NHS partnership working and improvement; we've been here before

A number of large scale programmes are running in the NHS in England where communities are getting together to improve health and social care services. The projects have a wide membership from mostly statutory public sector organisations but also some in the voluntary sector. As some of the strategies sounded familiar I checked the Department of Health website.

I was involved in partnership working in the NHS in the mid and late 1990's. At that time in England there were also Healthy Action Zones which seem very similar to many of the programs underway at present. It seems to topic is coming round again but with a new language and consequently a delay in making changes. There are many papers and documents available form around 2002 - 2004 which have self-assessments, methods, best practice examples, case studies and similar. I find it so disappointing that those who are responsible for the spread of good practice and large scale change feel the need to continue to reinvent wheels - thus not practising what they preach.

If you are interesting in learning what has gone on before and in adopting and adapting existing ideas for large scale change then try out these papers from the Department of Health:

Working in Partnership; developing a whole systems approach (notable because it covers productivity - and this was 2002...)

Governance in partnership checklist of good practice

If you only want what is new then try
Working with Stakeholders which is 2010

Airlines & Healthcare; what can we learn

We consider airlines safe so in healthcare we adopt some (and only some) of the techniques they use to be safe - like checklists used by pilots and engineers. I say @some@ because we often forgot some of the more basic and fundamental safety aspects employed by arilines - the often more complex human resources, financial aspects, organisational learning, training etc.

Putting safety aside I read the report by the USA Bureau of Transportation on the statistics for 2009. In 2009 of the 19 airlines who reported they had an average on-time arrival performance of 79.5%. Hmmm. What I like about this figure is it represents the complexity of different airlines, operating in different ways, to different airports - and all affected in some way by the things out of their control, like the weather. This sounds to me like the healthcare system - in public sector systems anyway. So the airline travel system in 2009 was designed for 1 late arrival in every 5 flights. This makes me feel a lot better about the flow of patients around the National Health Service in England. A way higher percentage experiences experiences on time care. I also feel that the NHS is able to work well in a crisis like bad weather.

Ever lost your baggage? Well in the USA in 2009 3.91 bags were mishandled (isn't that a lovely term!) in every 1000 handled. This was an improvement from the 5.26 in 2008 - well done. As rates go these mishandlings are very few. Of course, if it is your bag lost, then the amount of year on year improvement and the overall rate is of no interest. A failure is a failure. This reminds me of the way most healthcare projects adopt goals that are less than perfect. For instance, 95% of patients to be treated xxx. What this tells me is that the improvement project team and the organisation are opting to design for a certain amount of failure. And I am not sure I am happy with this. Mistakes I can forgive. Designed in failure rate, often large ones, are to me a sign of lack of confidence in the people and processes. And as a patient I am less confident being treated there.

We have a great deal to learn about and adopt from other sectors as part of improving healthcare. What have you adopted from another industry and how has it worked for you?

Keeping track of progress; learning from DHL

It's a long story, but the short version ends with my handbag needing to be sent from Stockholm to Buckinghamshire in England. This experience has left me wondering why it is we find it so difficult to keep track of patients within a hospital, let alone across systems.

From time of pick-up to signature at home I could watch the 24-hour journey unfold (one click on a weblink, no data entry). I could see what action was being taken at each stage. If you're interested you can see the detailed information below (it's not the greenest of journeys...). It took only 2 minutes from the time of signature for the information to appear on the system.

Yes, patients are not parcels. Patient information also requires a certain degree of confidentiality management. However, I wonder what it would be like if within hospitals (let's start somewhere simple) we were able to keep track of the inpatient, figure out in which corridor they are now, how long they have been waiting for their scan, whether they have had their meal etc. This information will provide insight into the systems and the patient's experience. Maybe we could start by monitoring blood samples in this way as they are already bar coded. Maybe we could start with a system to help keep track of patients in the hospital for who speaking is difficult, such as those with dementia, stroke or some other disabling condition.

I wonder what else we can learn from DHL about how to monitor and improve pathways using technology?


585907200 - Detailed Report
Date Time Location Service Area Checkpoint Details
Oktober 18, 2009
11:59

Arlanda - Sweden Försändelse hämtad
Oktober 19, 2009
18:04

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
18:28

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 19, 2009
18:49

Arlanda - Sweden Anlänt till DHL i Arlanda - Sweden
Oktober 19, 2009
19:48

Arlanda - Sweden Lämnat avsändare
Oktober 19, 2009
19:55

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
22:16

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 20, 2009
00:15

Leipzig - Germany Anlänt till DHL i Leipzig - Germany
Oktober 20, 2009
00:46

Leipzig - Germany Processed at Leipzig - Germany
Oktober 20, 2009
03:27

Leipzig - Germany Skickad från Leipzig - Germany
Oktober 20, 2009
05:28

London-Heathrow - UK Skickad via London-Heathrow - UK
Oktober 20, 2009
05:37

London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
05:51

London-Heathrow - UK Anlänt till DHL i London-Heathrow - UK
Oktober 20, 2009
06:18

London-Heathrow - UK Processed at London-Heathrow - UK
Oktober 20, 2009
06:41

London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
07:33

Gatwick - UK Anlänt till DHL
Oktober 20, 2009
09:12

Gatwick - UK Ute för leverans med kurir
Oktober 20, 2009
10:39

Gatwick - UK Signatur

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.