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.

Large scale change projects are seldom a linear process

In my experience any change process is a messy one where people are concerned. I can have a step-by-step guide to help me change a wheel on my car which is very useful. As the individual involved the guide can't really be designed to cope with my emotions following a flat tyre though fortunately the wheel, wheel nuts, jack and car itself tend to behave predictably and with a high degree of certainty - meaning the step-by-step guide is helpful.

Whether the project is small scale or large scale, there will be a varying degree of predictability and certainty when implementing projects within people-based systems. For large scale change where multiple projects will be run, the complexity increases. There are many different project management systems, some of which are specifically designed to cope with this messy process.


A linear version of project management assumes a sequence of steps, taken in a logical and predictable manner.

The diagram above gives an example of the stages and the effort over time. Reflecting on my own experience of implementing large scale change projects in healthcare I would plan for more effort in the conceptual phase and know that the time spent in each phase is not equal; it will vary according to each project and context.

While part of me would love to work with teams and organisations in an emergent way, to help improvement be revealed and new behaviours learnt and applied, I know that some project management is required when working within the structure of an organisation. One project management model I use is the following:

While this version starts to show some of the interdependencies of each stage in a project, there is always room to draw more lines. However, I like how this model shows the reporting / evaluating stage and how this feeds back into the planning stage. Namely this is an ongoing cyclical process rather than a linear step-by-step approach.

This model also works for me when the project is about implementing existing good practice in a different context. This model allows for the process and solution to be adapted so it work within the next context most effectively.

Presentations to watch; 2009 Quality & Safety in Healthcare - Berlin

Part of sharing good practice and enabling others is about just that - sharing. I was unable to attend the International Forum on Quality & Safety in Healthcare, run by the IHI and the BMJ, held in Berlin in March 2009. However, I can watch the plenaries and check out the posters. I can also contribute to ongoing discussion. It is really good to see what used to be "closed" and only for those who could afford to attend, is now more available and creative in the ways messages can be sent out and conversations continued.

Plenaries: http://www.axisto.com/webcasting/bmj/berlin-2009/
Plenary 1 — What patient-centered care really means
Plenary 2 — Medical success leads to medical error: how health professionals accept responsibility for safety
Plenary 3 — Transforming whole systems: in search of theory and method

For all poster details and other resources: http://internationalforum.bmj.com/multimedia/multimedia-resources

To discuss the plenaries and posters: http://doc2doc.bmj.com/forums.html?slPage=overview&slGroupKey=f1ee0d38-22c5-450d-9f33-40bf110975f7

Healthcare needs new norms to counter abuse of power

I believe the problem we’re facing in improving the quality and safety of healthcare is about setting new norms rather than the eternal quest to take innovative ideas or set of guidelines and then impose these on the rest of the system. Yes, this “pilot and spread” approach is useful and can be demonstrated to raise standards, though there may be questions about sustainability of results and few organisations review improvement programs three or more years after they were completed to test this.

Obviously new norms can’t be “set” as such. Where does our current norm come from? I think of a norm as the sum of all the behaviours actually at work in a system. A different norm therefore requires a different set of behaviours – not only (if at all) a planning meeting to decide and list these behaviours but an actual change in the behaviour of one, then two, then three, then four and so on people in the way they act and interact with each other.

More about this norm approach in forthcoming posts. In this post I am thinking more about why we end up with the norm we have. For example, what is the norm at work in an organisation where 400 or more patients are harmed or die inappropriately (for a series of reports / investigations on UK health organisations http://www.cqc.org.uk/publications.cfm?widCall1=customDocManager.search_do_2&tcl_id=2&search_string=&top_parent=4513&tax_child=4574 ) or where one nurse is able to harm and kill a number or patients http://www.nytimes.com/2009/04/03/us/03nurse.html?_r=1? No doubt there are many causes involved in each and every event. However, I’ve been asking myself the question “Why is it so difficult to shift the norm?” Allied to this is the question for me of “How can professionals reach the stage where they become part of a norm that seems to go against their stated values, yet do nothing – their behaviour continues “as normal?”

There are procedures for the NHS in England to manage whistleblowing http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4050929 and again, there will be many reasons why people don’t step outside of a norm and take action. So why is this norm “pull” so strong?

One reason I have been dwelling on is the abuse of power. Not so much a conscious step but rather one which is part of our human condition. And when enough people behave in ways where power is being abused, then a norm develops so others, who may not be inclined to do so, end up part of the problem.

How is abuse of power part of our human conditions? We know from a number of experiments that stated values, professional promises and personal beliefs can go out the window if the circumstances are right. For example, the Stanford Prison Experiment in 1971 (http://www.prisonexp.org/ for a slideshow / discussion guide on the whole process) demonstrated in laboratory conditions that when put in a position of power (the guards) about a third of the “guards” showed sadistic tendencies, meting out punishments and inventing ways to humiliate their “prisoners”. The famous Stanley Milgram experiment http://en.wikipedia.org/wiki/Milgram_experiment in 1961 showed how when participants are morally distanced from the consequence of their actions and when they believe in the power of the authority demanding action, they will continue behaviour even when they can see it is physically harming another person. Around two-thirds of participants showed this behaviour. There are many other examples as well, not least of which come from politics and wars.

So what does this mean for raising the standards of healthcare? Imagine working in an organisation where a critical mass of people (clinical professionals as well as managers and administrators) feel distanced from their actions, feel the need to respond to authority figures, are in a stressful context and feel they can act in ways that are driven by their own very personal demons. The sum of the behaviours exhibited become the norm culture.

So when I encounter really good examples of clinical or administrative practice and I am asked to help with spreading this to other places, then one of the key things I am thinking about is the underpinning behavioural dynamic. What is it about the team and the behaviour of the individuals in the team, that contribute to their identified quality / safety improvement performance? What is their norm? To what extent is this about how they manage the power dynamics? And if others are to adopt their work, what will this do to their use and abuse of power within their own systems? How will they break free of their current norm? Whose behaviour will be critical in this shift of norms?

I’ve been through the process of listing, rather objectively, the behaviours required for good practice to be adopted. Maybe this is helpful in working out just what needs to be done to effect the change. What I know now is a list of behaviours is not the same as the behaviour itself. I am also a great deal more aware of the context in which behaviours are played out and I am open as to the impact of power dynamics in a system.

This is messy stuff that doesn’t lend itself to the predominant method of change in healthcare, namely the issuing of a “how-to” guide. I think it requires conversation, dialogue, self-awareness and attentiveness. There’s no quick fix.

Pull vs Push; Twitter Case Study - 90 day project

One of the mantras of working out how to implement good practice more widely is "pull don't push". This refers to the need for potential adopters of a good idea to "pull" the information to themselves and then to act on it. This is a very different dynamic from the "push" of sending out case studies, instructions or clinical guidelines and then expecting others to implement the recommendations. (I wrote a paper on this topic with Paul Plsek in 2003; S. W. Fraser & P. Plsek, "Translating evidence into practice: can it be done through the process of spread?" Education in Primary Care, May 2003)

Theory is often interesting and sometimes useful. Practice is usually difficult and never quite what you expect. Thinking about "push" vs "Pull" I decided to run my own 90 day project to see what I could learn about enabling "pull".

This blog is both about Twitter as well as about a 90 day project process. If you don't know what Twitter is then check out this video: http://www.youtube.com/watch?v=ddO9idmax0o

Context
With Twitter http://www.twitter.com/ you share information, 140 characters at a time, with those who follow you. You also get to "listen" to those who you follow, and if you like, you can forward on their messages to your own followers (called retweeting). It is easy to follow someone; do a search for names or keywords you're interested in and then click on the "follow" button. You may also see a message someone has put up and then decide to follow them.

But how do you attract followers? How do you get a pull? This was my project question.

90 Day Project Aim
To get my profile in the top 100 of England and top 100,000 of all Twitterers (of a population 2 million and growing). I chose a ranking rather than a number of followers as I felt this is more aligned with my intention and context. A bit like choosing to reduce hospital costs by having no infections, rather than counting the number of infections. One of the complications of measuring ranking is you have to keep up your position in an ever increasing pool (the denominator is increasing rapidly).

Results
On 27th December 2008 I had 7 Followers. On 2nd April I had 347 followers. Average growth per day was 8 and the current trend predicts 536 followers within 30 days. I have used http://www.twittercounter.com/ to measure progress. My ranking worldwide is 79,492 and within England it is 79th http://www.twitterholic.com/

Learnings:

1. It really does work to learn from where other have gone before. I was 45 days into my 90 day project before I realised I hadn't practised what I preached, namely discover the existing good practice. Only then did I search for other's experiencing of generating a pull and adopt some of their ideas. This helped, though it was not enough.
2. It is possible to get started (on Twitter and I believe anything else) without knowing exactly how you're going to do it. For me, the act of the 90 day project meant I had to learn how the technology and system worked. It focused my attention.
3. Measurement is crucial. I check on a regular, sometimes daily basis to see whether my actions where having an impact. Ok, so this is easy when there are systems in place to do the measurement, though I would find it hard to know what was a successful strategy without this. After a while I began to see pattern in the data which matched my Twitter behaviour. Quite amazing really...
4. A "pull" is about adding value. No-one is going to follow unless they have a reason to do so. Equally, they can unfollow at any time (and I had one wobble when the graph slipped back due to unfollows - largely due I think to me unfollowing a lot of people - we sort fo went into a negative slide). So I have started to learn how to create a pull through a virtual medium communicating only 140 characters at a time. So if this was a non-Twitter project I would still think about what value am I adding for others and how succinctly can I communicate with them in a way that works for them
5. The social process of retweeting is important. I am valuing others' messages and sharing - then they do the same. As humans we are inherently social. Encouraging trust, openness, enabling and allowing connections and networking seems to be fundamental. Why should I expect anyone to follow me if I don't share, put others' messages forward (always attributed) etc?
6. I put my Twitter link on my email signature, added a button to my website, integrated it with my three blogs. What I am seeing is the links between these online activities and how they feed one another. Using a variety of tracking software I can see which ones are triggering followership. Maybe for other 90-day change projects it is important to think widely and outside the direct scope of a project in order to influence change.
7. One of the scary things about a pull vs a push is you're not in control. Yes, I can see who follows me and I can then choose also to follow them or not, I can also block people. However, by letting go I have discovered some new contacts, new people that I would not have encountered before. Yes, I have also encountered some fairly random followers who I see no reason why they should follow me. But who am I to judge? And that is the point.
8. When it came to updates I tried to be regular and consistent (something every day or two), aimed not to overwhelm at any stage and to tread lightly.

What will I be doing in the future

I will continue with Twitter as I find it useful. I've now set a different goal which is about quality rather than quantity. I want to test the next stage of "pull" - where something gets acted on as a result of a "pulled" tweet. This won't be easy to measure. I was fascinated by the recent example of this type of "pull-action" from Stephen Fry and Twitter. At the time he had around 352,000 followers (he is in the worldwide top 20). One day he tweeted a link to an Open University website / game. This OU page / game then got 52,000 hits in a single day. Around 15% of his followers acted instantly on a tiny fragment of a message. And the numbers were big.

If 15% of clinicians, professionals and managers in healthcare acted almost instantly on a message they had pulled, I wonder what might be the impact? Scary, huh...

Follow me on Twitter: http://www.twitter.com/sarahfraser

Are you a story teller or a story catcher?

The movement to teach people how to tell stories so they increase their armoury of techniques for influencing is a fine one. Part of me feels we all know how to tell stories, we do so at home, at dinner parties, to strangers on the train etc. Maybe we need to feel there is permission to do so in the workplace. Maybe some of us need the theory and structure to help us frame useful work-related stories. What we do know is that enabling the spread of good practice and large scale change is dependent on the concept of the story.

Part of me feels that story "telling" is not only just half of the technique, but also it panders to the predominant hierarchical, patriarchal "I'm in charge" thinking. For example, an executive who writes and delivers their "story" is doing so with an intent in mind. Yes, it moves the instruction and influencing process one step away from head and closer to heart, though is it enough?

I believe the courageous leaders will be those who grasp the importance of story catching. An inspirational book called "Story Catching" by Christina Baldwin is an excellent resource. I see story catching as about holding the conversations, reflecting on what has been said - and what hasn't been said, appreciating the value of social networks and relationships, and knowing that the creation of the story is the point at which meaning is developed. Stories are part of the way we identify ourselves with communities (other groups of similar people), they reflect who we really are and they are our legacy.

A story catcher is someone who participates in the conversation. They are someone who listens out for the story and listens to it. A story catcher is not as much concerned with imposing their story on others but in helping others develop their own stories and in bringing people together to create new stories. They may help capture it as it unfolds (writing learning learning journeys). This is not really the same as documenting and then sharing the documentation in the hope others are interested. It may partially be this, though I feel the intention is more to help others see the meaning in other people's stories.

All this sounds woolly, fluffy and complex. Yes, it is not as clean, cool and organised as disseminating a case study of good practice with the expectation others will enjoy it and then implement it. Mostly, being a story catcher is a messy business attached to the world of relationships and communities.

Teller or catcher? It's a both / and. If I had to vote I would say 30% of the impact is in knowing how to craft and tell a good story and 70% is about the ability to hold the space for conversation, to listen, to co-create stories, to find my meaning in others' stories - to be a catcher.

What do you feel about the difference between story telling and story capturing?