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. 

Paper: Complexity science and spread

Well, the best bit about this paper for me is the introduction of the terms SUS - scale up and spread!  It focuses on self organisation (complexity science principle) and how the complexity of healthcare and all the interactions are part of the problem of SUS programs.

Now, I'm biased and I'm with Ralph Stacey who says that when we think we can "control" or "use" self organisation then we are operating with a mindset not much different from Taylorism (see his work on complex responsive processes which superceded complex adaptive systems around 2001).

Whilst using insights from complexity science is useful, it is just that - an insight. When it comes to moving on to a more practical thought about - "so what do we do now", CAS and Complexity Science as such, falls flat.  There is a well trodden, pragmatic and practical systems theory and modelling that would be helpful in understanding interdependences - "Systems Thinking". Unfortunately it requires a bit of effort to grasp and seems not to have the cachet of "complexity science". Shame.

Soc Sci Med. 2012 Jul 4. [Epub ahead of print]
How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts.
Lanham HJ, Leykum LK, Taylor BS, McCannon CJ, Lindberg C, Lester RT.

Report: Cross Sector Working to Support Large Scale Change

The Health Foundation has come up trumps with a fabulous light touch literature scan of evidence around how cross sector working influences large scale change.

I commend you to read it.

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?

An introduction to Activity Theory

I'm finding Activity Theory very useful for thinking about large scale change. Traditional quality improvement, implementation science, dissemination science, organisational development and the like, are all useful. However, every theory has its limitations and although Activity Theory isn't perfect, it does provide some thought-provoking challenges.

There's a good 9 minute introduction, though you do need to be in a quiet place and be concentrating...

Sustainabilty of QI results; we're not sure how to make it happen

I love systematic reviews. Someone else does the hard work of synthesising the literature and pointing out the strengths and weaknesses.

If you come across anyone purporting to tell you how you can sustain the results of your improvement work, then send them this paper.  Basically, we're not sure how sustainability happens other than it is a complex matter, and not one for a checklist or one day seminar. What I like about this systematic review is it points out the complexity, the system dynamics issues and the need for published work to identify the contextual factors in the sustainability (or not) or results.

Excellent work here by the authors.
Thank you.


Implement Sci. 2012 Mar 14;7(1):17. [Epub ahead of print]
The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.
Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M.




Partial Abstract

"RESULTS:
Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.
CONCLUSIONS:
Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment."

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.

Is the role of an organisational champion effective?

The label "champion" is a complex one to wear and one which I've been a bit cautious about recommending anyone use.  In the UK, it's been common to identify that enthusiastic doctor or nurse, label them the champion for the work and then expect them to get on and lead the changes.  Sometimes this works, and sometimes it doesn't.

There's a really interesting paper published (by Hendy & Barlow, Imperial College, London) which examines the role of the champion and their effectiveness in one program in the UK. I like this research because it is lengthy (three years is a long time) and ethnographic. Their bottom line, it seems, is that it's good to be a champion in your own patch, but as soon as you're expected to deliver your champion role outside your regular context, then the effectiveness drops off. This is instinctively logical but all the same it's good to see some research on the topic.

Soc Sci Med. 2012 Feb;74(3):348-55. Epub 2011 Mar 1.
The role of the organizational champion in achieving health system change.

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 

Why one to many is not a large scale change strategy

Large scale change is about the numbers.  If part fo your strategy for large scale change is to develop or use networks to communicate your message then you need to understand the mathematics of networks.

If you don't know about Sarnoff's Law, Metcalfe's Law and Reed's law - then watch this video, which if nothing else, explains why broadcasting messages is low impact. It's 10 minutes long but hang in there - it's the best explanation I've heard for a long time.





The numbers:
Sarnoff: 1 message to 20 people: network score of 20

Metcalfe: Email and telephones connect humans and help small groups form: because everyone can connect to everyone, the potential is 20 x 20, meaning a network score of 400.

Reed: the value of the network is exponential in social networking, going beyond the establishing communities.. So it's 2 to the power of 20 which is 1,000,000.

Reed's Law is about scale.
Social networking matters.

Predicting implementation success from organisational readiness

I've wondered for a while whether there is any evidence that we can predict the success of a change based on the organisation's readiness for the change - else why would we bother with worrying about readiness? As always, loads of researchers have not only been worrying about this issue, they have also been investigating it. I found numerous papers, however, one captured my interest - probably because of the rational and detailed way in which the research was conducted.   The conclusion as I figure it, is that it all depends on the biases (or not) in the readiness instrument.

You can read this paper here.

6 different types of change by scale - 2: Changing Minds

Large Scale Change means different things to different people. In his book, Gardner suggests six different types of scale. I found these different levels useful in thinking through the strategies I might use to effect proposed changes.

1. Large scale changes involving diverse populations on a national or regional basis
2. Large scale change involving an homogeneous group (e.g. peer group such as theatre nurses)
3. Changes brought about by technology, science or art (e.g. a whole generation has been influenced by Harry Potter)
4. Changes within formal settings (I think of bounded organisations here).
5. Small gatherings and the more intimate shifts in perspective (e.g. group of friends who decide to change their exercise habits and support each each)
6. Changing one's own mind (which, of course, we never admit is probably the most difficult!)

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.

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?

Model 6: data, information, knowledge, wisdom

The Liebowitz (1999) model of DIKW is helpful if you are looking for something with details to give you ideas on what you might do in your own work. I can see how this can be used to evaluate large scale programs. The value aspects are useful reminders of the underlying purpose in moving to each stage, and therefore gives an idea of what might need to be planned for in a large scale program to achieve each step.

Scheming Virtuously; A Handbook for Public Servants

Nick Charney (Canada) has written a brief e-guide on how to get things done in the Public Sector, perhaps innovatively, whilst keeping our sanity, job and relationships.

Highly commended and you can download Scheming Virtuously; A Handbook for Public Servants as a pdf from the davepress blog (which is worth subscribing to davepress.net).

When stories and Powerpoint clash

A mantra I keep hearing is "we need to tell stories to influence change." I agree with this, however, I do have a few provisio's

• if the story has no relevance to your message then why are you telling it?
• if you provide a personal story to illustrate your values then please make sure it connects with the audience at the time (please update and avoid repeating)
• when you use PowerPoint to tell your story there seems to be a dissonance - the method is not matching the intent

As a method of influence, especially for large scale change, stories work well because they contain the emotive meme that a PowerPoint presentation usually lacks.  So let's use stories, but let's use them advisedly and with care.

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?

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