New Tools Wiki - a stunning set of resources

The newtools workshop wiki is the most amazing set of resources I have come across for months - and those of you who know me well know that I don't use "most amazing" very often. I'm at a loss for words on how to describe it so you need to go and have a look for yourself.

Be prepared to spend some time exploring it...

How to implement 7-30-90 Day projects

“Being busy does not always mean real work. The object of all work is production or accomplishment and to either of these ends there must be forethought, system, planning, intelligence, and honest purpose, as well as perspiration. Seeming to do is not doing. “ - Thomas A. Edison

The purpose of this blog is to set out some ideas on the how of a 90-day improvement project within the context of healthcare. This project process is evolving so please add comments to this post so everyone can learn from your experience.

Principles:

• Having more time doesn’t mean getting more done
• Manage the tasks not the time
• Deliver incremental value
• Deliver results within a defined timeframe
• Honour the concept of organisational learning and continuous improvement
• Discover a rhythm of change and implementation that balances risk with results
• Use these ideas as ingredients and make your own recipe
• Ensure a focused, targeted and committed action process

      “Absorb what is useful, reject what is useless, add what is specifically your own.“ –Bruce Lee

There are a variety of approaches. The choice of your approach will depend on your strategic aim, the timing that best suits you as well as the nature of your improvement process.

STEP 1: Create your format based on your timescale

“Once you have mastered time, you will understand how true it is that most people overestimate what they can accomplish in a year - and underestimate what they can achieve in a decade!” - Tony Robbins

It is possible to deliver changes in 3 days (see Kaizen methods for further information). 

Consider your desired results, the amount of people who need to be involved in the process, the team and organisational culture as well as the nature of the problem to be solved / the solution to be implemented.  With this in mind, look at the options below and see which most closely matches your needs.  Where possible make your task

 smaller and the timing shorter.

All of the timescales contain a basic strategic rhythm of

a) diagnostic steps

b) implementation focus

c) review and next steps

 It is possible to design a 90 project so the phases are sequential, or it can be built up from a series of smaller 30 day cycles.  The choice depends on your strategy for change:

“Hell, there are no rules here - we’re trying to accomplish something.” - Thomas A. Edison

Why 90 days?

• Scope is more complex though is manageable within the timescale
• Sufficient interdependencies that will need to be followed through with conversation and negotiation
• Good if have high energy people working on the project who can also maintain their focus

Why 30 days?

• May be easier to commit to than 90 days or 18 months
• Deal with the now; plans remain relevant
• Long enough to see an improvement (or not, so can then change the strategy)
• Scope is such that one individual or a small team can make the changes with no further resource to committees or individuals for permissions

Why 1 week?

• Good for those who are too time / task pressured to commit to improvement
• Able to test an improvement-through-learning process
• If used as part of a longer project the 1 week cycle can provide a mechanism for involvement (different people different weeks)
• Good for working with those with a low energy

	Diagnostic	Implementation	Review
12 week (90 day)	4 weeks	6 weeks	2 weeks
8 week (60 day)	2 weeks	5 weeks	1 week
4 week (30 day)	1 week	2 weeks	1 week
1 week (5 day)	1 day	3 days	1 day

A diagnostic phase includes, to varying degrees, some of the following (remembering that diagnosis is part of the change process as individuals discuss and assess their own situation):

R  What is the current situation, including baseline measures; this needs to be localised to the context of those making the changes. Process and value mapping, relationship mapping and other techniques are useful here.

R  Creating ideas for change and improvement; being creative rather than just implementing known tasks (otherwise we end up with low energy projects)

R  Understanding any interdependencies and carrying out appropriate negotiation

R  Planning, designing, getting in the resources that may be need (like equipment) etc.

An implementation phase includes, to varying degrees, some of the following

R  Action, with measureable results

R  Learning, from personal and team reviews

“Words may show a man’s wit but actions his meaning.” - Benjamin Franklin

A review phase includes, to varying degrees, some of the following

R  Working out what is going well, and why

R  Figuring our and being honest about the problems, and then working through some ideas to resolve these

R  Capturing personal learning as well as team and organisational learning, specifically noting those things you would like to do / feel more of

A project of any length can be constructed from a weekly pattern of activities.

“If we did all the things we are capable of, we would literally astound ourselves. “ - Thomas A. Edison 

Misusing numbers to sell project results

The more I know about statistics, the less confident I am about my own use of numbers and the more suspicious I am of any publicised data. The oracle on this topic is Dr Ben Goldacre, author of Bad Science, one of my favourite reads.  A new book out by Charles Seife called Proofiness; the dark art of mathematical deception is along similar lines.

When it comes to scaling up the results of improvement work across a wider population, the danger of inflating the opportunity is significant. These are some of the numerical problems that have come my way in the past few week:

1. Hospital a got a 30% improvement, therefore if we multiply this across the whole county, this 30% improvement will give us a £1.3 billion saving.  Humpf? So I need to know how representative of the national picture was Hospital A. I need to know the numbers and not the percentages behind this statement. I need to know how generalisable the improvement process is. And that is before we get to understanding how the savings are calculated.
2. Pathway b is delivering 212.3 more patients in a shorter time of 8 days.  Humpf? More than what and shorter than what? The 212.3 gives me the wobbles because I've never seen 0.3 of a patient. Seife discusses the art and deceptiveness of the specific number in his book - see a relevant excerpt.
3. 87% of hospitals have adopted the use product y. 87% of what population - national, region, the city? What counts as use - have they used it once or are they using it all the time. Did they try it out or have they made it part of their regular routine? Did just one ward test it once or have more (all?) wards tested it and are using it all the time?  These questions are important in understanding the true nature of what has, or has not, been spread throughout a system.

Are there any headlines of numbers that make you wonder?

Connection is key for innovation

A little luck and a lot of perspiration is no longer the prerequisite for innovation. Nowadays connections, relationships and networks are key.

Steven Johnson's next book is about Where Good Ideas Come From. You can watch him in action on this TED video (which starts with a picture and talk about the Grand Cafe in Oxford).



A couple of key points include:

1. Innovation is the result of the brain making new connections and these connections mirror workplace connectivity.  The better the networks and more complex the relationships then the more likely it will be that good ideas arise. His premise is that innovation is an interactive process.
2. The architecture of space is important if ideas are to be generated and spread - he has looked into what environments have contributed to innovation. If we want innovation we need to design spaces that enable connections.
3. Great ideas that appear to spark from nowhere are most likely the result of a long period of incubation which may not be obvious and are most likely cobbled together from a variety of existing ideas.. He argues that ideas are networks and the way of thinking about them as sparks, illumination etc is no longer relevant.

Patient Experience; report to help Boards build patient and public experience into quality fo care

If you are steeped in the healthcare quality improvement methods you will know how important it is to understand the patient experience. Scaling up project results to a wider audience does not mean the patient's views are no longer important. While the theory is obvious the practice is not. It can be difficult to engage non-executives and Board members with the patient experience and a new report on the Patient Experience  issued by Dr Foster in the UK covers the following:


Foreword 
Key messages 
The scope of this report 
What is patient experience? 
Good intelligence guide: The basics 
Good intelligence guide: Measuring what matters 
Good intelligence guide: Building an intelligent report 
Good intelligence guide: Advice from the sharp end
Board briefing: Intelligence types and uses 
Board briefing: 2010 policy directions 
Board briefing: Glossary 
Board briefing: The current state of play 
References 
Acknowledgements 

It provides advice on how Boards can produce a meaningful intelligence report on the patient experience. I particularly like the checklists and the brevity with which it is written.  They have nicely avoided the temptation to burst into theoretical concepts.

I found this report via Jocelyn Cornwall's blog at the Kings Fund - another good source of information.

Learning networks or social movements? Which is best for large scale change?

I'm not sure there is a specific answer as to whether learning networks or social movements are best for large scale change.  However, my personal preference is for learning networks and these are my reasons:

1. learning networks connect the people who are interested in solving the problem, and they do so in an interactive, participative and empowered way. In comparison social movements have the image of someone wanting to make something happen and in manipulating the joining in process and to an agenda they have set.
2. learning networks are about the exchange of information, discussion and both personal and group learning. Personal behaviour may change as a result of learning about something new from within a peer group. When a group discovers new knowledge and feel the creative process of doing so, they may become quite committed to then implementing changes.
3. learning networks can be direct and specific. They can be topic based or professional grouping based.
4. there is a sense of an output with learning networks. Social movements are useful in that they are purpose driven, however, learning networks to me are more concrete, pragmatic and easier to associate with outcomes and results.
5. we know learning networks work in healthcare while social movement theory is in its infancy. I am a proponent of using the existing knowledge we have to best effect.

This doesn't mean social movements are not useful, rather that I am sceptical about their ability to deliver results, especially when we know learning network can have an impact.

There is an excellent paper on Learning networks for sustainable, large scale change which is worth a read. 

Options for large scale spread; excellent new report by WHO, IHI, Harvard

A new report about large scale change and spread of simple, high impact interventions is available now. And it is a really good summary of methods old and new. I highly recommend it for anyone planning simple large scale spread, especially if you think you know the answers. This report summarises a variety of methods and is very pragmatic in it's use of examples.

The World Health Organization Patient Safety Programme and the Harvard School of Public Health commissioned the United States Agency for International Development’s Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), to present its understanding of and experience with the effective adoption of simple, high-impact interventions, such as the Surgical Safety Checklist. URC is joined in this effort by the Institute for Healthcare Improvement, which also has decades of experience in this field.

Readers should note this report and advice covers the spread of simple, high impact changes - namely it does not cover complex, system related changes.

The report covers:

III. Spreading Evidence-based Interventions
IV. The Scientific Basis for Spread
A. Framework for Spread
B. Individual Adoption and Behavior Change
C. Positive Deviance
D. Factors that Influence the Rate of Spread
E. Understanding the Social System
F. Integrating Content into Process Design
G. Testing and Implementing Change
H. Executing for System-level Results
V. Approaches for Large-scale Spread
A. Natural Diffusion Approach
B. Executive Mandates
C. Extension Agents Approach
D. Emergency Mobilization Approach
E. Affinity Group Approach
F. Collaborative Approach
G. Virtual Collaborative
H. Wave Sequence Approach
I. Campaign Approach
J. Hybrid Approaches
K. Lessons Learned from Large-scale Spread
VI. Which Approach Should Be Used to Disseminate Checklists?

(And thank you to the authors of the report for referencing my book on how good practice doesn't spread)

5 checks to test whether your conference call is productive

Conference calling is often touted as the more productive way to have a meeting. In many cases it is, however, some calls are so badly organised, chaired and processed, that it may have been better to meet face to face - or not meet at all.

1. Don't start on time.
"We'll wait another couple of minutes for Dean and Tam."
silence
"Is Mike on the line?"
silence
"Janet can you call Mike on his mobile to check he is dialling in"
Silence

If 20 people wait 3 minutes past the start time for the people who have not joined the meeting it means 1 hour has been wasted. If 100 people wait 3 minutes it is the equivalent of 5 hours wasted by the organisation.

A good way round this problem is to predictably open the line 5 minutes before the session starts and then predictably start on time - every time. You wouldn't keep the meeting room door locked until the advertised start of the meeting.




2. Use slides
"For those of you with Internet connections, you'll see the agenda. What? Oh Mary, yes, I'm sorry, the agenda is so up to date it couldn't be circulated beforehand."
...
"Can everyone see the slides?"
"Next slide please. No, go back one. Yes, that's it."
...

Slides are used mostly as personal notes for the person speaking. As some people don't have access to the computers when they dial in, any necessary slides should be circulated before the call (rather than afterwards). Some learning styles work better when they have had time to read and then contribute.

3. Rely only on audio
Meetings of any sort work best when there is trust. Unless the session is an online seminar when your role is to push out information via some slides to a large group, then video is essential. Even in the seminar option, the speaker needs to use video.  The more participants who use video, the more everyone will pay attention and not do their email at the same time.  Multitasking is proven not to be productive.  A 90 minute conference call with everyone doing two tasks at once is unproductive. It could be replaced by a 30 minutes, focused, video-face-to-face committed time discussing what matters.

When presenters refuse to use the video option they lack the ability to influence using body language. The same goes for listeners. This makes the call ineffective and unproductive as messages have to be repeated.

4. Don't use names
'Thanks for that..um.. sorry, who was that who agreed to review the budget?"
...

Audio, especially without visual, is anonymous - which may account for why some groups enjoy using it - it feels like they are having meetings yet no much happens to move the work forward. Anonymity is not a good name as it means listeners have to work hard to keep connected.

Each time you speak, say your name: '"Sarah here, I like what you're proposing Simon, however, I am not sure about item 3."  Try and say the other person's name as often as possible to let them know you are connecting with what they are saying.

5. Have a call when an email would have done
Holding a meeting is an act of power and control, and one to be used with care.  If the intent of the call is to share information then consider first whether an email or discussion group would be a better and more productive option.  If group discussion is required - then a call is good. If information needs to be shared and not much discussion is expected or required, then another method is far more productive. Many calls can be replaced by the use of efficient and productive discussion groups and document storage systems. Huddle is a great one, though Google groups/documents is a good start.  The real issue here is about power and control; relinquishing the weekly conference call and replacing it with an online discussion group means someone has lose control of the process.

Measuring large scale change

Many complex programs are designed to deliver large scale change. A key concept is knowing when a change is being made, and whether it is in the right direction.  Large system change is different to process change in that it seldom has a clear beginning and end, has multiple causal factors (some of which we will never know), and the result is often separated from the action in time and space.

Differentiating the types of measures from each other helps, as well as estimating and checking connecting between them.  The following categories may be useful to you in deciding how to measure what.

Inputs: a bit like a baseline measure though perhaps a bit more active. It could be the number of patients not attending their appointments or the % of staff committed to a new organisational vision.

Activities: this counts how much is done of something designed to engender change. IN the case of large scale change there may be a variety of activities underway at the same time. This could be the % increase in number of people attending a workshop, the number of patients

Outputs: the results of the specific activities. So if the number of employees attending a patient experience workshop increased, and the workshop had an aim of improving staff satisfaction, then an output would be the amount of increase in staff satisfaction (and perhaps compared to areas where employees had not attended the workshop.

The above three measures often look alike. What is key is to understand what large scale change is being measured and to think through, and perhaps map, the links between the identified measures.

Outcomes: this differs from outputs in that it moves up a higher level - more long term, bigger impact. For example, if patient satisfaction increases then an outcome may be more patients returning, more income etc.

Impacts: this is the final level of measure. Perhaps the organisation reaches a new public grading, patients in the local area experience better health as a result of the improved services etc. Reduced health inequalities is another example.

Identifying the measures is only half of the learning from measuring for large scale change.A key step is to find a way to map out the linkages between the measures. To do this at the start of a program is helpful as learning from the actual measures can be replotted. This will help identify whether movement to the large scale change is underway as a result of the current activities - or not.

Choosing the right chart to show your project progress and performance

Essential to any improvement project and spread / adoption campaign is a system to measure progress. An Excel produced bar or line chart on the regulation maroon and blue is suggestive of either a lazy monitoring process or one which is not turning data into useful information.

In large programs fundholders often like to see comparisons between one sub-project or site and another. Or maybe you are interested in how the results are stacking up as a whole; for example, are all the sites adopting all the elements of the new project? Do you know the best way to show a trend of your data? What about relationships between different data?

A favourite place to download Excel templates for your charting needs can be found at the Chart Chooser. Best of all, you can work out which template best suits your needs using their diagnostic process.

Do you have any templates for charts used to monitor the spread / adoption process or project improvement that you would like to share? Leave your comments below.

The Intelligence of crowds

It is difficult to subvert the ego of the individual and go with the average of the crowd - yet when the crowd's results outperform those of individuals it may be time to do some creative thinking about how we make chnages in healthcare - or anywhere else.  A classic example of the wisdom of the crowds is the "how many marbles in a bottle" challenge. With a decent sample, the average of the crowd is usually very close to the actual number. In comparison, individual's results are varied, the range is big and there are few that are close to the target.

NPR has interviewed the author of a book on the subject.


In his book The Perfect Swarm, Len Fisher talks about swarm intelligence -- where the collective ideas of a group add up to better solutions than any individual could have dreamed up, including an example of how UPS reorganized its driving routes using the logic of an ant colony.

You can listen to the interview (17 mins) or read a transcript.

Listen out for the way in which UPS redesigned their routes using swarm logic.  Do you think the same is possible for the redesign of patient pathways?

6 resources for Patient Centred experience and Design (EBD)

Ensuring "involving patients" is more than rhetoric is a challenge. For any healthcare project, be it an innovation or an attempt to spread good practice and adapt evidence to work locally, engaging with patients and service users is a challenge.  This post suggest five resources to help you.


1. The Picker Institute Europe is a world leader in working with patients on a large scale and covering public, private and the voluntary sector.  Their remit is to work with healthcare providers and commissioners to:

• measure patient experience
• gather patient feedback
• analyse the findings
• develop action plans
• engage patients in service improvement
• evaluate improvements and
• communicate developments back to your Board and stakeholders.

Available from their website is a comprehensive toolkit for Using Patient Experience. It is free.

2. The USA based Institute for Patient Centred Design is unique in that it provides resources on design not only for healthcare professionals but also to patients; excellent way of practising what they preach! They have a number of documents and surveys (free) available online.

3. The Centre for Health Design has an evidence based focus. They have a number of evidence based design resources on their website and their Healthcare Leadership portal has excellent PDFs for download and access to a variety of multimedia resources. This includes an excellent review on the literature of evidence based design These are free.

4. The NHS Institute which covers the NHS in England, has a toolkit on Evidence Based Design which is available to NHS England staff (max 20 copies) for free, and £30 for copies for others. They also have a facilitator's pack available for purchase.

5. The UK Department of Health has published a toolkit on understanding detailed patient experience data. Although this does not cover design and involvement in depth it is a useful kit to help you understand what to do with the data you are presented with. 

6. The Design Council in the UK is running a project about Designing for Patient Dignity. While most of this covers the physical aspects of patient care, the case studies and design process make for interesting reading. They have published a 25 page booklet which is free to download. 

If you have any favourites I've not covered here then please leave your notes and a link in the comments on this blog.

Productive Partnering self assessment tool

The NHS Institute, working with PriceWaterhouseCoopers, developed a self assessment tool to help English Primary Care Trusts to figure out how best to create and maintain multi-sector partnerships.

The self assessment is the result of a program that aimed to reduce health inequalities which involved multiple different stakeholders coming together for the purpose of the project. The tool is aimed at groups who need to work together to deliver complex health orientated outcomes.

Getting evidence into practice is difficult enough. Doing this when there are multiple stakeholders is even more complex, risky and prone to non-delivery.  This tool goes some way to helping groups figure out how best to work with each other, with a health outcome in mind.

5 tools for understanding and assessing organisational learning

Organisational learning is a vast discipline full of theories, models and frameworks.  The ability for an individual, team or organisation to learn is a key factor in determining whether the results of a project will be sustainable beyond the duration of the project.

1. The Society for Organisational Learning is the home of the topic and the first port of call for information. There is an excellent overview of OL for beginners and the timeline is interesting for anyone who feels they have heard something similar before but not sure when.
2. SCSI (Social care institute for excellence) has a resource pack that works well for health and social care public sector programs. This pack is designed to allow organisations to assess whether they are a learning organisation, that is, an organisation that uses evidence-based practice and informed decision-making. The resource pack will be beneficial to chief executives, senior managers, frontline staff, service users and carers. The pack has been developed by SCIE Practice Development staff, in collaboration with service users, carers and staff in social care. We would like to thank all those who contributed to the production of this resource pack.
3. Harvard Business Review have an online version of an OL survey for personal use. It links to the article,  "Is Yours a Learning Organization?"
4. The Learning Needs Analysis Toolkit is a useful source not only for the survey but also a variety of links to underpinning theories.
5. European Consortium for Learning Organisations has resources for download with a knowledge management bias.

The above links comprise only a small selection of a vast quantity of resources available.  Feel free to add your favourite link in the comments below.

Mobile learning may be more significant than web learning for healthcare

Educational methods have long been one of the key strategies to encourage the adoption of existing good practice and evidence in healthcare. The predominant method is face-to-face sessions though over the last three or four years this has started to be replaced by virtual sessions. The Web has been the technology used ofr the virtual learning, however, the advent of smart phones suggests learning via the mobile may be overtake the web portion of learning and may dig deeper into the face-to-face session.

The chart above comes from Ambient Insight Research who have an excellent article on this topic.

Are your spread plans including the use of mobile learning and technology?.

What are 30, 60 and 90 day projects?

We all want results as quickly as possible from any project team.  In fact, we want the results now!  Quality improvement projects are by nature a cyclical process where a few steps are taken, then tested, evaluated and then a few more.In complex organisations and systems such as healthcare, the cycles of change can take a long time It can be challenging to keep staff motivated after the initial months of the project.

The concept of the 90 day project comes from research where the aim has been to shorten the cycle of learning from the often 3 or 5 year project horizon. Projects like these accelerate some of the learning, but not all.   In healthcare improvement programs, accelerated timescales can be useful at the start, in the middle or the end of a formal program. At each stage they will have a different focus.

At the start of a project, short timescales can be used to get some momentum going. A 7 day sub-project is an excellent way to focus on commitment and action right up front. Half way through a project a series of say 3 x 30 day projects can be run in parallel with different teams all focusing on the same result. Or they could be run in series.  At the end, a series of rapid projects can help cover all the loose ends and ensure comprehensive results.

So what is a short project?  We know what it isn't:

• not a replacement for the overall project
• an easy option; all short projects need planning 
• not for everyone

If you want to run a short timescale project then consider the following:

1. for the same topic, different teams will choose different lengths of project. This is because the specific context for change is one of the the biggest factor in the speed of implementing change.
2. be practical, pragmatic and realistic
3. focus on the outcome to be delivered rather than traditional project planning
4. remember this is one technique that may work for some people and may not work for others

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Online Clustered Networks Spread Behavior Change Faster

Online communities have different dynamics to face-to-face communities of practice. New research suggests that for online communities, behaviour spreads more quickly when the community is grouped into networks with overlapping connections than when left to develop more random and distant links.

If you are managing online communities then the research is worth a closer look as it may provide hints on how to design and support it so behaviour and influence can spread amongst the participants.

For communities of practice not online this clustering effect is not new. Research has been around since the 1970's which show the importance of bringing groups together geographically, thematically and/or by profession or person type. As humans we like to be with people similar to ourselves and are most influenced by those the same as us - if Joe can make the change then I will probably be able to as well.

There is a lot of buzz about social movements, mobilising and organising for change in healthcare. One of the success criteria for this work will be the depth to which those doing the organising as well as those participating understand network dynamics, and design accordingly.  Random networks are less influential.

Using Twitter in the Classroom or Organisation

Twitter feels like one of those applications that has been searching for its use. Within healthcare, specifically the NHS in England, its use has been limited. Many organisations see it only as another media channel through which they advertise their services. A few, however, have grasped its potential to spread the word  in a personal way and are using Twitter as a means of engaging with patients and staff. A good example is @OBMH (Oxfordshire and Buckinghamshire Mental Health).

While healthcare is prevaricating and the organisations that preach and teach innovation are being slow to catch onto what is now practically a mainstream communication method, education has been stealing a march. An excellent blog post about using Twitter in the classroom includes a framework which made huge sense to me and helped me think through how best to use twitter in a training event as well as for the duration of a healthcare improvement project.

Not only does it help communication for the project it also adds in the "spread" and "Scale up" component that it so often missing.   If you are worried about the word student, then substitute patient or staff member. What I particularly like about this framework is it is a way for organisations using Twitter to self assess their use of it.

(Picture from Prof Hacker http://chronicle.com/blogPost/A-Framework-for-Teaching-with/26223/)