New systems model to simulate spread and adoption of good practice

I've worked with Ken Thompson of Bioteams to develop a systems simulation of the spread and adoption of good practice.  Our aim has been to provide a method for individuals and teams to play about with different strategies and to model the impacts of those strategies. It's not a prediction tool, but rather one which helps you gain an insight into the complexities  It's been important to us to produce a simulation which provides an adoption curve - having an idea of the speed (or not) of spread is crucial to your planning.

The simulation is ready for testing. It's not perfect, and we'd love to demo it and take your feedback on how to make it even better. Feel free to tweet Sarah @sarahfraser or Ken @kenthompson, leave a reply to this blog, or email Sarah, if you'd like to have a go.

A screenshot of the main screen is below. You can choose your strategies and then simulate, quarter by quarter, the rate of adoption. There are other input screens where you can assess your readiness for change and where you can enter details about the strategies you'd like to use.

Readiness for change - an adopter's diagnostic tool

The Agency for Healthcare Research and Quality (USA) has a fabulous tool that can be used by potential adopters in helping them decide whether to adopt an innovation in their organisation. Whilst the questions appear rather basic, they are comprehensive, evidence based and the way in which the diagnostic has been put together really helps the decision-making process.

I commend it to you.

Download the PDF Diagnostic here

Paper: An Operationalization of the Interactive Systems Framework Support Systems

This paper has a long and complicated title.The bottom line seems fairly straightforward - that train the trainers (TOT) activities and technical assistance (TA) can lead to success when scaling up the adoption of evidenced based practices.

Am J Community Psychol. 2012 Jun 19.
Using a Training-of-Trainers Approach and Proactive Technical Assistance to Bring Evidence Based Programs to Scale: An Operationalization of the Interactive Systems Framework's Support System.
Ray ML, Wilson MM, Wandersman A, Meyers DC, Katz J.

Readiness for Spread. Whose readiness - the adopter or the "pusher"?

One of the most frequently asked questions I get is how program managers can assess whether organisations and teams are ready for spread. For me, the answer is a lot more than a quickie checklist or diagnostic tool - I've tried many, including developing my own, but they have their limitations. The first question to think through is "whose readiness"?

1. ADOPTERS: Mostly I have program managers wanting to know whether organisations and teams they want to adopt something are ready. This is a useful question to ask, and indeed much of the literature focuses on these potential adopters. So yes, it's good to consider their readiness and there are a multitude of tools and techniques for doing this - any good change management assessment will work.
2. "PUSHERS": What most people forget is to assess the readiness of the "pushing" organisation to go through the spread process. For example, a regional organisation may want all physician practices to adopt the use of new diabetes guidelines which includes an information monitoring system. It may sound obvious, but the "pushing" organisation does need to make sure they are ready and geared up for others to adopt the process.They need to have the support and systems in place. Often, great practices and ideas can be adopted so quickly that the "pushing" organisation panics and then becomes part of the "slow-adoption" problem as they put limits on the process.
3. CONTEXT: Finally, the context is crucial. When it comes to large scaling up activities, it's vital to assess the readiness of the context that organisations and teams find themselves in. For example, the context where a pilot program achieved great results may have changed in the year or so since they completed their work: a change of government, the financial crisis, new technology etc.

So, when you are next assessing the readiness for your spread / scaling up program, do take the time to think through the three different angles.

Focusing on High Impact changes in the NHS may be damaging. Try MIME instead.

Identifying the "top 10" or the "top 5" high impact changes that NHS organisations can implement - then pushing them to do so, has consequences.

1. Unless the identified high impact change is shown to be generalisable (that is it has been tested in different contexts and a similar result has been achieved), then there is a significant probability that the change may not be high impact at all.  When we take one result from one place, then roll up the possible benefits across all organisations we are making a fundamental mathematical, and change process, error.   If we do want to do large scale mathematics then we need to know the baseline at each potential organisation, the match in context to the originating result, and then do a weighted calculation across the system.

2. Not all high impact changes are equal - in the amount of effort and resource (read ££££) they take to implement. A great result may sound good, but if it takes so much resource to implement that the payback time is 10, 15 or even 20 years, then yes it is high impact - but not in the way intended.  The challenge is to find a way to get the impact - but with less cost associated in the process of doing so.


MIME = Maximum Impact, Minimum Effort.


(and of course, LIME, low impact, maximum effort, should always be avoided)

Do your "high impact" exhortations meet the MIME challenge?

Is Activity Theory useful for large scale change?

There's no shortage of theories and models for how good practice can be "spread". I'm part fo the problem by generating some of them.... I've recently become curious about the use of Activity Theory as a means of large scale change in healthcare settings.   It's a bit of an eclectic theory from the social sciences - but then, PDSA cycles were once an eclectic Japanese theory.

Wikipedia has a good intro.  Basically, the benefits of Activity Theory is it combines all system levels into one model of change - from individual through to policy. And I like that.

Greg, Entwistle and Beech have a new paper which considers how AT can be applied usefully in healthcare.

Soc Sci Med. 2012 Feb;74(3):305-12. Epub 2011 Mar 1.
Addressing complex healthcare problems in diverse settings: Insights from activity theory. 
This is their abstract: "In the UK, approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and 'rolled out' across organisations. When the designated 'best practice' is not implemented, this is interpreted as local - particularly management - failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail. We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on "objects of activity" which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice. The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the 'best practice' of rapid response teams."

Why don't we search for evidence?

So I'm perplexed.

I've spent years listening to leaders at all levels - from unit, to department, to organisation, to region, to National  - all say they want "other people" (usually those "beneath" them) to adopt existing good practices.

That's all good and well.

But when I press these leaders on what efforts they've made to check the literature, search for existing guidelines or consider the experience of people similar to themselves - they all look at me blankly.  One recently told me that "that sort of thing is for the people who need to improve, not me. They need to adopt guidelines."  When I pressed him about the opportunity he has to learn from others in the design of his large scale intervention, he replied "We're different."

I shall invest a new piece of equipment - a mirror.

How does organisational context impact spread and adoption

Those who know me, know I am critical of the continued use of Roger's Diffusion Curve as a means of telling people how and how to plan for the spread and adoption of good practice. If you read Roger's work in depth you will understand its limitations.

One of these is the lack of attention to context. It's fairly obvious to anyone involved in spread and adoption of good practice that leadership, organisational culture and readiness to change etc. are all important in the process. The problem is, although many models and frameworks are drawn up to show how context is important - which is an excellent first step - there is a shortage of published work on the topic.

A key problem is that those who publish ignore the contextual factors.  A recent review paper by Emmens, Weiner & Fernandez looks at this issue.


Health Educ Behav. 2012 Feb;39(1):87-105. Epub 2011 Jul 1.
Systems antecedents for dissemination and implementation: a review and analysis of measures 

New Paper: How to use an article about quality improvement (JAMA Nov 2010)

One of the difficulties in spread and adoption is, on the one hand avoiding the temptation to take the results from one project and then do a back of the envelope calculation and announce if the results were spread then there would be x billion savings etc; and on the other hand, if you're a project lead, how do you read a piece of evidence and work out its relevance for your own work?  There is a new paper out which touches on this subject.

 JAMA. 2010 Nov 24;304(20):2279-87.

How to use an article about quality improvement.

Fan E, Laupacis A, Pronovost PJ, Guyatt GH, Needham DM.

Abstract

Quality improvement (QI) attempts to change clinician behavior and, through those changes, lead to improved patient outcomes. The methodological quality of studies evaluating the effectiveness of QI interventions is frequently low. Clinicians and others evaluating QI studies should be aware of the risk of bias, should consider whether the investigators measured appropriate outcomes, should be concerned if there has been no replication of the findings, and should consider the likelihood of success of the QI intervention in their practice setting and the costs and possibility of unintended effects of its implementation. This article complements and enhances existing Users' Guides that address the effects of interventions--Therapy, Harm, Clinical Decision Support Systems, and Summarizing the Evidence guides--with an emphasis on issues specific to QI studies. Given the potential for widespread implementation of QI interventions, there is a need for robust study methods in QI research.

Different types of practice; good, best, novel, emergent

The definition of good practice has always been contested and maybe the use of the phrase "spread good practice" is part of the problem as to why adoption of existing practice is so difficult.  The Synefin model provides us with four categories of practice:

1. Best Practice (simple systems where the idea is obvious to all and obvious to adopt)
2. Good Practice (complicated systems where the relationship between cause and effect is less obvious, some investigation is needed and usually adaptation in order to solve the problem
3. Emergent practice (this occurs in complex systems where you only figure out in hindsight how something happened, how the results occurred - and this analysis is not necessarily predictive.
4. Novel Practice from chaordic systems where there is no relationship between cause and effect

If the goal of a large scale program is to spread the use of methods or techniques that deliver improvement then I think it is important to be able to diagnose what type of practice is being touted. Often novel or emergent practices are praised as the solutions to problems, putting the pressure on other individuals, teams and organisations to do something similar - and when they don't they are castigated for not trying.

The devil in the diagnosis of type of practice. Do you have any examples of the different types of practice?

(If you are reading this in an email or on your smartphone, to get automatic updates on this blog go to http://spreadgoodpractice.blogspot.com/ and click on the Subscribe Button)

Using Twitter in the Classroom or Organisation

Twitter feels like one of those applications that has been searching for its use. Within healthcare, specifically the NHS in England, its use has been limited. Many organisations see it only as another media channel through which they advertise their services. A few, however, have grasped its potential to spread the word  in a personal way and are using Twitter as a means of engaging with patients and staff. A good example is @OBMH (Oxfordshire and Buckinghamshire Mental Health).

While healthcare is prevaricating and the organisations that preach and teach innovation are being slow to catch onto what is now practically a mainstream communication method, education has been stealing a march. An excellent blog post about using Twitter in the classroom includes a framework which made huge sense to me and helped me think through how best to use twitter in a training event as well as for the duration of a healthcare improvement project.

Not only does it help communication for the project it also adds in the "spread" and "Scale up" component that it so often missing.   If you are worried about the word student, then substitute patient or staff member. What I particularly like about this framework is it is a way for organisations using Twitter to self assess their use of it.

(Picture from Prof Hacker http://chronicle.com/blogPost/A-Framework-for-Teaching-with/26223/)

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

Spread or Adoption? Which terminology works best for you?

Do you talk about spreading good practice or helping other to adopt good practice?

The difference is one between push and pull. Spread implies a push out, top down and hierarchical approach and adoption suggests we are unable to do the change and that the best we can do is help someone else to do it.

It sounds subtle but the difference is significant. Enabling the pull is difficult to do using a top down approach in the organisation. Yes, it is not only possible but downright useful for the organisational leaders to create a context and structural environment that enables professionals to be aware of and be able to implement existing good ideas. However, the application, the changes, are made by those who are affected by them, not the leaders.

It sounds to me that in the last year or so healthcare around the world has started to use the phrase large scale change to take the place of spread and adoption. I wonder whether this is due to the difficulty of the original two words?

4 kinds of relationships

So much of spreading good, known and evidenced practice is based on social connections and relationships. John Maxwell has four ways in which relationships can be categorised.

1. Some people add things to life (we enjoy them) +
2. Some people subtract something from life (we tolerate them) -
3. Some people multiply something in life (we value them) *
4. Some people divide something in life (we avoid them) /

If a key role of the person who group is trying to influence others to change their behaviour then it might be useful to reflect on the relationship between the "spreader/pusher" and the "adopter/puller".

There are some people I avoid (4) and I am unlikely to even receive the messages they are pushing out, let alone act on them. In a similar vein, those I tolerate (2) I will probably put them low on my priority list and will be fairly sceptical about what they put out. Whether I adopt anything they are pushing will be a matter of personal judgement.

On the other hand, those whose company I enjoy (1) I will probably get to hear a lot about what they are saying, thinking about and pushing in my direction. I will take their information in quite quickly, though may still toss the ideas about before making any changes to my behaviour.

Those I value I will probably not wait for them to send me information. I will be finding ways to connect, listen out carefully and will most likely shift my behaviour quite quickly when they send out behaviour related messages.

So which types of relationships are you creating and endorsing?

If products, ideas and results are not spreading and being adopted then maybe you need to do an ethics check

The most frequent issue people contact me about is "my project results or project methods are not spreading to other places / are not being adopted by other people". A key reframing here is to ask the question "Why isn't my xxx being spread and adopted?". This is the first step in figuring out the problem - and solution.

I wrote a book a few years ago that faced this issue and provided some ideas to get round it. One topic not covered in detail in the book though one I have since reflected on is that of ethics.

House (1980) provides a list of ethical mistakes which include:

Clientism; this is when we are so focused, as facilitators, project managers and consultants, that we do what the client wants rather than a deeper investigation into what problem needs to be solved. This is prevalent in healthcare where there are multiple clients or where facilitators are unable to take the difficult discussions and fall back on making their clients happy. Any consultant can make their client happy - can they help their client solve identified problems, even if it means walking away or referring on if they are not the best person to help? Projects which have been implemented to serve one specific client are unlikely to be adopted by others as they instinctively feel the solution does not meet their own need.

Methodologicalism; assuming that following a ethnically correct method is the same as being ethical. This is an interesting issue for the spread and adoption of guidelines. Different professionals may have alternative interpretation of the ethics are different parts of the guidelines. This conflict results in the oft heard "this won't work here" or "this won't work for my patient". On solution is to discuss and be transparent about the ethical paradoxes involved.

Elitism; giving the most powerful the strongest voice. This is a concern for the development of solutions and introduction of change methods. The most powerful and loudest voice may not be the most connected to the context in which they are requiring change. Potential adopters may instinctively push back against what they perceive are "loud voices". Or they may try to make the changes to keep the "loud voices" at bay and only partially gain the benefits. This issue is also linked to the concept of "inventoritis" which was the subject of an earlier post.

To what extent are your spread and adoption issues linked to ethical dilemmas?

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

Improvement Projects: Do no harm

A common issue raised by project managers who are trying to implement existing good practice with individuals and teams is one of resistance to change. I am constantly seeking ways to reframe the term "resistance" as a means of moving away from a potentially obstructive and destructive frame of reference.

I've been wondering whether one of the reasons people appear to "resist" adopting even what is well evidenced as good practice is because of a natural and at times perfectly reasonable conservative attitude towards risk. The medical profession has the theme of "do no harm". My feeling is often we are asking professionals to take on the solutions designed by others and in different contexts without providing the potential adopters with the evidence that the results are both relaible and generalisable. Reliable in the sense they can be repeated int he same context with the same results. Generalisability is what is proved when the intervention (improvement process) can be done in a different context and obtain similar results.

Without this evidence of generalisability in our improvement work I feel professionals will continue to be suspicious of changes.

In additon, do we ever publish the knock on consequences and the adverse effects of improvement work? A quick trawl of improvement projects published in high impact journals in the last 2 months demonstrates the attitude that improvement work is all good. None fo 12 papers that I looked at provided (or even hinted) at any negative consequences. Without honesty abotu improevemnt work and results I suspect we will continue to encounter "resistance" to change - and I will consider this an appropriate response to any solution being touted for implementation where there is no demonstartion of generalisability and no discussion about identified adverse consequences.

SMS Texting Campaigns; awareness to action

Mobile phone technology has the means to change lives. A number of campaigns have been running where SMS/texting technology is being used not to raise awareness but rather to deliver action. I'm interested in this as it is breaking some of the "communication rules" and what is in the old research about how ideas spread and are adopted.

An excellent example is from UK Transplant where there are a number of campaigns running to increase the number of people prepared to donate tissue and organs. In the South West of England a campaign is running until April 2010 combining regular advertising and sms texting. The posters create awareness and then if anyone standing int he bus shelter wants to act by registering on the UK Transplant Organ Donor site they can send a simple test to a number with the word GIVE. This is still a pilot and the resulst will be interesting. I am all in favour of innovative ways of moving from awareness to action and this method is modern and relevant to societal trends.

If you want to add your name to the register then go to become a donor
If you want to read about this campaign go to sms campaign

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.

Photo from www.freephoto.com