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?

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.

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?

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.

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.

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 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 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?

        

Redisorganisation in healthcare: the theory and the practice

A good friend, Bill Russell, tweeted a link to "A surrealistic mega-analysis of redisorganization theories" published in the Journal of the Royal Society of Medicine, December 2005.  Yes, it's a Christmas edition spoof, however, there is some unnerving truth underlying the splendidly irreverent - and creative - paper.  I share it nervously, as I wouldn't be surprised to find it turned into a PowerPoint and a half day course being run to teach people the theories.

The paper got me thinking about the tendency of Healthcare Improvement Leaders to grasp at the latest theory that comes their way, further confusing the people they are expected to serve with their "leadership".  Recently I have encountered an exhortation about the need for consistency and a single model for change in the NHS; countered by the push of new ideas and theories, which dilute this message.  As well as new concepts being presented as though they are the next best way to make an improvement / support change; the concept is a concept - it has not been fully tested.

The frivolousness and scattergun approach for supporting healthcare staff and their organisations is unlikely to be a useful one.  My concern is the endless search for the quick fix is confusing people. In addition, when one theory ends up not working in practice, then I'm not seeing the evaluations, reviews and sharing of lessons (as in role modelling learning and improvement). Therefore each new concept is being built on an ever-weakening foundation.

The value of of those who lead improvement and change in healthcare  I believe, should be based on the depth and pervasiveness of change they support, rather than on the number of new concepts of pilot projects they put into the system.

Five iPhone apps the NHS can learn from

Many healthcare organisations are getting on the “app-wagon” by repackaging some of their regular website material.  In most cases, the “innovative” bit is the use of the iPhone’s GPS function for maps. Is this innovation? Not for me.

I’m on the lookout for apps which redesign interaction with health services, that support patients in caring for themselves and their families – and basically, ones which have an underlying brilliant idea that can only be implemented on a smartphone. 

In the end I didn't find any apps that lit me up – though I did find some that gave me ideas for apps that could be developed.

Wounds by BSN Medical Ltd, May 2012, UK only, FREE

You use your iphone camera to take a snapshot of the wound, then use the symbols to categorise it by wound need, depth and exudate level (for the non-clinical this means how bad, deep and weepy it is).  Then the appropriate dressing is suggested – and of course, this is their own brand of dressings. I’m not into promoting one type of dressing but this app is IDEAL for the NHS. Why hasn’t anyone produced this for the reduction of pressure ulcers – linking to the NHS Supplies dressings?  What I like about this is no improvement project is required – implementing an app will redesign the process of assessing and treating wounds/ulcers in the most fundamental way.

iScrub Lite, Free, May 2010

The premise is good hygiene and this app records observations and lets you email those observations. Whilst I am sure this is for audit folk, I can imagine that in the hands of patients (maybe lend them an iPhone while they are in hospital) it would have a big impact.  This would be fabulous if it was populated with the addresses for the contacts in each healthcare organisation in the NHS.

MedCrowd, Oct 2010, Free

This is an app designed to crowdsource medical opinions. I suspect it’s not really taken off but the concept is excellent.

Patient Journal, Free, June 2010

I like this because it is a place I can keep all the notes about being in hospital. The only problem is it really needs to be managed by the carer as the patient may be too ill to use it.  I think this would be good for longer temr patients or just for patients in general to keep track of their interactions with healthcare.  It works because it provides a structure only and doesn’t try to give me advice.

Mixed Messages, Free, June 2012

This is a training app aournd doctor-patient communication. I like the concept and it makes sense for much of the training programs that go on in the NHS to be put into a format like this. It’s simple, focused and not overworked.  No more books, manuals, workshops or PowerPoints!

Innovative changes to care pathways can increase hospital admissions

Innovative changes to care pathways can increase hospital admissions - really? Well, a report from the Nuffield Trust in March 2011 suggests there is little or no evidence that community interventions lead to a reduction in hospital use.

The report is a good one with a firm research founding - in the absence of any randomised control data. It points out that redesigning pathways can discover unmet need which may account for an increase in hospital attendance.

What caught my attention was that using their own data, each of the eight interventions assessed demonstrated a reduction in hospital use. However, when compared to control groups, there was in fact an increase. This leads me to one of the ongoing issues I have with "innovation" or "improvement" projects. It's easy to come up with a measurement system and set of goals and sample size that has inbuilt biases to ensure good results - and win prizes. But in the end, improvement needs to be tested against control groups.

I recommend you read the full research report, if only to grasp the seriousness of this issue.

Research: How engaged are patients in their healthcare

The Heatth Foundation has released an excellent report on their research into patient engagement. It's one of the most up to date and significant reports I'e seen on this topic for a long time. It makes for some uncomfortable reading, especially regarding patients who have long term conditions.  There is a summary report, but I commend the full version for required reading for all NHS Commissioners and those working on improvemet projects.

Book Review: Overtreated by Shannon Brownlee

The subtiutle of this book is "Why too much medicine is making us sicker and poorer". This book was quite shocking. I know there is a lot of what goes on in healthcare that is unnecessary yet to find a huge amount of detail and information in one place really put the issue into perspective. It is focused mainly on the USA though there are many parallels with other health systems.

Throughout the book, the author provides stories and examples to illustrate the data and statistics that without the stories would appear cold and less shocking.

As I read through the book, particularly in the early chapters I found myself going "I know him/her"! Shannon Brownlee hooks a fair amount of the debate onto the actions of some of the current health leaders in the USA (you might like to read the book to see if you are mentioned...!) There is an excellent chapter on the VA Healthcare systems, how it has improved and in many cases how it is an example of how healthcare in the USA could look and feel.

Chapters include:

• Too much medicine: complelling arguments as to why population based healthcare would be a real improvement
• The most dangerous place: beware the hospital and what might happen
• Your local hospital: how uncoordinated care and overtreatment results in poor outcomes
• Broken hearts: how the latest fad takes root, based on economics
• The desperate cure: an argument for evidence based care if there ever was one
• The limits of seeing: an expose on the limits to radiology tests
• The persuaders: mmm who is influencing whom, and why?
• Money, drugs and lies: why not to believe everything published in journals
• The doctor isn't in: all about managed care
• When less is more: some ideas to cope with over-capacity and overtreatment in the USA

This book is a must for every health care improver who believes their own project is making a difference... The strategic and tactical issues raised in it really provide a new perspective.

Book Review: Sustaining lean healthcare programme; a practical survival guide - Eaton & Phillip

Different book styles appeal differently, to different people. This one appealed to me because it is relatively short (94 pages plus appendices), well organised, uses bullet points and lists, checklists, diagrams and has some short examples to illustrate points.

Contents include:

1. Where are you on your journey
2. Why do only 24% succeed?
3. Going Lean
4. The top ten signs of a failing programme
5. Creating a lean healthcare organisation
6. Four key checklists
7. The next eight things to do...

So do only 25% succeed? The authors suggest there are 8 critical success categories Communications. resources, involvement, training, implementation, compass, achievement and leadership (yes, these do spell "critical"). If you like wordplay then read the book and discover PRISM, CAD, VSE, RIE, RPE, FIT, FMEA etc. Not as bad as it looks in a list here. I found them a good description, and sometimes reminder, of basic principles.

The chapter on the top 10 signs of a failing program is easily read. For each reason there is an explanation of what you may experience, why it happens and then what you can do about it.

The four checklists you need? One each on people, success, tools and culture. Nothing really new to me, just nicely organised.

I particularly liked the Appendices which included key lean phrases and concepts (worth the price of the book for its organisation and simplicity), audit form, guide to common saying (fabulous!), and then a number of "how to" guides.

I know Mark Eaton has actually implemented lean in healthcare. This book is a demonstration that when written by someone who has got their hands dirty it turns into valuable desktop reference.

Evidence: Quality Improvement Training

The Health Foundation has released a useful, and I think important, scan of the literature surrounding the strategy, content and process of training others in quality improvement. The document is a comprehensive and well organised summary of their scan of an enormous number of papers.  You can download the 52 page PDF from their website.

What  I liked about this literature scan is their focus on the impact of training. If you are responsible for organising or delivering quality improvement training then I recommend this literature review.

Report: Virtual QI Collaborative

It seems to have taken years for the QI family round the world to gain their trust in virtual improvement programs. My personal experience is they can work as effectively as face-to-face programs, although they need to be designed to work in a different way and need proper virtual facilitation.

There's a useful report about a virtual QI collaborative from the Robert Wood Johnson Foundation. The results look pretty good to be.

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

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

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

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