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

Readiness for change diagnostics: Some evidence

I'm ambivalent about the concept of "evidence" for much of the change and improvement work we do in healthcare because so many of the concepts and processes are contested.  However, that doesn't stop me checking for evidence and testing my own prejudices.


There are a number of papers  and publications which touch on the topic of readiness for change.  



Review: Conceptualization and Measurement of Organizational Readiness for ChangeA Review of the Literature in Health Services Research and Other Fields
Weimer, Amick & Lee
All literature reviews need to be considered as a service to humanity. This one covers the concept of readiness for change in healthcare and reviews 43 instruments in use.




Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

Sharon Hamilton, Susan McLaren and Anne Mulhall

This team conducted a comprehensive review and evaluation using multiple strategies which I like. They also used the Team Climate Inventory.

^{Monograph: Assessing & enhancing readiness for change; implications for technology transfer.}

^{Backer, David & Soucy}

^{Not a peer-reviewed paper as such, but it has some excellent perspectives on what readiness for change means - and doesn't mean.}

Systems Antecedents for Dissemination and Implementation; A Review and Analysis of Measures
Emmons, Weiner, Fernandez, TuThe conclusion in this paper seems ot be there is no common ground for the use of measures or consistency in the way in which they are applied, hence leading to difficulties in figuring out what might be the best strategy.


There are many more papers - if you find any, please leave notes in the comments box.

Readiness diagnostic tools for spread, scaling up, dissemination

So how do you know whether your organisation is ready to embark on a program to adopt existing good ideas / evidence in a systematic way?

As in previous posts, most of the answer to this question is a no-brainer - you know the answers already (see previous posts).  However, sometimes it's nice to have a checklist or set of tools to help you check whether what you know about is actually in place.

There are many general tools / checklists available which check whether your team or organisation is ready to do something different.  Most of these assess the culture of the group. The disadvantage here, which is why I suspect many people avoid these types of tools, is if you find out that your culture is not ready, many people lack the patience to go through the necessary cultural change - or they just don't have the time for this "pre-work".

Generic tools can be useful for learning about your organisation though they can be a good (and time-wasting) displacement activity by organisations.

The best types of diagnostic tools are those which are specific to the change in hand.  Specific means they are designed around and for the type of change proposed.

1. One of the best examples I know of specific diagnostic tools come from, the US National Council on Aging. For their Chronic Disease, Falls and Depression scale up plans they have open access tools which can be completed online or you can download the PDF to read through.  Each of these is specific to the adopting community and the type of innovation proposed for scale up / spread / dissemination.
2. NICE - yes, the National Institute for Health & Clinical Excellence (NHS) has been at the forefront of providing tools that support the introduction of evidence. These are excellent spreadsheets, populated with the NHS data and ready to use.  Unfortunately, I don't hear about them being used on a regular basis - especially by commissioners.

The problem with tools and diagnsotics is no difference than the problem with any other thing we want to spread or be adopted - most people would prefer to create their own because the credibility for many members of staff lies in the excitement and status of creating their own, rather than using someone else's. If you're offered a diagnostic tool - have a good look at it - if it is specific to the innovation it may be very useful for you.

Leaders need to role model "Spread"

If asked what the one thing leaders can do to better enable the spread and adoption of good practice in their organisation, it would be - "Be a role model".

I wrote in this blog on this topic back in May: "Why don't we search for evidence."

It's no good leaders exhorting that their staff need to adopt good practice and to use "evidence" if they don't do the same.  There's no quick fix. There's no substitution.

Next time you wonder why it is your staff don't search for, adopt or actively spread known good practices, then ask yourself when last you searched for or adopted a good practice.

Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials

A good friend, Bill Russell, told me about a paper produced by the UK Cabinet Office calling for Randomised Controlled Trials for Public Policy. I was sceptical. When he told me Ben Goldacre (author of the excellent book, "Bad Science") was involved I was intrigued, and then wondered whether it was a spoof. But it isn't.

Hallelujah!

This paper is required reading. [update: new link] I commend it to you all and especially those I've been trying to convince for years that spreading improvements or innovations can have an ethical bias - how do you know it's a good and effective thing to spread?

And when you've read it - read it again. This has to be the best paper I've read for some years.

(I hope someone has passed it on to the Department of Health and the NHS Commissioning Board.)

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 

Altering mental content - 3: Changing Minds

I come across clients who are sp captivated by the notion of spreading good ideas by stories that they forget that they also need to provide the theoretical base for the change, as well as the need to identify the key concepts - and - if required, support the development of skills to enable others to change.

I drew the above chart as my way of showign how all these topics need to come together.  Next time I am involved in helping someone draw up a spread plan, I'll spend time working through what we need to do to provide the mental content to help others adopt new practices.

Seven Key Factors in how minds change - 1: Changing Minds

Notes from the book "Changing Minds" by Howard Gardner (2004)

What I learnt was that if we want to help someone change their mind about what constitutes good practice (and thereby figure their practice is not the best so they need to decide to adopt a better practice), then it helps if we can:

1. Demonstrate what has to be changed in a way that someone can figure out for themselves what the reason is for them to change. Some people do this analytically and others deduce or infer from what they learn that a change is necessary. I think it's important to understand it's the adopter who needs to reason, not the person pushing the change.
2. Research, evidence, statistical analysis etc is crucial when working with healthcare professionals for whom this is the base of their practice. The onus of evidence is on the person pushing the change.
3. The proposed change needs to connect at the emotional and intuitive level with the potential adopter. The really good proponents of change can combine the emotive, rational and evidence content in their rhetoric.
4. The concept of redesciption intrigued me. I can see now that the person who can describe the proposed change in many different ways, whilst remaining true to the core concepts and values, is more likely to be able to convince others to change.  Not least, being able to redescribe means you know your stuff and this enhances the credibility of the proposal.
5. Rewards are obvious - pay someone and they are more likely to do it. But this doesn't always lead to the mind changing. The most basic reward is praise and confirmation of the new behaviour.
6. Real World Events - means tagging your proposals to outside influences. As a friend pointed out to me recently, a great time to raise the profile of pancreatic cancer would have been in the days after Steve Jobs died. To make the most fo these (not always sad) events, is to be prepared.
7. Resistance... it takes two to create resistance. The best way I know to deal with it is to stop pushing and to see things form the other's perspective - then, find a way to break through the debate.

Three Collaborative Models for Scaling Up Evidence-Based Practices

A new paper is out is Adm Policy Mental Health (See abstract below). Two of the models are those I've presented on and published about - the rolling cohort and the cascading dissemination model. There are also subsets of these methods - see my book 101 ways to improve your collaborative. 


Three Collaborative Models for Scaling Up Evidence-Based Practices

Chamberlain P, Roberts R, Jones H, Marsenich L, Sosna T, Price JM.

Source

Abstract

The current paper describes three models of research-practice collaboration to scale-up evidence-based practices (EBP): (1) the Rolling Cohort model in England, (2) the Cascading Dissemination model in San Diego County, and (3) the Community Development Team model in 53 California and Ohio counties. Multidimensional Treatment Foster Care (MTFC) and KEEP are the focal evidence-based practices that are designed to improve outcomes for children and families in the child welfare, juvenile justice, and mental health systems. The three scale-up models each originated from collaboration between community partners and researchers with the shared goal of wide-spread implementation and sustainability of MTFC/KEEP. The three models were implemented in a variety of contexts; Rolling Cohort was implemented nationally, Cascading Dissemination was implemented within one county, and Community Development Team was targeted at the state level. The current paper presents an overview of the development of each model, the policy frameworks in which they are embedded, system challenges encountered during scale-up, and lessons learned. Common elements of successful scale-up efforts, barriers to success, factors relating to enduring practice relationships, and future research directions are discussed.

Canadian Best Practices Portal - Healthcare

The Public Health Agency of Canada has a very interesting website: Canadian Best Practices Portal.  I think it is an excellent example of helping to spread good practice.

1. It describes interventions (best practices) without overly classifying them. The reader can make their own judgements of value and worth. I also like the way these are summarised as they are written for the reader and not as corporate sales pitches which is a temptation other organisations fall foul of. 
2. The resources have a great at-glance feature which show how they relate to define, search, appraise, synthesise, adapt, implement, evaluate.
3. Their list of systematic review sites is extensive and pitches these best practices as being based on evidence which is both appropriate and welcome for healthcare interventions.

Video: Christakis on Social Networks, Spread

Nicholas Christakis is my hero - his research is moving us on from the staid, static and way out of date work of Rogers (Diffusion of Innovations). I recommend spending 18 minutes to watch the video below if you're part of or planning any large scale change, social movement (not that I believe they can be planned), spread of project results.

The shift to norms being spread and not behaviours is significant. What are you doing in your own project work to build on this?

New Paper: What is the experience of national quality campaigns?

I liked the conclusion in this paper - "..may depend on.." as it summarised my experience of national quality campaigns - the results depend on a multitude of factors - and I would add depends on the perspective/s of the stakeholders involved.

 Health Serv Res. 2010 Dec;45(6 Pt 1):1651-69.

What is the experience of national quality campaigns? Views from the field.

Bradley EH, Nembhard IM, Yuan CT, Stern AF, Curtis JP, Nallamothu BK, Brush JE Jr, Krumholz HM.

OBJECTIVE: To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements.

CONCLUSIONS: The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.

Influencers: How trends become Contagious

The DigitalBuzz blog is one of my great sources. They found a high video (a film, really) Influencers: How trends become Contagious from R+I Creative that documents the importance of Influencers in setting new trends that move to mainstream. No theory, models or management gobbledegook in it!

eLearning 1: 5 Resources for supporting online discussions

Creating and moderating an online discussion group requires more than sending out an email inviting people to join. In some cases it is not the cheap, quick fix you may be after. It's work. Treat it like a project - from strategy, planning, resource allocation through to evaluation.

Here are a few of my favourite resources on the topic:

1. Designing and Managing online discussions from Oxford Brookes University (PDF paper, with references - my favourite)
2. Teaching with online discussion forums - good introduction 
3. Online discussions: Tips for Instructors from the Centre of Teaching Excellence at the University of Waterloo. Web page with bullet hints
4. Using discussion boards to engage students 
5. How to avoid problems with online discussions - student guide. Short web page with more links on it. USeful because it is from the student/user perspective

Gartner's Hype Cycle is more useful than the Rogers' Diffusion of Innovation Curve

The classic Diffusion of Innovation curve was created by Everett Rogers back in the 60's, before many improvement facilitators were born.The terms, early adopter, majority, laggard etc have survived because they provide an explanation for something that is often difficult to fathom - how different groups of people respond differently to the same innovation. I have written at length (see previous posts and books) about the limitations of this theory and it inability to predict or provide guidance about what to do next.

Gartner introduced a theory in 1995 designed to explain what happens when a product or innovation is hyped, and then goes through various stages to acceptance. I like this theory because it steps away from the position of blaming people for not doing something and focuses more on the intrinsic value of the innovation or product.

Image from Wikipedia: Hype Cycle

The Trigger is the first breakthrough event that starts the interest in the product/innovation. This is followed by the peak of inflated expectations where the optimism for application outweighs the difficulties. The focus is on the possibility of the product/innovation. The trough of disillusionment comes when the failures start stacking up, expectations are not met, or something new comes along and this idea is no longer fashionable.  The slope of enlightenment may turn up years later when the original idea is tweaked and adapted and made more applicable. The plateau of productivity is reached when the product/innovation becomes mainstream due to its stability and usefulness.

Obviously, this curve will have different shapes for different products. Here are a couple of exercises:

1. Take one product/innovation which you believe to be at the Plateau of Productivity, and track back, seeing how the curve shapes with regards time and visibility (visibility = talked about, in the press, on agendas etc)
2. Map your current products, innovations and ideas on the cycle and see what you learn. Are they grouped in one area? What might you need to do to manage the transition to the next phase?

Let me know how you do by filling in the comments section below.

Options for large scale spread; excellent new report by WHO, IHI, Harvard

A new report about large scale change and spread of simple, high impact interventions is available now. And it is a really good summary of methods old and new. I highly recommend it for anyone planning simple large scale spread, especially if you think you know the answers. This report summarises a variety of methods and is very pragmatic in it's use of examples.

The World Health Organization Patient Safety Programme and the Harvard School of Public Health commissioned the United States Agency for International Development’s Health Care Improvement Project (HCI), managed by University Research Co., LLC (URC), to present its understanding of and experience with the effective adoption of simple, high-impact interventions, such as the Surgical Safety Checklist. URC is joined in this effort by the Institute for Healthcare Improvement, which also has decades of experience in this field.

Readers should note this report and advice covers the spread of simple, high impact changes - namely it does not cover complex, system related changes.

The report covers:

III. Spreading Evidence-based Interventions
IV. The Scientific Basis for Spread
A. Framework for Spread
B. Individual Adoption and Behavior Change
C. Positive Deviance
D. Factors that Influence the Rate of Spread
E. Understanding the Social System
F. Integrating Content into Process Design
G. Testing and Implementing Change
H. Executing for System-level Results
V. Approaches for Large-scale Spread
A. Natural Diffusion Approach
B. Executive Mandates
C. Extension Agents Approach
D. Emergency Mobilization Approach
E. Affinity Group Approach
F. Collaborative Approach
G. Virtual Collaborative
H. Wave Sequence Approach
I. Campaign Approach
J. Hybrid Approaches
K. Lessons Learned from Large-scale Spread
VI. Which Approach Should Be Used to Disseminate Checklists?

(And thank you to the authors of the report for referencing my book on how good practice doesn't spread)

Mobile learning may be more significant than web learning for healthcare

Educational methods have long been one of the key strategies to encourage the adoption of existing good practice and evidence in healthcare. The predominant method is face-to-face sessions though over the last three or four years this has started to be replaced by virtual sessions. The Web has been the technology used ofr the virtual learning, however, the advent of smart phones suggests learning via the mobile may be overtake the web portion of learning and may dig deeper into the face-to-face session.

The chart above comes from Ambient Insight Research who have an excellent article on this topic.

Are your spread plans including the use of mobile learning and technology?.

The quickest way to spread scale up change

The most common question I am asked is whether there is a quick way to spread desired change across groups.

My Nobel Prize entry for answering this question is as follows:

"Yes and No"

The fact you are asking the question means you are in a type of powerful relationship over those with whom you want to interact and change. Namely you want them to do something different/ly and you want them to do it quickly.

The "Yes" answer is dependent on the carrot and stick approach. Pay a twelve year old to clean his bedroom and if the reward is big enough, the bedroom will be cleaned. Pay doctors a reward for meeting a quality target and they will achieve it (evidence the NHS and GPs). The stick approach is less effective but still works. It is no longer common to see anyone on their mobile phone while driving in the England. The stick of a fine and points on your license has worked, combined with appeals to common sense.

The "No" answer comes from asking questions like those listed below. If I get more than two or three "No's" in response then I suggest to the person asking that they have probably answered their own question.
- are you making the change yourself?
- can you describe to me the three main reasons why the person you want to change thinks this will be a good idea?
- do you apply the methods you are proposing in your own work and/or personal life?
- is your reason for this work more than doing a good research project you can publish later
- will the person/group you want to change see the change as coming from somewhere other than yourself?
- do your plans involve more than a communication exercise?
and so on

Crowdsourcing shifts us from what to how

"to improve" is a verb. A verb is a "doing word". Improvement is action. Collecting and storing examples of good practice is a displacement for action. Huge knowledge banks where the thing of the 1980's (yes, thirty years ago) and by the late 1990's were largely discredited as a mechanism for helping spread good practice. The few organisations that did manage to leverage the codified knowledge, did so because they institutionalised through clever IT systems, the search and sharing of knowledge. Note, this sharing was linked to the individuals with the ideas and not odd pieces of extracted information. The personal relationship mattered.

What does the modern day action to improve look like when we are aiming to avoid the reinvention of wheels?

a) We crowdsource. We call on the community for their ideas. However, asking for and then collating ideas is not crowd sourcing - it is a cheap way to create an ineffective database. Crowdsourcing works when participants rate ideas, decide which is best. Many organisational leaders fear crowdsourcing because the answers may not be what they want.

b) We get more active in presenting the problems and then asking people to provide answers - as an open call. The joy in this approach is it is not limiting the solution to the thinking and mindsets of employees. This has been around for at least a decade and the are many websites and systems to help make this happen. Some organisations even provide all their data so others, not part of the organisation, can use it to help solve the problem. The first step to making this happen s to give up control and to ask for help.

In the UK we are experiencing the crowdsourcing as the Government has set up systems to ask for ideas on solving problems. I like the way they are asking the citizens on ideas and not restricting it to Government employees only.

Crowdsourcing gives the vote to the hungry consumers and nto to the turkeys.

Some Crowdsourcing links and resources


1. Wikipedia: for starters

2. IdeaScale is where you can set up your own Q&A and ranking community for innovations. There are hundreds of existing web applications for crowdsourcing so if you are spending money creating your own then let's hope there is am excellent reason for doing so.

3. Fevote - place to make suggestions and get votes on them (great for research and tests of change)

4. Kluster: - stunning group decision-making tool

5. Good blog post on crowd sourcing resources

To share or not to share?

I've spotted a proliferation of new initiatives within the NHS in England attempting to encourage staff to share their knowledge online. While this sounds like a useful and pragmatic action to take I wonder what the implications might be.

The main exhortation is about encouraging staff to share what has worked well for them. I expect there will be many who would like to share, though inputting your information into a fairly anonymous database is at the higher end of the perceived risk continuum. Without knowing who (as in a person) will be editing or reading the information, many people will be hesitant to "share" in this way.

The proliferation of different places to share is also confusing. In their own way, each organisation requesting sharing is doing so for the right reasons. However, how do you choose - NHS Networks, NHS Institute, NICE, own organisation's database... random sharing with colleagues using other online networks, professional groups?? Each organisation requesting sharing is doing so for it's own reasons and these reasons may not be easily identifiable by those who are targetted.

For some healthcare staff and their organisations the incentive to share may feel like a perverse one. In a competitive market there may be a disincentive to provide information about how well or how innovative you have been. In my experience the best results are seldom shared because of this restriction. So what we do get shared is often the less innovative and more obvious results of projects and changes.

I think the issue is not "to share or not to share". Sharing is only part of the story. Sharing is only of value if there is someone listening and looking. If the main group looking at what is shared is the group who owns the database then the value of what is shared is quite limited. The real issue is in encouraging staff to look and listen, to be curious and to accept that in just about everything thing they do and every problem they have, someone, somewhere has already addressed it - and this information is already available.

So if you're developing databases to captured shared information then a few pointers to consider:
a) how much of your time, budget and strategy is devoted to encouraging the look and listen?
b) how unique is your database? How will it be found and why should those who are searching use your database?
c) In what way can you build on or link to existing databases so you build a wider knowledge base rather than divide up a crowed space?
d) How can you move from the transactional share and disseminate approach to one which is based on the concept of interaction, dialogue and learning?