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THE MOST POWERFUL IDEA IN IMPLEMENTATION SCIENCE: THE VERTICAL SLICE TEAM

Updated: Feb 11, 2023



Short version

  • In healthcare, on average, it takes 17 years for 'best practice' to achieve 14% uptake across the system as a whole

  • When you use a Vertical Slice Team (VST), you can achieve 80% within 3 years

  • A VST is a cross-section of people from throughout the organisation or community

  • In a school, a VST might include a senior leader, a middle leader, and early career teacher, a very experienced teacher, the special educational needs coordinator, a teaching assistant… all the people who have a valid perspective on the problem you're trying to solve

  • It’s important to understand that this is not just a consultation exercise. Essentially, the responsibility for your chosen area of school improvement is devolved to the VST.

  • The VST is then tasked with writing - and then executing - a comprehensive implementation plan, which often takes around 3 to 5 years to implement to the point of sustained, positive change

  • Next week, we’ll look at how the Vertical Slice Team works - and we’ll start to understand why this is such a game-changing strategy - as Margot Thomas, Deputy Head at Lamphey Primary School, explains here:



Full-fat version

Last week, we looked at some of the problems with top-down change:

  • Black box leadership

  • Human nature

  • Consultation is often not meaningful

  • Top-down change requires coercive methods where there is resistance

  • People want to be seen to be compliant, rather than co-owning the change process

  • Senior leaders are often not in role for long enough

  • One-year leadership courses

  • Groupthink

This week, we're going to look at a powerful strategy that helps us overcome each and every one those problems: the Vertical Slice Team (VST).


To set the scene, we need to turn to the world of healthcare.


In healthcare, we have a pretty good idea as to what constitutes “best practice” - the clinical and therapeutic methods that lead to the best patient outcomes.


For many years, healthcare researchers have wanted to know: to what extent is evidence-based practice - what we know to be gold-standard, best practice - actually happening in the real world?


The answer to this question is really quite alarming. Research suggests that on average, it takes 17 years for a piece of evidence-based, gold standard practice to achieve 14% uptake across the healthcare system as a whole. (1)


You read that correctly. 17 years. 14% uptake. These are both bad numbers.


What this means is that should you find yourself in a hospital, there's a surprisingly high chance that you'll receive a suboptimal treatment, despite the evidence being available that other treatments may be more effective.


To address this problem, implementation scientists have started to implement change by assembling a ‘Vertical Slice’ implementation team.


In a Vertical Slice Team, you take a cross-section through the organisation and you get different types of people sitting around the decision-making table together.


Instead of having all the big decisions made by senior managers and senior clinicians, which is what usually happens, you assemble a Vertical Slice Team that includes some of those senior people, but also includes junior doctors and nurses, hospital administrators, patient representatives - all the people who have expertise on an aspect of the problem you're trying to solve.


And so you look at the problem through multiple lenses if you like, and then you write - and then execute - a detailed implementation plan, often over a 3 to 5 year period. It's important to understand that this is not just a consultation exercise - the vertical slice team essentially becomes the executive, tasked with overseeing this particular policy.

So this is not top-down change, but it's not bottom up either. It's people at all levels of the organisation working in harmony toward a common goal.


And we find that when we implement change in this way - using an expert implementation team - we can achieve 80% coverage within 3 years. (1)


Which is a bit more like it! Or rather, a lot more like it.


Let’s look at an example of what this looks like in practice.



Case study: Cincinnati Children’s Hospital


A few years ago, medics at the Cincinnati Children’s Hospital became concerned by the very high level of hospital admissions due to asthma.


To get to the root of the problem, they reached out into the community and assembled a Vertical Slice Team which included, among others, school nurses, pharmacists and asthma patients themselves.


  • The school nurses said: “Kids are forgetful. They’re always leaving their medication at home.” So the team made sure that asthma medication was always available in school.

  • The pharmacists said: “People often don't pick up their prescriptions because they work long hours, or don't have a car.” So they started delivering asthma medication to people's homes.

  • And the families of asthma patients often said: “My landlord won't do anything about the damp and mould in my home.” So they provided legal aid to take on the landlords.

In short: the VST approach enabled the medics to look at the problem from every conceivable angle. Wherever they encountered a problem, they took steps to make that problem go away.


Within five years of adopting this approach, hospital admissions due to asthma had reduced by 50%. In the following 3 years, the readmission rate reduced by a further 50%. This led to a 24% reduction in school days missed, a 30% reduction in absenteeism from work, and huge financial savings for the hospital.


To recap, using a VST approach led to:

  • Reduced admissions due to asthma

  • Reduced readmission rate

  • Reduced school days missed

  • Reduced workplace absenteeism

  • Huge financial savings

This is what you might call a win-win. Win. Win-win.



Vertical Slice Teams in schools


In a school, a VST might include a senior leader, a middle leader, an early career teacher, a more experienced teacher, the special educational needs coordinator, a teaching assistant… The precise make-up of the team depends on the problem you're trying to solve.


In a primary school, it's a good iodea to have representation from a range of age groups - from early years, key stage one and key stage 2, for example. In a secondary school, it's a good idea to have representation from a range of different subject disciplines.


The number of people in the team can vary, depending on the size oof the school. Usually, it ranges from 3 to 12, although usually, there are around 5-6 in an average-sized primary school, and 8-10 people in a secondary school.


As with the healthcare example above, it’s important to understand that this is not just a consultation exercise. Instead, the responsibility for a chosen area of school improvement is devolved to the VST. The VST is then tasked with writing - and then executing - a comprehensive implementation plan, which often takes around 3 to 5 years to implement to the point of sustained, positive change.


Next week, we’ll look at how the Vertical Slice Team works - and we’ll start to understand why this is such a game-changing approach to making change stick.


Until next time, here's an extended clip of Margot Thomas, Deputy Head at Lamphey Primary School, talking about the impact this training has had on her thinking:




References


(1) Fixsen, D., Blase, K., Van Dyke, M. (2019). Implementation Practice and Science. Active Implementation Research Network. Chapel Hill, NC, p62.

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