – How to use the COM-B model Behaviour Change Wheel within Quality Improvement work
Use COM-B to identify barriers and facilitators to change
The COM-B model proposes that there are three components to any Behaviour (B): Capability (C), Opportunity (O) and Motivation (M). Those three areas are the key drivers of behaviour (Figure 3a+b).
Figure 3a – The COM-B Model
Capability refers to whether we have the knowledge, skills and abilities required to engage in a particular behaviour. Its two components are:
- Psychological Capability: our knowledge/ psychological strength, skills or stamina
- Physical Capability: our physical strength, skill or stamina
Opportunity, in the context of this model, refers to the external factors which make the execution of a particular behaviour possible. Its two components are:
- Physical Opportunity: opportunities provided by the environment, such as time, location and resource
- Social Opportunity: opportunities as a result of social factors, such as cultural norms and social cues
Motivation refers to the internal processes which influence our decision making and behaviours. Its two components are:
- Reflective Motivation: reflective processes, such as making plans and evaluating things that have already happened
- Automatic Motivation: automatic processes, such as our desires, impulses and inhibitions
Figure 3b – The COM-B Model explained
If we were to apply this behaviour change model to a simple example relating to improving health through healthy eating and we can briefly break down some of the influences on that behaviour using the COM-B model so you get an idea of how to use this model with teams when planning improvement work (Figure 4).
- If the goal behaviour (B) was to ‘eat healthily’
- Someone would need to have the capability (C) to understand how to eat healthily. This may be related to the knowledge of what is and isn’t healthy, what forms a balanced diet as well as the skills needed to eat healthily, such as having the ability to cook.
- The next thing they would need is the motivation (M), for instance understanding the positive and negative consequences of eating healthily and what each of these choices would mean for them.
- The final element of this model that is needed to change behaviour is opportunity (O). This may be related to the physical opportunity to eat healthily e.g. do they have the time to shop and cook healthily? Do they also have the financial resource to eat healthily and are there shops geographically nearby that sell healthy food? Alongside the physical opportunity, there is also a need of the social opportunity. This is related to things like cultural norms etc. If their family all order take-out food every night, then this may disrupt their ability to eat healthily.
Figure 4 – The COM-B Model applied
Therefore, as you can see, you can use this framework to map the barriers and facilitators to your identified behaviour in a comprehensive and methodical way, ensuring you have thought about all the areas that may influence behaviour.
The team who created the COM-B model have also created the Behaviour Change Wheel as a tool that can be used in conjunction with it (Figure 5). The green section in the middle of the wheel is the COM-B model that we have just explored. The red section outlines the different types of interventions that you could consider and is explained in greater detail in Figure 6. As a side note, the grey area on the outer perimeter of the circle is focused at an organisational or policy level and concentrates on the bigger influences of behaviour such as legalisation and regulation.
Figure 5 – The Behaviour Change Wheel
Figure 6 – The Behaviour Change Wheel – Intervention functions
There are many different change theories and models that try and unpack the change process and help us understand its complexities. Some of these come from theoretical lens of individual change and others come from the theoretical lens of organisational change. They all contain helpful perspectives, processes and tools to help us manage change. As ‘Improvers’ our work can benefit from knowing about some of these. If our article has sparked an interest and you would like to know then please see the reference list and ‘quick guide’ hand-out below.
If you would like any support with fine tuning your improvement project and would like to explore using this change model in your improvement work then please do not hesitate to speak with an improvement coach or book a slot at our QI Clinic where we can help you on your improvement journey.
Thank you to Dr Sarah McAllister for this month’s feature article.
To book a QI Clinic slot, please email us at cnw-tr.improvementsupport@nhs.net and we look forward to hearing from you. Additional details re QI Clinic and other educational opportunities are below.
If you would like to read more about the COM-B model and the Behaviour Change Wheel then please see the following ‘quick guide’ link: https://social-change.co.uk/files/02.09.19_COM-B_and_changing_behaviour_.pdf
References:
Michie S. et al. (2011) The behaviour change wheel: a new method for characterising and designing behaviour change interventions.” Implementation science 6(42) doi:10.1186/1748-5908-6-42
**useful for more in-depth reading around the COM-B model and Behavior Change Wheel
Michie S. et al. (2014) The Behaviour Change Wheel: A guide to designing interventions. London, Silverback Publishing.
**useful if you want a step-by-step guide on how to use the Behaviour Change Wheel
McAllister S. et al. (2021) Developing a theory-informed complex intervention to improve nurse-patient therapeutic engagement employing Experience-based Co-design and the Behaviour Change Wheel: an acute mental health ward case study BMJ Open 11: e047114. doi: 10.1136/bmjopen-2020-047114
**useful if you want to consider how to use the Behaviour Change Wheel with service users and carers
Improvement Stories
Building on the introduction of our first ‘Improvement Story’ in our newsletter last month with Arthur Wong, we would like to share an improvement story with you from Preston Ward.
This story is by Amina Juma and her team’s improvement project to reduce incidence of physical violence within an eight-bedded in-patient assessment unit for adults with learning disabilities and mental health difficulties on Preston Ward at the Kingswood Centre in north west London.
Preston Ward: Reducing incidence of Physical Violence
We knew we had a problem with the number of incidents of physical violence on the ward. Our patient safety incident data from datix was showing us that we had a high rate of incidence that we wanted to reduce. Therefore, with the support of our coach, Jack Pooler, we chose to set our aim to reduce the number of episodes of physical violence on our ward by 50% by July 2022. As a team, we knew we wanted to do this work to create a safer environment for service users and improve staff morale and confidence in managing risk both in and out of the ward. In the scoping phase of this project we knew we wanted to understand what matters to our service users, carers and our staff. This information informed and shaped our project.
We iteratively tested multiple change ideas through PDSA cycles, which helped us to understand what worked well and what we needed to adapt. Based on this, we found that safety huddles by the ‘whiteboard’ at the beginning of our shift had a significant impact on team member’s situational awareness. This increased understanding of key priorities of the day is something that we value. In addition, other change ideas that we have successfully tested have been the uses of safety crosses that are shared on our team’s Quality Improvement project board.
One of our change ideas co-designed with our service users was to introduce smart televisions to increase individual choice and increase communal activity that bring service users and staff together. One service user fed back:
“I am so excited to be watching my favourite TV programme now, I will look after this television and not damage it like I did the last one”
We have also commenced multidisciplinary safety huddles were datix safety data is reviewed and the sharing of learning from incidents occurs. These huddles have also been effective in sharing learning and exploring challenges relating to our improvement efforts. The project team also fed back:
“This project has brought cohesion to the team as we all have the opportunity to participate and it feels like we all own this project. In addition, with the increased visibility of our project, other professional groups are becoming interested in participating in our improvement work. This multidisciplinary approach is great to see and is bearing positive results.”
As team we are very proud of our run chart data on LifeQI (on-line quality improvement platform) and have had a shift in our data towards improvement in the number of episodes of physical violence in September and October with our current median of two episodes per week. We are also very proud of the fact that we have reduced the weekly median number of physical restraints from seven to one since we commenced this improvement project.
Going forward we want to continue to build on these successes to achieve sustained improvement in the reduction of physical violence and aggression in our ward.
If you would like to know more specific details about this project then please click on the link HERE to see this team’s poster submission to the CNWL Safety Conversation Day 2021 or email us at cnw-tr.improvementsupport@nhs.net and we will be very happy to connect you with the Preston Ward manager, Amina Juma.
The Improvement Academy
This has been an exciting and busy time for the Improvement Academy this month. Please see our new Improvement Academy website www.cnwl.nhs.uk/ia and twitter handle @CNWLImprovement.
Looking Ahead
CNWL Improvement Awards
Have you been part of an improvement project in CNWL over the past year? 
Have you considered celebrating and sharing your work?
Applications are now open to submit a poster to the Improvement Academy to receive an Improvement Award. The deadline for submissions is 5:00pm on 25 March 2022.
The Improvement Academy has introduced new Improvement Awards for teams that can evidence sustained improvement in CNWL services. These will be awarded on a six-monthly basis by the Improvement Academy Faculty. The awards are recognition of excellence in improvement achievements.
Successful entries will receive:
- A certificate with names of the presenter(s) and author(s)
- All awards will be displayed on the Trust website
- Selected submissions will be invited to showcase their work via a short presentation to the Trust’s executive leadership team at the online CNWL Improvement Awards on 19 April 2022.
- The top three winners will be offered one to one coaching and support from the Improvement Team to write an abstract and submit them to an external national or international conference.
This will be a great opportunity for you to share the important work that you are doing to improve your services, celebrate your improvement work and share your learning with others across the Trust and externally.
Submissions can either be made in a poster format or a word format. For a poster template and information on how to submit click here. If you would prefer to submit in a word version, please click here.
Example posters from the last year’s Safety Conversation Day can be viewed here.  
If you have any questions, please email cnw-tr.improvementsupport@nhs.net, and an Improvement Team member will be in touch. 
News from the Practicum 2021/2022
#CNWLQIPracticum2021
The fourth round of workshops for project teams on the QI Practicum took place on 22 & 24 February with teams sharing success and valuable learning and insights that they have gained during the testing of their change ideas. These were valuable opportunities for teams to learn together in a collaborative learning environment together with both service users and carers that generated much positive discussion.
There was some great qualitative feedback from teams from multiple workstreams and the teams enjoyed sharing their progress and learning using LifeQI as a platform to share their improvement journeys. More updates from our #CNWLQIPracticum2021 can be found by following us on twitter by clicking HERE @CNWLImprovement.
News from our active courses: Level 2 & Level 4
Level 2: QI Project Team Leader Training
Last month the first cohort of level 2 training commenced on 3 February with a group of 13 attendees. This first session was aimed at providing leaders with an appreciation of the role of an improvement project team leader and the skills and knowledge to undertake this role. All participants are now in action period where they are shaping their projects with support of a QI coach from the Level 4 Coach development programme who is assigned to their projects. We are looking forward to our next session on 8 March where we will be coaching participants in a group environment providing wrap-around support to participating staff. It has also been an invaluable experience both co-designed and co-facilitated this programme with service user and carer representatives using blended learning styles to enhance our participant’s learning experience.
Level 4: Improvement Coach Development Programme
This month, the group of 16 staff training to become improvement coaches have focussed their learning on how to have coaching conversations. Practicing their skills in using the GROW coaching model whilst actively working with their improvement teams. In March, they will be moving onto their next module: Getting Started. Where they will learn about the role of stakeholders and baseline data in improvement before moving onto working with groups and tools for creative thinking.
Our improvement coaches will learn a number of tools to help teams to think beyond the day to day routine and consider creative ideas for change.
We value the above feedback from our teams and will be incorporating this into the design of future session. We also look forward to sharing more updates with you relating to these programmes as they progress.
Upcoming education opportunities
The QI Clinic is here to support your improvement ideas:
** Session times increased for 2022!! **
Book time with us today to discuss
We are excited to announce that we have listened to your feedback and have increased our QI Clinic time slots from 20 to 30 minutes. So take the opportunity today to book a QI Clinic slot while they are still available!
We look forward to hearing about your improvement ideas and look forward to supporting you in bringing these improvement ideas to life in your workplace.
The QI Team have regular 30minute sessions that are bookable in advance to help staff with any questions or issues relating to your improvement work. You will have exclusive access to both an Improvement advisor and coach to help you think through your messy problem. The QI Clinic runs every Friday with bookable slots at 12.00 noon & 12.30 pm
To book, send a request stating your preferred Friday and time to cnw-tr.improvementsupport@nhs.net and we shall confirm back to you with a diary invite and link to your QI clinic slot.
We look forward to speaking with you!
Level 1: Bronze - Bitesize (Intro to QI) New dates for 2022!
Dates for the ever-popular monthly 3-hour virtual QI training on the model for improvement and how to set out on a QI project are bookable on LDZ at: https://cnwllearning.org/login/index.php
Search for ‘Bitesize QI’ to find the course, which is available on these dates all starting at 9.30am:
- Tuesday 15 March 2022
- Tuesday 10 May 2022
- Tuesday 14 June 2022
- Tuesday 12 July 2022
- Tuesday 9 August 2022
- Tuesday 13 September 2022
- Tuesday 11 October 2022
- Tuesday 15 November 2022
- Tuesday 13 December 2022
Useful Links
Contact information for Improvement Advisors:
|
Diggory Division |
Peter Toohey |
peter.toohey@nhs.net |
|
Goodall Division and Corporate |
Peter Smith |
|
|
Jameson Division |
Bridget Browne |