Consolidating my blogs

I'm consolidating my blogs so from now on you'll find me posting over on


SARAH FRASER WRITES
http://sarahfraserwrites.blogspot.com//

IKEA effect for improvement projects

The IKEA effect is the tendency for people to place a disproportionately high value on objects that they assembled themselves, such as furniture from IKEA, regardless of the quality of the end result (Wikipedia definition).

Unfortunately the same effect appears in many improvement projects I encounter, no doubt due to the same issues. After the investment of over coming the complexities of getting the thing working, the emotions involved, the panics, the restarts, etc etc, it's inconceivable there could be anything better. It's also inconceivable to throw it away and start again or replace it within living memory.

If the project has a great result, then that's just perfect. However, where the result is less than good, it's this IKEA effect that comes into play and makes the problem difficult to resolve. It's also known as inventoritis - when we fall in love with our inventions and lose the ability to customise them on the basis of feedback.

Do check your improvement work today. IKEA effect?

The outdoors is my preference for a classroom

My job title of "Senior Explorer" might surprise those who expect the more formal Director, or President, or Consultant - but it more accurately explains what I do.  I tend not to direct, preside or consult - but I do explore... Most importantly, I am spending more and more of my time with my clients in the wonderful classroom called the outdoors. It's a marvelous antidote to Powerpoint, fluorescent lighting, stale air and aching backs.

Sometimes a short walk around the grounds of the hospital is enough, or a half hour stroll through the neighbouring streets can get the minds shifting into another gear. Or we can be a bit more ambitious and go for a walk into the Chiltern Hills or around the grounds of a National Trust property where I can lead a small group through some high level and detail of analogies in organisational change. There's a great deal to learn from plants, insects, the weather, trees etc. - and that's before the bodies have loosened up and the brains have been given permission to be a bit more creative.

Appleacre Adventures is a division of my company. If you're feeling really adventurous I can lead you on a two week expedition through the desert in Namibia - or maybe an overnighter on canal boat reflecting on the large scale change theory and practice of the Victorians and the applicability of their principles for the public sector in 21st Britain will suffice for you... Or maybe you'd prefer a few hours of guided personal reflection "on the hoof"?

What I've learnt is that outdoors, the quality of the learning and the radicalness of the thinking is significantly increased.  And it's not just a walk - for those of you who know me - I've invested a great deal in ensuring I understand how to leverage the benefits of outdoor learning.

When over efficiency means less productivity

I was, at first, speechless when I heard about an NHS friend who spend part of her work days perched on the edge of another colleague's desk because there wasn't enough space for her to work. I hadn't heard about the Government Policy, introduced in 2011 that for administrative areas, there should be only 8 desks provided for 10 people - this is called Agility working. Huh?

You can read about this cost saving exercise here: https://www.gov.uk/government/news/government-property-strategy-cuts-millions-in-costs If you want to see the NHS business case document on how it is built into cases then you can find this here (item 23): www.england.nhs.uk/wp-content/.../11/five-cse-bus-mod-chck-lst.docx 

Now I am all for cost saving and inefficiencies but there's something not working if someone is trying to do their job balancing their laptop on the corner of a desk, wires trailing, knees wrapped round edges etc. Apart from anything it's not respectful.  I'd not put up with it, but then, even in the administrative areas of the NHS, there's fear and concern for jobs.

[sigh]

I've not blogged for a while. I was waiting until I had something I really wanted to say.  I think it's time to speak out and to speak up. So I'm going to start doing just that.

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.