Paper: The concepts of scalability...

A new paper is out which looks at the concepts of scalability - what is meant by it and how to health promotion interventions consider scalability.

"Increased focus on prevention presents health promoters with new opportunities and challenges. In this context, the study of factors influencing policy-maker decisions to scale up health promotion interventions from small projects or controlled trials to wider state, national or international roll-out is increasingly important. This study aimed to: (i) examine the perspectives of senior researchers and policy-makers regarding concepts of 'scaling up' and 'scalability'; (ii) generate an agreed definition of 'scalability' and (iii) identify intervention and research design factors perceived to increase the potential for interventions to be implemented on a more widespread basis or 'scaled up'. A two-stage Delphi process with an expert panel of senior Australian public health intervention researchers (n = 7) and policy-makers (n = 7) and a review of relevant literature were conducted. Through this process 'scalability' was defined as: the ability of a health intervention shown to be efficacious on a small scale and or under controlled conditions to be expanded under real world conditions to reach a greater proportion of the eligible population, while retaining effectiveness. Results showed that in health promotion research insufficient attention is given to issues of effectiveness, reach and adoption; human, technical and organizational resources; costs; intervention delivery; contextual factors and appropriate evaluation approaches. If these issues were addressed in the funding, design and reporting of intervention research, it would advance the quality and usability of research for policy-makers and by doing so improve uptake and expansion of promising programs into practice.

Health Promot Int. 2013 Sep;28(3):285-98. doi: 10.1093/heapro/dar097. Epub 2012 Jan 12.

Milat AJ, King L, Bauman AE, Redman S."

Business learning from walking: 7. What to do when you reach your goal

Every project needs a plan of what to do when the project reaches its goal.

When I've finished a 14 mile walk I need to know how and where I'm going to rest my feet, dry off or warm up depending on the weather, going to get a meal etc.  The end of the walk is the not the end of the entire process. Just as I'm unlikely to organise a dinner party for the evening of a long walk, I'd like to know when I end a project that there's going to be a time of rest, recuperation and celebration.

Business learning from walking: 6. All time is not equal

You've seen the plans that show a pleasant linear progress of tasks that are planned to be completed as a constant pace over the duration of the project. We know that plans are not the change process itself but we still tend to think of things happening over time in a nice equal and fair sort of way.

To understand how all time is not equal, take a walk up your nearest steep hill. A mile on the flat might take you 20 minutes to walk. Add in a quarter of a mile uphill and you could end up adding ten minutes to your time to walk a mile. Add in a grassy field with no clearly marked path and a broken stile and a mile could end up forty minutes. Alternatively, add a field of nervous cows and you may run through it, matching an Olympic qualifying time for a mile.

Change projects are no different. While the measurement of months stays the same unfortunately the tasks, even if simple, may end up taking far more time than expected.  I good project management adage is to look at the final plan and add in 30-50% extra time. Then go back and check where this time may be needed.

Timing is not the same as pacing. When walking, it's good to know your own pace - how many steps it takes to cover a certain distance. This is an individual measure. In projects, it's useful to agree as a team the pace for certain tasks and then from that build up the overall timescales.

Business learning from walking: 5. Beware Groupthink

groupthink  (ˈɡruːpˌθɪŋk)
— n
	a tendency within organizations or society to promote or establish the view of the predominant group

Collins English Dictionary - Complete & Unabridged 10th Edition
2009 © William Collins Sons & Co. Ltd. 1979, 1986 © HarperCollins
Publishers 1998, 2000, 2003, 2005, 2006, 2007, 2009
Cite This Source

The trouble with groupthink is it's easily understood in theory and spotted in others. It's like a cloak that everyone can see from the outside but from your own perspective it's invisible.

I've been in walking groups where we've all agreed on the route we're taking. We stop and check - and we continue to agree that the mast over the is the mast on the map and therefore the path we take is this one over here... The fact that none of us spotted there were two masts about a quarter of a mile apart is groupthink.  Basically one person suggested the visual markers and pointed them out on the map and we all agreed, enthusiastically. And we ended up retracing our steps about a mile and a steep hill later...  We've also ALL walked past a path closed sign because we didn't want to believe the path was really, really closed, despite a couple of people questioning the route.

Would you fly with an airline where the pilots were subject to groupthink?
Would you like to undergo surgery where there is groupthink in the operating theatre?

Speaking up is not all about whistleblowing and making a drama out of an everyday moment. It's about pointing out the obvious, not allowing yourself to conform, being unafraid to ask a question and to hold out for a considered answer. The responsibility for avoiding groupthink is with the self - not with others.

from restortivepractice.org

Business learning from walking: 4. Teamwork trumps individual heroism

Walking alone is as about much fun as doing a change project on your own. Even if you like your own company, working alongside others will enhance the process in both cases. Sometimes it's enough on a walk to have someone to chat with, to help you put a blister on the heel of your foot or to give you a second opinion on the choice of path to take.

Walking in a group is a bit like working in a project team. You go at the pace of the slowest - there's no point in rushing ahead to a milestone to then sit and wait for someone to catch up. It's far easier to support the slower person as you go along as it may increase their confidence and fitness. Same goes for project teams.

The "hero" who strides ahead and out of sight of the group is no hero at all.

The Isle of Wight Coastal path is a moving feast and as we gathered on a group walk recently, it is collapsing  on a daily basis. Out group was faced with a section of path that had fallen away leaving no clear route forward. Do we retrace our steps (see previous post) or find a way around? One member of te group who has climbing experience assessed the risks and found a way for us to clamber around holding onto a fence while he supported us from underneath! It was not very dignified, but it worked and we were soon continuing down the path, adrenaline leaving us slightly elated.

Change projects will reach those points where it seems impossible to go on. Things happen that could not have been predicted. That's the time to check the skills of the group. If you can help then it's time to step up and take the lead. Assessing the risks is important.

Teamwork means giving up some control, allowing others to take the lead as their skills fit the task, and giving each other the physical, intellectual and emotional support required to reach the agreed goal.

Business learning from walking: 3. Never fear turning back or retracing your steps

I learnt an important lesson last week when walking on the Isle of Wight. Well, I learnt many lessons, but one of them was that sometimes it's easier to turn back and retrace your steps, than to go into unplanned territory.

We'd walked for a hour or so, it was hilly and we'd just headed down a steep hill that was so steep in places there were steps. Popping out between the hedges we realised something was wrong. After much deliberating and map checking, we had two options:( a) take a new, unplanned path that would get us back to where we wanted to be that was longer, less scenic and involved riskier road walking, or (b) hike the half mile back to the last decision point, even if it mean a steep 200ft climb back up the hill. After some whimpering and puffing from me, we got back on our planned track.

All change projects reach dead ends or go off track - often due to enthusiasm for trying new ideas. It's important to keep the goals in  mind and to assess any difficult situations. In my experience we tend not to have the courage to go back a few project steps and start again. Instead we blunder on and end up taking a longer and more tortuous route to get to where we need to be.  In future, I'll be asking more questions and keeping in mind the possibility of going backwards to go forwards.

Part of knowing when to turn back and when to go on is an important skill, and this is covered in the next post in this series.

Business learning from walking: 2. Knowing where you are is more important than knowing where you are going

Picture from simonmainwaring.com

It's a truth that you have to start where you are. Whether it's starting a walk along a trail or a new change initiative to streamline the repeat prescribing process, you begin where you are - not where you think you are.  Anyone who has run a process mapping event will know that participants love to create maps and plans about what they want to happen, where they want to be. Focusing on the reality of what actually happens seems far more difficult. It's fairly boring too. To start your walk you need to be able to place your finger on the map and say "We are here". To start a change program you need to be able to use all the data you have to state your current position.

Would you start walking a linear trail, like the Thames Path or Hadrian's Wall, without knowing where you are starting from and whether you are at the place you expected to be?  I may decide to start walking the Thames path but if my actual start point is 8 miles from the predicted start point, then it's goign to be a very long day and probably one with many disappointments.

After you've started moving, you need to keep track of where you are. In business we do this by measuring our progress. These measurements need to be close in time to the actions and decisions. If I walked a route saying I would check the map at every hour on the hour (monthly reporting?) then I could quite easily waste time and energy by going in the wrong direction.  Every decision point needs a check between plan and actual progress.

I can talk a lot about where I want to end up with my walks, as Many talk a lot about what the results fo their change program will be. But in the end, those results and goals are dependent on a system and practice of knowing where you are, at any point along the way.

Business learning from walking: 1. The plan is not the event

Picture from grough.co.uk

Advice is never to leave for a walking adventure without a map and compass – and a sandwich, drink and set of waterproofs is also a good idea.  In business we have our plan as our map. But just as the map we read and mark while sitting in the comfort of our warm and dry home, the plan we create in our offices is never going to be what actually happens.

 A tree may have fallen across the path – a barrier to change is discovered that the plan didn't take into account.  Someone twists an ankle – a key staff member goes off on long term sickness. It snows – a new directive from on high impacts the organisational plan

Never set out without a plan, but never assume that having spent hours (or days, weeks, months) on the plan that the event is now sorted. The plan is prework. No imagining beforehand can take the place of an actual walk under the trees, beside the sea or over a field. Similarly, no amount of planning can predict the actual path and experience that any organisational change will take. 

Designing social media impact; a challenge for healthcare improvers

Social media is the in thing in healthcare organisations - Twitter, Facebook, LinkedIn etc. These systems have been around for 5 years or more but are now catching on in healthcare as they are seen as a method for sharing messages quickly and a way to bring diverse and segregated communities together. And this works well.

The challenge is to integrate the use of social media into the mindset of the quality improver.  The Improvement Model asks three questions - all of which are relevant for social media use:

1. What are we trying to accomplish?
2. How will we know its an improvement?
3. What changes can we make that will result in an improvement?

If you're starting out using, say Twitter, and you're in a healthcare quality improvement role the have a think about:

• What do you want to achieve? What is your purpose in using Twitter? Do you want to discover new info from others, link to others, use the media as a broadcast system, raise awareness, raise your own profile... etc? You need to have a purpose.
• How will you know it's an improvement? In the Twitter case, how will you know whether you are reaching your purpose / objectives and in a way that's better than what you do now? It really helps to think about this.  How will you measure your progress? How will you learn? Will you be using an analytics system to learn about what works (classic PDSA processes work very well for understanding how Twitter can work for you).
• Linked to the measures above, how will you maintain your learning and continue to get better and better at using Twitter?

In my experience it's best to thing through purpose and practice as part of starting on the social media road. An online social media account where nothing happens tends not to be a good strategy.

David Whyte: The workplace poet and loaves and fishes

No celebration of poetry in the workplace can be complete without including David Whyte. He has decades of experience of bringing emotion into the workplace - but importantly, does this with respect  dignity and the understanding of employee and organisational processes.  I wasn't quite sure which of his stunning pieces to incidentalnclude in this blog. In the end I have chosen the one I use the most.  

David Whyte shares his poetry via his website. It's a great resource.  You may find this is an interview by Maria Seddio with David Whyte useful background.. I like it because it probes the why he does what he does and gives an insight into his caution and delicateness in bringing poetry to the workplace. [PDF]

Loaves and Fishes

This is not
the age of information.

This is not
the age of information.

Forget the news,
and the radio,
and the blurred screen.

This is the time
of loaves
and fishes.

People are hungry
and one good word is bread
for a thousand.

  -- David Whyte
      from The House of Belonging 
     ©1996 Many Rivers Press

How do I use this in the workplace?

This is useful for provoking deeper discussion about social movement and language. How one word, one short sentence, once moment - can create a shift in mindsets of others.  It's also about the difference between information and words that move people.  A good exercise with a group using this poem is to consider their own language and they own use of words. What are they commonly using? What evidence do they have of hyperbole and how effective is this?

The poem is not as straightforward as it looks and some people may read into it and feel quite different perspectives from others. It's important to listen to and respect these differences.

Poetry for the theorist: Poetry Month April 2013

If your interest in poetry in the workplace is broader than checking out a few poems, then there's an excellent Afterword to a book that is available as a PDF. It covers the history of poetry in the workplace, contains poems to illustrate the descriptive analysis and overall give a well rounded exposition on the topic.

I've not been able to find out the source of the PDF as I found it rather serendipitously. If anyone knows please leave a comment on this blog.

Poetry Month April 2013: Workplace Safety Poems

Safety? Poetry? You must be mad, I can hear you thinking. But no, there is such a thing and such a poet. Don Merrell specialises in writing poems about safety in the workplace.  Poetry has the advantage of appealing to the emotions. Safety at work is not only about check-lists  board papers, risk assessments and significant incident reviews. It's a mindset - and mindsets are about beliefs and values - which in turn are emotional factors.

I CHOSE TO LOOK THE OTHER WAY (Don Merrell)

I could have saved a life that day,
But I chose to look the other way.
It wasn’t that I didn’t care;
I had the time, and I was there.

But I didn’t want to seem a fool,
Or argue over a safety rule.
I knew he’d done the job before;
If I spoke up he might get sore.

The chances didn’t seem that bad;
I’d done the same, he knew I had.
So I shook my head and walked by;
He knew the risks as well as I.

He took the chance, I closed an eye;
And with that act, I let him die.
I could have saved a life that day,
But I chose to look the other way.

Now every time I see his wife,
I know I should have saved his life.
That guilt is something I must bear;
But isn’t’ something you need to share.

If you see a risk that others take
That puts their health or life at stake,
The question asked or thing you say;
Could help them live another day.

If you see a risk and walk away,
Then hope you never have to say,
“I could have saved a life that day,
But I chose to look the other way.”

How do I use this poem in the workplace?

Safety has an emotional angle and a poem like this allows a small group to discuss issues that might otherwise not be tabled in regular mtgs. I use this only in small groups so there is time and respect for listening to how it makes people feel. Do they have an example of when they "looked away". How did they feel? What might happen if they don't "look away".

Often patient safety is set up to be a systems issue - and it is. But it is also about individual mindsets and beliefs. This poem brings the individual to the fore and helps people understand their role in ensuring a safe process and workplace.

The issues are, of course, not about the poem, but about the workplace and what might be done to improve safety for all.

Poetry Month 2013: Dawna Markova

I heard Dawna Markova speak at the Systems Thinking Conference in the USA some years ago. It was two hour plenary session and it felt like twenty minutes. Looking back, it was a session that changed my life - and it did it through poetry. I came home and repurposed my life.

The poem that captured me is one that is well known: "I will not die an unlived life".  I've copied some key lines in this post but I urge you to look at this website which has the background to the poem and why Dawna wrote it. It comes from a book by the same title. Reading a few lines in isolation is helpful, but reading the whole book is life transforming.

I will not die an unlived life. 
I will not live in fear 
of falling or catching fire. 
I choose to inhabit my days, 
to allow my living to open me, 
to make me less afraid, 
more accessible; 
to loosen my heart 
until it becomes a wing, 
a torch, a promise. 
I choose to risk my significance, 
to live so that which came to me as seed 
goes to the next as blossom, 
and that which came to me as blossom, 
goes on as fruit. 

How can this poem be used in the workplace?

The intent of this poem is primarily about purpose - about renewing and regaining it. It's about not being a victim to circumstance. It's about "risking your significance".

I use this in coaching and small group work when there's a need to investigate "purpose" and reasons for doing what we do and being who we are. It helps with setting priorities and finding ways to identify passion.

Ultimately, the poem is also about humility and stewardship, so it's also good to use with leaders, to help them feel their place in their world.

The poem can elicit some very deep and personal feelings so I don't use it in large groups. Dawna Markova can do this because it's her poem and she's an amazing poet-professional.  I try to give the readers a safe place to feel its meaning.

It takes courage to be positive in times of change

When is feels like someone has tipped all the water out of your glass, it's difficult to take the "glass half full" positive approach.  But if the glass was more than half full then maybe losing a little of the contents is right, as horrifying a thought as that may be.

I'm obliquely referring to all the changes in the NHS in England in the last few months. I found March a very depressing time to be on Twitter as the chorus of disapproval for change grew louder, and at times, more aggressive. In the end, the changes have happened. What happens now is a matter of attitude.

Complaining is easy. Coming up with the shift in mindeset that's required to make the changes work is far more difficult. I'm not prone to Bible quotes but there's a good one from Matthew 7:3 "And why beholdest thou the mote that is in thy brother's eye, but considerest not the beam that is in thine own eye?"

The challenge for those complaining loudest now is to be sure that what they're complaining about is not something they have a part in. It's time to examine the fears that lie behind the complaints and to help those who see only the negative that there are patients and communities who want to make the changes work for them.

Poetry Month: celebrating poetry in the workplace

Graphic from grammar.dictionary.com

April is Poetry month.  For many, the last time they read a poem was in school, and even after class discussion they didn't really understand it.  I went off-piste on my academic learning a couple of years ago and completed a Masters in Creative Writing at Oxford Brookes University. It was a great course, notable for being practical - the academic-speak and theory was kept to a minimum. The aim was to turn out writers - and better readers.

Poetry is not "my thing" when it comes to creative writing. I have recently had returned to me the book of poetry I wrote as a teenager in 1979. Sheesh - the angst!  I do occasionally get my thoughts around a poem, but like may others who scribble their thoughts in verse, it feels too personal to share.

It's this same intimacy that draws us, as readers, to a poem. There's that feeling of instant connection when you read a poem and absolutely identify with the line you've just read. It's as though someone has said what you've been feeling - not what you've been thinking. Poetry has the ability to shine a light on those feelings we didn't realise we had.

Is it appropriate to bring poetry into the workplace? I don't see why not, and there is a whole discipline on this topic. And there are poets who specialise in this - David Whyte being my poet-hero.

Throughout April, I'll be blogging about poetry in the workplace, and sharing some of the poems that have meaning to me.

Paper: Implementing culture change in healthcare; theory & practice

This excellent paper on implementing culture change in healthcare; theory and practice was published 10 years ago. It's still relevant and there is no need to start another cohort of research on the theory now that "culture" is a big theme for the NHS.

Readers of this blog will know my aversity to the continuous stream of repetitive research - with insufficient action to put it into practice.  Culture is a difficult topic. The word defies easy definition  yet it's bandied around as both a devil and panacea - a cause of and a solution to the problems facing the NHS.

This paper is available free of charge and is worthy of a read and discussion with your colleagues.

Knowledge Worker 2.0

I continue to fret that the dominant model for understanding healthcare organisations and in defining methods to improve them, comes from an old fashioned industrial process methodology (Lean). I think this continues to hold the stage because it is easy to understand a process and to make charts that count things. It makes us feel better.

But healthcare is not only a service industry it is one based on relationships. The workers are predominantly knowledge workers.  And the role, the use of and the ways in which knowledge workers connect is changing rapidly.

If the whole concept of the knowledge work is an unfamiliar one then have a look at the presentation below. And if you role is one of making improvements in a system then think about how you might go about such changes when you conceive of staff - and patients - as knowledge workers.

Knowledge Worker 2.0 - Power to the people from Stephen Collins

When an app becomes a care plan and a pathway co-ordinator; Asthma AWA

This is a guest blog post from Howard Last. He contacted me after my spate of reviews about healthcare apps. He's provided more information about the asthma web app AWA.  If you'd also like to guest blog then please contact me.

Putting the ‘technology horse’ before the cart was our aim in developing the asthma ‘web app’ (AWA). It is, regrettably, so often the other way round. I work as a GP in an inner city area and was acutely aware of the needs of patients with asthma and the shortcomings in provision of asthma care. I also have an interest in I.T. so it wasn’t long before I wondered how we could use I.T. to address these clinical needs. Making use of Web 2.0 we developed an ‘app’ which tackles the major issues contributing to poor asthma control: inhaler technique, patient education and provision of a care plan.

The provision of a care plan in particular is one area which needs improvement. The AWA control plan is the key component in the application. Patients without a care plan are four times more likely to need an acute admission with poorly controlled asthma. Yet, only one third of asthmatics have a plan. The AWA makes it much easier for a GP or asthma nurse to provide a personalised plan for a patient during a consultation. Subsequently, patients have access to a web-based version of their care plan either through PC or mobile devices. But it goes one step further. The AWA care plan, unlike a paper-based version, adapts dependent on the patients asthma control, prompting an increase in treatment with poor control or allowing a ‘step-down’ with good control. In other words it promotes self-care.

The AWA also provides an alternative healthcare pathway to the traditional model where patient care takes place in GP surgeries or hospitals. The AWA allows the healthcare professional and patients to interact remotely. This is particularly valuable for the ‘difficult to engage’ patient. In asthma care this translates into teenagers. This is a group who are always resistant to invitations to asthma clinics but for who the use of a mobile phone or tablet is second nature.

I think the success of an ‘app’ depends on two simple principles based on need and data handling. First, there has to be a clear clinical need for an ‘app’. Secondly, collecting data is not in itself sufficient.  Doing something useful with the data for the benefit of patients is the crucial step. I believe the AWA passes these tests. Whether it is innovative, I will leave you to decide.

Howard is happy to be contacted if anyone would like more information about the AWA.

Paper: Improving organizational climate for quality and quality of care: does membership in a collaborative help?

I'm always banging on about the need to publish "negative" results - well, I'm pleased to see this paper has received some air time. The authors investigated whether teams that were a member of a collaborative improvement process ended up with changes in their local organisational culture.  The answer is mostly a "no".

"There was no significant effect of collaborative membership on quality-oriented climate and mixed effects on service quality. Doctors' ratings improved significantly more in intervention clinics than in control clinics, staff helpfulness improved less, and timeliness of care declined more. Ratings of doctor-patient communication and willingness to recommend doctor were not significantly different between intervention and comparison clinics."

Improving organizational climate for quality and quality of care: does membership in a collaborative help?

9 Change Models

It's often joked there are as many models for change as there are consultants selling them! I've curated a list of some of these, focusing mainly on the graphic that explains the model. If I've got an opinion on the model I say so. Each of the models has a link where you can get further information about it.

1. From Six Seconds, focusing on the emotional aspects underpinning any change

2. From ichnage.biz. I like the "and then you start all over again"

3. From Smartcompany; nice blend of known frameworks

4. The Innovation Change model is nothing new, but a good reminder

5. Peopleandprocess have an interesting model which made me think. I like it.

6. The Driving change model from CMA is simple but I like the language reframing

7. Not so much a model as a comment on models (but I liked the pic)

8. I like the input / output aspect of this model from Metavolution

9. This model is based on Prochaska & DiClemente's. I like this edit.

Paper: Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

Ah, context. Context matters in healthcare interventions and so many improvement projects and similar interventions ignore context. This paper,  Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments, is important because it attempts to discover measures that influence interventions into account. The results are mixed.

"We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited."

Implementation Science 2012, 7:121

Outsiders cannot change NHS Culture - only NHS staff can do that

The responsibility for a change in behaviour and subsequent culture in NHS organisations, lies with the staff employed in those organisations, not with any external body.

NHS Organisation: the NHS is not an organisation by most definitions  It is not a singular corporate body..

Definition of "Organisation" from Business Dictionary:

A" social unit of people that is structured and managed to meet a need or to pursue collective goals. All organizations have a management structure that determines relationships between the different activities and the members, and subdivides and assigns roles, responsibilities, and authority to carry out different tasks. Organizations are open systems--they affect and are affected by their environment."

The NHS is a system, and one composed of formal organisations (with differing structures) and informal networks and collaborative structures that include other government bodies (social care) as well as NGO's and social enterprises. The Department of Health is not the NHS. Nor are consultancies, improvement bodies (acting as consultancies), regulators etc. These are their own organisations, with their own cultures with underlying behaviours, that also need to change.

It's easy to tell someone else or another organisation that they need to shift their mindsets and behaviours. However, following the Francis Report, the best place for everyone to start is by looking at their own teams and organisations, assessing their own culture, and making the efforts to change their own personal and group behaviours. This needs to happen not only for those organisations who deliver health care services, but also those organisations that are government funded to support the delivery of healthcare.

For these "outsider" organisations, the cultural and behavioural questions need to be reflective of their own internal behaviours and the impact these have had on NHS delivery organisations. They also need to be an honest appraisal of the cultural norms that exist within, and how these may be played out in the way they "support" the NHS Delivery organisations.

No-one needs a consultant or a clever framework to do these reviews, nor an expensive and complicated change programme. Large change initiatives operate as a displacement activity for not facing up to the details of the changes required. Real change starts with two people sitting down, telling their stories to each other, listening, mulling over the behaviours that may need adapting, then committing to have a go at changing their own behaviour, and to including others in their conversations.

Report: Practical Guidance for scaling up healthcare innovations

There's a FAB report from WHO and Expandnet with clear and concise guidance for the scaling up of healthcare innovations.

There's no excuse now to write more how to guides (yes, that includes me!0 - let's get using the guidance we have to make a difference.

The report covers:


Scaling up: definition and underlying principles 
Why successfully tested innovations? 
A guided process from the outset 
Who should use this guide? 
Content and structure of this guide 

2. An applied framework for scaling up 
The innovation 
The user organization 
The environment 
The resource team or organization 
Strategic choice areas 

3. The innovation 
Attributes of innovations that enhance the potential for scaling up 
How to enhance the attributes of success and the potential for sustainable scaling up

4. The user organization(s) 
Attributes of user organization(s) that facilitate successful scaling up 
How to enhance the capacity of the user organization(s) to ensure successful scaling up 

5. The environment 
How to maximize the opportunities for sustainable scaling up inherent in the environment 

6. The resource team or organization 
Attributes of a successful resource team or organization 
How to ensure that the resource team or organization can maximize the potential for sustainable scaling up


7. Strategic choices for scaling up 
Type(s) of scaling up 
Dissemination and advocacy 
Organizing the scaling-up process 
Costs of scaling up and resource mobilization 
Monitoring and evaluation of scaling up 

8. Strategic planning and management of scaling up are a balancing act 
How to create and maintain balance in scaling up 

9. Conclusion 
References 

Mostly free Pages Numbers Keynote templates for the IPad

Trying to use your IPad instead of your laptop or desktop? I find it's ok as long as I don't want to create anything of length or complexity. Many of the templates designed for Windows, tend to get reformatted strangely when on the iPad.  Here are a few of my favourite places to get templates for my iPad Pages, Keynote and Numbers:

1. There are 156 templates available from Jaxworks. I've not checked them all. They do have a US bias but that's not an issue. They cover the entire gamut of business planning and management.
2. You can find templates for Pages, and Keynote here.
3. There are templates in iTunes which cost around £0.69 for a bundle - not a bad price to save time and to cheer up what might be a dull report or presentation.

Resources and Links about Positive Deviance

image from plexisinstitute.org

Positive deviance is an asset based method of change - find what works well and do more of it. I've been harping on about this for year but now it seems it has its time.  I've curated a list of resources and links in case you want to learn more about this concept.

1. Wikipedia has a decent overview of what PD is about.
2. The PD initiative is a key resource centre which includes an comprehensive set of resources including presentations, videos, books etc. Most importantly is has many case studies of PD in action. 
3. The 7 characteristics of positive deviants I'm not entirely certain about the who of PD being the same as the what, but nonetheless, there are lessons to be learnt from both aspects.
4. Here is a YouTube list of various videos covering different aspects of PD
5. The BMJ had a paper on the topic in 2009 - useful for those who need a bit of theory and credibility to back up what may seem a little "woolly"

Redundant? Starting up on your own? Free Business Planning Templates

The redundancies notices have been issued. CV's are being spruced up and the calculators are out as many NHS staff figure out whether they can work under their own steam, on contract, as consultants  by starting up their own business...

The one most important fact of a business, for which there are no exceptions, is "Cash is King".

Even if you think your new organisation you're starting up will be subbed by the Department of Health or some other contract - the same statement holds. You can't pay staff, your telephone bill, you rail-fare etc, unless you have cash in the bank.

Cash is not a promise of work - there are plenty of those that don't deliver/
Cash is not an invoice - though if you're desperate, you can ask the bank to give you a loan against it.

Cash is when the money is in the bank account.

Business planning is essential if you're planning to go on your own. You'll find that the plans have more meaning than any plan you've done for an organisation  You need an in year plan and at least a 3 - 5 year plan that sets out your strategies and goes down to the level of cash - in the bank.

To help you, I've complied a list of free templates you can use for your business planning processes:

1. There are 5 excellent plans, check-lists, budget summaries etc available from Invoiceberry.  As with all plans you'll need to edit and customise to make them your own, but the details are covered in these.
2. Microsoft Office has a number of templates for download.. They have a SWOT, 5 yr plan, business plan, balanced scorecard and an excellent waterfall forecasting model which analyse profit and loss, and balance statement each month (remember, cash is king).
3. Bplans has templates for different types of businesses - in case you are feeling like opening up a restaurant or a bicycle repair shop.
4. Teneric has a comprehensive suite of tmeplates, including a free course on how to write a business plan

Paper: Realist randomised controlled trials: A new approach to evaluating complex public health interventions

Realist reviews of complex healthcare interventions are all the rage - and justifiably so. The realist process is far better as discovering and questioning the complex interactions within health and social care than more linear methods. Specifically, it investigates the how and why of interventions, rather than a singular focus on the what.  It's the way forward.

Realist randomised controlled trials: A new approach to evaluating complex public health interventions.
Bonnel, Fletcher, MOrton, Lorenc, Moore.

Soc Sci Med. 2012 Dec;75(12):2299-306. 

The words innovation and improvement can be misleading

If you want an idea or activity to be judged as good, then label it as an innovation or an improvement. Correct?  Well, I'm not sure it should be, but it seems that's what happens. I've been wondering why it is that the words "innovation" and "improvement" are assumed to represent "the good".

At a high level, there is an ethics issue; to whom does the "good" belong? New ideas often stem from crises, and crises are often either sourced from or produced by competition. When one side creates an innovation, the other side loses.

At a more detailed level, what worries me is that by labelling an idea or activity using words that come with the assumption of good, is that we:

• fail to evaluate whether the idea does what it intends (fidelity; more about fidelity here)
• fail to check whether there are unintended consequences in applying it
• fail to understand the drive of the person or organisation behind it
• urge the spread of a "good" practice, without assessing its value
• just accept; and the more we just accept, the more we open the floodgates to ideas and activities which may no longer be what we need

There's a lot of talk in the NHS about the need for "innovation". It will be good when this is grounded into discussion about the problems that need to be solved and then the ideas and activities being introduced to solve them. Solutions need to stand on their own right, not be labelled to give them credibility.

Cutting the cloth does not a slimmer NHS make

The NHS in England is undergoing a fundamental change  It's driven by the need to cut the cloth - to cut the expenditure. The trouble is, if the body of the organisation is still fat, then trimming the clothes will neither a pretty picture nor a happy organisation. The body needs some work.

It's a little like telling someone who is used to living a life where they can buy designer clothes  shop for the best cut in steaks and live in the best areas - that they have to buy from Primark and live in a less desirable area.  Obviously this is not an ideal situation. But it is one where the person starts to live within their means. Yes, it means life will never be the same, but if the person doesn't make the shift then they may face bankruptcy and lose everything. Surely it's better to take control and create a new life that is sustainable.

The NHS has a lot of fat in it. There is waste, despite the doomsayers who tell of the end of the NHS due to budget cuts (cloth cutting). This fat often isn't obvious (it is hidden deep within the organs of the organisational body, often in small streaks, but there nonetheless. When I can buy a ream of paper cheaper than an NHS organisation - there is waste. When I or a member of my family has difficulty in getting discharged from outpatients - there is waste.

I'm on my personal mission not to become part of the obesity epidemic. I am pleased to have got through a number of (healthcare...) events without resorting to the biscuits and pastries. Maintaining an exercise regime in the snow is difficult - but not impossible  I know that buying clothes two sizes smaller will not cure what's lying beneath them.  A radical shift in behaviour is required from me.  And so for the NHS - a radical shift in how services are designed to meet the future needs of future patients is necessary. While I commiserate with the pain staff in the NHS are going through, I do hold out hope, as a patient, that eventually the cloth cutting will move on from losing staff to rethinking the way care is delivered.

3 reasons why UK healthcare should not copy US innovations and improvement methods

I've nothing against the US, it's healthcare system and the methods used by various US organisations to improve their outcomes and processes. I don't live there so my opinion on their healthcare system doesn't matter. What is my business is the importing of US methodologists and solutions into a different context.  At a high level, learning new methods such as the Improvement Model is helpful, but at a more concrete level, copying "what worked in the USA" into the NHS will always be fraught with difficulties.

Reason 1: The USA outcomes are worse than the UK.
The IOM has released a new report US Health in International Perspective; shorter lives, poorer health. The facts are stark. US citizens die younger than their peer countries, despite paying more. Crucially, the report suggests that 20% of avoidable mortality is due to poor healthcare (rather than system related issues or behavioural choices).  Specifically, the US is worse than many countries in infant mortality & low birthrate, injuries and homicides,obesity & diabetes,  heart disease, chronic lung disease.

So why are we copying "solutions" from a system which is providing for worse outcomes than ours?

Yes, it can be argued that some care processes have better outcomes, but even then, there are difficulties. For example, it's widely touted that men with prostate cancer live longer than men with similar condition in the UK. If you look into the detail, yes, US men get diagnosed earlier - but they die at a similar average age as men with prostate cancer in the UK; the US men just had longer with the diagnosis, the treatment and the cost. More details on this and similar topics on the Cancer Research Science Update Blog.

Reason 2:  US model is based on cash for activity
The incentive for the majority of healthcare services is to provide more activity as a means of generating more income. This leads to overtreatment. Sharron Browlee's book "Overtreated; why too much medicine is making us sicker and poorer" is an excellent expose on this topic.

I had a debate with a US improvement consultant yesterday about why the NHS may not be rushing to implement rapid response systems in hospitals. We have a different value system, we have a different set of economics, and a different culture about death and dying. Solutions that work in US hospitals may not be the best ones for our NHS. Yes, we still need to resolve some of the underlying issues - but I hope we can do so in a way that fits our own culture, social and economic constraints.

Reason 3: The opportunity for delivering change & improvement in publically (and part-private..) funded health system far outweighs the private led US model.
Even though the NHS is under pressure to privatise part of the healthcare services, the fact that we do have a publicly driven system, connected to social care as well - means we have an incredible opportunity to devise solutions to problems that are truly radical. While we fuss about the speed at which patients are supposed to get electronic access to their records, and how to link them with hospitals - at least we have electronic records. We have register of people with conditions, and many good primary care organisations use these to do their best for the health of their local population.

I sometimes feel that whilst we are in the embrace of US-led improvement and change methodologies we are not devising ones that will make the most of our specific context. A good start is the NHS Change Model, which is sufficiently bland yet comprehensive, to provide useful and reasonable guidance for change.  It's not earth shatteringly clever - but it is one for the NHS, by the NHS, and I believe will be helpful for the NHS.

What if managers held end of day briefings like nurses do?

Nurses do briefings at the end of their shifts. I was reminded of this by @nurchat on Twitter as it s one of the topics for their weekly #nurchat tweetup. The reminder tweet made me think - why don't healthcare managers have a similar end-of-day briefing?

The briefings can be managers with their teams, or groups of managers - I like the idea of the Executive team holding an end-of-day briefing session.There are both advantages and disadvantages to holding one, though the only disadvantages I can see are ones about timing.

Benefits

• Reflection on the day's operational activities
• Reflection on personal contribution to the day's operational activities
• Highlight priority issues
• Ensure priority issues don't fall between the management gaps
• Improved communication skills
• Improved meeting skills

Disadvantages

• when is the end of the day for managers (though a briefing can be held at 4:45 for 15 mins)
• perception that the briefing gets in the way of other meetings
• poor briefing skills means it turns into a long meeting

It seems that much of the imperative for improvement and innovations pushes nurses to learning from managers - maybe now is the time for manager to be looking at what nurses do very well, and learn new skills of their own.

National Poetry at Work Day 15 Jan; One for the innovators

January 15th, 2013. It's National Poetry at Work Day.  How will you use and encounter poetry in your workplace today?

To celebrate, here is a poem that for me fits also in the innovation and improvement workplace. Poetry is about disconnecting the brain and triggering feelings.  Does the poem below mean anything to you?  What can we learn from it about how it feels to be an innovator?

The Viola

Your mauve face squared to the sun,

            velvet soft, centred with cream

                        atop delicate stalks.

                                    -  a wild viola.

Alone in the cracks of the flagstones

            thrusting between cement crusts

                        strikingly out of place

                                    - a solitary beacon.

I watch as pedestrians acknowledge you,

            stepping aside, bowing to your bravery;

                        you bruise gently

                                    - a defiant messenger.

You shiver as the shadows pass.

            I came back the next day;

                        you had hung on

                                    - a dusty viola

January 2013 Thought Leader of the month: Paul Levy

Throughout 2013 I will be posting my thought leader of the month. It will be a personal view, of course, and I aim to recognise those I follow and whose thoughts I appreciate.

My January 2013 Thought Leader of the Month is Paul Levy.

·       Paul hosts the blog “Not running a hospital;” and he is also active on Twitter.  He’s a former CEO of a large Boston hospital and he has things to say – and he says so eloquently and with authenticity. I follow his thought leadership, even though it is USA centric and I am UK based, because he’s not afraid of speaking up when necessary, of praising when deserved and criticising constructively when required. He shares a variety of thoughts, from science, statistics, service redesign, stories and personal stuff too. This means it's easier to understand his perspective. He’s rounded and it’s easier to trust him because you get to understand his perspective. He messed up once at work, at he made an apology public on his blog - that's the authenticity that attracts me as a follower.

There are five articles in my thought leadership series:

1. What or who is a thought leader
2. Being a thought leader
3. Organisations as thought leaders; some healthcare examples
4. Medical Thought Leadership
5. Thought Leadership 2.0

You can vote / suggest February's Thought Leader by tweeting #hcthtldr

Thought Leadership 2.0

Graphic from Indiangroup.com

I came across the 2.0 version of thought leadership from the article by Maria Tabaka in Inc.  She has posited that social media has opened the way for a new form of thought leadership where

“[…] the Internet allows ordinary people with extraordinary ideas to lead and make a difference. Do you have what it takes?”

I've been saying for some years that the Roger's Diffusion of Innovations version of an opinion leader is well out of date (the book was first published in 1984). Many peer reviewed papers continue to reference this outmoded version of opinion leadership, without considering how social media and other technology based platforms has changed the opinion and thought leadership landscape.

Maria's advice on being a 2.0 thought leader is straightforward; you have to work at it.

“Begin by becoming a true expert in your arena. Do your research, and then do more research. Learn to speak about your ideas with passion; become a story-teller. Your passionate disposition will recruit followers and other leaders who respect and appreciate your insight. These folks will spread the word!

Step onto the stage, speak to live audiences, upload videos that teach and inspire, write, write, and write some more. Guest blog, invite others to blog as your guest. Author that book that has been burning to get out. Promote yourself to podcasters and broadcasters who speak to the same or a similar audience.

I like the way Maria focuses on the need to keep doing research. This is a theme from many of the publications about being a thought leader. To be out there, you need to be out there with something, some new content. You need something to be passionate about. Thought leadership is about going to depth, about sticking with a concept or idea and bringing it to life.  It’s not about spouting forth on the latest craze you’ve read about.

Thought Leadership 2.0 is about using social media to best effect.  It’s more than hanging on Twitter. Here’s a checklist of some activities a TL 2.) may be involved in. How many can you tick off.

• Active on Twitter; engage in conversation, retweet others (without making them your own), share useful information and links
• Participate in LinkedIn groups; specifically those groups within your thought leadership domain
• Host a Facebook Page, or two
• Maintain a personal blog and update it on a regular basis
• Guest blog for other influential sites / people / organisations
• Host your own podcast / video series
• Guest on others’ podcasts or video
• Use other social media sites such as Foursquare, Google+ etc

Yes, it’s hard work, but TL 2.0 is about extending your reach and cementing your passion in the reality of virtual relationships.

Previous articles in this series include:

1. What or who is a thought leader
2. Being a thought leader
3. Organisations as thought leaders; some healthcare examples
4. Medical Thought Leadership