Adoption of guidelines: trust?

A perennial issue on spread and adoption is how clinical guidelines are adopted - or not. There is an industry researching what happens, what might be useful intervention and what you can then do to increase the speed and amount of adoption.

My own rather accidental piece of "research" raised a new question for me: to what extent is trust both an enabler and disabler of the adoption process?

So I've been cooking. The real thing, with recipes. I spent the better part of a month working through many of the Women's Institute favourite 650 recipes. A trusted cookbook and mostly failsafe. What I found is it is incredibly difficult to follow a recipe down to all the details. The more I used recipes the more I found myself adapting them - to varying degrees of success.

Then I moved on to Nigella's Express cookbook. A week later I noticed I was slavishly adhering to every minute detail. Not like me at all. So what was going on here?

Nigella writes in the first person and the way recipes are written has engaged me in a new way. When a note in brackets suggests options, reassures you that she really did mean 250ml double cream or reinforces why this step is important, then it seems more trust in the process is repaid by more attention to detail in following instructions.

Many clinical guidelines are produced by committees. Yes they may be great sets of instructions, however, are they written as mechanisms that attract trust? I wonder what would happen if a trusted peer rewrite guidelines in a personal language and tone. Would they be adopted more quickly?

I did think maybe this is about personal choice of style of communication. Maybe. And should that detract from finding some novel ways to encourage the adoption of guidelines?

Stories and Examples are different

We know that stories engage hearts and minds more than bullet points on a PowerPoint or a three page proposal. I believe there is a very important difference between stories and examples.

Stories are personal. I know a story when the person telling it comes alive with the emotions attached to the story. I can feel their passion, enthusiasm, sadness, delight - whatever. I am drawn into their personal experience. It is stories like this that engage me.

When someone stands on a stage and tells someone else's story - then for me that is an example. No matter how much we resonate with the other person's story their passion, enthusiasm, sadness, delight - whatever - is unlikely to be captured by the example-teller. Examples are helpful, though I suggest they are no different from the paragraphs in papers. They are second-hand and no longer associated with the context and emotions that go with them.

I am sometimes asked if a story I have used can be used by someone else. I usually recommend they find a way of developing their own reservoir of stories. This is sometimes difficult. Those who develop and advance theories may find their work disconnected from the reality of practice. The best way to both test the theories and develop your own stories is to test them out on a small scale. Not only will this provide self-confidence, it will also demonstrate the practicalities of your theory or suggestion and increase your personal credibility as you have a personal story to tell.

In the event you are unable to experience your own story, then I suggest capturing someone else's using a short video. Then allow their story to be told as they wish.

In the next week, try to focus on gathering, maintaining, treasuring your own stories. If you find yourself giving an example - telling someone else's story - then take a breather and see how you might do something differently to get the outcomes you desire from your listeners.

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Knowledge Management on my iPhone/iTouch

A key aim in healthcare is to reduce variation. One of the methods to do this is to encourage the sharing and adopting of good practices.

• Problem 1: where is the good practice and who is doing what?
• Problem 2: how do I get to hear of good practices?
• Problem 3: how do I share what I am doing?

If data is information and knowledge is information we can use to make decisions, then how can data about good practices be shared.

A free application called "Healthmap: Outbreak near me" for the iPhone/iTouch has got me thinking. You can submit data about any disease and the location. This gets added to their database. You can see on a map any number of different diseases from Swine Flu through to African Horse Sickness. You can search by location, keyword or disease. If you allow it, the system can let you know what diseases are currently prevalent in your current location (using the GPS function).

So my please is for someone to develop the application for say, diabetes or cardiac care. I want to be able to find who (locally is great) is doing well on these healthcare processes and has something to share. Maybe even a version for patients where we can see the currently publicly available healthcare data on a map and in a searchable way. Also, we could add comments about services using the system.

The technology to do all this is here and available. As with so much I encounter in healthcare I suspect it may be another decade before we see something like this used.

Can someone prove me wrong please?

When we adapt do we spread & implement effectively?

The script often spoken and written by people involved in the spread of good practice goes along the lines of "we need to customise the process / protocol / idea so it fits best in our context", or "we need to expect the process / protocol / idea will be customised".

Part of me fully support and understands this. Yet another part of me is questioning what we mean by adaptation. When we use the term is it because:

• we didn't have the time and/or inclination to discover the important contextual variables and then design with and around these
• we are so in love with our solution (see earlier post about "inventoritis") that we expect others to copy it as it is, or maybe with just a few small tweaks
• we are too afraid to work through the adaptation process and how the solution might be adapted because we may discover the desired outcome may not be achieved
• we can't figure out how another place or team might use the process or idea so we defer to adaptation as the way round this
• we know the new process will require quite a lot of facilitation and support to make it happen so we use adaptation as a means for engaging others (so they don't think they are adopting someone else's idea) and as a means for garnering implementation support
• we can spread partly formed ideas and processes, or ones still in their innovative design state

So what is the adapting process? In a foreword by Richard Dawkins in Susan Blackmore's book about memes, is a couple of examples which got me thinking.

1. Are you expecting a copying process, knowing there will be some natural adaptation. Dawkins uses the example of copying a picture. One person copies a picture, passes to another to copy and so on. After a number of copies the picture may not resemble the original very much. In fact, I suspect some may start to put their own context, thoughts and ideas on the picture, thus rendering it something different both in visual status as well as in meaning.
2. Do you intend someone to copy instructions? If I am shown how to make a complex origami figure using a set of 30 simple instructions, then I can teach someone else, using the same instructions. That person can then teach someone else and so on. In this case, most of the time, we can posit that after 20 teaching/replications the origami figure would look the same. By focusing on the instructions then someone can even correct a minor slip when they make their copy. However, if once of the instructions gets left out and this omission is replicated then the paper figure will end up an entirely different shape.

So this brings me to issuing clinical guidelines and the expectation of their adoption and use, and sometimes adaptation for local use. Some questions I have are:

• Do we know what happens when we issue guidelines and say "may them local". To what extent do they match the fidelity of the original in terms of outcome?
• What happens when one of the guidelines instructions is omitted (accidentally or purposefully)? How much of the original outcome is retained?

If you have any thoughts on this topic of adaptation them please comment or email me.

Books on Lean for Healthcare

I am sometimes asked to recommend a book on Lean. On my book blog I have given one a short review this month. Others on my shelf include:

The Elegant Solution; Toyota's formula for mastering innovation, by Matthew May

Has some good hints, tips and checklists in it. I particularly like the IDEA (Investigate, Design, Execute, Adjust) process and form. For me this has more applicability to many projects I work with in healthcare than they way PDSA's are used (probably inappropriately) to write up projects and action.

Journey to Lean; making operational change stick, by John Drew, Blair McCallum, Stefan Roggenhofer

I like this book because it sets out the hard work involved. The authors also do the full set - namely, they include and emphasise the behavioural and mindset changes required. The use of stories and examples is helpful in putting the change processes into context.

Lean Hospitals; improving quality, patient safety and employee satisfaction, by Mark Graban

Very much a lean theorist book. Lots of Japanese terms. I liked the way the book is framed specifically for healthcare and this may make it easier to grasp some of the technical language and methods. I was a bit disappointed that the focus is so much on the technical and less on the social / cultural / behavioural aspects.

Sustaining Lean healthcare programmes; a practical survival guide, by Mark Eaton and Simon Phillips.

I reviewed this book this month. Short, sweet and worth it for the glossary of definitions! Simple and most useful for beginners or for sharing with other staff who need to know a bit about Lean but don't need to be overwhelmed by too much detail.

Lean for Practitioners; an introduction to Lean for healthcare organisations, by Mark Eaton

Another short and sweet book. If you only have 45 minutes on the train to get up to speed with some Lean Thinking - then this book will work for you. Mark's style includes bullet points, short paragraphs and checklist - worked for me.

Lean for Dummies, by Natalie Sayer and Bruce Williams

Probably the most useful Lean book I have but I am too scared to walk around carrying it! Rich in detail and an excellent reference.

Fear of failure? Never Events need a target of zero

So how would you feel if you were the patient of a surgical team whose improvement target for the "Never" event of wrong site surgery was - to reduce by 20%? A "Never" event is something that, by definition, should never happen. The NHS in England have a list of 8 that are so well evidenced they should be adopted for implementation with no further discussion.

Why then are we seeing targets for Never Events that are not zero? My recent experiences suggest the following dynamics at play:

• zero is too difficult a target to achieve in healthcare (try telling that to the patient who has just had their wrong kidney removed or the suicide that happened when on 1-1 watch and using non-collapsible rails). Admittedly in some healthcare processes zero may be a tough tartget, however, Never Events mean never.
• we may not meet the target (fear the failure and the knock on consequences for individuals, teams and project work); when I encounter this I realise I am working with an individual or group who fear the failure of improvement greater than they feal the failure of harming a patient.
• it's not worth all the changes for zero (the costs of the change outweight the cost of full redeuction of a never event); this is, of course, a judgement call and my hope is it is made with full data analysis and consultation of those involved. Some never events happen so seldom it may be difficult to justify the changes required.
• we don't believe the research is good enough; the NHS in England (National Patient Safety Agency) have streamlines a varietyof Never Event lists to determine a core 8 which are well proven in all aspects. More research I suggest is not required.
• we will take a while to get to zero; that's ok, then let's see a desired outcome of zero and some leeway to reduce over time. The trick is perhaps not to design for a 20% reduction in year 1 but rather to design for zero in year 3 and monitor progress over time.

Never events need targets of Zero - 0. They should never happen.