New systems model to simulate spread and adoption of good practice

I've worked with Ken Thompson of Bioteams to develop a systems simulation of the spread and adoption of good practice.  Our aim has been to provide a method for individuals and teams to play about with different strategies and to model the impacts of those strategies. It's not a prediction tool, but rather one which helps you gain an insight into the complexities  It's been important to us to produce a simulation which provides an adoption curve - having an idea of the speed (or not) of spread is crucial to your planning.

The simulation is ready for testing. It's not perfect, and we'd love to demo it and take your feedback on how to make it even better. Feel free to tweet Sarah @sarahfraser or Ken @kenthompson, leave a reply to this blog, or email Sarah, if you'd like to have a go.

A screenshot of the main screen is below. You can choose your strategies and then simulate, quarter by quarter, the rate of adoption. There are other input screens where you can assess your readiness for change and where you can enter details about the strategies you'd like to use.

On being productive

I thought I'd start 2013 reading around the topic of productivity at work.  I was looking for new ideas and testing my own assumptions. After a fair amount of reading, this is where I ended up.




General principles

• Productivity means different things to different people
• Learning styles matter; so there's no point in promoting one method as the best - it needs to fit the style of the person, and their workplace. People who shout about a specific system are those who discovered something so perfect that works for them - this doesn't mean it will work for everyone else
• A home office and freelance lifestyle is not the same as a 9-5 office job

What I do already, that works for me, that I will continue

• When I am with a client I do only that client's business; I stay present (and this means being organised, not doing email etc)
• Don't do work email after 5pm on a Friday and before 7am on a Monday. I've learnt that even if I've been away for a week, I can get through it all in a couple of hours on Monday morning
• Don't accept paid work on a Monday. This means I don't travel on a Sunday (which is important to me). It also means I have Monday to get sorted, do admin, meet my Mum for lunch, go to the Post Office, read a book, research papers etc.
• When I'm in my home office I try to do one task before turning on the computer (filing, reading a paper, tidying up), then one task before opening my email (designing an agenda, writing ppt or paper).
• Use lists. I have a "lab book" which usually has all my lists in it but I have been using the Allen Getitdone app which syncs my lists across PC, iPad, smartphone. I'm not entirely certain I like it but will keep trying it for another 3 months. I do like the way you can send emails to it, then schedule working with them.
• Work with my energy. I'm a morning person. I know I do very little between 11:30 and 2:30 pm so I don't bother any more. I go for a walk or lie on the sofa and read a book.
• I don't try to work while I travel. The results are never good. So I sleep, relax and read. This does mean I need to put preparation time into my diary. I've always felt that preparing while travelling is not giving the work my proper attention.
• Finally, my favourite productivity technique is the Pomodoro method. You work (set timer) for 25 mins, then take a 5 minute break - and repeat. Do one thing in the 25mins (like this blog post). After a few repeats, take a 15 minute break.  I divide my productive time into these 25 minute blocks. And have 3 of them during the day for doign my email.  You can download a Chrome Pomodoro extension to be the timekeeper.

What new ideas I got from my reading

• not so much new as a reminder - exercise is good for me. So I shall put in the diary.
• turn off the Twitter alerts!!

Consistency of leadership matters

No matter what "evidence" you seek, leadership is always in the top ten of factors necessary for change and transformation of systems of care - or any system for that matter. There are books, papers and reviews all trying to qualify the type of leadership that works well.

I've been asking myself whether length of time in a leadership role makes a difference. When I look about me at the organisations who are held up as role models for good organisational processes, good collaborative working and good results - most often the leadership team has been in place for many years. Not just one leader, but at least 2 or 3 of the team.

Perhaps it important just to be there to hold the history and to maintain some form of continuity. Doing this while everything changes around you means the good leaders are naturally those who learn to adapt themselves  and their organisation, to the changing context.  I suspect they don't have great charismatic abilities, not do they espouse clever theories - they just get on with the job - year by year.

I applaud that level of commitment.

What happens when your quality improvement project is too long

Quality improvement projects have traditionally been 18 months long - at least that's my experience in the healthcare in the NHS in England. I expect they are that length of time because it is about the right length of time to second someone into the role of project leader. After 15 years of experience, I believe this is far too long for a QI project.




The problems with 18 month projects

• they take 18 months... 
• over-work the process; carry out redundant tasks to fill the time (every project leader wants to look good)
• too much emphasis on innovation and clever solutions, that are difficult for others to adopt
• difficult to maintain focus over so many months
• many clinical staff are unwilling to commit to the project
• the context changes  reforms, new organisations, new care methods - all come into play during the period of the project

Instead, I advocate the 90 day project. This is enough time for the average team to implement the average type of changes; and average matters. Most teams can imagine 90 days and are more likely to commit to making the effort to improve a targeted area. They will know within 90 days whether their efforts were worth it. 90 day projects need lots of planning by the project leader, though this can be done with minimal intervention with the clinical team, leaving them to spend more time with patients. They are best done with known best practices that are known to work in a similar context.

For more info on 90 day projects from this blog:

1. What are 90 day projects
2. How to implement 90 day projects

Or hang in there for my new book on 90 day projects which will be out in January 2013.

Who does “Improvement”?

When I ask national and regional teams what their purpose is, they usually say something along the lines of “to deliver improvement in our health system”.  I’m not so sure about this. The people who deliver the actual improvement are those who make the changes. What advisors, consultants, internal change groups, OD departments etc. do is to enable and support others making the change. It’s perhaps a rather arrogant stance for those wearing an “improvement” badge to think they are making the improvement.

To be an improvement leader is to sit in the mist of humility, where your personal satisfaction comes from seeing others develop, from watching them stand on the stage and share their experiences, and from knowing that the success of others is sufficient to satisfy one’s own ego.

The improvement leader is a sherpa, whose role it is to support, and when the time comes, to applaud the team’s success, quietly, from the shadows.

A Mandate for NHS Improvers?

The new NHS Mandate sets out the standards the patients and their families should expect. It is both strategic and operational. It’s not perfect but what it does contain is specific and difficult to argue with. Yes, there will always be things it hasn’t covered, but in the end, it’s better to have something than nothing.

What might be a Mandate for people whose task it is to support he implementation of the Mandate, to work with CCGs in making local changes and whose role it is to help individuals and teams create the new NHS.  I’ve drafted a few thoughts on this mandate, please add your comments if you have additional items to add.

The NHS you support should expect interventions that:
1. deliver a good return on investment
2. take the minimum of staff time away from the patient
3. are directly connected to the CCG or provider business
4. are for the user of the intervention
5. focus on the NHS rather than other systems national or internationally
6. practice what they preach (QIPP especially)
7. others?

How can patients use social media? 7 thought provoking references

There's a buzz at The 24th National Forum run by the Institute for Healthcare Improvement; and it's not just because the weather is warm in Florida and thousands of gallons of coffee is being consumed.  It's taken a while (I did the first social media presentation there about 5 years ago) but social media is hit the top of the agenda.

One of the questions being discussed is how patients and their families are using social media.
I've done a run round the Internet and collated some references to help this discussion. There are some condition specific references, most notably diabetes - however, I'e stuck with the more generic links.

• 4 ways social media can improve your medical practice AMEDNews; useful tips with some examples
• Using Twitter for e-patient communication  A comprehensive PDF guide
•  NHS reaction to online patient feedback is changing Guardian Newspaper article 2011
• Patient satisfaction in the age of social media  Excellent blogpost by MD suggesting some disruption necessary
• Can Twitter be used for doctor-patient communication from same blog as above
• Unleashing the Power of Social Media for Patient Experience  Has some useful links to examples
• How the NHS uses Twitter  Guardian Newspaper 2011 

Hospitals as prisons

To compare a hospital to a prison is challenging. Maj Rom, leader in Sweden for the project to improve the experience of life for the Elderly, used this comparison to wake us up, to make us think, to challenge our perceptions.

I found this a shattering concept, but the more I considered it, the more I realised we can learn from the challenge. Where else, toher than in a hospital and a prison do we:
• Have rules regarding who may enter, who may visit and the times of this visit (and even what they may bring in with them)
• Segregation for those with problems (like infections)
• Rows of beds, organised like cells, with a co-ordinating point for the “guards”
• A hierarchy that determines behaviour and where the inmate/patient is the recipient and often seen as the lowest of the low – to be done to be organised, to have rules explained
I could go on, but you know how the list continues. You may even discover that some of the aspects of prison are better than hospital – privacy, own TV, better food etc.) Try it out at your next meeting.  Or better still, walk around your nearest hospital with the eyes of an alien comparing it with a prison.

The challenge is not to make the comparisons, but to figure but what this means to us.  It’s not about criticising hospitals but it is about engaging with what we have created and finding the strength to change what we don’t like.

Spread and implementation; making practices real

At a recent awayday for a team in Sweden who are working to improve the experience of life for  the elderly, I had the fortune to listen to and work with Bodil Jonsson. I was thinking out loud and expressing my concern that the use of the word “spread” may allow people using it to disengage with the reality of what is involved. There is an ease by which leaders say “spread”, and then disengage themselves from the detail of what it means. So insteadI tend to use “implementation” as this word, to me, has a more active feel, and directs the users to consider what might be involved.

Bodil suggested the Swedish word “forverkliga” (please imagine the two dots on the o). This means to make real”. This was a light bulb moment for me. Think about guidelines; is the issue to spread them, to implement them – or to make them real. I like forverkliga because reality is made in one’s own context, thus enabling adaption, without further explanation And making real is far more than the objective task of copying another’s good idea. Instead it is the process of taking another’s idea and focusing on the added value to, say, the patient; unless something is made real, there is no value.

In my mind’s eye I say websites full of stories and examples, of guidelines and exhortations – and at once, saw useful information, that was of no value unless “made real”.

Forverkliga.

Rain, risk and redesign

It’s come as a shock to me to discover that teenage cousins in California have a “rain schedule” at school. Basically when it rains, children are kept indoors in their classrooms.  If this were the case in England our children would probably never see daylight!  Rain is seen as bad, something to be avoided – wrong even. Apart from my concern that they are disconnected from the realities and needs of life on earth, I was provoked into thinking about risk and perception.

One of the reasons for the corralling indoors is to reduce the risk of colds and flu (though this is a fallacious one), that they don’t have the clothes for wet weather (really?) and they might slip and injure themselves. We have the health and safety elves in England too, so overly risk averse behaviour is one we know well. However, all learning involves some risk.

In healthcare, I wonder what we are perceiving as so risky that we reduce the ability for anyone to learn. Health services are by their nature risky and much of the safety discipline is about reuing that risk. But is there something else we’re doing that we don’t recognise as limiting learning?

The only thing I can think of at the moment is the way we redesign (improve, change) services. The predominance of the Improvement Model and the attending PDSA cycles are a way in which we reduce risk, and I think, may actually reduce learning rather than enhance it.  I’m open to other thoughts and perceptions about this – please leave a comment on this blog if you feel differently.

Social Friction; the essence of innovation

There are as many theories of creativity and innovation as there are consultants – I suspect! Most of these have at their core, the concept of the “spark”, the moment when the new idea pops up.  There are theories as to how this happen. For some people this appears to happen when they are working on their own and get   new insight – for others it is the product of analysis, debate and reflection.

A spark is the product of friction. This friction can be internal or external. Not everyone can abide internal friction; to be able to hold contrasting thoughts at the same time, to read away from one’s own perceived knowledge and to ask oneself the disconfirming question. For many, it is easier to work in a group and encourage the challenges and questions that lead to new knowledge. But the value of this group work is in relation to the group’s ability to handle critical debate and questioning.

What saddens me most is when groups avoid this friction. They end up with interesting new ideas, but the potential of their knowledge and experience coming together to discover breakthrough concepts is diminished. This is a waste of capacity. The long term cost of this lost opportunity is significant.

When you next work in a group whose remit is to develop new ideas or to innovate, then consider how you manage social friction. Does the group seek out the disconfirming questions? Is the “solution” grasped too quickly?  Look around you – is all that experience and knowledge truly being employed in the creation of something that adds value.

Use-worthiness

The pleasure and advantage of working in different cultures, with unfamiliar languages and with bright and thoughtful people, is the discovery of new perceptions.  I was reviewing a systems model developed with Ken Thompson with a team in Sweden. We were considering how to “package” it in a way that made sense to those who might use it.

Bodil Jonsson provided the term “use-worthiness”. No, this isn’t an English term (and I think there isn’t an easy Swedish translation either) but I know exactly what it means. This one term covers the remit of technical usability as well as the value to the user. I like the way it conjures up the notion of return on investment (ROI); that something is worth using.

“Use-worthiness” – what does it mean to you?

How do we tell our Emperors and Empresses that we know they are naked?

Image from: www.emperorerswithoutclothes.com

The fable about the Emperor who had no clothes is well known. He believed he was wearing sumptuous velvet adorned with jewels, but in truth he was naked. His minions played along with him, "dressing" him every day and complimenting him on his attire.  Then one day, someone decided to tell the truth...      

How to diagnose whether you are an emperor or empress

1. Do you have strong beliefs about something?  What people or processes do you have in place to ensure you are not believing your own beliefs? For example, a mentor or critical friend who has the strength to point out when you are dashing about naked.
2. Do you have "minions" around you who are constantly agreeing with you, forwarding your tweets, nodding their heads in meetings and running about in the shadow behind you.  Can you remember the last time someone really disagreed with your point of view? Does it happen often? Do you ever disagree and have a constructive debate with someone?
3. Do you talk about your "clothes", are you constantly changing them, adding jewels etc.  The endless focus on the clothes, and the changing thereof, can make it difficult for "minions" to comment.
4. Do you marginalise the person who disagrees with you. This may happen without any conscious thought. You could be picking up a signal and then ignoring them out of fear they may point out what you already know.

A number of CEO's have mentioned to me that one of their greatest fears on appointment to their role, is that staff no longer tell them the truth about what it happening and instead tell them what they think they want to know. They then set up ways to counter this problem.

If you are an improvement leader in healthcare  do you have a way to check the extent to which your clothes belong to an emperor or empress?

        

Book Review: Arbesman - The Half Life of Facts: why everything we know has an expiration date

I don't why I never thought of knowledge as decaying over time. Especially when knowledge acquisition and transfer / spread is my specialist topic. Arbesman provides excellent examples and a logical argument to support his hypothesis that facts die out at a predictable rate. This is a fascinating thoguht, especially as in healthcare we believe that we constantly press against "old" facts which are stuck in the system. A reframing to think about what their "half-life" might be, is a useful and inspiring one.

Arbesman has come up with new vignettes rather than trotting out the old favourites. This is not a new take on an old subject, but rather a new subject requiring some disconfirming thinking.

Review of iPhone apps for patients in England

I chose to find and check out apps that patients in England can use – though I did find some excellent ones for patients in other countries  We have some catching up to do…. This is not a comprehensive list and I looked at those that interested me. I've avoided ones that are specifically disease related as I will review those separately. I've also not repeated the apps in my review of iPhone apps for the NHS.

All apps are free, unless specified, and I have no links or specific benefits from any organisation listed in this post.

RCP Stroke Guidelines 2012 – Patient and Carer

Another great title. This is patient specific advice from the Royal College of Physicians and I LOVE the fact it is based on the Guidelines published in 2012. This is a proper app, with a proper evidence base, doing something proper. It would be great to see apps like these for all clinical guidelines. It’s well designed and easy to navigate. And includes links to stroke clubs and other services. Why this works is it is not just a sales pitch for one service or organisation – it is designed around the patient. The first truly patient centred app that I've come across.

Patient.co.uk

This is an information based app with all their leaflets on health, conditions and diseases.  You can also find services close to you. Useful, though I’m not certain about the advertising. Others have reviewed the app as having some technical difficulties and the disadvantage of not being able to store a leaflet for viewing offline.

Communicating with foreign language speaking patients (in English, German, French, Japanese): A guide for doctors and nurses

Wonderful title that explains all. Although this is targeted at doctors and nurses, the app is also useful for patients. Of course there is Google Translate which is probably the best app for language translation as it includes all known languages – though this app does cover some of the more complex medical terminology.

GP Ratings £0.69

A simple app locating GP surgeries and giving you their ratings by using the open data available. It’s a useful way to make data useful, though as the data is made available free of charge some may prefer not to pay. What I liked is the way I could see the details of ratings for my own practice. But would I want to pay 69p to see this once, as I would be unlikely to use it again, as I have little option for changing to another GP.

Redisorganisation in healthcare: the theory and the practice

A good friend, Bill Russell, tweeted a link to "A surrealistic mega-analysis of redisorganization theories" published in the Journal of the Royal Society of Medicine, December 2005.  Yes, it's a Christmas edition spoof, however, there is some unnerving truth underlying the splendidly irreverent - and creative - paper.  I share it nervously, as I wouldn't be surprised to find it turned into a PowerPoint and a half day course being run to teach people the theories.

The paper got me thinking about the tendency of Healthcare Improvement Leaders to grasp at the latest theory that comes their way, further confusing the people they are expected to serve with their "leadership".  Recently I have encountered an exhortation about the need for consistency and a single model for change in the NHS; countered by the push of new ideas and theories, which dilute this message.  As well as new concepts being presented as though they are the next best way to make an improvement / support change; the concept is a concept - it has not been fully tested.

The frivolousness and scattergun approach for supporting healthcare staff and their organisations is unlikely to be a useful one.  My concern is the endless search for the quick fix is confusing people. In addition, when one theory ends up not working in practice, then I'm not seeing the evaluations, reviews and sharing of lessons (as in role modelling learning and improvement). Therefore each new concept is being built on an ever-weakening foundation.

The value of of those who lead improvement and change in healthcare  I believe, should be based on the depth and pervasiveness of change they support, rather than on the number of new concepts of pilot projects they put into the system.

Feedback needs to be both ways, especially for patients

Feedback is important, in almost any context I can think of. In quality improvement we are continually asking staff and patients for feedback about their experiences. I make a point of completing feedback forms that are sent to me because I believe that my opinion will - somewhere down the line - count.  Mostly this is on trust as I never get any feedback to me as to whether my involvement has been worthwhile.

Asking me, the patient for feedback is giving me the impression that you believe my views are important  Not letting them know me results of my feedback is, sort of, forgiveable (it would be nice to what "what happened later").  But what is really difficult to get to grips with is on-line feedback which is then not answered. NHS Choices runs an excellent on-line feedback scheme where patients can leave their notes about their experience.  In many cases the organisations respond with an explanation. And for many patients this is enough - to know that someone cares about their experience.

For my own GP practice there are a few pages of negative comments from patients whose experience is an issue. The fact there are no recent replies to these comments leaves me feeling like wanting to leave a note about there being no feedback...

Feedback: it works both ways.

Five iPhone apps the NHS can learn from

Many healthcare organisations are getting on the “app-wagon” by repackaging some of their regular website material.  In most cases, the “innovative” bit is the use of the iPhone’s GPS function for maps. Is this innovation? Not for me.

I’m on the lookout for apps which redesign interaction with health services, that support patients in caring for themselves and their families – and basically, ones which have an underlying brilliant idea that can only be implemented on a smartphone. 

In the end I didn't find any apps that lit me up – though I did find some that gave me ideas for apps that could be developed.

Wounds by BSN Medical Ltd, May 2012, UK only, FREE

You use your iphone camera to take a snapshot of the wound, then use the symbols to categorise it by wound need, depth and exudate level (for the non-clinical this means how bad, deep and weepy it is).  Then the appropriate dressing is suggested – and of course, this is their own brand of dressings. I’m not into promoting one type of dressing but this app is IDEAL for the NHS. Why hasn’t anyone produced this for the reduction of pressure ulcers – linking to the NHS Supplies dressings?  What I like about this is no improvement project is required – implementing an app will redesign the process of assessing and treating wounds/ulcers in the most fundamental way.

iScrub Lite, Free, May 2010

The premise is good hygiene and this app records observations and lets you email those observations. Whilst I am sure this is for audit folk, I can imagine that in the hands of patients (maybe lend them an iPhone while they are in hospital) it would have a big impact.  This would be fabulous if it was populated with the addresses for the contacts in each healthcare organisation in the NHS.

MedCrowd, Oct 2010, Free

This is an app designed to crowdsource medical opinions. I suspect it’s not really taken off but the concept is excellent.

Patient Journal, Free, June 2010

I like this because it is a place I can keep all the notes about being in hospital. The only problem is it really needs to be managed by the carer as the patient may be too ill to use it.  I think this would be good for longer temr patients or just for patients in general to keep track of their interactions with healthcare.  It works because it provides a structure only and doesn’t try to give me advice.

Mixed Messages, Free, June 2012

This is a training app aournd doctor-patient communication. I like the concept and it makes sense for much of the training programs that go on in the NHS to be put into a format like this. It’s simple, focused and not overworked.  No more books, manuals, workshops or PowerPoints!

Review of NHS iPhone apps

A number of NHS “innovators” are up there with their iPhone apps. I say “innovators” loosely as most of the apps are no more than websites in an app – useful but hardly innovative.  What’s more interesting is the lack of apps, even the most basic ones, from one of the world’s largest systems.

The NHS brand is one of the most well known in the UK, and using it and looking after it is important. There is now even a Brand Manager (c.£90k post) on the National Commissioning Board. From my days as the advertising manager in Esso, I know how important it is to make sure logos and accreditations are used properly.  My review of apps discovered many people using the NHS brand when they are not the NHS, and others in the NHS are not using their brand at all.

I chose the apps that appeared under a search for “NHS” on iTunes AND where there was NHS in the logo or title of the app.,The apps listed are all free.  

  

NHS Direct’ health & symptom checker

One of my favourite NHS apps and one I have used. It feels like the whole of NHS Direct is in my pocket. The feature of finding, for example, a pharmacy nearest to where I am standing is very useful. Comprehensive, easy to use and a flag bearer for app quality.

NHS Drinks Tracker

Not entirely clear but I think this is from NHS Choices (they could use their branding on the app logo perhaps?). Interesting to play with but it looks like it lacks flexibility to suit a wide range of users – as verified in the comments for the app.  Maybe an update is required? There’s also a Dept of Health Change for Life Drinks Tracker (do we need duplication?).

NHS Quit Smoking

Branded in the app as NHS Choices. I like the way it counts the amount of money saved according to the number of days you go without smoking.

NHS BMI healthy weight calculator and tracker

Another NHS Choices app. Clear and easy to use. Like the other apps in the series, it looks from the comments, like it could do with an upgrade.  There is stuff competition in app-world for BMI calculators and food intake / exercise trackers, so there needs to be a good reason for someone to use this one.

NHS Give Blood

From the NHS Blood and Transplant service, though confusingly the app logo doesn’t use the NHS branding. It’s a map function of where to give blood locally. I can see this being very useful in a crisis.

NHS 24 MSK help

Hmmmm, pink logo and very strange branding. Developer is NHS 24. Looks like an exercise app. Didn’t inspire me to download it and try it.

UK Clinical Trials Gateway (NHS Institute for Health Research)

Nice – I like it when the name of the app says what it is about and who it is from. As they say in their blurb, it’s for everyone, patients included, and covers the portfolio of clinical trials registered in the UK. I expect I can also get this off a website somewhere, so the innovation here is packaging it all up – a but like NHS Direct.  There is evidence of the app being updated which also enhances its credibility with me.

NHS Moodometer

This one took some detective work to understand. It’s an app to measure your moods. Useful if you’re in the process of understanding your own moods. It has the NHS logo on it. It comes from 2together NHS Foundation Trust – which I found out is in Gloucestershire – not obvious at all who they are and what they do from their name!  If they are using this app with staff then we need to know about this innovative use of it…

NHS Bristol and NHS Yorks & Humber

This is a well-designed organisational app that looks like it can be a standard one for many NHS areas. It’s more than a replication of their website and it is wonderfully designed for us.  It covers ICE (in case of emergency), your personal reminders and notes, where to find which service and cleverly uses the clour coding of the campaign to reduce A&E attendances (the thermometer). This app has a purpose which goes beyond advertising services.   Will need an update after all the structural changes.

My visit to Guys’s and St Thomas’ NHS Foundation Trust

Excellent. Designed for the patient, this app covers appointments, hospital information and maps.  I like the fact the name of the app says what it is for, and the integration with GPS on the phone is useful.

NHS Tameside and Glossop

Not certain about the logo use but the app is one that has broken away from the regular brochure / map / information approach.  Instead it is disease based giving information about conditions and pathways. I am not sure who is the intended audience? The name of the app left me thinking this was about the organisation but the contents are something different.

Welcome to St George’s Hospital

Another one with an app name that is useful. This is another information type app. I found some of the colouring a bit difficult to read and the design is rather poor. There’s a nice facility for providing feedback to the Trust – though I haven’t tested this.

NHS ActiveME

An app from the Royal Hospital for Rheumatic Diseases NHS Foundation Trust allowing the monitoring of daily activity levels.  Nice. Nice. Nice!  Beautiful design, easy to use and I love the graphic reports.

NHSCovWarks

Hmmmm apart from the rather short hand title, I’d not know this was an NHS app. The app logo is coloured stripes – which become obvious when you look at the app – it’s another one of the “ where do I go for what” apps”. 

Northumbria Healthcare’s GP Clinical Information Exchange

OK, so this is something different. Also has CiiX on the app logo. Says it gives real-time infomration about services, clinics and consultants  Not sure what it means by real-time, but what I like is it moves beyond being an directory to adding in some information about what to do if certain thing happen – and that’s good. I’m just not sure we need to add another acronym to the business.

NHSSC Health & Safety Awareness

Logo alert here, if only for adding SC to the NHS. It’s South Central (will need to update (or delete) app when the structural shifts happen). Seem to be aimed at staff though not entirely clear. I like the content but the title, logo and framing is poor.

Resources for Lean in Healthcare: 1 - Free Templates

This is a gathering of resources for those who are implementing Lean techniques in Healthcare.

The list below is a selection of the freely available templates for various Lean techniques. These haven'#t been tested so do carry out a PDSA to test them before using.

Rapid Improvement Event
Preparation
Running an event


Process Mapping
Drawing a process map in Excel


Fishbone Diagram
Fishbone & problem solving - Excel


6S Alphabet Game
Excel Template
Excel lesson plan
How to flowchart

Paper plane exercise
Powerpoint template

Will Improvement be the new Nokia? An open letter to NHS Improvement Leaders

An Open Letter for NHS Improvement Leaders

Look around you - how many people are using a Nokia phone?

My first mobile phone, in the 1990's, was a Nokia. I wish I'd kept it as it sells on eBay now for more than it cost at the time. However, it's now perceived as an art form, not as a workable option for making phone calls.The demands on mobile technology have also moved on - I use my smartphone less for making calls and more for reading email and playing Bejewelled.

What happened is the context changed. The markets developed, the customers upped their expectations. Nokia, very successful in the early days of mobile technology got comfortable with their success. They became blind to the shifts and the need to dump their favourite (and no doubt hotly promoted in-house) technologies.

The basic concepts of mobile technology has not changed much - but the products have changed significantly.

The basic concepts of what we understand as quality improvement have not changed much since the days of Deming - what hasn't developed much are the products to implement change. TQM has been rebadged, with minor modifications into Lean, which has been rebadged, again with minor mods into a variety of corporate improvement programs. And so on.

Now, I'm not suggesting we throw out all the good things we know about improvement (I can't bring myself to call it improvement science" - it isn't a science.)  We can keep the basic concepts. However, I do feel strongly that retaining "legacy products and programs" is lazy. If you feel the need to say "we need to retain what works" then think through how that sounds to NHS staff - and what it reminds you of.*

Every improvement product designed in and for the NHS has been a consequence of the context within which it was designed, then implemented. The NHS is making enormous changes  both structurally, conceptually and clinically.  Retaining "legacies" doesn't feel like support to this new context.

Be brave, NHS Improvers. Match the pace and scale of the changes in the NHS around you. Let go of your outdated models, methods, tools and products, in just the same way as thousands of NHS staff are having to do on a daily basis for the practises they believe are useful and good.. Design for the future.  Practise what you preach and get innovative - from within.  And I mean truly innovative. I don't mean coming up with an edited version an existing product, or a new framework for something. Instead, create the breakthrough applications that not only fit in the current context, but reset the whole discipline of "improvement" in healthcare. The NHS has an enormous amount of improvement experience and brainpower - use this to good effect.

Nokia missed the boat. It's trying to turn around, but playing catch up in a fast developing market is far more difficult than leading the market by designing the market - think Apple.

In April 2013 the NHS boat will sail. New structures will be in place, along with new demands that will change the face of the NHS for both staff and patients.  My hope is for "improvement" to be on the same boat, and not one of the tugs pulling in the opposite direction.


Note: * Improvers often talk about wanting others to adopt new practises and when these people don't want to, they're labelled as "resistant to change". I'm just saying...

Reframing patient empowerment

It's good to talk - and following a chat with friend and colleague Bill Russell. I've been thinking about why it is "patient empowerment" doesn't seem to work in practice.

Firstly, it is an irony (check here for a definition and more info on what irony is). There is a dissonance between its implied meaning and what it literally means. Just thinking of the term assumes that someone other than the patient has power - and by creating a program or concept called "patient empowerment" comes across as them with the power trying to give them without the power, some of their power - ultimately the ones with the power are still power-full.  Hence the irony.

Secondly, who thought you in healthcare had the power anyway?  As a patient I am the only person who has power of my health  I may need help from health professionals, the gym instructor, my mother, advice from the bookclub ladies, thoughts from the parish priest etc.  The issue is that I may be seeking a way that health providers do not take away the power I have when I access them.

Thirdly, maybe thinking it is all about power is the problem.  Power itself has no use unless it is applied, employed, or used. This process is called influencing. Some people, with little obvious power can get a lot done through effective influencing - and vice versa. So I wonder what would be different if we thought about the relationship/s and the influencing flows between patients and healthcare providers?

Please add a comment if you have any reframing propositions for "patient empowerment"

Social Media and Emergency Planning: What is your policy and procedure?

There's a good blog post by Ben Proctor on how Emergency Planning can/might/does work as part of Emergency Planning strategies. There are some good references in it to more academic reviews and publications. Lots for the NHS to learn about, I think.

Innovative changes to care pathways can increase hospital admissions

Innovative changes to care pathways can increase hospital admissions - really? Well, a report from the Nuffield Trust in March 2011 suggests there is little or no evidence that community interventions lead to a reduction in hospital use.

The report is a good one with a firm research founding - in the absence of any randomised control data. It points out that redesigning pathways can discover unmet need which may account for an increase in hospital attendance.

What caught my attention was that using their own data, each of the eight interventions assessed demonstrated a reduction in hospital use. However, when compared to control groups, there was in fact an increase. This leads me to one of the ongoing issues I have with "innovation" or "improvement" projects. It's easy to come up with a measurement system and set of goals and sample size that has inbuilt biases to ensure good results - and win prizes. But in the end, improvement needs to be tested against control groups.

I recommend you read the full research report, if only to grasp the seriousness of this issue.

Book Review: Crucial Conversations by Patterson, Grenny, Mcmillan & Switzler

This book has the subtitle "Tools for talking when the stakes are high" and I found there was not a single page that disappointed me. Part way reading through the book I thought this is all common sense, and of course a lot of it is. However, the authors are showing and telling in an extremely compelling manner that you just can't help going "aha", oh-yes", "of course" every few minutes. My copy is full of notes, highlighter marks and pages turned over.

So what's the meat in the book?

At its heart is a dialogue model which is about me and the other and how we each act, feel, tell a story and see/hear. In our dialgue we are aiming to create a pool of shared meaning and there are a number of factors that impact this, such as safety, and silence (withdrawing, avoiding, masking) and violence (controlling, attacking, labelling). All this sounds cold in this description, what brings this book alive is the way the authors develop the model with the use of various tools and stories. It's impossible to read it anot feel connected yet at the same time feel empowered to do something about your next high stakes conversation.


You can download book chapters and sample MP3 audio from http://www.vitalsmarts.com/books_more.aspx . There is also the stress test to discover your style under stress.

Book Review: Time Traps by Todd Duncan

You can't manage time but you can manage your thoughts, actions and tasks - that is the underlying premise of this powerful book. I read the book a couple of years ago and in a rare moment, I decided to read it again as I found I was often using the mantra of its premise and was seeking to find more ways to satisfy my desire to get a grip on the slippery slope of the balance between time and tasks.

The book is written with sales in mind though I didn't find this detracted at all from my personal context and I expect anyone who deals with many interactions with others will find it helpful.

The author talks the reader through a number of traps. The first is the identity trap. This is how when time is monopolised by our work we become our work - and thus how important it is to rethink time, to rebalance as part of regaining our personal identity. Secondly there is the organisation trap where the author suggests that most sales people are disorganised, out of control and say they lack the time to catch up. Well, that sound like a lot of the stories I hear from many people! And what I say sometimes as well!!! He suggests learning to stop all unnecessary tasks before they steal time, admit legitimate tasks onto your list of things to do, and make sure you know the difference between necessary and productive tasks. Then take action and assess how you're doing.

He also talks about the Yes trap, and then how to say No, or sacrifice more sales for the benefit of others. He has some interesting things to describe on the value of saying no. Then there is the Control Trap and the issues of letting go and learning to delegate. The technology trap should be familiar to those caught by their email, and for sale people he discusses the Quota trap. And if you're not trapped out yet, there is also the Failure Trap and the Party Trap.

I know this book changed how I felt about time and the management of it the first time I read it and certainly, the second time around, I was reminded to take some more detailed action steps.

Go to here http://www.timetrapsbook.com/ to download a chapter or to carry out the self assessment on the eight traps.

Research: How engaged are patients in their healthcare

The Heatth Foundation has released an excellent report on their research into patient engagement. It's one of the most up to date and significant reports I'e seen on this topic for a long time. It makes for some uncomfortable reading, especially regarding patients who have long term conditions.  There is a summary report, but I commend the full version for required reading for all NHS Commissioners and those working on improvemet projects.

Paper: Surgical Safety Checklist - more than checking a box

Fabulous - the authors have published a study where the results show there's a problem. I've been harping on about the lack of negative studies for years. So well done to the authors.

Basically, they've done some follow up work to see how well used the surgical safety checklist is. No surprises to discover that is most cases only 4 of the 13 items were checked. They suggest there is a problem with the fidelity of implementation, and a poor dissemination strategy and implementation.

Fidelity really is key. There's no point in shouting from the rooftops that 100 hospitals are using a checklist, for example, if it is not being used as intended. The results will not be as good as the pilot study. The return on investment for the project will not be as good. And, who knows, in some programs, the results may actually be worse than if the program hadn't been disseminated.

Fidelity. Important.

Surgery. 2012 Jul 6. [Epub ahead of print]
Implementing a surgical checklist: More than checking a box.
Levy SM, Senter CE, Hawkins RB, Zhao JY, Doody K, Kao LS, Lally KP, Tsao K.

Book Review: NO! How one simple word can transform your life, by Jana Kemp

This makes a change from all the "Yes, you can" books! It's basically about getting over the fear of saying now and taking control of any circumstance without negative consequences. A critical aspect as you might imagine is tone of voice and the author words hard to ensure we understand that it's critical we get this right - not too fast, too harsh and to make sure we choos the right words when we do mean it. It is also key to stick to your decision when you've make it.

Kemp has a model called the POWER of No which has an acronym from POWER: Purpose, options, when, emotional ties and rights/responsibilities. She suggests that using this acronym will help us to make a yes / no decision based on the right issues at the time. For me I find it a lot to think about when considering a yes/ no response online, though I suppose you get better at it with practice.

In essence the decision prcess goes like this
- think about the purpose and context of the decision
- what option do you have? What resources are available?
- when is it due? What is the deadline and can you meet it?
- be realistic about the emotional ties
- consider your rights and responsibilities

I'll be trying out some "No's"....

Paper: Complexity science and spread

Well, the best bit about this paper for me is the introduction of the terms SUS - scale up and spread!  It focuses on self organisation (complexity science principle) and how the complexity of healthcare and all the interactions are part of the problem of SUS programs.

Now, I'm biased and I'm with Ralph Stacey who says that when we think we can "control" or "use" self organisation then we are operating with a mindset not much different from Taylorism (see his work on complex responsive processes which superceded complex adaptive systems around 2001).

Whilst using insights from complexity science is useful, it is just that - an insight. When it comes to moving on to a more practical thought about - "so what do we do now", CAS and Complexity Science as such, falls flat.  There is a well trodden, pragmatic and practical systems theory and modelling that would be helpful in understanding interdependences - "Systems Thinking". Unfortunately it requires a bit of effort to grasp and seems not to have the cachet of "complexity science". Shame.

Soc Sci Med. 2012 Jul 4. [Epub ahead of print]
How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts.
Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT.

Book Review: The Wisdom of Crowds by James Surowiecki

It's quite annoying to find out that groups make better decisions than you can as an individual - but a very powerful thought. However, the groups need to be diverse, independent and decentralised (so that may exclude a few crowds I can think of...)

We are essentially cooperative beings and meld our behaviour around that of others. One of the examples in the book is how crowds flow in shopping centres, how we move on staircases etc. We do all this even when there are no explicit rules. Mind you, as someone who regularly travels to the US from the UK I know what it is like to accidently move against this flow when I forget to walk on the "right". So maybe there are more socialised rules and logic than the author makes explicit.

One theme in the book which did appeal to me was the notion of the difference making a difference. While it seems inefficient, having a diversity of ideas seems to allow meaningful differences of ideas, especially at the early stages of decision making - and this is important. Groups also need to be able to distinguish good ideas from bad ideas and having more to choose from helps.

There is some helpful work about distinguishing the difference between situations which are easily defined by a single answer, such as the weight of an ox, and those which are more co-ordination problems, such as traffic manageemnt. Co-ordination problems come when all individuals want to go their own way. Here the wisdom of the crowd sound a lot like complexity science and simple rules and I wasn't totally convinced of all of his arguments. However, they were interesting.

A thought provoking book which much more to say that the few bits I have mentioned here.

The book's website is here http://www.randomhouse.com/features/wisdomofcrowds/ where there is a lot of detail and audio to download.

Book Review: New Age of Innovation; Prahalad & Krishnan

If you're interested in large scale change and innovation then you'll find this book fascinating. On the one hand it felt like there was nothing startlingly new to me yet on the other it was neatly put together in a readable way that made sense.

A key premise is the current trend of personalisation and how value is based on the unique experience we all want. The authors refer to this as N=1. Current technology drives this, social networking, web 2.0 etc. How can we co-create value with our users and consumers? What are the challenges with managing who owns the knowledge? All good questions. They also suggest we need to make the most of collaborative networks, electronic and face-to-face, be flexible and ensure scalability. I liked the section on scalability and in my mind there is more in here than what they covered. This is a key element and is also linked to their second premise.

The 2nd key premise is the one that resources need to be global and they use another little formaula: R=G. Here they suggest the issue is that access to resources is more importnat than providing products; namely it is the solutions that matter rather than the kit or pieces. I think I agree with this. Again, scalability comes up.

They mention social movements and how they figure in the process as well as organisational transformation. There was nothing much new in the organisational process other than the context of the infomrational technology infrastructure - well, that is rather new and for some people rather perplexing.

If you've not yet engaged with Web 2.0 and new technology then this is definitely worth a read.

Paper: Developing capable QI leaders

A paper for those who have the pay-for access... Cincinnati Children's Hospital have been running cohorts of leaders through 6-month programs. The results look impressive, with two thirds completing their QI projects and a third of those involved presenting their project work at conferences.

BMJ Qual Saf. 2012 Jul 12. [Epub ahead of print]
Developing capable quality improvement leaders.
Kaminski GM, Britto MT, Schoettker PJ, Farber SL, Muething S, Kotagal UR.

Book Review: The Art of Changing the Brain by James Zull

I was recommended this book by Paul Batalden and he was right - it is excellent.

The subtitle is "Enriching the practice of teaching by exploring the biology of the brain". The author manages to integrate biology and neuroscience with educational and learning tactics. For me the book brought to light the process of learning in the sense of how the structure of the brain influences the process.

Zull explains the natural relationship between the structure of the brain and learning, how brain connections change data into knowledge, the way that evolution of the brain is linked to how we are motivated in our learning, and the importance of emotions in the learning process.

While the book covers some breadth of biology at no time was it too complex to follow for someone like me who has limited knowledge of the subject. I think, if you did know more about biology, then you would possibly get more out of the book than me.

Parts I really like was when Zull got practical and linked the discussion to how teacher can then use this knowledge to provide better learning experiences. Having made the links to brain structure it really made sense. I have been testing out some of the ideas and techniques and they do seem to work for me and for those with whom I work.

If you're a fan of PDSA cycles then on reading this you will probably have a major "Aha" moment as you figure out just how they work!

Report: Cross Sector Working to Support Large Scale Change

The Health Foundation has come up trumps with a fabulous light touch literature scan of evidence around how cross sector working influences large scale change.

I commend you to read it.

Paper: Evidence based surgery - don't show this to the patients!

I stopped to read a summary of this paper, mainly because I was struck by the thought that surgery may not be evidence-based... The best bit about this paper, for me, is that the authors have described the elephant in the room (or should that be in the operating theatre). Well done to them.

World J Surg. 2012 Aug;36(8):1723-31.
Evidence-based surgery: barriers, solutions, and the role of evidence synthesis.
Garas G, Ibrahim A, Ashrafian H, Ahmed K, Patel V, Okabayashi K, Skapinakis P, Darzi A, Athanasiou T.

Book Review: Groundswell by Charlene Li & Josh Bernoff

The authors define a groundswell as “…a social trend in which people use technologies to get the things they need from each other, rather than from traditional institutions”. mmm that sounds like an important thing to know about if you think you're a traditional institution, or if you think you're breaking new ground, or if you're a consumer wondering why you're starting to feel left out the loop.

What I liked about the book was the examples and case studies. Usually I skip these, however, I foudn these ones riveting reading. Who needs thriller novels when the business world presents us with such chaotic and roller coaster events. Fabulous.

I also found the way the book was constructed and organised to be very helpful, especially when faced with a disconcerting topic. Far from being disorganised, the underlying structure helped get the message through.

Read this book and it will move you on from thinking about "all we need to do is have the odd blog and a fancy web 2.0 website" and get you into strategising about your social media presence. I have always been convinced that social media is not just for the youngesters and this book has all the examples and conceptuals models to help you create some of your own thinking for your business to prove it is for everyone.

The book has, as you would expect, a great website. http://www.forrester.com/Groundswell/index.html It is good to see them practising what they preach. They have a blog and there is also a social media profiling tool you can download and use.

I'm not one for giving 5 stars to a book, but this one deserves it. I might just read it a second time.

Digital Engagement: DoH, NHS, England

The Dept of Health is getting up to speed with digital engagement. There's an intro available on the website, along with links to other policies and hints etc.

Worth a look if you're in the NHS and new to all this social media and digital stuff.

Paper: Developing clinical guidelines - excellent set of papers

Here is a paper (series of three) from authors who are experts in this field. I've always been a bit ambivalent as to whether guidelines actually work - in terms of changing behaviour. I'm still not convinced but it's good to see a bit more work being done to identify the target audiences for guidelines as well as considering conflicts of interest etc.  Getting them right is a lot more complex than just collating what seems to be best practice, writing it up and then distributing them widely.

Oh, and the full text of the papers is free - that's nice. http://www.implementationscience.com/series/ClinPracGuidelines

Developing clinical practice guidelines

Edited by: Prof Martin Eccles, Dr Paul Shekelle 

Collection published: 4 July 2012

These articles describe the state of the art in developing clinical practice guidelines. As well as updating on established areas, such as evidence review and group composition, they also address contentious areas - conflicts of interest - and new and emerging topics including updating guidelines, dealing with co-morbidities and guideline implementability.

(Picture and text above is from the Implementation Science Webpage)

Book Review: Overtreated by Shannon Brownlee

The subtiutle of this book is "Why too much medicine is making us sicker and poorer". This book was quite shocking. I know there is a lot of what goes on in healthcare that is unnecessary yet to find a huge amount of detail and information in one place really put the issue into perspective. It is focused mainly on the USA though there are many parallels with other health systems.

Throughout the book, the author provides stories and examples to illustrate the data and statistics that without the stories would appear cold and less shocking.

As I read through the book, particularly in the early chapters I found myself going "I know him/her"! Shannon Brownlee hooks a fair amount of the debate onto the actions of some of the current health leaders in the USA (you might like to read the book to see if you are mentioned...!) There is an excellent chapter on the VA Healthcare systems, how it has improved and in many cases how it is an example of how healthcare in the USA could look and feel.

Chapters include:

• Too much medicine: complelling arguments as to why population based healthcare would be a real improvement
• The most dangerous place: beware the hospital and what might happen
• Your local hospital: how uncoordinated care and overtreatment results in poor outcomes
• Broken hearts: how the latest fad takes root, based on economics
• The desperate cure: an argument for evidence based care if there ever was one
• The limits of seeing: an expose on the limits to radiology tests
• The persuaders: mmm who is influencing whom, and why?
• Money, drugs and lies: why not to believe everything published in journals
• The doctor isn't in: all about managed care
• When less is more: some ideas to cope with over-capacity and overtreatment in the USA

This book is a must for every health care improver who believes their own project is making a difference... The strategic and tactical issues raised in it really provide a new perspective.