Redisorganisation in healthcare: the theory and the practice

A good friend, Bill Russell, tweeted a link to "A surrealistic mega-analysis of redisorganization theories" published in the Journal of the Royal Society of Medicine, December 2005.  Yes, it's a Christmas edition spoof, however, there is some unnerving truth underlying the splendidly irreverent - and creative - paper.  I share it nervously, as I wouldn't be surprised to find it turned into a PowerPoint and a half day course being run to teach people the theories.

The paper got me thinking about the tendency of Healthcare Improvement Leaders to grasp at the latest theory that comes their way, further confusing the people they are expected to serve with their "leadership".  Recently I have encountered an exhortation about the need for consistency and a single model for change in the NHS; countered by the push of new ideas and theories, which dilute this message.  As well as new concepts being presented as though they are the next best way to make an improvement / support change; the concept is a concept - it has not been fully tested.

The frivolousness and scattergun approach for supporting healthcare staff and their organisations is unlikely to be a useful one.  My concern is the endless search for the quick fix is confusing people. In addition, when one theory ends up not working in practice, then I'm not seeing the evaluations, reviews and sharing of lessons (as in role modelling learning and improvement). Therefore each new concept is being built on an ever-weakening foundation.

The value of of those who lead improvement and change in healthcare  I believe, should be based on the depth and pervasiveness of change they support, rather than on the number of new concepts of pilot projects they put into the system.

Leaders need to role model "Spread"

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

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

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

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

How is evidence being used?

Having moaned in this blog a few days ago about people not searching for evidence, I see a small group have set out a protocol to examine just how managers and professionals access the evidence.

I hope they will also do the negative study - those who are not accessing the evidence...


Implement Sci. 2012 Mar 21;7(1):22. [Epub ahead of print]
Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.
Kyratsis Y, Ahmad R, Holmes AH.


"Abstract
BACKGROUND:
We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK’s National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers’ perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations.
METHODS:
The study will involve nine comparative-case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems.
DISCUSSION:
Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready."

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.

Do you share your experiences?

I recently watched a three year old coming to terms with her one year old brother's need to hold a toy that until recently she thought belonged to her.  Sharing - it doesn't necessarily get any easier. But for some people, it is automatic. Dr Michael Bergstrom from SKL, Sweden, sent me a one page summary and a pictures of the top 10 slides (in his opinion) from the Paris Euroforum.

Just a perfect example - of sharing.

Improvement Leaders - role modelling

Improvement leaders know a great deal of theory. One aspect of leading that I am constantly aware of, is the need to role model - practice what you preach. It's no good me pushes for the Lean 5S of a hospital ward if my own office is a complete mess. There's a dissonance here.

I recently attended a workshop at NHS Improvement in the UK. This is a smallish group who are dedicated to working with healthcare professionals to improve care. They are all very practical, work in clinically specific teams, and have good results from their projects. They don't get huge press coverage for their work, largely I think because they are humble - and too busy to do PR and marketing!  I joined the session at dinner and was inspired by the way they were holding a raffle to raise funds for a need close to their own values. Not only did they raise money, but there was a lot of fun in doing it.

I left the session the next day quite inspired - and know they will be inspiring others in their day to day work.

Difficult Conversations 1: The DED Technique

Dealing with the difficult situation is difficult - usually because emotions are running high and emtoional responses tend to send all good planning straight out the window. One technique I've found useful is simple enough to remember when the flak hits the fan and tends to work well - the DED technique.

D = Describe 

E = Example

D - Discussion

Describe the behaviour you're finding difficult, how it makes you feel and explain the wider impacts of the behaviour. Without any description the other person probably has no idea why you are upset.

Then provide an example of what it is you've just described. Without an example the other person may think you're making it up and may not be able to ground the descriptions in reality.

Discussion - or I prefer the term dialogue as that presumes it is a two-way thing - is the obvious important and final step. If the first D and the E have gone well then the discussion should be fairly straightforward - though posisbly still emotive.

Do you have a favourite technique you'd like to share?

Productivity 4: Leaders need to be productive

This is the fourth in the Productivity series by Sarah Fraser. Is is possible to have a productive organisation if the leader is not productive?

This short video by Patrick Collins focuses on how leaders can use the 80:20 rule to ensure they focus on what matters and what provides the value you provide as a leader.



If you think you know the 80:20 rule, then I challenge you to watch this video and test whether you put it into action.

Online Clustered Networks Spread Behavior Change Faster

Online communities have different dynamics to face-to-face communities of practice. New research suggests that for online communities, behaviour spreads more quickly when the community is grouped into networks with overlapping connections than when left to develop more random and distant links.

If you are managing online communities then the research is worth a closer look as it may provide hints on how to design and support it so behaviour and influence can spread amongst the participants.

For communities of practice not online this clustering effect is not new. Research has been around since the 1970's which show the importance of bringing groups together geographically, thematically and/or by profession or person type. As humans we like to be with people similar to ourselves and are most influenced by those the same as us - if Joe can make the change then I will probably be able to as well.

There is a lot of buzz about social movements, mobilising and organising for change in healthcare. One of the success criteria for this work will be the depth to which those doing the organising as well as those participating understand network dynamics, and design accordingly.  Random networks are less influential.

Role modelling large scale change is tough

Sometimes getting the big stuff done means finding a way to manage the little stuff. I find when I’m trying to work on a big project, designing large scale change programs, developing spreading good practice interventions and other activities which require a complex set of activities, I am easily distracted from my leadership role unless I employ a few tactics.

I have been wondering whether one of the reasons large scale change doesn’t get implemented is because we may project our own disorganisation and unproductiveness onto the systems, processes and people who are intended to be part of that change. Namely, is there a large scale change we need to adopt ourselves before we can scale up any change process to teams, organisations and systems?

It’s all well and good saying the big things are the priority and therefore I should spend most of my time on them. However, no-one has told that to all other small requests, queries and information despatching that usually ends up in my email inbox.

Now I am very cautious about treating the small stuff as not important. It was Dame Anita Roddick who once said that “anyone who ever doubts that small things can have a big impact has never spent the night in a tent with a mosquito”. So I treat the “small stuff” with care. But how does this help with creating, managing and delivering on the big stuff and priority projects?

I employ a few specific tactics to keep me focused and on track. My consultancy role has me working at two polar opposites; virtually, attached to a computer, and face-to-face with clients. (There is a twilight world in between called “travel” but we’ll leave that for now.)

I am in charge of my computer. I am the head that organises how best to use it and I work hard not to let the computer-tail wag my dog.
- I aim to complete one task in the morning before I turn on the computer
- Then I complete one task, such as reviewing a document, before opening my email inbox
When I do open my email, I delete without opening anything where the subject line looks like the message has little to do with me, then I read them. If I can reply in 2 mins then I do so. If not I drag the mail to the tasks or calendar button in Outlook and allocate some other time to handle it.
- Then I get on with the priority tasks, which I may or may not have allocated time for…
- I allocate one hour a week, usually Fridays if I am in the office then, to a swift check around all my online team working systems.
So, before I can work on the big stuff I need to find a way to more productively manage the smaller stuff. This reminds me of the NHS Institute’s Productive Wards http://www.institute.nhs.uk/ system where an investment in getting yourself, your ward, organised means you have more time to care (big stuff).

When face-to-face with other people, at a single or multiple day event, at meetings etc., my singular contribution is that of my presence. I know that physical presence needs to be combined with my emotional and intellectual presence.

- I aim not to take calls, look at or answer emails while I am F2F. (This did take about 6 months to wean myself off the habit as well as enable my email-senders to gain the trust that I do still value what they email and I will respond, fully and care-fully, when I can focus on them.)
- I avoid travelling with other people’s business to do. This means I am not preparing next week’s presentation for another client in the breaks between working with the F2F client. (This is a capacity / demand issue and I have employed the same techniques used in healthcare service delivery. It has been a tough learning curve).

My own experiences leave me with the feeling that practising and implementing some of the changes we require of others provides some salutary lessons. It’s hard to encourage role modelling as part of a change strategy unless you also see yourself as a role model. Maybe that is one of the toughest challenges about spreading good practice and implementing large scale change? Namely, we have to change ourselves before we can ask other to change themselves.