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. 

Coaching, feedback and behavioural tools - MBTI

So what tool or method do you use for your coaching practice or other organisational and improvement work?

Over my career I've been on the receiving end of a number and also tried a variety with different clients.  I've ended up using MBTI (Myers Briggs Type Indicator) as my main method for helping others - to help themselves. My main reason is this tool is well evidenced, has been in place for decades and is used successfully in many countries. The evidence base is important for me as I believe it is necessary for healthcare to demonstrate the use of evidence-based techniques and tools.  The techniques can't be administered or debriefed unless you've been accreditated which means there is a consistent standard world-wide.

Other reasons I prefer MBTI:

• it is more than a one-off
• it can be scaled from individual through the team and organisation
• it works well to support change processes
• the evidence base, being huge, allows greater depth of understanding
• it is common enough that it provides a "language" for staff to use in times of difficulty

Do you know of or use other behavioural techniques which have an evidence base similar to MBTI and can also be scaled up in their use?

Paper: Three Collaborative models for scaling up evidence-based practices

In "101 ways to improve your collaborative" I described a number of ways to spread / scale up innovations using the collaborative model in different formats.  In this paper

Adm Policy Ment Health. 2012 Jul;39(4):278-90.
Three collaborative models for scaling up evidence-based practices.
Chamberlain P, Roberts R, Jones H, Marsenich L, Sosna T, Price JM.

... the authors explore the merits and demerits of the Rolling Cohort, The Cascading Dissemination Model, and the Community Development Team.

Readiness for change - an adopter's diagnostic tool

The Agency for Healthcare Research and Quality (USA) has a fabulous tool that can be used by potential adopters in helping them decide whether to adopt an innovation in their organisation. Whilst the questions appear rather basic, they are comprehensive, evidence based and the way in which the diagnostic has been put together really helps the decision-making process.

I commend it to you.

Download the PDF Diagnostic here

No benefits from spread, scaling up unless the baseline is poor?

I've been going on about the issue of top-down spread / scaling up initiatives which overstate the benefits. For example, if the pilot projects gets a 50% improvement, then that is, of course, relevant to their baseline. And we can only translate this benefit across a system f we know the baseline of all the individual potential beneficiaries. The worse we can do is take a national average and then assume everyone can get the same 50% improvement that the pilot site obtained.

I've written about this in "Undressing the Elephant: Why good practice doesn't spread in healthcare" and it's great to see a systematic review based around diabetes care that supports the notion that "interventions solely targeted at healthcare professionals seem to be beneficial only is baseline HbA(1c) control is poor". [This research and paper was funded by Ontario Ministry for Health]

Lancet. 2012 Jun 16;379(9833):2252-61. Epub 2012 Jun 9
Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis.
Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, Galipeau J, Halperin I, Vachon B, Ramsay T, Manns B, Tonelli M, Shojania K.

Readiness for change diagnostics: Some evidence

I'm ambivalent about the concept of "evidence" for much of the change and improvement work we do in healthcare because so many of the concepts and processes are contested.  However, that doesn't stop me checking for evidence and testing my own prejudices.


There are a number of papers  and publications which touch on the topic of readiness for change.  



Review: Conceptualization and Measurement of Organizational Readiness for ChangeA Review of the Literature in Health Services Research and Other Fields
Weimer, Amick & Lee
All literature reviews need to be considered as a service to humanity. This one covers the concept of readiness for change in healthcare and reviews 43 instruments in use.




Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

Sharon Hamilton, Susan McLaren and Anne Mulhall

This team conducted a comprehensive review and evaluation using multiple strategies which I like. They also used the Team Climate Inventory.

^{Monograph: Assessing & enhancing readiness for change; implications for technology transfer.}

^{Backer, David & Soucy}

^{Not a peer-reviewed paper as such, but it has some excellent perspectives on what readiness for change means - and doesn't mean.}

Systems Antecedents for Dissemination and Implementation; A Review and Analysis of Measures
Emmons, Weiner, Fernandez, TuThe conclusion in this paper seems ot be there is no common ground for the use of measures or consistency in the way in which they are applied, hence leading to difficulties in figuring out what might be the best strategy.


There are many more papers - if you find any, please leave notes in the comments box.

Paper: An Operationalization of the Interactive Systems Framework Support Systems

This paper has a long and complicated title.The bottom line seems fairly straightforward - that train the trainers (TOT) activities and technical assistance (TA) can lead to success when scaling up the adoption of evidenced based practices.

Am J Community Psychol. 2012 Jun 19.
Using a Training-of-Trainers Approach and Proactive Technical Assistance to Bring Evidence Based Programs to Scale: An Operationalization of the Interactive Systems Framework's Support System.
Ray ML, Wilson MM, Wandersman A, Meyers DC, Katz J.

Readiness diagnostic tools for spread, scaling up, dissemination

So how do you know whether your organisation is ready to embark on a program to adopt existing good ideas / evidence in a systematic way?

As in previous posts, most of the answer to this question is a no-brainer - you know the answers already (see previous posts).  However, sometimes it's nice to have a checklist or set of tools to help you check whether what you know about is actually in place.

There are many general tools / checklists available which check whether your team or organisation is ready to do something different.  Most of these assess the culture of the group. The disadvantage here, which is why I suspect many people avoid these types of tools, is if you find out that your culture is not ready, many people lack the patience to go through the necessary cultural change - or they just don't have the time for this "pre-work".

Generic tools can be useful for learning about your organisation though they can be a good (and time-wasting) displacement activity by organisations.

The best types of diagnostic tools are those which are specific to the change in hand.  Specific means they are designed around and for the type of change proposed.

1. One of the best examples I know of specific diagnostic tools come from, the US National Council on Aging. For their Chronic Disease, Falls and Depression scale up plans they have open access tools which can be completed online or you can download the PDF to read through.  Each of these is specific to the adopting community and the type of innovation proposed for scale up / spread / dissemination.
2. NICE - yes, the National Institute for Health & Clinical Excellence (NHS) has been at the forefront of providing tools that support the introduction of evidence. These are excellent spreadsheets, populated with the NHS data and ready to use.  Unfortunately, I don't hear about them being used on a regular basis - especially by commissioners.

The problem with tools and diagnsotics is no difference than the problem with any other thing we want to spread or be adopted - most people would prefer to create their own because the credibility for many members of staff lies in the excitement and status of creating their own, rather than using someone else's. If you're offered a diagnostic tool - have a good look at it - if it is specific to the innovation it may be very useful for you.

Readiness for Spread. Whose readiness - the adopter or the "pusher"?

One of the most frequently asked questions I get is how program managers can assess whether organisations and teams are ready for spread. For me, the answer is a lot more than a quickie checklist or diagnostic tool - I've tried many, including developing my own, but they have their limitations. The first question to think through is "whose readiness"?

1. ADOPTERS: Mostly I have program managers wanting to know whether organisations and teams they want to adopt something are ready. This is a useful question to ask, and indeed much of the literature focuses on these potential adopters. So yes, it's good to consider their readiness and there are a multitude of tools and techniques for doing this - any good change management assessment will work.
2. "PUSHERS": What most people forget is to assess the readiness of the "pushing" organisation to go through the spread process. For example, a regional organisation may want all physician practices to adopt the use of new diabetes guidelines which includes an information monitoring system. It may sound obvious, but the "pushing" organisation does need to make sure they are ready and geared up for others to adopt the process.They need to have the support and systems in place. Often, great practices and ideas can be adopted so quickly that the "pushing" organisation panics and then becomes part of the "slow-adoption" problem as they put limits on the process.
3. CONTEXT: Finally, the context is crucial. When it comes to large scaling up activities, it's vital to assess the readiness of the context that organisations and teams find themselves in. For example, the context where a pilot program achieved great results may have changed in the year or so since they completed their work: a change of government, the financial crisis, new technology etc.

So, when you are next assessing the readiness for your spread / scaling up program, do take the time to think through the three different angles.

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. 

Changing Minds by Howard Gardner

A book with the subtitle "The Art and Science of Changing our Own and Other Peoples' Minds" intrigued me. So much of the change process and scaling up better practice across larger systems involves helping others change their minds.  I've made a few notes from the book which I will post here in a series over the coming days.  I recommend you get hold of a copy and have a read for yourself.

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?

(If you are reading this in an email or on your smartphone, to get automatic updates on this blog go to http://spreadgoodpractice.blogspot.com/ and click on the Subscribe Button)

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/)

The quickest way to spread scale up change

The most common question I am asked is whether there is a quick way to spread desired change across groups.

My Nobel Prize entry for answering this question is as follows:

"Yes and No"

The fact you are asking the question means you are in a type of powerful relationship over those with whom you want to interact and change. Namely you want them to do something different/ly and you want them to do it quickly.

The "Yes" answer is dependent on the carrot and stick approach. Pay a twelve year old to clean his bedroom and if the reward is big enough, the bedroom will be cleaned. Pay doctors a reward for meeting a quality target and they will achieve it (evidence the NHS and GPs). The stick approach is less effective but still works. It is no longer common to see anyone on their mobile phone while driving in the England. The stick of a fine and points on your license has worked, combined with appeals to common sense.

The "No" answer comes from asking questions like those listed below. If I get more than two or three "No's" in response then I suggest to the person asking that they have probably answered their own question.
- are you making the change yourself?
- can you describe to me the three main reasons why the person you want to change thinks this will be a good idea?
- do you apply the methods you are proposing in your own work and/or personal life?
- is your reason for this work more than doing a good research project you can publish later
- will the person/group you want to change see the change as coming from somewhere other than yourself?
- do your plans involve more than a communication exercise?
and so on

If products, ideas and results are not spreading and being adopted then maybe you need to do an ethics check

The most frequent issue people contact me about is "my project results or project methods are not spreading to other places / are not being adopted by other people". A key reframing here is to ask the question "Why isn't my xxx being spread and adopted?". This is the first step in figuring out the problem - and solution.

I wrote a book a few years ago that faced this issue and provided some ideas to get round it. One topic not covered in detail in the book though one I have since reflected on is that of ethics.

House (1980) provides a list of ethical mistakes which include:

Clientism; this is when we are so focused, as facilitators, project managers and consultants, that we do what the client wants rather than a deeper investigation into what problem needs to be solved. This is prevalent in healthcare where there are multiple clients or where facilitators are unable to take the difficult discussions and fall back on making their clients happy. Any consultant can make their client happy - can they help their client solve identified problems, even if it means walking away or referring on if they are not the best person to help? Projects which have been implemented to serve one specific client are unlikely to be adopted by others as they instinctively feel the solution does not meet their own need.

Methodologicalism; assuming that following a ethnically correct method is the same as being ethical. This is an interesting issue for the spread and adoption of guidelines. Different professionals may have alternative interpretation of the ethics are different parts of the guidelines. This conflict results in the oft heard "this won't work here" or "this won't work for my patient". On solution is to discuss and be transparent about the ethical paradoxes involved.

Elitism; giving the most powerful the strongest voice. This is a concern for the development of solutions and introduction of change methods. The most powerful and loudest voice may not be the most connected to the context in which they are requiring change. Potential adopters may instinctively push back against what they perceive are "loud voices". Or they may try to make the changes to keep the "loud voices" at bay and only partially gain the benefits. This issue is also linked to the concept of "inventoritis" which was the subject of an earlier post.

To what extent are your spread and adoption issues linked to ethical dilemmas?

To share or not to share?

I've spotted a proliferation of new initiatives within the NHS in England attempting to encourage staff to share their knowledge online. While this sounds like a useful and pragmatic action to take I wonder what the implications might be.

The main exhortation is about encouraging staff to share what has worked well for them. I expect there will be many who would like to share, though inputting your information into a fairly anonymous database is at the higher end of the perceived risk continuum. Without knowing who (as in a person) will be editing or reading the information, many people will be hesitant to "share" in this way.

The proliferation of different places to share is also confusing. In their own way, each organisation requesting sharing is doing so for the right reasons. However, how do you choose - NHS Networks, NHS Institute, NICE, own organisation's database... random sharing with colleagues using other online networks, professional groups?? Each organisation requesting sharing is doing so for it's own reasons and these reasons may not be easily identifiable by those who are targetted.

For some healthcare staff and their organisations the incentive to share may feel like a perverse one. In a competitive market there may be a disincentive to provide information about how well or how innovative you have been. In my experience the best results are seldom shared because of this restriction. So what we do get shared is often the less innovative and more obvious results of projects and changes.

I think the issue is not "to share or not to share". Sharing is only part of the story. Sharing is only of value if there is someone listening and looking. If the main group looking at what is shared is the group who owns the database then the value of what is shared is quite limited. The real issue is in encouraging staff to look and listen, to be curious and to accept that in just about everything thing they do and every problem they have, someone, somewhere has already addressed it - and this information is already available.

So if you're developing databases to captured shared information then a few pointers to consider:
a) how much of your time, budget and strategy is devoted to encouraging the look and listen?
b) how unique is your database? How will it be found and why should those who are searching use your database?
c) In what way can you build on or link to existing databases so you build a wider knowledge base rather than divide up a crowed space?
d) How can you move from the transactional share and disseminate approach to one which is based on the concept of interaction, dialogue and learning?

The continuum of spread: from outward communication to behavioural change

A few days ago I toyed with the idea of producing an FAQ sheet to cover the top 10 questions I am asked about how to spread good practice. Then I realised the answers are in my books and also in this blog. However, I'll revisit some of these questions over the coming weeks.

The top question is.... "how do I spread good practice"! And this usually sends me into panic mode. My immediate response includes:
What do you want to spread (and really, what, like skills, attitudes, behaviours etc)
How do you know it is good practice and who will recognise it as such?
Who is the target audience? Are you sure you are meaning individuals and not organisations?
What do you need people to do?
Why are you planning to do this? What is your stated and underlying intention?
I could go on...

I realise now that in most cases the big question comes from people in charge of something. Either they have the legitimate authority for a group (like Medical Director, CEO) or they are in a facilitative role (National body, program managers, consultancy). In both cases they want someone else to do something. The word "spread" gets used because either they have little authority over the people they want to change or they believe a softer-bottom-up-gentle approach will help people make the change. They may be right.

As the request to spread is coming from those "in charge" it is not surprising that the underlying question I think they are trying to ask is "How can we best communicate our good practice?". How do we communicate in a way that enables the right people to become aware of and do something about our topic? This is the standard approach to spread.

My experience in the last 10+ years on helping make large scale changes across healthcare systems is communication strategies and plans are not enough. Consider this continuum:

Spread (Communicate/Market/Advertise)--->
Communicate for behaviour change (Social Marketing)--->
Organisational change activities (OD, improvement projects)

Traditional spread programs limit themselves to clever and thoughtful (hopefully) design of outward communication. I say hopefully because in the most cases in healthcare the default button is set to "write an article" or "type up a case study".

As a minimum I feel spread needs to include the behavioural change aspect. Without this the communication is worth-less. The techniques from social marketing are a good place to start. This also means the behaviours required to change need to be identified as part of the "what" of the good practice.

Finally there is the perspective of the organisation. Again, my experience has led me to favour this approach. When the intended changes are part of or as a minimum identified as contribution to the organisation's purpose and objectives, with appropriate leadership support, then imprivement happens. Without this contextual setting the speed of adoption is much slower. Also, the breadth of adoption across the organisation may be limited. And there may be inappropriate adaptation to the good practice to such an extent that the intended benefits are not achieved.

So how do we spread good practice? I suggest the first place to start answering this question is to ask "why do you want to spread this good practice?". The aim here is to answer this in detail to get beyond the "to make things better" answer. This reframing will elicit the underlying motives and will direct an appropriate spread strategy.

SMS Texting Campaigns; awareness to action

Mobile phone technology has the means to change lives. A number of campaigns have been running where SMS/texting technology is being used not to raise awareness but rather to deliver action. I'm interested in this as it is breaking some of the "communication rules" and what is in the old research about how ideas spread and are adopted.

An excellent example is from UK Transplant where there are a number of campaigns running to increase the number of people prepared to donate tissue and organs. In the South West of England a campaign is running until April 2010 combining regular advertising and sms texting. The posters create awareness and then if anyone standing int he bus shelter wants to act by registering on the UK Transplant Organ Donor site they can send a simple test to a number with the word GIVE. This is still a pilot and the resulst will be interesting. I am all in favour of innovative ways of moving from awareness to action and this method is modern and relevant to societal trends.

If you want to add your name to the register then go to become a donor
If you want to read about this campaign go to sms campaign

Adoption of guidelines: trust?

A perennial issue on spread and adoption is how clinical guidelines are adopted - or not. There is an industry researching what happens, what might be useful intervention and what you can then do to increase the speed and amount of adoption.

My own rather accidental piece of "research" raised a new question for me: to what extent is trust both an enabler and disabler of the adoption process?

So I've been cooking. The real thing, with recipes. I spent the better part of a month working through many of the Women's Institute favourite 650 recipes. A trusted cookbook and mostly failsafe. What I found is it is incredibly difficult to follow a recipe down to all the details. The more I used recipes the more I found myself adapting them - to varying degrees of success.

Then I moved on to Nigella's Express cookbook. A week later I noticed I was slavishly adhering to every minute detail. Not like me at all. So what was going on here?

Nigella writes in the first person and the way recipes are written has engaged me in a new way. When a note in brackets suggests options, reassures you that she really did mean 250ml double cream or reinforces why this step is important, then it seems more trust in the process is repaid by more attention to detail in following instructions.

Many clinical guidelines are produced by committees. Yes they may be great sets of instructions, however, are they written as mechanisms that attract trust? I wonder what would happen if a trusted peer rewrite guidelines in a personal language and tone. Would they be adopted more quickly?

I did think maybe this is about personal choice of style of communication. Maybe. And should that detract from finding some novel ways to encourage the adoption of guidelines?

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.