The words innovation and improvement can be misleading

If you want an idea or activity to be judged as good, then label it as an innovation or an improvement. Correct?  Well, I'm not sure it should be, but it seems that's what happens. I've been wondering why it is that the words "innovation" and "improvement" are assumed to represent "the good".

At a high level, there is an ethics issue; to whom does the "good" belong? New ideas often stem from crises, and crises are often either sourced from or produced by competition. When one side creates an innovation, the other side loses.

At a more detailed level, what worries me is that by labelling an idea or activity using words that come with the assumption of good, is that we:

• fail to evaluate whether the idea does what it intends (fidelity; more about fidelity here)
• fail to check whether there are unintended consequences in applying it
• fail to understand the drive of the person or organisation behind it
• urge the spread of a "good" practice, without assessing its value
• just accept; and the more we just accept, the more we open the floodgates to ideas and activities which may no longer be what we need

There's a lot of talk in the NHS about the need for "innovation". It will be good when this is grounded into discussion about the problems that need to be solved and then the ideas and activities being introduced to solve them. Solutions need to stand on their own right, not be labelled to give them credibility.

Book Review: Rippling; how social entrepreneurs spread innovation throughout the world. Beverley Schwartz 2012

Social entrepreneurs work on societal problems; they push against the norms of societies, governments and organisations. They develop unique solutions because they have to. Social entrepreneurs are not the stuff of organisational employees. These are very focused individuals who operate outside of regular structures to make change happen. They speak up, point out and are unafraid to plough, what at times is, a lonely furrow.

This book is about large scale change and transformation. It's neither an academic review nor a pop-science polemic. Instead it covers the stories of real social entrepreneurs as they create and implement systems changing innovations.

The book provides a number of case studies and draws out some guiding principles and lessons.

Advice on being a social entrepreneur includes:

• "Take responsibility for your life"; this is about getting out there and up there with what you believe in. It's about taking your ideas and working full out to find sponsorship and to convince others. It's not about "selling" a corporate idea within the corporation, although the way social entrepreneurs influence provides useful lessons.
• "Remain objective". This sounds really odd but the essence is to avoid falling on love with your idea so much taht you're unable to see it's faults and end up defending it when others try to improve it. It is about focusing on the benefits to others - note: to others, not to yourself or your organisation.
• "Do something"; social entrepreneurs are not thought leaders or academics. They are people who get things done and they do this by marshalling their own resources (internal and external) and expending personal energy on keeping the action going. They are in for the long term and demonstrate remarkable consistency of purpose. They are 'doe-ers'.
• "Solution"; They are entirely solution focused. They constantly work to find a solutions to keep their work moving forward. They tend not to use the language of "problems" or consider problems as barriers - instead they are the opportunities to improve and speed up implementation. Sounds a bit obvious and trite - but the case studies in this book demonstrate this.

Schwartz identifies four characteristics of social entrepreneurs:

1. Purpose
2. Passion
3. Pattern
4. Participation

To some extent these seem the same characteristics that are used to define good leadership or those who foster social movements. From reading her book, I think Schwartz is positing that its the amount of each of these characteristics that matters: amount and strength. Social entrepreneurs are not spending time on office gossip, annual planning away days, business planning processes - they are putting the maximum amount of energy into their fundamental beliefs, and taking them to action.

Great book. 

Social Friction; the essence of innovation

There are as many theories of creativity and innovation as there are consultants – I suspect! Most of these have at their core, the concept of the “spark”, the moment when the new idea pops up.  There are theories as to how this happen. For some people this appears to happen when they are working on their own and get   new insight – for others it is the product of analysis, debate and reflection.

A spark is the product of friction. This friction can be internal or external. Not everyone can abide internal friction; to be able to hold contrasting thoughts at the same time, to read away from one’s own perceived knowledge and to ask oneself the disconfirming question. For many, it is easier to work in a group and encourage the challenges and questions that lead to new knowledge. But the value of this group work is in relation to the group’s ability to handle critical debate and questioning.

What saddens me most is when groups avoid this friction. They end up with interesting new ideas, but the potential of their knowledge and experience coming together to discover breakthrough concepts is diminished. This is a waste of capacity. The long term cost of this lost opportunity is significant.

When you next work in a group whose remit is to develop new ideas or to innovate, then consider how you manage social friction. Does the group seek out the disconfirming questions? Is the “solution” grasped too quickly?  Look around you – is all that experience and knowledge truly being employed in the creation of something that adds value.

Five iPhone apps the NHS can learn from

Many healthcare organisations are getting on the “app-wagon” by repackaging some of their regular website material.  In most cases, the “innovative” bit is the use of the iPhone’s GPS function for maps. Is this innovation? Not for me.

I’m on the lookout for apps which redesign interaction with health services, that support patients in caring for themselves and their families – and basically, ones which have an underlying brilliant idea that can only be implemented on a smartphone. 

In the end I didn't find any apps that lit me up – though I did find some that gave me ideas for apps that could be developed.

Wounds by BSN Medical Ltd, May 2012, UK only, FREE

You use your iphone camera to take a snapshot of the wound, then use the symbols to categorise it by wound need, depth and exudate level (for the non-clinical this means how bad, deep and weepy it is).  Then the appropriate dressing is suggested – and of course, this is their own brand of dressings. I’m not into promoting one type of dressing but this app is IDEAL for the NHS. Why hasn’t anyone produced this for the reduction of pressure ulcers – linking to the NHS Supplies dressings?  What I like about this is no improvement project is required – implementing an app will redesign the process of assessing and treating wounds/ulcers in the most fundamental way.

iScrub Lite, Free, May 2010

The premise is good hygiene and this app records observations and lets you email those observations. Whilst I am sure this is for audit folk, I can imagine that in the hands of patients (maybe lend them an iPhone while they are in hospital) it would have a big impact.  This would be fabulous if it was populated with the addresses for the contacts in each healthcare organisation in the NHS.

MedCrowd, Oct 2010, Free

This is an app designed to crowdsource medical opinions. I suspect it’s not really taken off but the concept is excellent.

Patient Journal, Free, June 2010

I like this because it is a place I can keep all the notes about being in hospital. The only problem is it really needs to be managed by the carer as the patient may be too ill to use it.  I think this would be good for longer temr patients or just for patients in general to keep track of their interactions with healthcare.  It works because it provides a structure only and doesn’t try to give me advice.

Mixed Messages, Free, June 2012

This is a training app aournd doctor-patient communication. I like the concept and it makes sense for much of the training programs that go on in the NHS to be put into a format like this. It’s simple, focused and not overworked.  No more books, manuals, workshops or PowerPoints!

Review of NHS iPhone apps

A number of NHS “innovators” are up there with their iPhone apps. I say “innovators” loosely as most of the apps are no more than websites in an app – useful but hardly innovative.  What’s more interesting is the lack of apps, even the most basic ones, from one of the world’s largest systems.

The NHS brand is one of the most well known in the UK, and using it and looking after it is important. There is now even a Brand Manager (c.£90k post) on the National Commissioning Board. From my days as the advertising manager in Esso, I know how important it is to make sure logos and accreditations are used properly.  My review of apps discovered many people using the NHS brand when they are not the NHS, and others in the NHS are not using their brand at all.

I chose the apps that appeared under a search for “NHS” on iTunes AND where there was NHS in the logo or title of the app.,The apps listed are all free.  

  

NHS Direct’ health & symptom checker

One of my favourite NHS apps and one I have used. It feels like the whole of NHS Direct is in my pocket. The feature of finding, for example, a pharmacy nearest to where I am standing is very useful. Comprehensive, easy to use and a flag bearer for app quality.

NHS Drinks Tracker

Not entirely clear but I think this is from NHS Choices (they could use their branding on the app logo perhaps?). Interesting to play with but it looks like it lacks flexibility to suit a wide range of users – as verified in the comments for the app.  Maybe an update is required? There’s also a Dept of Health Change for Life Drinks Tracker (do we need duplication?).

NHS Quit Smoking

Branded in the app as NHS Choices. I like the way it counts the amount of money saved according to the number of days you go without smoking.

NHS BMI healthy weight calculator and tracker

Another NHS Choices app. Clear and easy to use. Like the other apps in the series, it looks from the comments, like it could do with an upgrade.  There is stuff competition in app-world for BMI calculators and food intake / exercise trackers, so there needs to be a good reason for someone to use this one.

NHS Give Blood

From the NHS Blood and Transplant service, though confusingly the app logo doesn’t use the NHS branding. It’s a map function of where to give blood locally. I can see this being very useful in a crisis.

NHS 24 MSK help

Hmmmm, pink logo and very strange branding. Developer is NHS 24. Looks like an exercise app. Didn’t inspire me to download it and try it.

UK Clinical Trials Gateway (NHS Institute for Health Research)

Nice – I like it when the name of the app says what it is about and who it is from. As they say in their blurb, it’s for everyone, patients included, and covers the portfolio of clinical trials registered in the UK. I expect I can also get this off a website somewhere, so the innovation here is packaging it all up – a but like NHS Direct.  There is evidence of the app being updated which also enhances its credibility with me.

NHS Moodometer

This one took some detective work to understand. It’s an app to measure your moods. Useful if you’re in the process of understanding your own moods. It has the NHS logo on it. It comes from 2together NHS Foundation Trust – which I found out is in Gloucestershire – not obvious at all who they are and what they do from their name!  If they are using this app with staff then we need to know about this innovative use of it…

NHS Bristol and NHS Yorks & Humber

This is a well-designed organisational app that looks like it can be a standard one for many NHS areas. It’s more than a replication of their website and it is wonderfully designed for us.  It covers ICE (in case of emergency), your personal reminders and notes, where to find which service and cleverly uses the clour coding of the campaign to reduce A&E attendances (the thermometer). This app has a purpose which goes beyond advertising services.   Will need an update after all the structural changes.

My visit to Guys’s and St Thomas’ NHS Foundation Trust

Excellent. Designed for the patient, this app covers appointments, hospital information and maps.  I like the fact the name of the app says what it is for, and the integration with GPS on the phone is useful.

NHS Tameside and Glossop

Not certain about the logo use but the app is one that has broken away from the regular brochure / map / information approach.  Instead it is disease based giving information about conditions and pathways. I am not sure who is the intended audience? The name of the app left me thinking this was about the organisation but the contents are something different.

Welcome to St George’s Hospital

Another one with an app name that is useful. This is another information type app. I found some of the colouring a bit difficult to read and the design is rather poor. There’s a nice facility for providing feedback to the Trust – though I haven’t tested this.

NHS ActiveME

An app from the Royal Hospital for Rheumatic Diseases NHS Foundation Trust allowing the monitoring of daily activity levels.  Nice. Nice. Nice!  Beautiful design, easy to use and I love the graphic reports.

NHSCovWarks

Hmmmm apart from the rather short hand title, I’d not know this was an NHS app. The app logo is coloured stripes – which become obvious when you look at the app – it’s another one of the “ where do I go for what” apps”. 

Northumbria Healthcare’s GP Clinical Information Exchange

OK, so this is something different. Also has CiiX on the app logo. Says it gives real-time infomration about services, clinics and consultants  Not sure what it means by real-time, but what I like is it moves beyond being an directory to adding in some information about what to do if certain thing happen – and that’s good. I’m just not sure we need to add another acronym to the business.

NHSSC Health & Safety Awareness

Logo alert here, if only for adding SC to the NHS. It’s South Central (will need to update (or delete) app when the structural shifts happen). Seem to be aimed at staff though not entirely clear. I like the content but the title, logo and framing is poor.

Innovative changes to care pathways can increase hospital admissions

Innovative changes to care pathways can increase hospital admissions - really? Well, a report from the Nuffield Trust in March 2011 suggests there is little or no evidence that community interventions lead to a reduction in hospital use.

The report is a good one with a firm research founding - in the absence of any randomised control data. It points out that redesigning pathways can discover unmet need which may account for an increase in hospital attendance.

What caught my attention was that using their own data, each of the eight interventions assessed demonstrated a reduction in hospital use. However, when compared to control groups, there was in fact an increase. This leads me to one of the ongoing issues I have with "innovation" or "improvement" projects. It's easy to come up with a measurement system and set of goals and sample size that has inbuilt biases to ensure good results - and win prizes. But in the end, improvement needs to be tested against control groups.

I recommend you read the full research report, if only to grasp the seriousness of this issue.

Book Review: New Age of Innovation; Prahalad & Krishnan

If you're interested in large scale change and innovation then you'll find this book fascinating. On the one hand it felt like there was nothing startlingly new to me yet on the other it was neatly put together in a readable way that made sense.

A key premise is the current trend of personalisation and how value is based on the unique experience we all want. The authors refer to this as N=1. Current technology drives this, social networking, web 2.0 etc. How can we co-create value with our users and consumers? What are the challenges with managing who owns the knowledge? All good questions. They also suggest we need to make the most of collaborative networks, electronic and face-to-face, be flexible and ensure scalability. I liked the section on scalability and in my mind there is more in here than what they covered. This is a key element and is also linked to their second premise.

The 2nd key premise is the one that resources need to be global and they use another little formaula: R=G. Here they suggest the issue is that access to resources is more importnat than providing products; namely it is the solutions that matter rather than the kit or pieces. I think I agree with this. Again, scalability comes up.

They mention social movements and how they figure in the process as well as organisational transformation. There was nothing much new in the organisational process other than the context of the infomrational technology infrastructure - well, that is rather new and for some people rather perplexing.

If you've not yet engaged with Web 2.0 and new technology then this is definitely worth a read.

Readiness for spread, dissemination, scaling up

Spread, scaling up, dissemination, diffusion - whatever you want to calls it - does NOT happen in healthcare in the automatic "tipping point" way of Gladwell.  This is largely because in healthcare, the NHS being one great example, the desire to spread is a top-down prescriptive one - which is most companies would be dealt with a a large scale implementation project.  Similarly, just focusing on how to describe and communicate  the innovation is not enough. (I've written about this in previous posts.)

Whatever you call it and whatever methods you use, there is evidence that there are some key factors which need to be in place before you set off on a large scale "thingy".  These are not clever, and, in fact, are annoyingly obvious. Obvious does not mean simple.  You already know about the list below and one major step forward in your large scale work is to examine why you're not working on these "readiness" factors.

1. Strategic focus: if the imitative is not named and talked about in the organisation (and team) level as a strategic piece of work to do, then it's probably not a large scale change or one which will be given priority
2. Executive sponsor: who in the organisation is responsible and accountable for the implementation (not the planning) of the change?
3. Day-to-day leadership: is the initiative being talked about?
4. Spread aim: is there a clear aim and method of measuring progress for spread / scaling up?
5. Spread / scaling up Plan: is there one? Is there one that scales down each level of implementation?
6. Costs: are the costs of the change clear? DO they include the staff time coasts? Is there an agreed ROI for the scale up?
7. How will fidelity be ensured? (Fidelity = what is scaled up / spread is the same as the initiator project)

Some references:

(There are many references available in peer-reviewed papers, however, as many of you have complained you don't have access to these, I have listed some more general and open access references. If you know of other easy access references then please comment on this blog.)

• IHI: A framework for spread
• Agency for Healthcare Research & Quality: Innovation readiness for spread
• Some of my books: Rolling out your project includes a whole section on diagnosing readiness for change. 

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.)

Do middle managers matter in healthcare improvement?

There are libraries full of research and case studies on how doctors (and increasingly other health professionals) as well as executives, influence the implementation of healthcare improvement and innovation.  Middle managers, the cream in the éclair (often squeezed out) have not been in the headlines. But there is a new paper out which looks at their role and its importance. More research is needed.



Implement Sci. 2012 Apr 3;7(1):28.
Uncovering middle managers' role in healthcare innovation implementation.
Birken SA, Lee SY, Weiner BJ.

What is disruptive innovation?

A disruptive innovation is not a breakthrough innovation that has taken something and made better.It is an event or product which transforms the entire notion of the experience or product.
We would like disruptive innovation in healthcare, but mostly we do breakthrough innovation - at best.

Listen (<5mins) to the definition of disruptive innovation from the man himself, courtesy of Harvard Business Review (HBR)

The Innovator's DNA - book by Dyer, Gregerson, Christensen

The Innovator's DNA; Mastering the five skills of disruptive innovators is a book that we really need - right now - as we try to rearrange public services so we reduce costs and improve quality. I hear many people talk innovation but few actually doing it. I also think there are many innovators hidden away in organisations; just because they aren't smart at advertising themselves doesn't mean their abilities shouldn't be harnessed. So be on the look out for the following:

1. Associating; innovators connect the dots and see patterns between seemingly unrelated topics, tasks and issues
2. Observing: innovators spot emerging trends long before the formal reviews because they are intense observers of the small details.
3. Experimenting; innovators try things out - they don't necessarily talk about it or spend their time encouraging others to do it - they test things out themselves
4. Questioning; innovators can be a pain in the rear because they are curious and because they like discovering new stuff
5. Networking; it's difficult to spot patterns, notice details and test things out unless you have buddies. Innovators are terrific networkers and often link with others outside what may appear to be "normal" interests. They are also involved with groups outside their employment.

How would you rate yourself on these five categories?

Connection is key for innovation

A little luck and a lot of perspiration is no longer the prerequisite for innovation. Nowadays connections, relationships and networks are key.

Steven Johnson's next book is about Where Good Ideas Come From. You can watch him in action on this TED video (which starts with a picture and talk about the Grand Cafe in Oxford).



A couple of key points include:

1. Innovation is the result of the brain making new connections and these connections mirror workplace connectivity.  The better the networks and more complex the relationships then the more likely it will be that good ideas arise. His premise is that innovation is an interactive process.
2. The architecture of space is important if ideas are to be generated and spread - he has looked into what environments have contributed to innovation. If we want innovation we need to design spaces that enable connections.
3. Great ideas that appear to spark from nowhere are most likely the result of a long period of incubation which may not be obvious and are most likely cobbled together from a variety of existing ideas.. He argues that ideas are networks and the way of thinking about them as sparks, illumination etc is no longer relevant.

Measuring large scale change

Many complex programs are designed to deliver large scale change. A key concept is knowing when a change is being made, and whether it is in the right direction.  Large system change is different to process change in that it seldom has a clear beginning and end, has multiple causal factors (some of which we will never know), and the result is often separated from the action in time and space.

Differentiating the types of measures from each other helps, as well as estimating and checking connecting between them.  The following categories may be useful to you in deciding how to measure what.

Inputs: a bit like a baseline measure though perhaps a bit more active. It could be the number of patients not attending their appointments or the % of staff committed to a new organisational vision.

Activities: this counts how much is done of something designed to engender change. IN the case of large scale change there may be a variety of activities underway at the same time. This could be the % increase in number of people attending a workshop, the number of patients

Outputs: the results of the specific activities. So if the number of employees attending a patient experience workshop increased, and the workshop had an aim of improving staff satisfaction, then an output would be the amount of increase in staff satisfaction (and perhaps compared to areas where employees had not attended the workshop.

The above three measures often look alike. What is key is to understand what large scale change is being measured and to think through, and perhaps map, the links between the identified measures.

Outcomes: this differs from outputs in that it moves up a higher level - more long term, bigger impact. For example, if patient satisfaction increases then an outcome may be more patients returning, more income etc.

Impacts: this is the final level of measure. Perhaps the organisation reaches a new public grading, patients in the local area experience better health as a result of the improved services etc. Reduced health inequalities is another example.

Identifying the measures is only half of the learning from measuring for large scale change.A key step is to find a way to map out the linkages between the measures. To do this at the start of a program is helpful as learning from the actual measures can be replotted. This will help identify whether movement to the large scale change is underway as a result of the current activities - or not.

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/)

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.

Innovation may be a barrier to improving healthcare

I know I am on a sensitive topic here. However, the angle I'd like to mention is one that concerns me. I worry it might be a case of the emperor's new clothes. So just in case, I'd like to strip the outer layer of clothing off something that we take for granted and assume is "a good thing". Innovation.

It was announced this week that the NHS in England will have a prize fund of £20 million pounds to go to individuals, teams or organisations who come up with innovations that make a substantial improvement to services. So what I am wondering, is whether this is helpful, or in fact whether prizes and the ongoing emphasis on innovation is helping deliver long term, sustainable, effective and efficient improvements in the delivery of healthcare?

Disconfirming question #1: Why develop more innovation when the current good ideas, innovations etc are used by so few? I wonder what the impact would be if £20 million pounds was up for grabs if you could demonstrate you have implemented an existing evidenced good practice? Do we need more activity on research and new stuff when we have lists and lists of practices that can be of benefit if actually implemented? If an innovation comes up with an idea to get evidence into practice across whole systems and large groups of people, without them really noticing it, then yes, I am behind it. But I am not behind single, one off innovations which are so off the wall that the normal healthcare population can't conceive of ever implementing them.

Disconfirming question #2: Why emphasise innovation and not research? Though a part of me is frightened that any more research will go over old ground - so maybe that is why an innovation focus may be better?

Disconfirming question #3: Why focus on starting something new when stopping something that doesn't work might have more of an impact. The BMJ published in 2004 a list of "bad ideas" or practises in general use which are no longer considered "good practice". These sorts of practices continue to mean large variations in care. So if the innovation rewarded is one which erasing the use of "bad ideas" then I'm all for it.

Disconfirming question #4: Why focus energy on creating new ideas when the same energy could be focused on activity around implementing known and evidenced good ideas. Before I turn entirely into a "grumpy old woman" I do see that innovation and creativity is good. However, as a taxpayer in our system I want to see action on what we know already can work. I suspect tough times like a recession will enable the natural innovators to do their stuff - and they will do this regardless of prizes or focus. It's the greater norm population that doesn't regularly do innovation that bothers me; how can we get action underway there?

Disconfirming question #5: What is innovation anyway? This could leave to a philosophical debate. It could be that anyone implementing an existing known-elsewhere practice will feel it is like an innovation when they implement it in their own context. I suspect this is not what the prize organisers have in mind.

Yes, I do understand innovation and the need for it. My feeling is the innovating population will innovate anyway - that's their nature. I want support, profile and focus on getting existing known practice into place and in stopping known "bad ideas". We could start with hand washing - or someone could come up with an innovative something that means hand washing is an irrelevant activity in the drive to reduce hospital acquired infections.

The fallacy of the tipping point

A few years ago I had my own epiphany when debating with someone the value of the concept of the "tipping point" when applied to social change processes.

Most of the research literature as well as the populist books subscribe to the notion that when you get the write idea and it tweaks opinion leaders and the target population, then it will spread automatically once it has reached its tipping point which can be anywhere from 15 - 30% of the total population.

All well and good though this research is descriptive; namely it describes something that has happened. It is not inherently predictive. Many people have written books and articles with their ideas on how to take the descriptive lessons and apply then predictively. However, there are very few longitudinal studies which chekc these implemented efforts with what actually happens.

If you do want a predictive method then there have been a number of formula around for 70 or so years all of which can be used to guide you in your implementation efforts.

Another fundamental issue is the tipping point usually refers to transformational innovation. It is when something quite new and novel gets adopted by others. It has little or no relevance for communities where incremental improvement is underway. Some studies make a point of assuming that innovation is the same as improvement, and they can thus include all innovation spread and adoption research into their models and theories. However, I beg to differ. Anyone who has a strategy of incremental improvement I suggests avoids using the tipping point as a planning tool.

I've written before about the concept of opinion leadership and my ambivalence about it (see earlier blog posts). The tipping point is fairly well predicated on the theory of opinion leaders yet there is much research to demonstrate the wekness in this model.

Yes, you may see many charts showing what looks like an S-curve in the adoption of an idea. However, my first question is to ask what was the total population, namely to how many peopel did you intend this idea to spread? ONce you have the total population you will most likely notice that what you are seeing as an S-curve may not be much mroe than the variation you might get in the early phases of adoption.

Next time I read a strategy and implementation plan that says something like "Once 25% of the population has adopted the change the rest will pick it up" I will continue to be sceptical.

The power of impossible thinking

The title of this blog isn't my own - it comes from a brilliant book by Jerry Wind. So what is impossible thinking and what does it mean to business, healthcare and the spread of good practice? To use one of the most famous examples - let's review the breaking over the four minute mile by Roger Bannister in 1954. At that time the perceived wisdom was that to break the barrier required a specific set of circumstances, like a certain temperature, no wind and a track of hard clay. And a large home crowd cheering on the runner would also help. What did Bannister do? He set out on a cold English day, on a wet track in front of a small crowd - and broke the record.

It's what happened next that is interesting. The four minute barrier had stood for decades. As soon as Banister broke it, everyone else started beating his times, and they continue to do so. It was as though the mental barrier was broken and to do that it meant breaking through a significant amount of "perceived wisdom".

So I wonder what "perceived wisdom" we have that is holding up the rapid spread of ideas and good practice across our organisations? What barriers do we have to implementation? One that bother me is the constant lowering of expectations and improvement targets on the basis they could never be reached. As these are then accumulated across the organisation they then accumulate their weaknesses.

Some mental spring cleaning perhaps? Questions to provoke:

• What significant barrier to improvement needs to be broken?
• What is the pereceived wisdom and how can it be reframed and challenged?
• If the barrier is broken, what might be the size of the prize?

Creative Commons 2008 Sarah Fraser Attribution-Non-Commercial-Non-Derivative

Adopting existing ideas is boring

This really energised senior nurse asked me, after I told a story about working in the oil industry, whether I felt challenged in the job I'd been describing. She went on to refer to her own role as exciting and fulfilling. She was brimming with enthusiasm and delight as she described it. Later on in the day, as a group, we discussed power, motivation and trust.

While not a topic for discussion on the day, it dawned on me at the time that one of reasons for the slow transfer of existing knowledge from one place to another, from one team to another, might be because it just isn't interesting, exciting or motivating enough.

I often hear good practice, ideas and innovation all rolled into one. The same words and phrases are used and assumed to be the same. For the individuals and teams involved in the initial work, it may be an innovation - in the sense it was something new and exciting. It was part of it being meaningful to them. It may have enabled them to gain reward in the sense of recognition for their efforts. We know that these types of factors are very important in determining job satisfaction.

What happens to many of these early innovations is they reach the stage where someone else then decides they need to be spread wider in the system and adopted by others. What I'm wondering about is how we can make this adoption process meet the job satisfaction needs of the second line adopters. Because when they get given a list of what are now routinised tasks to integrate into their work, I am sensing they see this as extra work and this is landing on the dissatisfaction side of the motivation curve. Doing small cycles of change to integrate into their own context appears, in many cases, to be insufficient to stretch these individuals and teams to meet their needs for making this meaningful, challenging and reward based.

How can we take existing ideas and help others see these as novel in their own circumstances?

I have some provocations to reflect on:

a) Instead of continually using the phrase "Let's not reinvent the wheel" - how about encouraging a reinvention of the wheel. Instead, encourage a curiosity. Direct and focus the interest. Provide support and information where it may help. Avoid providing solutions unless asked. Insist on goal orientated outcomes and measure these.

b) Think of everyone, at every stage in the adoption process, as an innovator. In order to have the best job satisfaction, they just innovate in different ways. So how best can I find out for my system who like to innovate in which way? How best can I use this to get the result I need?

c) Instead of implementing tasks and going for outcomes, how can I deliver increased meaningful work and increased job satisfaction. Working on the basis that almost everyone wants to do a good job, my suspicion this may end up int he same place though from a different starting position.

What I'll be doing from now on is checking communication and materials designed for spread and will assess and ask how these are designed to motivate those receiving them. How will they provide meaning to their work? What reward and recognition systems are in place?

I'm not motivated to change my behaviour when bored, so it's hard to think who else might be.

CC 2008 Sarah Fraser Creative Commons Attribution-Non-Commercial-No Derivative