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?