Designing for large scale change

The scale of "large" change depends on your perspective and intent. Usually, any change of significance feels large scale if it dominates a large part of your life. At what point does the PDSA cycle method become less than useful in delivering change?

In healthcare improvement work over the last 10 or more years we have been fixed within the domain of PDSA cycles and the Improvement Model. This is a useful technique in (a) testing out ideas where we are unsure whether they will work and (b) in implementing change on a small scale. These methods have a tendency to produce large number of pilot projects, many of which demonstrate good results. The exhortation is then to "scale up" or "spread" the results to others. So far, this has proven very difficult - and not unreasonably so.

The difference between designing for scale and doing Improvement Model/PDSA type projects lies in the intent. If the intent is for all those for whom the topic is applicable to implement changes to demonstrate an improvement, then consider what might be the opportunities if the focus is on large scale design rather than demonstrator projects:

i) a large scale intent most likely has a large scale context; working with the wider system may help to identify areas where smaller changes can have a big impact. Namely, large scale design does not mean everyone has to do a lot of change. It could mean that if a few, cleverly targeted areas changed, then everyone benefits. We can only find these possibilities if we work with intent and the larger system
ii) we consider how the context interrelates to the aims of the project; context is critical in the process of adopting change ideas. Without highlighting and working on the context change is difficult to achieve
iii) with design as a focus and scale as the objective then we are more likely to seek out innovative solutions to age old problems. Sometimes replicating what we perceive to be good practice may in fact be part of what is hold back large scale improvement.

If you find it difficult to spread from pilot projects then maybe it's time to consider a design process for large scale improvement.

For more on why good practice doesn't spread, go to this book

Transformation versus Metamorphosis in Systems & Organisations

Gone are the days where the method of reducing variation and improving quality was focused on the incremental spread of good practice, using mostly communication methodology from the 1960's. The current mantra is "transformation". I am proposing an alternative, "metamorphosis", which may be a more relevant meaning-making metaphor in some circumstances.

We recognise when an organisation has transformed because we perceive a difference. This difference is usually one to stay. Slipping backwards to the old way is not an option. Transformation is something we recognise after the event. Thousands of books and papers have been published describing the experience of others and their own summary, meaning making and production of frameworks and models. However, underlying all the noise of methodology lies the premise that all transformation requires a behavioural change of significance. In addition, to transform usually requires a high degree of emotional commitment, trauma, distress and joy. Transformation is touted by "those at the top" as a process and outcome that is positive. However, for some it is necessarily an unpleasant process.

An alternative concept is "metamorphosis". This focuses on the striking change in appearance, in form and function, of an organisation or system. Individual may transform their behaviour, organisations and structures may morph into new, innovative and maybe even shocking forms. Morphing can happen slowly, the result of an incremental drip by drip process. Then we look back and see it now looks totally different. The changes around Mental Health Care in England from the 1970's to date are an example. Experience a deep depression in the 1970's and you would find yourself in an open ward of a Victorian building, treated (in a rough sense of the word) as a curious, complex and perhaps untreatable patient. Nowadays, you'd be cared for in the home by multi-disciplinary teams who recognise you as an individual with a family and personal set of circumstances. While drugs may be used, talking therapies also abound.

So what is it you are wanting from your quality improvement work? Are you requiring the sorcery of personal transformation or the magic of metamorphosis? Is the aim a behavioural one or a structural version? Of course both overlap and are dependent on each other, though a focus on form is different to a focus on individual behaviour. The resulting process and consequential outcomes will also differ.

One way to use these concepts is to think of transformation as a bottom up behavioural approach and metamorphosis as a top down structural and form based strategy. The two are related, differently.

Using Facebook Pages: A Guide for Governmental Organisations

The Learning Pool is one of my favourite resources for the use of social media in governmental organisations. Their guides are excellent.  I suggest you can download a copy of their latest guide which covers how to use Facebook pages to best effect.

The guide covers the basics like "what is a Facebook page", though to how to get the best use out of one as well as a step by step process to setting one up and marketing it. Huh, wish I'd written this guide myself!

Spread: Luck or Planning?

Duncan Watts is one of my heroes as he has been carrying out excellent research and simulations into how ideas, messages move between groups. In particular, I like the way his work is not dominated by the "diffusion" theories and how he is prepared to speak up when the results are different to those you may expect.

A recent experiment using song downloads from the Internet has come up with some interesting results and ones to make me think a bit more. An easy to read description of this here.

Some key results:
a) Luck plays a large part in what is successful (more than you might like to think about as you make plans for organisational and system success...)
b) If you lie (use false data etc) to your customers/target audience, at first they may go with you and then sensibility appears to win. At first it appears lying work.
c) When you lie, after a while behaviour of adopters/participants tends to revert back or change to what they perceive is the right thing to do. This reminds me of the issues we have with "sustainability" in healthcare change.

Any comments or thoughts about this research then do comment on this blog.

The continuum of spread: from outward communication to behavioural change

A few days ago I toyed with the idea of producing an FAQ sheet to cover the top 10 questions I am asked about how to spread good practice. Then I realised the answers are in my books and also in this blog. However, I'll revisit some of these questions over the coming weeks.

The top question is.... "how do I spread good practice"! And this usually sends me into panic mode. My immediate response includes:
What do you want to spread (and really, what, like skills, attitudes, behaviours etc)
How do you know it is good practice and who will recognise it as such?
Who is the target audience? Are you sure you are meaning individuals and not organisations?
What do you need people to do?
Why are you planning to do this? What is your stated and underlying intention?
I could go on...

I realise now that in most cases the big question comes from people in charge of something. Either they have the legitimate authority for a group (like Medical Director, CEO) or they are in a facilitative role (National body, program managers, consultancy). In both cases they want someone else to do something. The word "spread" gets used because either they have little authority over the people they want to change or they believe a softer-bottom-up-gentle approach will help people make the change. They may be right.

As the request to spread is coming from those "in charge" it is not surprising that the underlying question I think they are trying to ask is "How can we best communicate our good practice?". How do we communicate in a way that enables the right people to become aware of and do something about our topic? This is the standard approach to spread.

My experience in the last 10+ years on helping make large scale changes across healthcare systems is communication strategies and plans are not enough. Consider this continuum:

Spread (Communicate/Market/Advertise)--->
Communicate for behaviour change (Social Marketing)--->
Organisational change activities (OD, improvement projects)

Traditional spread programs limit themselves to clever and thoughtful (hopefully) design of outward communication. I say hopefully because in the most cases in healthcare the default button is set to "write an article" or "type up a case study".

As a minimum I feel spread needs to include the behavioural change aspect. Without this the communication is worth-less. The techniques from social marketing are a good place to start. This also means the behaviours required to change need to be identified as part of the "what" of the good practice.

Finally there is the perspective of the organisation. Again, my experience has led me to favour this approach. When the intended changes are part of or as a minimum identified as contribution to the organisation's purpose and objectives, with appropriate leadership support, then imprivement happens. Without this contextual setting the speed of adoption is much slower. Also, the breadth of adoption across the organisation may be limited. And there may be inappropriate adaptation to the good practice to such an extent that the intended benefits are not achieved.

So how do we spread good practice? I suggest the first place to start answering this question is to ask "why do you want to spread this good practice?". The aim here is to answer this in detail to get beyond the "to make things better" answer. This reframing will elicit the underlying motives and will direct an appropriate spread strategy.

Resources to understand tragedy of the commons

At the Institute for Healthcare Improvement's National Forum today, Don Berwick used the example of 2tragedy of the commons" in his Opening Plenary. His pitch was to encourage healthcare leaders to cooperate and work for the wider and more common good and to beware of continuing to work on a self-centred and healthcare industry basis.

For those interested in the concept of "tragedy of the commons" I have put some links in here where you can get more information.

The original article by Garrett Hardin in 1968 which introduced the concept can be found here.

A special issue of Science magazine provides not only all the critical papers you need to read but also links to excellent web resources. You can find this here:

Some games you can play to simulate and understand what is meant by ToC (though anyone trying to get onto the conference wifi will know just what it feels like!). You can access these here:

One of my favourite bloggers covered ToC a while back. You can read his post and associated comments here:

I've been a fan of Systems Thinking for years. There are loads of tools and techniques to understand how ToC occurs and how to work with it. I'm looking forward to healthcare improvers adding systems thinking techniques into the regular and perhaps rather technical improvement techniques. You can learn about ToC using causal loop diagrams here, and discover resources at Pegasuscom.

Any more - please add in the comments below.