Business learning from walking: 6. All time is not equal

You've seen the plans that show a pleasant linear progress of tasks that are planned to be completed as a constant pace over the duration of the project. We know that plans are not the change process itself but we still tend to think of things happening over time in a nice equal and fair sort of way.

To understand how all time is not equal, take a walk up your nearest steep hill. A mile on the flat might take you 20 minutes to walk. Add in a quarter of a mile uphill and you could end up adding ten minutes to your time to walk a mile. Add in a grassy field with no clearly marked path and a broken stile and a mile could end up forty minutes. Alternatively, add a field of nervous cows and you may run through it, matching an Olympic qualifying time for a mile.

Change projects are no different. While the measurement of months stays the same unfortunately the tasks, even if simple, may end up taking far more time than expected.  I good project management adage is to look at the final plan and add in 30-50% extra time. Then go back and check where this time may be needed.

Timing is not the same as pacing. When walking, it's good to know your own pace - how many steps it takes to cover a certain distance. This is an individual measure. In projects, it's useful to agree as a team the pace for certain tasks and then from that build up the overall timescales.

Business learning from walking: 4. Teamwork trumps individual heroism

Walking alone is as about much fun as doing a change project on your own. Even if you like your own company, working alongside others will enhance the process in both cases. Sometimes it's enough on a walk to have someone to chat with, to help you put a blister on the heel of your foot or to give you a second opinion on the choice of path to take.

Walking in a group is a bit like working in a project team. You go at the pace of the slowest - there's no point in rushing ahead to a milestone to then sit and wait for someone to catch up. It's far easier to support the slower person as you go along as it may increase their confidence and fitness. Same goes for project teams.

The "hero" who strides ahead and out of sight of the group is no hero at all.

The Isle of Wight Coastal path is a moving feast and as we gathered on a group walk recently, it is collapsing  on a daily basis. Out group was faced with a section of path that had fallen away leaving no clear route forward. Do we retrace our steps (see previous post) or find a way around? One member of te group who has climbing experience assessed the risks and found a way for us to clamber around holding onto a fence while he supported us from underneath! It was not very dignified, but it worked and we were soon continuing down the path, adrenaline leaving us slightly elated.

Change projects will reach those points where it seems impossible to go on. Things happen that could not have been predicted. That's the time to check the skills of the group. If you can help then it's time to step up and take the lead. Assessing the risks is important.

Teamwork means giving up some control, allowing others to take the lead as their skills fit the task, and giving each other the physical, intellectual and emotional support required to reach the agreed goal.

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: 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.

Productivity 5: What do we mean by "Productive"?

This is the fifth in the Productivity Series by Sarah Fraser. If you want to sign up to receive updates in your email inbox or your Reader (your choice) then go to the Blog and click on the Subscribe button.

So what do we mean when we say we want to be productive or we want our services to be productive? This is something we think we know but until we articulate exactly what we mean, the term is uncertain and ambiguous. What one person understands as productivity may not be the same meaning that another has.

The online dictionary provides a number of definitions and I liked the way it provides similar, related and dissimilar words.

ThesaurusLegend:  Synonyms Related Words Antonyms

Adj.	1.	productive - producing or capable of producing (especially abundantly); "productive farmland"; "his productive years"; "a productive collaboration" creative, originative - having the ability or power to create; "a creative imagination" fertile - capable of reproducing fruitful - productive or conducive to producing in abundance; "be fruitful and multiply" profitable - yielding material gain or profit; "profitable speculation on the stock market" successful - having succeeded or being marked by a favorable outcome; "a successful architect"; "a successful business venture" unproductive - not producing or capable of producing; "elimination of high-cost or unproductive industries"
	2.	productive - having the ability to produce or originate; "generative power"; "generative forces" generative
	3.	productive - yielding positive results successful - having succeeded or being marked by a favorable outcome; "a successful architect"; "a successful business venture"
	4.	productive - marked by great fruitfulness; "fertile farmland"; "a fat land"; "a productive vineyard"; "rich soil" fertile, rich, fat fruitful - productive or conducive to producing in abundance; "be fruitful and multiply"

Based on WordNet 3.0, Farlex clipart collection. © 2003-2008 Princeton University, Farlex Inc.

Using the above I came up with a number of questions to ask myself and others who claim to be working on increasing productivity:

1. If being productive can be defined as the capability to reproduce I wonder what productive spread is? I think it is about how efficiently we adopt and implement best practises, but that may not be the all of it.
2. If being productive is about abundance, how can we shift our mindset to one where we aim to use and create abundance rather than to streamline, cut and destroy services? How much impact can a mindset shift make?
3. If being productive is about yielding positive results, I wonder for whom these results are? How do we manage the differing expectations of different stakeholders?

How do you define "productive"?

Productivity 3: Productivity is more than a process

This the the third in a series of Productivity notes by Sarah Fraser. Productivity is more than a process.

New and improved policies can impact the design and implementation of efficiencies. For example, new recruitment, pension, appraisal and similar policy changes can impact processes not only in the short term but also long term. I do think that policy improvements are a necessary condition for many other efficiencies to be put into place.

Clinical productivity is often conceived as as "how hard are we sweating out clinical assets". Another way of looking at this is to see clinical productivity as the most up to date and best practice clinical methods being used. For example, continuing to carry our surgical procedures that are no longer proven to be effective is not productive.

Process productivity is the most familiar aspect of efficiency chasing in healthcare. Largely based on the principles of Lean (or reduced and less focused use of Lean) it is helpful but not enough to meet the healthcare challenges for the next 2 - 5 years.

Productivity 2: Reduced variation is not enough

This is the second in a series of productivity notes. Reducing variation is only part of the productivity process.

Reorganising processes so they are precise and prediction is helpful but not enough. In the diagram, the red dots are hitting the target in a predictable way. However, while they may be precise, they are not accurate. The green dots, with less precision, are more accurately placed around the bulls eye.

What I learn from this is the need to

• know the definition and position of the bullseye (what is the purpose of the process being improved)
• measure for accuracy as well as measuring variation
• fix accuracy first, then go for reduced variation

Productivity 1: Operational Efficiencies are not enough

This is a the first in a series of Productivity notes from Sarah Fraser.  Are your productivity projects innovative enough?

Organisations, like the NHS, will need to do more than streamline some processes as part of their cost saving initiatives. Many projects underway are badged as productivity improvement yet mostly they are about basic good management. For example, reducing DNAs (Did Not Attends), improving the Discharge Process, holding less meetings, carrying less stock etc. These are important and help to provide a good base form which to develop more innovative approaches, however, I am concerned few organisations considering gains in productivity through redesign and reconception of processes.

Many managers may feel like they are standing in the equivalent of the Victorian cotton mill with a clipboard in one hand and a stop watch in the other. Yes, it is possible to gain more efficiency from a process. I argue, however, that the leaps in efficiency come from reconceptualising what is being delivered. For example, in many countries for at least a decade, group appointments are available for patients with long term conditions. This is one small example of how rethinking a process can create both an efficiency and an improved patient experience.

How to implement 7-30-90 Day projects

“Being busy does not always mean real work. The object of all work is production or accomplishment and to either of these ends there must be forethought, system, planning, intelligence, and honest purpose, as well as perspiration. Seeming to do is not doing. “ - Thomas A. Edison

The purpose of this blog is to set out some ideas on the how of a 90-day improvement project within the context of healthcare. This project process is evolving so please add comments to this post so everyone can learn from your experience.

Principles:

• Having more time doesn’t mean getting more done
• Manage the tasks not the time
• Deliver incremental value
• Deliver results within a defined timeframe
• Honour the concept of organisational learning and continuous improvement
• Discover a rhythm of change and implementation that balances risk with results
• Use these ideas as ingredients and make your own recipe
• Ensure a focused, targeted and committed action process

      “Absorb what is useful, reject what is useless, add what is specifically your own.“ –Bruce Lee

There are a variety of approaches. The choice of your approach will depend on your strategic aim, the timing that best suits you as well as the nature of your improvement process.

STEP 1: Create your format based on your timescale

“Once you have mastered time, you will understand how true it is that most people overestimate what they can accomplish in a year - and underestimate what they can achieve in a decade!” - Tony Robbins

It is possible to deliver changes in 3 days (see Kaizen methods for further information). 

Consider your desired results, the amount of people who need to be involved in the process, the team and organisational culture as well as the nature of the problem to be solved / the solution to be implemented.  With this in mind, look at the options below and see which most closely matches your needs.  Where possible make your task

 smaller and the timing shorter.

All of the timescales contain a basic strategic rhythm of

a) diagnostic steps

b) implementation focus

c) review and next steps

 It is possible to design a 90 project so the phases are sequential, or it can be built up from a series of smaller 30 day cycles.  The choice depends on your strategy for change:

“Hell, there are no rules here - we’re trying to accomplish something.” - Thomas A. Edison

Why 90 days?

• Scope is more complex though is manageable within the timescale
• Sufficient interdependencies that will need to be followed through with conversation and negotiation
• Good if have high energy people working on the project who can also maintain their focus

Why 30 days?

• May be easier to commit to than 90 days or 18 months
• Deal with the now; plans remain relevant
• Long enough to see an improvement (or not, so can then change the strategy)
• Scope is such that one individual or a small team can make the changes with no further resource to committees or individuals for permissions

Why 1 week?

• Good for those who are too time / task pressured to commit to improvement
• Able to test an improvement-through-learning process
• If used as part of a longer project the 1 week cycle can provide a mechanism for involvement (different people different weeks)
• Good for working with those with a low energy

	Diagnostic	Implementation	Review
12 week (90 day)	4 weeks	6 weeks	2 weeks
8 week (60 day)	2 weeks	5 weeks	1 week
4 week (30 day)	1 week	2 weeks	1 week
1 week (5 day)	1 day	3 days	1 day

A diagnostic phase includes, to varying degrees, some of the following (remembering that diagnosis is part of the change process as individuals discuss and assess their own situation):

R  What is the current situation, including baseline measures; this needs to be localised to the context of those making the changes. Process and value mapping, relationship mapping and other techniques are useful here.

R  Creating ideas for change and improvement; being creative rather than just implementing known tasks (otherwise we end up with low energy projects)

R  Understanding any interdependencies and carrying out appropriate negotiation

R  Planning, designing, getting in the resources that may be need (like equipment) etc.

An implementation phase includes, to varying degrees, some of the following

R  Action, with measureable results

R  Learning, from personal and team reviews

“Words may show a man’s wit but actions his meaning.” - Benjamin Franklin

A review phase includes, to varying degrees, some of the following

R  Working out what is going well, and why

R  Figuring our and being honest about the problems, and then working through some ideas to resolve these

R  Capturing personal learning as well as team and organisational learning, specifically noting those things you would like to do / feel more of

A project of any length can be constructed from a weekly pattern of activities.

“If we did all the things we are capable of, we would literally astound ourselves. “ - Thomas A. Edison 

Choosing the right chart to show your project progress and performance

Essential to any improvement project and spread / adoption campaign is a system to measure progress. An Excel produced bar or line chart on the regulation maroon and blue is suggestive of either a lazy monitoring process or one which is not turning data into useful information.

In large programs fundholders often like to see comparisons between one sub-project or site and another. Or maybe you are interested in how the results are stacking up as a whole; for example, are all the sites adopting all the elements of the new project? Do you know the best way to show a trend of your data? What about relationships between different data?

A favourite place to download Excel templates for your charting needs can be found at the Chart Chooser. Best of all, you can work out which template best suits your needs using their diagnostic process.

Do you have any templates for charts used to monitor the spread / adoption process or project improvement that you would like to share? Leave your comments below.

What are 30, 60 and 90 day projects?

We all want results as quickly as possible from any project team.  In fact, we want the results now!  Quality improvement projects are by nature a cyclical process where a few steps are taken, then tested, evaluated and then a few more.In complex organisations and systems such as healthcare, the cycles of change can take a long time It can be challenging to keep staff motivated after the initial months of the project.

The concept of the 90 day project comes from research where the aim has been to shorten the cycle of learning from the often 3 or 5 year project horizon. Projects like these accelerate some of the learning, but not all.   In healthcare improvement programs, accelerated timescales can be useful at the start, in the middle or the end of a formal program. At each stage they will have a different focus.

At the start of a project, short timescales can be used to get some momentum going. A 7 day sub-project is an excellent way to focus on commitment and action right up front. Half way through a project a series of say 3 x 30 day projects can be run in parallel with different teams all focusing on the same result. Or they could be run in series.  At the end, a series of rapid projects can help cover all the loose ends and ensure comprehensive results.

So what is a short project?  We know what it isn't:

• not a replacement for the overall project
• an easy option; all short projects need planning 
• not for everyone

If you want to run a short timescale project then consider the following:

1. for the same topic, different teams will choose different lengths of project. This is because the specific context for change is one of the the biggest factor in the speed of implementing change.
2. be practical, pragmatic and realistic
3. focus on the outcome to be delivered rather than traditional project planning
4. remember this is one technique that may work for some people and may not work for others

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Pull vs Push; Twitter Case Study - 90 day project

One of the mantras of working out how to implement good practice more widely is "pull don't push". This refers to the need for potential adopters of a good idea to "pull" the information to themselves and then to act on it. This is a very different dynamic from the "push" of sending out case studies, instructions or clinical guidelines and then expecting others to implement the recommendations. (I wrote a paper on this topic with Paul Plsek in 2003; S. W. Fraser & P. Plsek, "Translating evidence into practice: can it be done through the process of spread?" Education in Primary Care, May 2003)

Theory is often interesting and sometimes useful. Practice is usually difficult and never quite what you expect. Thinking about "push" vs "Pull" I decided to run my own 90 day project to see what I could learn about enabling "pull".

This blog is both about Twitter as well as about a 90 day project process. If you don't know what Twitter is then check out this video: http://www.youtube.com/watch?v=ddO9idmax0o

Context
With Twitter http://www.twitter.com/ you share information, 140 characters at a time, with those who follow you. You also get to "listen" to those who you follow, and if you like, you can forward on their messages to your own followers (called retweeting). It is easy to follow someone; do a search for names or keywords you're interested in and then click on the "follow" button. You may also see a message someone has put up and then decide to follow them.

But how do you attract followers? How do you get a pull? This was my project question.

90 Day Project Aim
To get my profile in the top 100 of England and top 100,000 of all Twitterers (of a population 2 million and growing). I chose a ranking rather than a number of followers as I felt this is more aligned with my intention and context. A bit like choosing to reduce hospital costs by having no infections, rather than counting the number of infections. One of the complications of measuring ranking is you have to keep up your position in an ever increasing pool (the denominator is increasing rapidly).

Results
On 27th December 2008 I had 7 Followers. On 2nd April I had 347 followers. Average growth per day was 8 and the current trend predicts 536 followers within 30 days. I have used http://www.twittercounter.com/ to measure progress. My ranking worldwide is 79,492 and within England it is 79th http://www.twitterholic.com/

Learnings:

1. It really does work to learn from where other have gone before. I was 45 days into my 90 day project before I realised I hadn't practised what I preached, namely discover the existing good practice. Only then did I search for other's experiencing of generating a pull and adopt some of their ideas. This helped, though it was not enough.
2. It is possible to get started (on Twitter and I believe anything else) without knowing exactly how you're going to do it. For me, the act of the 90 day project meant I had to learn how the technology and system worked. It focused my attention.
3. Measurement is crucial. I check on a regular, sometimes daily basis to see whether my actions where having an impact. Ok, so this is easy when there are systems in place to do the measurement, though I would find it hard to know what was a successful strategy without this. After a while I began to see pattern in the data which matched my Twitter behaviour. Quite amazing really...
4. A "pull" is about adding value. No-one is going to follow unless they have a reason to do so. Equally, they can unfollow at any time (and I had one wobble when the graph slipped back due to unfollows - largely due I think to me unfollowing a lot of people - we sort fo went into a negative slide). So I have started to learn how to create a pull through a virtual medium communicating only 140 characters at a time. So if this was a non-Twitter project I would still think about what value am I adding for others and how succinctly can I communicate with them in a way that works for them
5. The social process of retweeting is important. I am valuing others' messages and sharing - then they do the same. As humans we are inherently social. Encouraging trust, openness, enabling and allowing connections and networking seems to be fundamental. Why should I expect anyone to follow me if I don't share, put others' messages forward (always attributed) etc?
6. I put my Twitter link on my email signature, added a button to my website, integrated it with my three blogs. What I am seeing is the links between these online activities and how they feed one another. Using a variety of tracking software I can see which ones are triggering followership. Maybe for other 90-day change projects it is important to think widely and outside the direct scope of a project in order to influence change.
7. One of the scary things about a pull vs a push is you're not in control. Yes, I can see who follows me and I can then choose also to follow them or not, I can also block people. However, by letting go I have discovered some new contacts, new people that I would not have encountered before. Yes, I have also encountered some fairly random followers who I see no reason why they should follow me. But who am I to judge? And that is the point.
8. When it came to updates I tried to be regular and consistent (something every day or two), aimed not to overwhelm at any stage and to tread lightly.

What will I be doing in the future

I will continue with Twitter as I find it useful. I've now set a different goal which is about quality rather than quantity. I want to test the next stage of "pull" - where something gets acted on as a result of a "pulled" tweet. This won't be easy to measure. I was fascinated by the recent example of this type of "pull-action" from Stephen Fry and Twitter. At the time he had around 352,000 followers (he is in the worldwide top 20). One day he tweeted a link to an Open University website / game. This OU page / game then got 52,000 hits in a single day. Around 15% of his followers acted instantly on a tiny fragment of a message. And the numbers were big.

If 15% of clinicians, professionals and managers in healthcare acted almost instantly on a message they had pulled, I wonder what might be the impact? Scary, huh...

Follow me on Twitter: http://www.twitter.com/sarahfraser

Differentiating the types of good practice matters

In my theoretical and practical travels I find that all good practice (however you'd like to define it) tends to be regarded as similar. What I mean by this, is there is little distinction as to whether the practice is designed to
a) make something happen
b) avoid something happening
This "commission" or "ommision" differentiation may be important. I'm working on it and if you have any ideas please then do put a comment in this post so we can add to the body of knowledge and share it openly. Or email me if you prefer.

Let's look at a couple of healthcare examples. In (a) we might be creating a new healthcare service for patients who have developed diabetes. Part of this might be to design and implement a new form of consultation called a group visit where a number of patients are seen together by a variety of different professionals. This has been successful in a number of places and we may like to copy what they have done. Yes, this may be to avoid something happening, but mostly, it is about adding something new into the system.

In contrast, we may be concerned at our hospital about the high level of MRSA infections. We want to avoid something happening. Yes, this may include something new being created, though the emphasis is on avoiding a situation.

The reason I feel this differentiation may be important is that the change process for the individuals and teams may be quite different. Understanding that they may be going through a different learning process whether they are taking on something more creative and new, or whether they are designing to avoid, may streamline and accelerate the adoption process.

For example, in the (b) avoidance example, the learning process is likely to be enhanced if the emphasis is on understanding the "near misses" so the individual / teams can discover how best to take action before the situation arises. Raising awareness and linking a "near miss" awareness to the ability to make a decision to fix it, may enable the individual to learn and sustain a new behaviour more rapidly. "Near misses" will also allow for the customisation nearly always required for the local context.

In contrast, in the (a) commission example, the learning process may be less organic and it may be possible to apply and use more straight forward project implementation techniques. These are unlikely to reduce the need to pay attention to the people issues, however, there may be as much success in using well known management tools as in using the more esoteric "spread" techniques.

"Making something happen" or "avoiding something happen" - do you think it makes a difference?


(c) 2008, Sarah Fraser

Charismatic leaders may hinder sustainability of improvement

Of course we know that the skill of the truly great leader is to leave behind a team and a succession plan that not only maintains the knowledge and practices that have generated their success so far, but also supports their ongoing learning and development.

Fine words. How often do you see that in practice where the person leading the team can be described as "charismatic"? I could blog for weeks on the definition of charisma at work, so have settled for now on it being a combination of personal traits that enable an individual to reach out to other's emotions in a way that taps their motivation to do things. Usually charming and persuasive these individuals get their own way amongst their systems, for better or worse. As far as public figures go, I'm thinking of people like Mother Teresa, Adolf Hitler, Winston Churchill, Martin Luther King etc.

So how does charisma affect the sustainability of results in improvement projects?

Here are some questions for you to think about when you next choose the person to lead a key project or programme in your organisation where the sustainability of results will be important.

Are you choosing the person because of their charisma? Maybe you feel the need to have someone with the energy and passion to start the project and to motivate others.

To what extent could the project become so identified with the individual that there is a risk that

• team members eventually become demotivated because they get less recognition / air time
• when (and it is most likely a when rather than an if) the leader moves on, the majority of the knowledge and PR moves on with them
• no-one is prepared to "tell the emperor he has no clothes", to provide feedback, thus diminishing the learning opportunities
• succession planning becomes impossible and the person is deemed irreplacable

So you're thinking, none of our project leaders are ever that charistmatic! Well, according to the theory, we are most likely to find many of these traits amongst the more innovative and early adopters of new practices (though not exclusively as some laggards can be highly and effectively persuasive...). It is likely that many pilot projects and early innovations are led by leaders who demonstrate the ability to capture the imaginations and hearts of their followers. These same individuals will later leave to follow other interests, for the similar reasons they got involved with the first pilot.

Take a close look around you. What patterns do you see linking the leaders of your improvement projects and the sustainability of the reults of those projects?

Now that's a research project worth doing. Anyone want to collaborate?

(c) 2008, Sarah Fraser