Paper: Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

Ah, context. Context matters in healthcare interventions and so many improvement projects and similar interventions ignore context. This paper,  Measuring organizational and individual factors thought to influence the success of quality improvement in primary care: a systematic review of instruments, is important because it attempts to discover measures that influence interventions into account. The results are mixed.

"We identified 186 potentially relevant instruments, 152 of which were analysed to develop the taxonomy. Eighty-four instruments measured constructs relevant to primary care, with content measuring CQI implementation and use (19 instruments), organizational context (51 instruments), and individual factors (21 instruments). Forty-one instruments were included for full review. Development methods were often pragmatic, rather than systematic and theory-based, and evidence supporting measurement properties was limited."

Implementation Science 2012, 7:121

Spread and implementation; making practices real

At a recent awayday for a team in Sweden who are working to improve the experience of life for  the elderly, I had the fortune to listen to and work with Bodil Jonsson. I was thinking out loud and expressing my concern that the use of the word “spread” may allow people using it to disengage with the reality of what is involved. There is an ease by which leaders say “spread”, and then disengage themselves from the detail of what it means. So insteadI tend to use “implementation” as this word, to me, has a more active feel, and directs the users to consider what might be involved.

Bodil suggested the Swedish word “forverkliga” (please imagine the two dots on the o). This means to make real”. This was a light bulb moment for me. Think about guidelines; is the issue to spread them, to implement them – or to make them real. I like forverkliga because reality is made in one’s own context, thus enabling adaption, without further explanation And making real is far more than the objective task of copying another’s good idea. Instead it is the process of taking another’s idea and focusing on the added value to, say, the patient; unless something is made real, there is no value.

In my mind’s eye I say websites full of stories and examples, of guidelines and exhortations – and at once, saw useful information, that was of no value unless “made real”.

Forverkliga.

Book Review: Sustaining lean healthcare programme; a practical survival guide - Eaton & Phillip

Different book styles appeal differently, to different people. This one appealed to me because it is relatively short (94 pages plus appendices), well organised, uses bullet points and lists, checklists, diagrams and has some short examples to illustrate points.

Contents include:

1. Where are you on your journey
2. Why do only 24% succeed?
3. Going Lean
4. The top ten signs of a failing programme
5. Creating a lean healthcare organisation
6. Four key checklists
7. The next eight things to do...

So do only 25% succeed? The authors suggest there are 8 critical success categories Communications. resources, involvement, training, implementation, compass, achievement and leadership (yes, these do spell "critical"). If you like wordplay then read the book and discover PRISM, CAD, VSE, RIE, RPE, FIT, FMEA etc. Not as bad as it looks in a list here. I found them a good description, and sometimes reminder, of basic principles.

The chapter on the top 10 signs of a failing program is easily read. For each reason there is an explanation of what you may experience, why it happens and then what you can do about it.

The four checklists you need? One each on people, success, tools and culture. Nothing really new to me, just nicely organised.

I particularly liked the Appendices which included key lean phrases and concepts (worth the price of the book for its organisation and simplicity), audit form, guide to common saying (fabulous!), and then a number of "how to" guides.

I know Mark Eaton has actually implemented lean in healthcare. This book is a demonstration that when written by someone who has got their hands dirty it turns into valuable desktop reference.

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.