Examples of the ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) and their associated skills
| SOFFTs/SOFFT skills | Example of successful deployment of SOFFT skill | Example of problems caused by not deploying SOFFT skill |
Adopting and promulgating the appropriate organisational environment:
| Ensuring a blame-free, nurturing and open environment: PBP, Middleswick A PBP lead attributed the initial success of the project to mutual trust, support and respectful critical dialogue. She persuaded staff to change practice by, ‘knowing the staff personally… always being there… never pulling rank or talking down to the staff or making them feel silly… being supportive and encouraging… giving feedback on performance without making people feel guilty, capitalising on staff’s desire to do a good job for their patients’ (Senior nurse, PBP lead). | Enabling staff to have difficult conversations: HAN, Premton Divisions between professional groups undermined the HAN project. One problem was ‘siloed’ handover meetings, with staff across specialties and departments meeting at different times with conflicting agendas. This was never reconciled, with coleads saying they needed greater confidence in dealing with apathy and resistance, especially with senior staff: ‘The initiative… was more top down, which means that although I was trying to do the bottom up bit, it felt there was a wedge in the middle that was somehow not really totally engaged’ (QI lead junior doctor, HAN). |
Managing the QI rollercoaster:
| Timing, coordination and momentum: TV, Upsworth The TV team needed to be persistent, determined and able to turn untoward events into opportunities when it became evident their enforced attempt to introduce change too rapidly was failing. They focused instead on just two high-risk wards, refining the approach before rolling out the change gradually. After 6 months, outcome data were more positive and the team’s morale, having been rock bottom, was restored enough to carry out a more effective roll-out. | Avoiding ‘initiativitis’: EC, Middleswick There were concerns that changes to EC would be lost among so many other QI projects in the Trust. A lack of time meant EC was not properly established, a problem compounded by too many competing demands (eg, winter pressures) and too many ongoing improvement projects: ‘They’re all good projects but you can only do so much’ (QI lead matron, EC). The result was that staff reverted to a culture that was less receptive to change. |
Getting the problem right:
| Codesigning QI work: NLD, Premton The core-competency document underpinning much of the project was designed through: (1) collating clinical experience and information from the successful use of patient discharge elsewhere; (2) ‘brainstorming’ with senior staff, particularly senior sisters and matrons; (3) reviewing effective models of supported discharge from other Trusts. Such was the level of experience within the Trust and the level of acceptance, the competency document was successfully adopted without piloting. | Understanding properly what is wrong and why: HAN, Premton A key factor undermining this project was the failure to establish the problem they wanted to solve: ‘It was very much process driven. It was, “We want to have a handover that looks like this” rather than, “the aim of changing our handover is…” Is it to make our patients safer? Is it to make our staff feel safer?…’ (QI lead matron, HAN). In addition, there was no clarity on how and why handover was a problem, and so there was no agreement on the need for change. |
Getting the right message to the right people:
| Getting the message right: NLD, Premton The nurses involved were aware that some consultant surgeons were dubious about the concept. They ‘read’ those consultants with skill, adapting their style to suit each individual. A ward manager, recognising that a head-on discussion might prove counterproductive, deliberately and slowly began using the nurse-led discharge terminology on every ward round until it became second nature for staff—resistant consultants included. | Getting to the right people: EC, Middleswick The team relied on ‘spreading the word’ through informal networks across all ward managers. Some felt this strategy of letting the word travel from the initial wards created anticipation from other wards. In retrospect, though, most recognised a launch event would have been better: attending a meeting and having ‘just a 10-minute slot to talk about it’ did not have sufficient impact. Roll-out depended on staff relaying the message correctly, which was not guaranteed and resulted in distortion of the message. |
Enabling learning to occur:
| Growing skills: PBP, Middleswick The PBP team attended a national QI course aimed at developing their intervention. The team felt the most valuable part of the course was meeting others doing similar work, learning from others’ experience of problem solving. Formal presentations and posters were less helpful as they ‘never really reported what they’d actually done’ (Senior physiotherapist, PBP). It was helpful for the team to realise they were not behind everyone else in preventing falls, which boosted confidence. | Creating the necessary culture of learning: TV, Upsworth The TV QI lead attended a course on Lean methodology, which she found useless and of little relevance to clinical practice. Instead, she drew on her own expertise and the skills of others in delivering the TV project. Although initially disappointed, the TV frontline lead was retrospectively relieved not to be allowed to attend the course as she felt this would ultimately be a waste of her overstretched time. |
Contextualising experience:
| Transforming the improvement to match the context: NLD, Premton The NLD project successfully balanced the need for fidelity to the improvement with adapting its design for different units. The matrons recognised that the diverse traditions of practice across wards required crucial adaptions without which it would have been rejected. They worked with staff to adapt NLD in a complex, diverse model, ensuring discharge activities were appropriate to the history and experience of each unit or ward. | Using experience to modify the intervention: EC, Middleswick The EC project used an adapted PDSA approach, making small tests of change, considering lessons learnt, tweaking the intervention and trying again. However, EC failed to continue with PDSA once roll-out had started, preventing methods from evolving to meet the contexts of wards not part of the initial development and piloting. Despite the varied reception and implementation between wards, the team felt compelled to stick to their strict timetable for spreading the practice, resulting in emerging problems not being addressed. |
EC, enhanced care; HAN, handover at night; NLD, nurse-led discharge; PBP, postural blood pressure; QI, quality improvement; TV, tissue viability.