Book Review: Performance Drivers by Olve, Roy & Wetter

Performance Drivers by Olve, Roy & Wetter
John Wiley & Sons, 1999
Purchased from Amazon



On the one hand the topic of this book seemed old and faded - there must be 10 new methods for change and improvement being issued every day - yet on the other hand, it seemed fresh and comforting, like a newly washed pair of favourite socks. It was comforting because it answered the questions I had in a way which build on my existing knowledge, and fresh because it left me with new ideas and measurement strategies.

Part I covers the reasoning behind the need for a Balanced Scorecard and how it is effective for strategic control. I liked the way the authors explained how the dynamic between measures is so important. I think so often this interdependence is lost, with the result that we have undesirable knock on consequences in our systems or we miss valuable opportunities for improvement.

Part II takes you through the process of building a Balanced Scorecard. The cases from different industries illustrate the diverse ways you can do this. There is more detail in here about understanding and using causal relationships between measures.

Implementing a Scorecard is discussed separately to building and designing one. This section, Part III, covers IT systems that help as well as the facilitation process to ensure the scorecard is used to develop a learning culture rather than performance management straight jacket.

Part IV explains how you can use Scorecards to inform parties outside the organisation and there is also a chapter on their use in the Public Sector. If you are working in the Public Sector you may like to start with this chapter.

Finally, Part V has hints, tips and advice on making the scorecard process a success. If it were me I would have put these notes earlier in the book as they are important.

If you are bereft of any ideas on what measures to use then the authors have helpfully compiled a "starter for 10" list in a useful Appendix.

I recommend this as a handbook for those who are searching for ways to measure the dynamic variables in a system or organisation, with the aim of learning from the output.

Using Twitter for Rumour Management

Twitter can be used in a zillion ways. I 've been doing some research to help my understanding how it can be used to manage rumours and/or bad news.

When it comes to rumour management, the first step is to pick up the rumours.  Use Google Alerts or similar programs to collect on a daily or weekly basis, comments that are being said about you or your organisation, or product. Use Twitter search to check if you are trending - for the worse... It's no good relying on traditional paper cutting services - the Interest is a hotbed of gossip, much of which never makes it into the printed papers.

The best form of rumour management is prevention.  Make sure there is lots of positive content about yo, your product or your organisation on the Web.  Use facts and details to enhance your credibility. Use Twitter to post content and to link to content. Retweet content which relates positively to you.

When something crops up, contact people directly and engage them in discussion (either on or off the web). Ignore them at your peril.  "Nipping in the bud" is the name of the rumour management game.  Ask your advocates to speak up for you using their social media methods. Remember Twitter is one way you can provide good answers to questions and allow others to see these answers.

If it gets really big, then call in a Crisis Management expert.It's unlikely that in-house communications departments will have the experience and expertise to manage an Internet based communications mess.

Here are some case studies:

• Guardian newspaper article referring to the 2011 London Riots and how Twitter was used to knock-down rumours
• Guardian resources provide various info graphics to show how rumours spread on Twitter - fascinating

How not to use Twitter

There are no hard and fast rule for using, or abusing, Twitter. But here are some of my "cautions".

1. Following everyone and anyone; indiscriminate following, in the hope you get followed, is a short term action with long term consequences. Before I follow someone, I often look at who they are following. That way I can get a feel about their interests.
2. Not having a profile photo or putting up a picture of your dog. I want to follow a human ad I want to know who they are. Anonymity doesn't allow for constructive tweeting.
3. Random discussion.  A bit of chat is fine, but when my Twitter stream is filled with a discussion on the merits of gooseberry jam versus Seville marmalade for the morning toast - then I'm going to do some unfollowing.
4. Too much personal information: I really don't need to know about your dandruff, your toenail fungus or what you got up to last night.  Perhaps you could save that for private discussions amongst close friends.
5. Using Twitter to sales pitch using automated Tweets: Endless automated tweets, or even ones done by hand which continually sales pitch your own stuff can feel a bit mob-handed and lead to unfollowing.

Paper: Three Collaborative models for scaling up evidence-based practices

In "101 ways to improve your collaborative" I described a number of ways to spread / scale up innovations using the collaborative model in different formats.  In this paper

Adm Policy Ment Health. 2012 Jul;39(4):278-90.
Three collaborative models for scaling up evidence-based practices.
Chamberlain P, Roberts R, Jones H, Marsenich L, Sosna T, Price JM.

... the authors explore the merits and demerits of the Rolling Cohort, The Cascading Dissemination Model, and the Community Development Team.

Paper: Strategies for sustaining a quality improvement collaborative and its patient safety gains

Int J Qual Health Care. 2012 Jun 4. [Epub ahead of print]
Strategies for sustaining a quality improvement collaborative and its patient safety gains.Parand A, Benn J, Burnett S, Pinto A, Vincent C.

In their words, the conclusions are

"This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention."

I'm not sure what this means other than 'watch and wait' and 'learn' - which is fine.

Readiness for change - an adopter's diagnostic tool

The Agency for Healthcare Research and Quality (USA) has a fabulous tool that can be used by potential adopters in helping them decide whether to adopt an innovation in their organisation. Whilst the questions appear rather basic, they are comprehensive, evidence based and the way in which the diagnostic has been put together really helps the decision-making process.

I commend it to you.

Download the PDF Diagnostic here

How to use Twitter to effect Social Change (Video)

"It takes many streams to create a river" - great quote from this video. I found this 3 minute video covers all the basics of Twitter good practice, especially for those who are hoping to influence social change through their use of the technology.  It was a bit quick and I had to rerun it to make sure I had all the info.

No benefits from spread, scaling up unless the baseline is poor?

I've been going on about the issue of top-down spread / scaling up initiatives which overstate the benefits. For example, if the pilot projects gets a 50% improvement, then that is, of course, relevant to their baseline. And we can only translate this benefit across a system f we know the baseline of all the individual potential beneficiaries. The worse we can do is take a national average and then assume everyone can get the same 50% improvement that the pilot site obtained.

I've written about this in "Undressing the Elephant: Why good practice doesn't spread in healthcare" and it's great to see a systematic review based around diabetes care that supports the notion that "interventions solely targeted at healthcare professionals seem to be beneficial only is baseline HbA(1c) control is poor". [This research and paper was funded by Ontario Ministry for Health]

Lancet. 2012 Jun 16;379(9833):2252-61. Epub 2012 Jun 9
Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.
Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, Halperin I, Vachon B, Ramsay T, Manns B, Tonelli M, Shojania K.

Readiness for change diagnostics: Some evidence

I'm ambivalent about the concept of "evidence" for much of the change and improvement work we do in healthcare because so many of the concepts and processes are contested.  However, that doesn't stop me checking for evidence and testing my own prejudices.


There are a number of papers  and publications which touch on the topic of readiness for change.  



Review: Conceptualization and Measurement of Organizational Readiness for ChangeA Review of the Literature in Health Services Research and Other Fields
Weimer, Amick & Lee
All literature reviews need to be considered as a service to humanity. This one covers the concept of readiness for change in healthcare and reviews 43 instruments in use.




Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

Sharon Hamilton, Susan McLaren and Anne Mulhall

This team conducted a comprehensive review and evaluation using multiple strategies which I like. They also used the Team Climate Inventory.

^{Monograph: Assessing & enhancing readiness for change; implications for technology transfer.}

^{Backer, David & Soucy}

^{Not a peer-reviewed paper as such, but it has some excellent perspectives on what readiness for change means - and doesn't mean.}

Systems Antecedents for Dissemination and Implementation; A Review and Analysis of Measures
Emmons, Weiner, Fernandez, TuThe conclusion in this paper seems ot be there is no common ground for the use of measures or consistency in the way in which they are applied, hence leading to difficulties in figuring out what might be the best strategy.


There are many more papers - if you find any, please leave notes in the comments box.

Paper: An Operationalization of the Interactive Systems Framework Support Systems

This paper has a long and complicated title.The bottom line seems fairly straightforward - that train the trainers (TOT) activities and technical assistance (TA) can lead to success when scaling up the adoption of evidenced based practices.

Am J Community Psychol. 2012 Jun 19.
Using a Training-of-Trainers Approach and Proactive Technical Assistance to Bring Evidence Based Programs to Scale: An Operationalization of the Interactive Systems Framework's Support System.
Ray ML, Wilson MM, Wandersman A, Meyers DC, Katz J.

Using Twitter for Customer Service

My own experience of using Twitter for customer service has generally been far better than trying to contact the brand by phone or email. British Airways were excellent during the ashcloud, and Menzies Airports responded quicker by Twitter than the receptionist when I had a problem at an airport.

My tips include:

1. Respond! There's nothing worse than contacting a brand via Twitter to find they only use their Twitter feed for pushing out automated tweets.
2. Be open. One way a customer can be supported is by reading your replies to tweets. This was useful in the Ashcloud incident.
3. Manage privacy. In contrast to the above, don't ask a customer for their personal details to be tweeted, or start conducting business transactions publicly on Twitter. Use the Direct Message facility.
4. Solve the Problem - Now. Don't pass the tweeter onto a phone line...
5. Tweet ahead. If you know there is likely to be an issue, start providing solution options in advance

In healthcare, the privacy issue is a tough one to manage. If a patient tweets an NHS organisation asking for a problem to be solved, then the conversation will still need to be managed carefully, to make sure privacy is not compromised. Check they want to continue the conversation via Twitter and give an alternative means of instant access communication.

Summer reading for Healthcare Change Leaders

Freedom is blogging in your underwear
How can this not be on your list!  It's about getting on with the job, the highlights of working form home - and basically, you've got no-one other than yourself to blame...


Ignore Everybody
Creativity is something you do, not what you steal from others. This is an edgy book with humour that works on the proposition that talent does not need props.



Poke in the Box
Seth Godin is one of my favourite authors. In this book he points out the necessity of standing out (not conforming) and the need to take the initiative. It will leave you feeling uncomfortable.

Velocity: The Seven New Laws for a World Gone Digital

Technology getting you down? Find out how others are embracing it, changing with the times and not waiting until new "things" have become mainstream. Are you ahead of your tribe, or just a digital follower?

Readiness diagnostic tools for spread, scaling up, dissemination

So how do you know whether your organisation is ready to embark on a program to adopt existing good ideas / evidence in a systematic way?

As in previous posts, most of the answer to this question is a no-brainer - you know the answers already (see previous posts).  However, sometimes it's nice to have a checklist or set of tools to help you check whether what you know about is actually in place.

There are many general tools / checklists available which check whether your team or organisation is ready to do something different.  Most of these assess the culture of the group. The disadvantage here, which is why I suspect many people avoid these types of tools, is if you find out that your culture is not ready, many people lack the patience to go through the necessary cultural change - or they just don't have the time for this "pre-work".

Generic tools can be useful for learning about your organisation though they can be a good (and time-wasting) displacement activity by organisations.

The best types of diagnostic tools are those which are specific to the change in hand.  Specific means they are designed around and for the type of change proposed.

1. One of the best examples I know of specific diagnostic tools come from, the US National Council on Aging. For their Chronic Disease, Falls and Depression scale up plans they have open access tools which can be completed online or you can download the PDF to read through.  Each of these is specific to the adopting community and the type of innovation proposed for scale up / spread / dissemination.
2. NICE - yes, the National Institute for Health & Clinical Excellence (NHS) has been at the forefront of providing tools that support the introduction of evidence. These are excellent spreadsheets, populated with the NHS data and ready to use.  Unfortunately, I don't hear about them being used on a regular basis - especially by commissioners.

The problem with tools and diagnsotics is no difference than the problem with any other thing we want to spread or be adopted - most people would prefer to create their own because the credibility for many members of staff lies in the excitement and status of creating their own, rather than using someone else's. If you're offered a diagnostic tool - have a good look at it - if it is specific to the innovation it may be very useful for you.

Readiness for Spread. Whose readiness - the adopter or the "pusher"?

One of the most frequently asked questions I get is how program managers can assess whether organisations and teams are ready for spread. For me, the answer is a lot more than a quickie checklist or diagnostic tool - I've tried many, including developing my own, but they have their limitations. The first question to think through is "whose readiness"?

1. ADOPTERS: Mostly I have program managers wanting to know whether organisations and teams they want to adopt something are ready. This is a useful question to ask, and indeed much of the literature focuses on these potential adopters. So yes, it's good to consider their readiness and there are a multitude of tools and techniques for doing this - any good change management assessment will work.
2. "PUSHERS": What most people forget is to assess the readiness of the "pushing" organisation to go through the spread process. For example, a regional organisation may want all physician practices to adopt the use of new diabetes guidelines which includes an information monitoring system. It may sound obvious, but the "pushing" organisation does need to make sure they are ready and geared up for others to adopt the process.They need to have the support and systems in place. Often, great practices and ideas can be adopted so quickly that the "pushing" organisation panics and then becomes part of the "slow-adoption" problem as they put limits on the process.
3. CONTEXT: Finally, the context is crucial. When it comes to large scaling up activities, it's vital to assess the readiness of the context that organisations and teams find themselves in. For example, the context where a pilot program achieved great results may have changed in the year or so since they completed their work: a change of government, the financial crisis, new technology etc.

So, when you are next assessing the readiness for your spread / scaling up program, do take the time to think through the three different angles.

Paper: Judgement Sampling; a healthcare perspective

A new paper from the healthcare statistical gurus Perla & Provost needs to be read by all leaders and improvement project leaders.

The premise is that we can't apply regular statistical approaches that rely on specific sampling techniques - if we're not using those sampling techniques. And in healthcare projects we seldom use scientific sampling methods, instead using a non-probability, judgement sampling method. In their paper they describe the method and  explain the impact for healthcare settings.

The paper is in a subscription only journal. (Bah-humbug...) So if you're not able to access this journal, you can learn more about judgement sampling at these places:

• FULL ACCESS PAPER: Sampling for qualitative research, by Martin Marshall
• List of definitions of various sampling methods
• What is judgement sampling?
• When to use and setback of judgement sampling
• Advantages & disadvantages of judgement sampling

The Perla & Provost paper can be found here:
Qual Manag Health Care. 2012 Jul;21(3):169-75.
Judgment sampling: a health care improvement perspective.

Book Review: Sway; the irresistable pull of irrational behaviour by Brafman & Brafman

Irrational behavour? Me? Never!

The Brafman brothers write a compelling story of how irrational our behaviour is in a variety of circumstances. While most of the book is well evidenced they bring each of the issues alive with stories that make sense - perhaps too much sense.

I'm getting a bit tired of the constant use of the airline industry as a safety example. So it was with interest I read through the case study on the crash at Tenerife which was one of the largest loss of life incidents. The authors demonstrate how the perception of loss played an important part in the creation of the incident.

Next up is a football team in the US which managed to beat all the major players but relinquishing their commitment to the predominant method of play. The story here is about how our commitment to a certain way limits our opportunities for growth and advancement. The authors show how loss and commitment add together to become a powerful irrational pull.

The chapter on value attribution is quite scary. They use a number of examples. One is of a famous violin player dressed casually playing complex tunes in an underground station during rush hour. hardly anyone paid him any notice at all. Yet some would pay large sums of money to hear him play on stage dressed in his dinner suit. The book is worth the read in this chapter about the discovery of a human fossil and how scientists of the day were not prepared to give it credence because the discoverer wasn't "one of them".

If you are currently either interviewing people for a job or going for interviews yourself, then the next chapter which looks at how initial diagnoses or decisions sway our long term responses to individuals.

Perceptions, beliefs and context come under scrutiny in the next chapter. If you want to understand why the USA has a Bipolar epidemic then read about it here. If you are involved in training and developing individuals then the examples of belief are important to understand.

So what is fairness? Read on to discover the importance of context.If you think monetary incentives are a motivation to change behaviour then the next chapter provides some examples which may rattle your thoughts. By now I was beginning to understand just how irrational we are as human beings. And just when I've grasped a bit of my own irrationality, the authors move onto the irrationality of groups, particularly looking at blockers and dissenters.

If you are wondering why no-one is following your instructions, why it is too difficult to plan something, why you always seem right and no-one else wrong... etc. then I thoroughly recommend this very readable book. It is an easy and relatively quick read (once - I had to reread to make sure I grasped what was being said).

7 Twitter Resources for Healthcare Professionals, NHS

If you're just getting started on Twitter, here are some resources you may be interested in:

1. 140 uses for twitter by healthcare - a blog post and one of my favourites. A bit old but still up there with challenges for you
2. Using Twitter in the classroom or organisation - nice framework
3. Canadian booklet on Twitter for Healthcare Professionals; short, sweet and to the point. Recommended.
4. How using twitter can help increase staff transparency and trust - one of my blog posts from a while back
5. Twitter for Doctors - by a doctor, with his experience
6. Pull vs Push; a twitter case study - this is my personal 90 day project from when I first started using Twitter. The lessons then are relevant to anyone starting up now.
7. Using Twitter as a social movements strategy; one of my blog posts from March 2009. Some actions to consider.

Why I was almost ready to vote for the NHS to go private

At the end of 2011 I received a letter from my GP practice to say they would no long be operating "today's work today" so no more calling up in the morning to get an appointment on the day. Instead you call, get advised a GP will call you back, then you go in if required.  You can book an appointment in advance, though currently if you want any appointment in under 2 - 3 weeks you're unlucky.

So much for the sustainability of the "Advanced Access" program....

Despite over a decade of modernisation efforts in the NHS, not only is access an issue, but the sheer waste of processes is still in action. It's hard to be forgiving of a primary care practice who say they are overworked when they duplicate processes and add in bureaucracy.  

For example, I need two armfuls of vaccinations for a camping trip to Africa later this year. I called the practice to book an appt with the travel clinic to be told the nurse who ran the clinic was on holiday. No, there is no back up when she is away. No I couldn't book an appt for when she got back (third week of July) as I first had to go in and collect a questionnaire. When I've completed it I then have to take it back in to them. (I learnt afterwards, through my own efforts that this form is available online but this was never mentioned to me.). No, I can't book an appt for the vaccinations but I can book an appt for a nurse assessment, after I've completed the form and after she's read it.  After that I can have the vaccinations.

I lost the will to live just listening to the process. I work. I can't afford to take that much time off for 4 or more visits to the practice, at times that suit only suit them and their staff holidays.

The receptionist told me I should try the MASTA private travel clinic in Oxford.  So I did.

Within an hour I had completed the online form, been called back by a nurse, had a 30 minute telephone consultation, had the yellow fever medical waiver organised (it arrived in the post 2 working days later) and had an appt to go in and get my vaccinations at a place that suited me on a date and time that suited by schedule.  [I wondered why NHS Direct couldn't offer this service?]

Yes, I had to pay, but using what I bill for my time, going private in this case cost 25% of the total cost the NHS would have been for me in lost time and travel costs.

*****

I'd like to balance my concern about primary care with the stunning service I've received from Stoke Mandeville Hospital. I've had to go through two diagnostic treatments in the last month. The first I chose my time to go in and the second I had to rearrange due to illness and chose a time and date to suit my schedule. Both times I packed a flask, book and prepared to wait. Both times I was called in before I even had time to sit down.  Quick. Efficient. Perfect.

Readiness for spread, dissemination, scaling up

Spread, scaling up, dissemination, diffusion - whatever you want to calls it - does NOT happen in healthcare in the automatic "tipping point" way of Gladwell.  This is largely because in healthcare, the NHS being one great example, the desire to spread is a top-down prescriptive one - which is most companies would be dealt with a a large scale implementation project.  Similarly, just focusing on how to describe and communicate  the innovation is not enough. (I've written about this in previous posts.)

Whatever you call it and whatever methods you use, there is evidence that there are some key factors which need to be in place before you set off on a large scale "thingy".  These are not clever, and, in fact, are annoyingly obvious. Obvious does not mean simple.  You already know about the list below and one major step forward in your large scale work is to examine why you're not working on these "readiness" factors.

1. Strategic focus: if the imitative is not named and talked about in the organisation (and team) level as a strategic piece of work to do, then it's probably not a large scale change or one which will be given priority
2. Executive sponsor: who in the organisation is responsible and accountable for the implementation (not the planning) of the change?
3. Day-to-day leadership: is the initiative being talked about?
4. Spread aim: is there a clear aim and method of measuring progress for spread / scaling up?
5. Spread / scaling up Plan: is there one? Is there one that scales down each level of implementation?
6. Costs: are the costs of the change clear? DO they include the staff time coasts? Is there an agreed ROI for the scale up?
7. How will fidelity be ensured? (Fidelity = what is scaled up / spread is the same as the initiator project)

Some references:

(There are many references available in peer-reviewed papers, however, as many of you have complained you don't have access to these, I have listed some more general and open access references. If you know of other easy access references then please comment on this blog.)

• IHI: A framework for spread
• Agency for Healthcare Research & Quality: Innovation readiness for spread
• Some of my books: Rolling out your project includes a whole section on diagnosing readiness for change. 

90 Day Projects

I've written about 90 day projects over the last couple of years:

1. How to implement 90 day projects
2. What are 90 day projects
3. Large Scale projects are seldom a linear process
4. Push vs Pull: Twitter Case Study 90 day Project

Many months on I am still convinced that we spend far too long on our healthcare projects. The tradition is they are planned for 18 months - often regardless of the size and difficulty of the change required. There are some changes which may need to be part fo a three to five year project, and others that can be achieved in 7, 30 or 90 days.

If you have examples of 90 day projects successful or not, then please leave a note in the comments. Thanks

5 Program Evaluation Resources

Here is a list of resources you may find useful if you're evaluating a large program.

1. A basic guide to program evaluation has lots of text but it organised into useful headings. Not too long and is good if you're looking for the rationale for carrying out an evaluation.
2. The Evaluation Cookbook is a splendid resource - apart from having a great title. Comprehensive yet not overwhelming. My favourite resource for evaluation.
3. The Evaluation Handbook from the Kellogg Foundation is a meaty text aimed at program managers on their funded programs - though its useful for similar, large scale programs.
4. A User Friendly Handbook for Evaluations is good if you have a scientific bent to your evaluation process.
5. Taking Stock: A Practical Guide to Evaluating your Own Programs is useful if your focus is on carrying out internal evaluations to assess your project work.

Leadership, Spread, Adoption & Sustainability

Here is a summary of some blog posts I've written with healthcare leadership in mind:

• Do middle managers matter in healthcare? (refers to a peer-reviewed paper)
• Why don't we search for evidence? (Importance of role modelling)
• Is the role of the organisational champion effective? (Refers to peer-reviewed paper)
• Leaders need to be productive (Video)
• Scheming virtuously: A handbook for public servants (links to the handbook)

Leaders need to role model "Spread"

If asked what the one thing leaders can do to better enable the spread and adoption of good practice in their organisation, it would be - "Be a role model".

I wrote in this blog on this topic back in May: "Why don't we search for evidence."

It's no good leaders exhorting that their staff need to adopt good practice and to use "evidence" if they don't do the same.  There's no quick fix. There's no substitution.

Next time you wonder why it is your staff don't search for, adopt or actively spread known good practices, then ask yourself when last you searched for or adopted a good practice.

Free SPC Templates for Excel

There are a  number of free templates available for your statistical process control data and charts.  It goes without saying that you should check that the template meets your needs and is the right type of SPC chart for your data.  I've not checked the accuracy of the following so please use at your own risk.

1. From Vertex42, a straightforward, simple spreadsheet with no complicated macros or other things to stymie your system
2. Statistical Solutions provide the entire range of SPC charts for free, though you do need to register. X Bar/S, I/MR, PChart, NPChart, Xbar-R Generator, XBar-S Generator, IChart Generator, APQP/PPAP.
3. There' are pages and pages of spreadsheets available here - of which SPC is one. I liked the Six Sigma Template Kit.