Managing the legacy of your project

Ending a project is as chaotic an affair as the start up. After the flurry of the beginning and the more measured stage of making progress, we are then faced with wrapping things up.  So what do you want to have as the legacy from your project?

Mostly it's all about figuring out how to keep the website going, debating where to put the useful resources that have been developed, and managing the process of celebrating results and saying goodbye to project teams.  But is this enough?

Project outcomes are good - and always worth advertising.

But what is your legacy? By legacy I mean the long term, sustainable, "thing" that has resulted form your program. Sometimes this isn't seen clearly until years later. There's an excellent paper I commend you to read which covers the difference between people, process and product legacies.  I particularly like the "reuse" concept.

An introduction to Activity Theory

I'm finding Activity Theory very useful for thinking about large scale change. Traditional quality improvement, implementation science, dissemination science, organisational development and the like, are all useful. However, every theory has its limitations and although Activity Theory isn't perfect, it does provide some thought-provoking challenges.

There's a good 9 minute introduction, though you do need to be in a quiet place and be concentrating...

Please. No. More. Research. We. Need. Action.

Now before you send me a complaint, I'll start by saying I do believe that research is a good thing. However, we can have too much of a good thing.

The February Editorial in Implementation Science pitches the question as to whether we need a scientific study for research on how to improve healthcare. Here are my thoughts:

• I am not convinced we need any more "what" when it comes to improvement; we are drowning in good practice, guidelines etc.
• When it comes to the how" then I'm more interested in getting people to the "do" stage of making changes, than in spending more time pondering how best to go about it.  By doing, the people learn.
• Researchers, and I'm a closet researcher so I know, tend to be separated from the real world in time and space. 
• I suspect we have 80% of the "how" that we need to improve healthcare. What we lack are the people within healthcare who are sufficiently motivated to make the changes - or get out of the way of people who are motivated to make the change

Implement Sci. 2012 Feb 29;7:10.
Does the world need a scientific society for research on how to improve healthcare?
Wensing M, Grimshaw JM, Eccles MP.

Sustainabilty of QI results; we're not sure how to make it happen

I love systematic reviews. Someone else does the hard work of synthesising the literature and pointing out the strengths and weaknesses.

If you come across anyone purporting to tell you how you can sustain the results of your improvement work, then send them this paper.  Basically, we're not sure how sustainability happens other than it is a complex matter, and not one for a checklist or one day seminar. What I like about this systematic review is it points out the complexity, the system dynamics issues and the need for published work to identify the contextual factors in the sustainability (or not) or results.

Excellent work here by the authors.
Thank you.


Implement Sci. 2012 Mar 14;7(1):17. [Epub ahead of print]
The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.
Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M.




Partial Abstract

"RESULTS:
Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.
CONCLUSIONS:
Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment."

How is evidence being used?

Having moaned in this blog a few days ago about people not searching for evidence, I see a small group have set out a protocol to examine just how managers and professionals access the evidence.

I hope they will also do the negative study - those who are not accessing the evidence...


Implement Sci. 2012 Mar 21;7(1):22. [Epub ahead of print]
Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.
Kyratsis Y, Ahmad R, Holmes AH.


"Abstract
BACKGROUND:
We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK’s National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers’ perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations.
METHODS:
The study will involve nine comparative-case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems.
DISCUSSION:
Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready."

Dissemination Science. OK, that's a useful way of thinking about it.
A framework for training competency in implementation and dissemination science - now that sounds very useful.

Acad Med. 2012 Mar;87(3):271-8.A framework for training health professionals in implementation and dissemination science.Gonzales R, Handley MA, Ackerman S, Oʼsullivan PS.


This is their abstract

"The authors describe a conceptual framework for implementation and dissemination science (IDS) and propose competencies for IDS training. Their framework is designed to facilitate the application of theories and methods from the distinct domains of clinical disciplines (e.g., medicine, public health), population sciences (e.g., biostatistics, epidemiology), and translational disciplines (e.g., social and behavioral sciences, business administration education). They explore three principles that guided the development of their conceptual framework: Behavior change among organizations and/or individuals (providers, patients) is inherent in the translation process; engagement of stakeholder organizations, health care delivery systems, and individuals is imperative to achieve effective translation and sustained improvements; and IDS research is iterative, benefiting from cycles and collaborative, bidirectional relationships. The authors propose seven domains for IDS training-team science, context identification, literature identification and assessment, community engagement, intervention design and research implementation, evaluation of effect of translational activity, behavioral change communication strategies-and define 12 IDS training competencies within these domains. As a model, they describe specific courses introduced at the University of California, San Francisco, which they designed to develop these competencies. The authors encourage other training programs and institutions to use or adapt the design principles, conceptual framework, and proposed competencies to evaluate their current IDS training needs and to support new program development."

What is disruptive innovation?

A disruptive innovation is not a breakthrough innovation that has taken something and made better.It is an event or product which transforms the entire notion of the experience or product.
We would like disruptive innovation in healthcare, but mostly we do breakthrough innovation - at best.

Listen (<5mins) to the definition of disruptive innovation from the man himself, courtesy of Harvard Business Review (HBR)

Is Activity Theory useful for large scale change?

There's no shortage of theories and models for how good practice can be "spread". I'm part fo the problem by generating some of them.... I've recently become curious about the use of Activity Theory as a means of large scale change in healthcare settings.   It's a bit of an eclectic theory from the social sciences - but then, PDSA cycles were once an eclectic Japanese theory.

Wikipedia has a good intro.  Basically, the benefits of Activity Theory is it combines all system levels into one model of change - from individual through to policy. And I like that.

Greg, Entwistle and Beech have a new paper which considers how AT can be applied usefully in healthcare.

Soc Sci Med. 2012 Feb;74(3):305-12. Epub 2011 Mar 1.
Addressing complex healthcare problems in diverse settings: Insights from activity theory. 
This is their abstract: "In the UK, approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and 'rolled out' across organisations. When the designated 'best practice' is not implemented, this is interpreted as local - particularly management - failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail. We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on "objects of activity" which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice. The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the 'best practice' of rapid response teams."

Why don't we search for evidence?

So I'm perplexed.

I've spent years listening to leaders at all levels - from unit, to department, to organisation, to region, to National  - all say they want "other people" (usually those "beneath" them) to adopt existing good practices.

That's all good and well.

But when I press these leaders on what efforts they've made to check the literature, search for existing guidelines or consider the experience of people similar to themselves - they all look at me blankly.  One recently told me that "that sort of thing is for the people who need to improve, not me. They need to adopt guidelines."  When I pressed him about the opportunity he has to learn from others in the design of his large scale intervention, he replied "We're different."

I shall invest a new piece of equipment - a mirror.

Self Management Support Tools and Resources

Hoorah! We're finally moving from what often feels the patronising approach of "empowering patients" to finding ways to truly be partners in their care process.  There are multiple projects and programs round the world which demonstrate what can be done.  I've put together a list of resources which you may find useful.

1. My favourite are from The Health Foundation. Their package is comprehensive and includes materials for training staff so is excellent for getting the message out there in a practical way. They've also got resources for improving patient skills.

2. The Institute for Improvement has a short guide which is useful if you want to check what you may need to do to get some benefits.

3. There's an excellent write up about the long term conditions collaborative in Scotland where they identify the top high impact changes you can make.

4. Selfmanagement,.co.uk also has resources and it's one of the few places I've seen where there's information on relevant published literature.  In fact, the more I look at this website, the more I feel it is perhaps the most comprehensive and useful...

Do you have any favourite self management support resource links you'd like to share? Please comment below and I'll add to this blog.

Do you share your experiences?

I recently watched a three year old coming to terms with her one year old brother's need to hold a toy that until recently she thought belonged to her.  Sharing - it doesn't necessarily get any easier. But for some people, it is automatic. Dr Michael Bergstrom from SKL, Sweden, sent me a one page summary and a pictures of the top 10 slides (in his opinion) from the Paris Euroforum.

Just a perfect example - of sharing.