Improvement Projects: Do no harm

A common issue raised by project managers who are trying to implement existing good practice with individuals and teams is one of resistance to change. I am constantly seeking ways to reframe the term "resistance" as a means of moving away from a potentially obstructive and destructive frame of reference.

I've been wondering whether one of the reasons people appear to "resist" adopting even what is well evidenced as good practice is because of a natural and at times perfectly reasonable conservative attitude towards risk. The medical profession has the theme of "do no harm". My feeling is often we are asking professionals to take on the solutions designed by others and in different contexts without providing the potential adopters with the evidence that the results are both relaible and generalisable. Reliable in the sense they can be repeated int he same context with the same results. Generalisability is what is proved when the intervention (improvement process) can be done in a different context and obtain similar results.

Without this evidence of generalisability in our improvement work I feel professionals will continue to be suspicious of changes.

In additon, do we ever publish the knock on consequences and the adverse effects of improvement work? A quick trawl of improvement projects published in high impact journals in the last 2 months demonstrates the attitude that improvement work is all good. None fo 12 papers that I looked at provided (or even hinted) at any negative consequences. Without honesty abotu improevemnt work and results I suspect we will continue to encounter "resistance" to change - and I will consider this an appropriate response to any solution being touted for implementation where there is no demonstartion of generalisability and no discussion about identified adverse consequences.

Disseminating guidelines using MBTI Style

One of the eternal difficulties in the dissemination and application of clinical evidence is what I believe to be the " style gap".

Either they are researched and written so generically it is difficult for any individual or team to see how they apply to them. Or they are written so specifically that individuals and teams are so constrained to the detail and working out how they apply to themselves, they don't implement.

Different groups and organisations have developed their own ways round this problems. At a National or Regional level, boards and groups develop guidelines that are generic and then disseminate with a covering letter urging local adaptation of these guidelines. They know there will need to be local differences and contexts taken into account so they acknowledge this. This raises some questions for me:

• to what extent does turning the generic into the specific mean the intended benefits remain?
• are there different bits that can be adapted in different ways? Do the authors suggest how different bits can be adapted?
• what are the systemic links with other pathways, clinical areas etc that need to be taken into account?
• what are the contextual variables that are necessary for the generic guideline to be implemented (things like resources)?
• Where to start? Something practical?

For those guidelines which are so specific as to be overwhelming

• how do all these details scale up into themes and topics?
• what are the patterns and links to systems that will be useful to know about?
• which if the details are most important? Which ones can be left out and the main benefits are still reached?
• is there a specific order to implementation?
• how to the parts integrate with other systems like IT and HR?

I don't know the solution to this. What I do know is that many clinical and process guidelines are written in the MBTI (Myers Briggs Type Indicator) N/Intuitive style. This is the big picture, system and pattern way of seeing things. In contrast many of those required to implement these guidelines are more comfortable working with details (MBTI S/Sensing) and make sense easier of instructions if they are practical and specific. Sometimes the reverse is true - S's develop guidelines for N's to implement.

All the other parts of the MBTI styles could be a factor in the adoption of messages that change personal behaviour.

Perhaps one way round this is to use dissemination processes and content in a way which best suits the style of the potential adopters rather than the comfort of the authors.

Keeping track of progress; learning from DHL

It's a long story, but the short version ends with my handbag needing to be sent from Stockholm to Buckinghamshire in England. This experience has left me wondering why it is we find it so difficult to keep track of patients within a hospital, let alone across systems.

From time of pick-up to signature at home I could watch the 24-hour journey unfold (one click on a weblink, no data entry). I could see what action was being taken at each stage. If you're interested you can see the detailed information below (it's not the greenest of journeys...). It took only 2 minutes from the time of signature for the information to appear on the system.

Yes, patients are not parcels. Patient information also requires a certain degree of confidentiality management. However, I wonder what it would be like if within hospitals (let's start somewhere simple) we were able to keep track of the inpatient, figure out in which corridor they are now, how long they have been waiting for their scan, whether they have had their meal etc. This information will provide insight into the systems and the patient's experience. Maybe we could start by monitoring blood samples in this way as they are already bar coded. Maybe we could start with a system to help keep track of patients in the hospital for who speaking is difficult, such as those with dementia, stroke or some other disabling condition.

I wonder what else we can learn from DHL about how to monitor and improve pathways using technology?


585907200 - Detailed Report
Date Time Location Service Area Checkpoint Details
Oktober 18, 2009
11:59

Arlanda - Sweden Försändelse hämtad
Oktober 19, 2009
18:04

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
18:28

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 19, 2009
18:49

Arlanda - Sweden Anlänt till DHL i Arlanda - Sweden
Oktober 19, 2009
19:48

Arlanda - Sweden Lämnat avsändare
Oktober 19, 2009
19:55

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
22:16

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 20, 2009
00:15

Leipzig - Germany Anlänt till DHL i Leipzig - Germany
Oktober 20, 2009
00:46

Leipzig - Germany Processed at Leipzig - Germany
Oktober 20, 2009
03:27

Leipzig - Germany Skickad från Leipzig - Germany
Oktober 20, 2009
05:28

London-Heathrow - UK Skickad via London-Heathrow - UK
Oktober 20, 2009
05:37

London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
05:51

London-Heathrow - UK Anlänt till DHL i London-Heathrow - UK
Oktober 20, 2009
06:18

London-Heathrow - UK Processed at London-Heathrow - UK
Oktober 20, 2009
06:41

London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
07:33

Gatwick - UK Anlänt till DHL
Oktober 20, 2009
09:12

Gatwick - UK Ute för leverans med kurir
Oktober 20, 2009
10:39

Gatwick - UK Signatur

SMS Texting Campaigns; awareness to action

Mobile phone technology has the means to change lives. A number of campaigns have been running where SMS/texting technology is being used not to raise awareness but rather to deliver action. I'm interested in this as it is breaking some of the "communication rules" and what is in the old research about how ideas spread and are adopted.

An excellent example is from UK Transplant where there are a number of campaigns running to increase the number of people prepared to donate tissue and organs. In the South West of England a campaign is running until April 2010 combining regular advertising and sms texting. The posters create awareness and then if anyone standing int he bus shelter wants to act by registering on the UK Transplant Organ Donor site they can send a simple test to a number with the word GIVE. This is still a pilot and the resulst will be interesting. I am all in favour of innovative ways of moving from awareness to action and this method is modern and relevant to societal trends.

If you want to add your name to the register then go to become a donor
If you want to read about this campaign go to sms campaign

Adoption of guidelines: trust?

A perennial issue on spread and adoption is how clinical guidelines are adopted - or not. There is an industry researching what happens, what might be useful intervention and what you can then do to increase the speed and amount of adoption.

My own rather accidental piece of "research" raised a new question for me: to what extent is trust both an enabler and disabler of the adoption process?

So I've been cooking. The real thing, with recipes. I spent the better part of a month working through many of the Women's Institute favourite 650 recipes. A trusted cookbook and mostly failsafe. What I found is it is incredibly difficult to follow a recipe down to all the details. The more I used recipes the more I found myself adapting them - to varying degrees of success.

Then I moved on to Nigella's Express cookbook. A week later I noticed I was slavishly adhering to every minute detail. Not like me at all. So what was going on here?

Nigella writes in the first person and the way recipes are written has engaged me in a new way. When a note in brackets suggests options, reassures you that she really did mean 250ml double cream or reinforces why this step is important, then it seems more trust in the process is repaid by more attention to detail in following instructions.

Many clinical guidelines are produced by committees. Yes they may be great sets of instructions, however, are they written as mechanisms that attract trust? I wonder what would happen if a trusted peer rewrite guidelines in a personal language and tone. Would they be adopted more quickly?

I did think maybe this is about personal choice of style of communication. Maybe. And should that detract from finding some novel ways to encourage the adoption of guidelines?