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.

Book Review: Rapid Transformation; A 90 Day Plan for Fast & Effective Change - Tabrizi

The change, improvement and OD fashion at the moment seems to be about speeding up the process. Part of me is a bit suspect about this because I believe change is a very personal and behaviour driven thing. However, another part of me believes that getting some momentum and steam behind an initiative is incredibly important.

Rapid Transformation was an easy read and I found many of the exhortations obvious, reasonable and at times felt like nothing new. What is new, however, is the exhortation to get your skates on and do stuff in 30 days that you might previously have taken 12 - 36 months to do. Another underpinning theme of the book is that incremental change is not enough. To survive and thrive organisations need to transform their businesses - and do so continuously and quickly. (Leaves me breathless just thinking about it...)

According to this book - and also in my experience - planning is everything.

Pre-planning stage: this is about ensuring you've fully diagnosed what the problem is that you're trying to solve. There seems to be no clear timeline on this and maybe this is where the devil lies. Maybe all change takes a long time to figure this out. SO if this preplanning stage takes months and years then the "rapid" is lost.

1st 30 days: Do the assessment; gather data and information and look to turn it into knowledge. This is a key stage and one which may at times be left out. Trick here is you get a max of 30 days to do this activity. Now that is new.

2nd 30 days: Get your future vision sorted, make sure all the goals are linked together and get this vision out to the organisation. You get 30 days to do this. In my experience the method of creating the vision and the method of communication is important. Somehow the author leaves me feeling this is an easy task to be done in 30 days.

3rd 30 days: Develop your plan. This is where you sort out the schedule for change etc.

So where is the implementation?

Ah, implementation begins on day 91.

I can see how for organisational transformation which is quite complex, that the implementation will take a long time (well, more than 90 days). However, with the preplanning stage and the implementation stage taken out of the way, this book focuses on just the getting started phase. While it does provide some useful ideas and methods for getting the right wax on the snowboard so you get a good combination of grip and slide, I do feel it is only part of the transformation story.

90 Day Projects

I've written about 90 day projects over the last couple of years:

1. How to implement 90 day projects
2. What are 90 day projects
3. Large Scale projects are seldom a linear process
4. Push vs Pull: Twitter Case Study 90 day Project

Many months on I am still convinced that we spend far too long on our healthcare projects. The tradition is they are planned for 18 months - often regardless of the size and difficulty of the change required. There are some changes which may need to be part fo a three to five year project, and others that can be achieved in 7, 30 or 90 days.

If you have examples of 90 day projects successful or not, then please leave a note in the comments. Thanks

How to implement 7-30-90 Day projects

“Being busy does not always mean real work. The object of all work is production or accomplishment and to either of these ends there must be forethought, system, planning, intelligence, and honest purpose, as well as perspiration. Seeming to do is not doing. “ - Thomas A. Edison

The purpose of this blog is to set out some ideas on the how of a 90-day improvement project within the context of healthcare. This project process is evolving so please add comments to this post so everyone can learn from your experience.

Principles:

• Having more time doesn’t mean getting more done
• Manage the tasks not the time
• Deliver incremental value
• Deliver results within a defined timeframe
• Honour the concept of organisational learning and continuous improvement
• Discover a rhythm of change and implementation that balances risk with results
• Use these ideas as ingredients and make your own recipe
• Ensure a focused, targeted and committed action process

      “Absorb what is useful, reject what is useless, add what is specifically your own.“ –Bruce Lee

There are a variety of approaches. The choice of your approach will depend on your strategic aim, the timing that best suits you as well as the nature of your improvement process.

STEP 1: Create your format based on your timescale

“Once you have mastered time, you will understand how true it is that most people overestimate what they can accomplish in a year - and underestimate what they can achieve in a decade!” - Tony Robbins

It is possible to deliver changes in 3 days (see Kaizen methods for further information). 

Consider your desired results, the amount of people who need to be involved in the process, the team and organisational culture as well as the nature of the problem to be solved / the solution to be implemented.  With this in mind, look at the options below and see which most closely matches your needs.  Where possible make your task

 smaller and the timing shorter.

All of the timescales contain a basic strategic rhythm of

a) diagnostic steps

b) implementation focus

c) review and next steps

 It is possible to design a 90 project so the phases are sequential, or it can be built up from a series of smaller 30 day cycles.  The choice depends on your strategy for change:

“Hell, there are no rules here - we’re trying to accomplish something.” - Thomas A. Edison

Why 90 days?

• Scope is more complex though is manageable within the timescale
• Sufficient interdependencies that will need to be followed through with conversation and negotiation
• Good if have high energy people working on the project who can also maintain their focus

Why 30 days?

• May be easier to commit to than 90 days or 18 months
• Deal with the now; plans remain relevant
• Long enough to see an improvement (or not, so can then change the strategy)
• Scope is such that one individual or a small team can make the changes with no further resource to committees or individuals for permissions

Why 1 week?

• Good for those who are too time / task pressured to commit to improvement
• Able to test an improvement-through-learning process
• If used as part of a longer project the 1 week cycle can provide a mechanism for involvement (different people different weeks)
• Good for working with those with a low energy

	Diagnostic	Implementation	Review
12 week (90 day)	4 weeks	6 weeks	2 weeks
8 week (60 day)	2 weeks	5 weeks	1 week
4 week (30 day)	1 week	2 weeks	1 week
1 week (5 day)	1 day	3 days	1 day

A diagnostic phase includes, to varying degrees, some of the following (remembering that diagnosis is part of the change process as individuals discuss and assess their own situation):

R  What is the current situation, including baseline measures; this needs to be localised to the context of those making the changes. Process and value mapping, relationship mapping and other techniques are useful here.

R  Creating ideas for change and improvement; being creative rather than just implementing known tasks (otherwise we end up with low energy projects)

R  Understanding any interdependencies and carrying out appropriate negotiation

R  Planning, designing, getting in the resources that may be need (like equipment) etc.

An implementation phase includes, to varying degrees, some of the following

R  Action, with measureable results

R  Learning, from personal and team reviews

“Words may show a man’s wit but actions his meaning.” - Benjamin Franklin

A review phase includes, to varying degrees, some of the following

R  Working out what is going well, and why

R  Figuring our and being honest about the problems, and then working through some ideas to resolve these

R  Capturing personal learning as well as team and organisational learning, specifically noting those things you would like to do / feel more of

A project of any length can be constructed from a weekly pattern of activities.

“If we did all the things we are capable of, we would literally astound ourselves. “ - Thomas A. Edison 

What are 30, 60 and 90 day projects?

We all want results as quickly as possible from any project team.  In fact, we want the results now!  Quality improvement projects are by nature a cyclical process where a few steps are taken, then tested, evaluated and then a few more.In complex organisations and systems such as healthcare, the cycles of change can take a long time It can be challenging to keep staff motivated after the initial months of the project.

The concept of the 90 day project comes from research where the aim has been to shorten the cycle of learning from the often 3 or 5 year project horizon. Projects like these accelerate some of the learning, but not all.   In healthcare improvement programs, accelerated timescales can be useful at the start, in the middle or the end of a formal program. At each stage they will have a different focus.

At the start of a project, short timescales can be used to get some momentum going. A 7 day sub-project is an excellent way to focus on commitment and action right up front. Half way through a project a series of say 3 x 30 day projects can be run in parallel with different teams all focusing on the same result. Or they could be run in series.  At the end, a series of rapid projects can help cover all the loose ends and ensure comprehensive results.

So what is a short project?  We know what it isn't:

• not a replacement for the overall project
• an easy option; all short projects need planning 
• not for everyone

If you want to run a short timescale project then consider the following:

1. for the same topic, different teams will choose different lengths of project. This is because the specific context for change is one of the the biggest factor in the speed of implementing change.
2. be practical, pragmatic and realistic
3. focus on the outcome to be delivered rather than traditional project planning
4. remember this is one technique that may work for some people and may not work for others

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Large scale change projects are seldom a linear process

In my experience any change process is a messy one where people are concerned. I can have a step-by-step guide to help me change a wheel on my car which is very useful. As the individual involved the guide can't really be designed to cope with my emotions following a flat tyre though fortunately the wheel, wheel nuts, jack and car itself tend to behave predictably and with a high degree of certainty - meaning the step-by-step guide is helpful.

Whether the project is small scale or large scale, there will be a varying degree of predictability and certainty when implementing projects within people-based systems. For large scale change where multiple projects will be run, the complexity increases. There are many different project management systems, some of which are specifically designed to cope with this messy process.


A linear version of project management assumes a sequence of steps, taken in a logical and predictable manner.

The diagram above gives an example of the stages and the effort over time. Reflecting on my own experience of implementing large scale change projects in healthcare I would plan for more effort in the conceptual phase and know that the time spent in each phase is not equal; it will vary according to each project and context.

While part of me would love to work with teams and organisations in an emergent way, to help improvement be revealed and new behaviours learnt and applied, I know that some project management is required when working within the structure of an organisation. One project management model I use is the following:

While this version starts to show some of the interdependencies of each stage in a project, there is always room to draw more lines. However, I like how this model shows the reporting / evaluating stage and how this feeds back into the planning stage. Namely this is an ongoing cyclical process rather than a linear step-by-step approach.

This model also works for me when the project is about implementing existing good practice in a different context. This model allows for the process and solution to be adapted so it work within the next context most effectively.

Pull vs Push; Twitter Case Study - 90 day project

One of the mantras of working out how to implement good practice more widely is "pull don't push". This refers to the need for potential adopters of a good idea to "pull" the information to themselves and then to act on it. This is a very different dynamic from the "push" of sending out case studies, instructions or clinical guidelines and then expecting others to implement the recommendations. (I wrote a paper on this topic with Paul Plsek in 2003; S. W. Fraser & P. Plsek, "Translating evidence into practice: can it be done through the process of spread?" Education in Primary Care, May 2003)

Theory is often interesting and sometimes useful. Practice is usually difficult and never quite what you expect. Thinking about "push" vs "Pull" I decided to run my own 90 day project to see what I could learn about enabling "pull".

This blog is both about Twitter as well as about a 90 day project process. If you don't know what Twitter is then check out this video: http://www.youtube.com/watch?v=ddO9idmax0o

Context
With Twitter http://www.twitter.com/ you share information, 140 characters at a time, with those who follow you. You also get to "listen" to those who you follow, and if you like, you can forward on their messages to your own followers (called retweeting). It is easy to follow someone; do a search for names or keywords you're interested in and then click on the "follow" button. You may also see a message someone has put up and then decide to follow them.

But how do you attract followers? How do you get a pull? This was my project question.

90 Day Project Aim
To get my profile in the top 100 of England and top 100,000 of all Twitterers (of a population 2 million and growing). I chose a ranking rather than a number of followers as I felt this is more aligned with my intention and context. A bit like choosing to reduce hospital costs by having no infections, rather than counting the number of infections. One of the complications of measuring ranking is you have to keep up your position in an ever increasing pool (the denominator is increasing rapidly).

Results
On 27th December 2008 I had 7 Followers. On 2nd April I had 347 followers. Average growth per day was 8 and the current trend predicts 536 followers within 30 days. I have used http://www.twittercounter.com/ to measure progress. My ranking worldwide is 79,492 and within England it is 79th http://www.twitterholic.com/

Learnings:

1. It really does work to learn from where other have gone before. I was 45 days into my 90 day project before I realised I hadn't practised what I preached, namely discover the existing good practice. Only then did I search for other's experiencing of generating a pull and adopt some of their ideas. This helped, though it was not enough.
2. It is possible to get started (on Twitter and I believe anything else) without knowing exactly how you're going to do it. For me, the act of the 90 day project meant I had to learn how the technology and system worked. It focused my attention.
3. Measurement is crucial. I check on a regular, sometimes daily basis to see whether my actions where having an impact. Ok, so this is easy when there are systems in place to do the measurement, though I would find it hard to know what was a successful strategy without this. After a while I began to see pattern in the data which matched my Twitter behaviour. Quite amazing really...
4. A "pull" is about adding value. No-one is going to follow unless they have a reason to do so. Equally, they can unfollow at any time (and I had one wobble when the graph slipped back due to unfollows - largely due I think to me unfollowing a lot of people - we sort fo went into a negative slide). So I have started to learn how to create a pull through a virtual medium communicating only 140 characters at a time. So if this was a non-Twitter project I would still think about what value am I adding for others and how succinctly can I communicate with them in a way that works for them
5. The social process of retweeting is important. I am valuing others' messages and sharing - then they do the same. As humans we are inherently social. Encouraging trust, openness, enabling and allowing connections and networking seems to be fundamental. Why should I expect anyone to follow me if I don't share, put others' messages forward (always attributed) etc?
6. I put my Twitter link on my email signature, added a button to my website, integrated it with my three blogs. What I am seeing is the links between these online activities and how they feed one another. Using a variety of tracking software I can see which ones are triggering followership. Maybe for other 90-day change projects it is important to think widely and outside the direct scope of a project in order to influence change.
7. One of the scary things about a pull vs a push is you're not in control. Yes, I can see who follows me and I can then choose also to follow them or not, I can also block people. However, by letting go I have discovered some new contacts, new people that I would not have encountered before. Yes, I have also encountered some fairly random followers who I see no reason why they should follow me. But who am I to judge? And that is the point.
8. When it came to updates I tried to be regular and consistent (something every day or two), aimed not to overwhelm at any stage and to tread lightly.

What will I be doing in the future

I will continue with Twitter as I find it useful. I've now set a different goal which is about quality rather than quantity. I want to test the next stage of "pull" - where something gets acted on as a result of a "pulled" tweet. This won't be easy to measure. I was fascinated by the recent example of this type of "pull-action" from Stephen Fry and Twitter. At the time he had around 352,000 followers (he is in the worldwide top 20). One day he tweeted a link to an Open University website / game. This OU page / game then got 52,000 hits in a single day. Around 15% of his followers acted instantly on a tiny fragment of a message. And the numbers were big.

If 15% of clinicians, professionals and managers in healthcare acted almost instantly on a message they had pulled, I wonder what might be the impact? Scary, huh...

Follow me on Twitter: http://www.twitter.com/sarahfraser