Large scale change through small interventions

The phrase "large scale change" seems to be flavour of the year. What I am learning is that it means different things to different people, even when they are working in and on changing the same system. Something here about perception and definition I think.

While large scale change is in the press and on the lips, "small scale" changes or tests of changes seem to be dropping out of fashion. For those who have cut their improvement teeth in the realm of the PDSA cycle will know about the limitations and also the value of small scale changes.

So where does small scale and large scale meet?

I am finding it useful to focus on the the words impact and implementation. How can I achieve a large scale impact (maybe it is possible to have a large scale change yet insufficient impact)? How can I implement large scale change? So let's use large scale impact and large scale implementation as a way to define our change intentions.

There are many ways to achieve a large scale impact. My search is for the small scale changes that can have a large scale impact. For me this means getting the most efficiency, productivity, quality, outcome, gain, benefit (whatever your choice of measurement is) from the least amount of effort and disturbance to the system.

This is about paying attention to the what appears to be the small, boring and probably not award-winning changes that can make a difference. Focusing only on the bright and shiny changes can have many adverse consequences. Yes, it's good to talk of transformation, though that does depend on your perspective of the system. From an objective, outsider view that seems a rational task to accomplish. From the insider, subjective perspective this can creative unnecessary disruption. Also, transformation as a rhetoric provides little clue as to the how of transformation (see Weick,2000 for more info on this dynamic). It is possible that accumulated small changes can result in transformation. However, in the present financial situation for most organisations I am seeking large scale impact with small scale effort.

How can we determine whether the small scale change will have a large scale impact?

Looking at Impact (high/low) and Volume (high/low) for a specific proposal can help determine where to start, where more data analysis is required and where to put organisational change resources.

I am specifically nervous about what looks like a high impact yet is over a very small volume. One of the adverse consequences of implementing change here is regular, routine and predictable processes can be disrupted on the pretence of improvement. Pretence because it may be that the reasons for the change, for example a small patient group that needs additional time or never seem to be treated the "best" way, come about because of trying to solve the wrong problem. It could be this patient group needs extra special care. One way to get this is to look for small improvements that can be made over the large more predictable groups. By doing this more resources can be freed up to work with those who, by definition, will always be special cases.

In the current financial context I am hard pressed to agree to work on any change process unless some basic data analysis has taken place which demonstrates it is both high impact and high volume. If not HI/HV then some explanation of the need to change and the knock on consequences of both doing and not doing the change would be helpful.

I have a growing list of examples where small changes can have a big impact. For example, how saving 2 minutes on this procedure here by using resources in a different way can save £500,000+.

If you have any examples like this let me know (respond to this blog or email me).

Weick, K. (2000). Emergent change as a universal in organisations.Breaking the code of change. M. Beer and N. Nohria. Boston, MA, Harvard Business School Press: 223-242

Selling ideas without application experience means low credibility

How do we get others to adopt new ideas? This is a question I am often asked. One way I find useful is to think about how I might not get someone to adopt a new idea. What can I do to stop it happening?

I was triggered into thinking this "negative" view when hearing a group of training course attendees debrief themselves after an event they had attended. The event was on a semi-innovative topic, with the participants exhorted to use a variety of new techniques in their work. It appears that those doing the training had not used or were not using at the time, the techniques they were espousing. This meant their own knowledge was superficial and lacked any credible examples, including the examples of what doesn't work so well. So the attendees I overheard all said they enjoyed the day and it gave them some new ideas, however, they were left feeling unable to actually carry out any of the techniques. They had received the equivalent of the management summary written by a technical writer and they wanted instead to be linked to the people who actually have experience of the techniques covered. When I asked whether they would adopt the techniques they all said "not until we see the organisation espousing them, use them".

This does give us a problem in how we get new ideas across to others. I find it useful to label courses, events, papers etc as "information" or "ideas only" events. Thus distinguishing them from the more "applied" events where we are expecting some demonstration and application of the techniques back in the workplace.

My caution is selling, training, espousing good ideas and theories - with the expectation others will use them - when the self (person, team, organisation) hasn't the experience of implementing them). This disconnect is obvious to the recipient of the message.

If we take a topic like protocols and guidelines or new theories on how to deliver improvement, this then emphasises the importance of having examples of good practice, examples from the people who have implemented it. Only they know the real issues in applying the techniques. Maybe we need to be patient in developing theory into practice and also be patient in finding and supporting those who are applying whatever it is we need to have in place. Without this, credibility of the espouser will drop off - yes, people will be entertained at workshops, but behaviour will not be changed.

Social media kits: CDC as a good example

Whatever your position on H1N1 swine flu, there is no doubting the news spread fast across the world.  Many change programs would like to emulate this type of activity; it is the Holy Grail of large scale change.

The CDC (Center for Disease Control and Prevention) in the USA is an excellent example.  I challenge organisations to respond as quickly, thoroughly and extensively as them.  In the case of H1N1 they didn't have a vast amount of planning time, though I suspect they had some contingency plans in place, to come up with a range of social media / social marketing tools.  So the first point to note is these were available almost instantly.  No waiting 2 - 3 months for a communications and marketing department to negotiate with an IT department following the meetings of the Change program division etc.... in order to get something done.

Secondly the CDC appreciates and understands the value of social media in getting messages out and helping them to spread, hopefully quicker than the virus they are focusing on.  Their H1N1 swine flu social media page  has:

• widgets; a whole variety to suits your own needs
• mobile information
• buttons
• online videos
• podcasts
• ecards
• rss feeds
• twitter link
• image sharing
• as for social networks you can find them on Facebook, mySpace, DailyStrength

Using social media is not the only way to communicate.  However, well done CDC for showing the way, probably breaking some rules in the process, and demonstrating to laggardly public sector organisations and departments how social media can be of value and no great sweat to implement.

Innovation may be a barrier to improving healthcare

I know I am on a sensitive topic here. However, the angle I'd like to mention is one that concerns me. I worry it might be a case of the emperor's new clothes. So just in case, I'd like to strip the outer layer of clothing off something that we take for granted and assume is "a good thing". Innovation.

It was announced this week that the NHS in England will have a prize fund of £20 million pounds to go to individuals, teams or organisations who come up with innovations that make a substantial improvement to services. So what I am wondering, is whether this is helpful, or in fact whether prizes and the ongoing emphasis on innovation is helping deliver long term, sustainable, effective and efficient improvements in the delivery of healthcare?

Disconfirming question #1: Why develop more innovation when the current good ideas, innovations etc are used by so few? I wonder what the impact would be if £20 million pounds was up for grabs if you could demonstrate you have implemented an existing evidenced good practice? Do we need more activity on research and new stuff when we have lists and lists of practices that can be of benefit if actually implemented? If an innovation comes up with an idea to get evidence into practice across whole systems and large groups of people, without them really noticing it, then yes, I am behind it. But I am not behind single, one off innovations which are so off the wall that the normal healthcare population can't conceive of ever implementing them.

Disconfirming question #2: Why emphasise innovation and not research? Though a part of me is frightened that any more research will go over old ground - so maybe that is why an innovation focus may be better?

Disconfirming question #3: Why focus on starting something new when stopping something that doesn't work might have more of an impact. The BMJ published in 2004 a list of "bad ideas" or practises in general use which are no longer considered "good practice". These sorts of practices continue to mean large variations in care. So if the innovation rewarded is one which erasing the use of "bad ideas" then I'm all for it.

Disconfirming question #4: Why focus energy on creating new ideas when the same energy could be focused on activity around implementing known and evidenced good ideas. Before I turn entirely into a "grumpy old woman" I do see that innovation and creativity is good. However, as a taxpayer in our system I want to see action on what we know already can work. I suspect tough times like a recession will enable the natural innovators to do their stuff - and they will do this regardless of prizes or focus. It's the greater norm population that doesn't regularly do innovation that bothers me; how can we get action underway there?

Disconfirming question #5: What is innovation anyway? This could leave to a philosophical debate. It could be that anyone implementing an existing known-elsewhere practice will feel it is like an innovation when they implement it in their own context. I suspect this is not what the prize organisers have in mind.

Yes, I do understand innovation and the need for it. My feeling is the innovating population will innovate anyway - that's their nature. I want support, profile and focus on getting existing known practice into place and in stopping known "bad ideas". We could start with hand washing - or someone could come up with an innovative something that means hand washing is an irrelevant activity in the drive to reduce hospital acquired infections.

Alignment or attunement for large scale change?

(Photo by Goodshoot Photos)

The term "alignment" is often heard in leadership groups, team meeting and in programme documents. Do we mean alignment when we use it?

I came to this question of alignment vs attunement on reading a review on the book "Enterprise-Wide Change; superior results through systems thinking" http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0787971464.html and the review is here: http://articles.directorym.net/Business_Alignment_and_Attunement-a1128711.html

Most of us working in the Public Sector and in healthcare will recognise that we are working within living systems. The nature of people interacting, interfacing, creating and constantly altering interdependencies - all creates a perpetually shifting culture - with the consequence of perpetually shifting performance.

Dictionaries suggest the meaning of "alignment" is to arrange to in a straight line or in parallel lines. It is a term that comes from a mechanical and industrial age and is an important one in engineering.

In contrast, "attunement" means to bring into a responsive or harmonious relationship. I like this term. For your large scale change or mechanism to spread good practice, are you conducting a quartet, a 12 piece orchestra, a 120 piece orchestra or even a series of large orchestras all required to play the same tune in different places at the same time? Imagine helping each member of this orchestra to perform their best. They are professionals and know how to tune their instruments, the great music will come from arranging their performance in a way that it harmonious.

How do we lead professional individuals and teams so they use their skills and capabilities to their maximum, yet do so in harmony with others around them? I like to think of the attuning process as including:

• future orientation; you may call this a vision, it may be a picture of what the future looks like, it may be taking time to feel what the end results needs to be like. An orchestra may listen to a previously recorded version. A programme team may visit a place where similar results have been achieved. It is about creating a collective sense of possibility
• a high level plan; for the orchestra this is the score. This may look like detail though there will also be a high level interpretation of the score by the conductor. The leader cannot do the playing for someone else, they can only guide their interactions with others, to create the overall result
• using individual excellence and surrendering this to the collective experience. By this I mean that it is essential for individuals to do their best, to work at their optimum, yet do so as a servant to the group. An individual may have a soloist part, though this is a contribution to the whole and is not the result in itself. In my experience we have many soloists playing well and being praised for their individual achievement with little leadership effort placed on containing these performances

When I am working with individuals, teams, organisations and systems in enabling large scale change my focus is not on seeing them in organised rows, neatly lined up. Instead my aim is to help them identify their tune, make conscious their personal capabilities and to discover ways to build responsive relationships and work in a harmonious way.