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.

Spread or Adoption? Which terminology works best for you?

Do you talk about spreading good practice or helping other to adopt good practice?

The difference is one between push and pull. Spread implies a push out, top down and hierarchical approach and adoption suggests we are unable to do the change and that the best we can do is help someone else to do it.

It sounds subtle but the difference is significant. Enabling the pull is difficult to do using a top down approach in the organisation. Yes, it is not only possible but downright useful for the organisational leaders to create a context and structural environment that enables professionals to be aware of and be able to implement existing good ideas. However, the application, the changes, are made by those who are affected by them, not the leaders.

It sounds to me that in the last year or so healthcare around the world has started to use the phrase large scale change to take the place of spread and adoption. I wonder whether this is due to the difficulty of the original two words?

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

Crowdsourcing shifts us from what to how

"to improve" is a verb. A verb is a "doing word". Improvement is action. Collecting and storing examples of good practice is a displacement for action. Huge knowledge banks where the thing of the 1980's (yes, thirty years ago) and by the late 1990's were largely discredited as a mechanism for helping spread good practice. The few organisations that did manage to leverage the codified knowledge, did so because they institutionalised through clever IT systems, the search and sharing of knowledge. Note, this sharing was linked to the individuals with the ideas and not odd pieces of extracted information. The personal relationship mattered.

What does the modern day action to improve look like when we are aiming to avoid the reinvention of wheels?

a) We crowdsource. We call on the community for their ideas. However, asking for and then collating ideas is not crowd sourcing - it is a cheap way to create an ineffective database. Crowdsourcing works when participants rate ideas, decide which is best. Many organisational leaders fear crowdsourcing because the answers may not be what they want.

b) We get more active in presenting the problems and then asking people to provide answers - as an open call. The joy in this approach is it is not limiting the solution to the thinking and mindsets of employees. This has been around for at least a decade and the are many websites and systems to help make this happen. Some organisations even provide all their data so others, not part of the organisation, can use it to help solve the problem. The first step to making this happen s to give up control and to ask for help.

In the UK we are experiencing the crowdsourcing as the Government has set up systems to ask for ideas on solving problems. I like the way they are asking the citizens on ideas and not restricting it to Government employees only.

Crowdsourcing gives the vote to the hungry consumers and nto to the turkeys.

Some Crowdsourcing links and resources


1. Wikipedia: for starters

2. IdeaScale is where you can set up your own Q&A and ranking community for innovations. There are hundreds of existing web applications for crowdsourcing so if you are spending money creating your own then let's hope there is am excellent reason for doing so.

3. Fevote - place to make suggestions and get votes on them (great for research and tests of change)

4. Kluster: - stunning group decision-making tool

5. Good blog post on crowd sourcing resources

4 kinds of relationships

So much of spreading good, known and evidenced practice is based on social connections and relationships. John Maxwell has four ways in which relationships can be categorised.

1. Some people add things to life (we enjoy them) +
2. Some people subtract something from life (we tolerate them) -
3. Some people multiply something in life (we value them) *
4. Some people divide something in life (we avoid them) /

If a key role of the person who group is trying to influence others to change their behaviour then it might be useful to reflect on the relationship between the "spreader/pusher" and the "adopter/puller".

There are some people I avoid (4) and I am unlikely to even receive the messages they are pushing out, let alone act on them. In a similar vein, those I tolerate (2) I will probably put them low on my priority list and will be fairly sceptical about what they put out. Whether I adopt anything they are pushing will be a matter of personal judgement.

On the other hand, those whose company I enjoy (1) I will probably get to hear a lot about what they are saying, thinking about and pushing in my direction. I will take their information in quite quickly, though may still toss the ideas about before making any changes to my behaviour.

Those I value I will probably not wait for them to send me information. I will be finding ways to connect, listen out carefully and will most likely shift my behaviour quite quickly when they send out behaviour related messages.

So which types of relationships are you creating and endorsing?

Social Movements and Healthcare; a confused application of theory?

I am perplexed by the rhetoric of applying social movement theory to healthcare. It seems strange to me that those in charge, with the power are creating what they they believe are "social movements". I suspect they are usefully taking some learning from social movements and then applying this learning to improve both project and programme management performance. This is a good demonstration of organisational learning and improved programme management.

My understanding of a social movement is it is started by the powerless, the forgotten voices. These people are united by a common cause and willingness to belong of a group identity. They push against those with power because they believe what the transformation change they desire is morally important, just and necessary. Anyone who opposes the social movement is seen as corrupt and unjust. The social movement wants to change the laws, wants political and social impact.

So when the power-full start to talk about creating a social movement I am a bit at sea. Yes, leaders can be trained to tell stories and speak with more passion (good leadership practice), though I believe the passion that social movement leaders exhibit is one of deep moral justice. This cannot be implanted into someone's heart or soul (let alone by those who hold the power)

Social movements are not narrow interest groups. They seek social transformation. An example in England right now is the EDL (English Defence League). They exhibit all the signs of a social movement. They are organised into divisions, protest, annoy those in power, and have a strong personal sense of what they believe is right.

How do social movements start? I suspect they are not created in the corporate boardroom. Certain events may trigger one as the publicity garners activist together. It could also be a compelling leader who knows how to speak to their people. Or a new generation that no longer wants the status quo. Teachers, writers and evangelists have also triggered movements.

Those power-full who want to create social movements are also perhaps ignoring the messiness and darker side of the process. Movements push against something. It is often not pleasant to be part of a process where the push against the established way of thinking results in a physical, intellectual and emotional battering. However, it is this side of the movements that provides their success. There is a persistency that only passion can bring. Taking just the nice bits and ignoring the other consequences is irresponsible.

Here are some tips if you are the power-full and want to try and benefit from the power of social movements.

a) find out who is doing what already on your area of interest. Can you support, in the background, so they move from being an interest group to something bigger (note, you work through them and don't enrol them into your own power-based program)
b) find out who the leaders are that people listen to, and support them to get their message heard. You will recognise a social movement leader when their rhetoric gets under your skin...
c) build in the story telling and organising principles of social movements into your own programmes, but know, always, that the goals of the program are yours from the power-full and may not be those of the grassroots.
d) If you are a corporation or large organisation then the grassroots are your customers - not your employees
e) when you feel a push against your power, stop, think and listen. In there may be the seeds of the same change you want, just presented differently.

Leave your comments below

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?

Airlines & Healthcare; what can we learn

We consider airlines safe so in healthcare we adopt some (and only some) of the techniques they use to be safe - like checklists used by pilots and engineers. I say @some@ because we often forgot some of the more basic and fundamental safety aspects employed by arilines - the often more complex human resources, financial aspects, organisational learning, training etc.

Putting safety aside I read the report by the USA Bureau of Transportation on the statistics for 2009. In 2009 of the 19 airlines who reported they had an average on-time arrival performance of 79.5%. Hmmm. What I like about this figure is it represents the complexity of different airlines, operating in different ways, to different airports - and all affected in some way by the things out of their control, like the weather. This sounds to me like the healthcare system - in public sector systems anyway. So the airline travel system in 2009 was designed for 1 late arrival in every 5 flights. This makes me feel a lot better about the flow of patients around the National Health Service in England. A way higher percentage experiences experiences on time care. I also feel that the NHS is able to work well in a crisis like bad weather.

Ever lost your baggage? Well in the USA in 2009 3.91 bags were mishandled (isn't that a lovely term!) in every 1000 handled. This was an improvement from the 5.26 in 2008 - well done. As rates go these mishandlings are very few. Of course, if it is your bag lost, then the amount of year on year improvement and the overall rate is of no interest. A failure is a failure. This reminds me of the way most healthcare projects adopt goals that are less than perfect. For instance, 95% of patients to be treated xxx. What this tells me is that the improvement project team and the organisation are opting to design for a certain amount of failure. And I am not sure I am happy with this. Mistakes I can forgive. Designed in failure rate, often large ones, are to me a sign of lack of confidence in the people and processes. And as a patient I am less confident being treated there.

We have a great deal to learn about and adopt from other sectors as part of improving healthcare. What have you adopted from another industry and how has it worked for you?

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?

Large Scale what? Change, outcome, implementation or impact?

I prefer the phrase "large scale outcome" or "Large scale implementation" to the more generic "large scale change". Why? When the words outcome and implementation are included it feels more active, more directive, more specific.

For example, it is possible to have a large scale change that is not resulting in the outcomes you set out to achieve. A huge amount of change can happen and yet only a small scale impact is achieved.

Equally it is possible to have a large scale impact from a a small change that might affect only a small scale (numbers and geography). Using Pareto analysis can provide organisations with hints on where to leverage the smaller changes for the bigger impacts.

By focusing on impacts, by elevating the results we want, we can design organisation and system interventions to deliver targeted outcomes. In my experience, many groups who talk of large scale change are ending up creating busy-work that is not specifically directed at delivering a large scale outcome. For me change does not equal outcome or impact.

I'm reminded of a quote from Thoreau which runs along the lines of "It is not enough to be industrious; what are you industrious about?"

Sharing - Seeking; a necessary dynamic of spread

The concept of large corporate databases capturing and storing "good practice" and "knowledge" was discredited by the late 1980's due to the costs involved and limited impact. It seems a standard approach to problem solving is to "start with what I know" and then if really desperate "find someone who can fix the problem". I frequently find that few managers and teams spend a short time seeking out information from those who have gone before them with regards the same problem.

A corporate database tends to be fairly clinical in approach. Woudl you rather get your ideas from the place where all entries have been approved, or from the hundreds of places on the web where forums are filled with people sharing not only technicalities of solving the problem, but also the emotion. Trust and credibility is importnat. How much do we trust the corporate database and how much do we trust what someone has written on a Forum.

Today I had a nightmare with MS Outlook consuming most of my computing CPU. The compiter temperature was rising along with my frustration and a literal metdown was predicted. A quick internet search revealed this was a common problem. The Microsoft database gace some suggestions but I chose not to follow them. INstead I found suggestions from "real" people, who reported on their tests of change and what worked for them, in their circumstance. Problem was eventually fixed (it was an overlarge normal.dot file if you're interested...)

I am hugely grateful for those who are questioning, providing repsonses and generally sharing their knowledge on internet Fora. Search engines are brilliant at organising this morass of wisdom. I really can't see how closed shop databases can be as effective in helping others solve problems.

The bottom lie though is the use of this wisdomw is dependent on some seeking it. So who will be actively seeking infomration from your database? If they use an internet search engine will they find your knowledge?

Designing for large scale change

The scale of "large" change depends on your perspective and intent. Usually, any change of significance feels large scale if it dominates a large part of your life. At what point does the PDSA cycle method become less than useful in delivering change?

In healthcare improvement work over the last 10 or more years we have been fixed within the domain of PDSA cycles and the Improvement Model. This is a useful technique in (a) testing out ideas where we are unsure whether they will work and (b) in implementing change on a small scale. These methods have a tendency to produce large number of pilot projects, many of which demonstrate good results. The exhortation is then to "scale up" or "spread" the results to others. So far, this has proven very difficult - and not unreasonably so.

The difference between designing for scale and doing Improvement Model/PDSA type projects lies in the intent. If the intent is for all those for whom the topic is applicable to implement changes to demonstrate an improvement, then consider what might be the opportunities if the focus is on large scale design rather than demonstrator projects:

i) a large scale intent most likely has a large scale context; working with the wider system may help to identify areas where smaller changes can have a big impact. Namely, large scale design does not mean everyone has to do a lot of change. It could mean that if a few, cleverly targeted areas changed, then everyone benefits. We can only find these possibilities if we work with intent and the larger system
ii) we consider how the context interrelates to the aims of the project; context is critical in the process of adopting change ideas. Without highlighting and working on the context change is difficult to achieve
iii) with design as a focus and scale as the objective then we are more likely to seek out innovative solutions to age old problems. Sometimes replicating what we perceive to be good practice may in fact be part of what is hold back large scale improvement.

If you find it difficult to spread from pilot projects then maybe it's time to consider a design process for large scale improvement.

For more on why good practice doesn't spread, go to this book

Transformation versus Metamorphosis in Systems & Organisations

Gone are the days where the method of reducing variation and improving quality was focused on the incremental spread of good practice, using mostly communication methodology from the 1960's. The current mantra is "transformation". I am proposing an alternative, "metamorphosis", which may be a more relevant meaning-making metaphor in some circumstances.

We recognise when an organisation has transformed because we perceive a difference. This difference is usually one to stay. Slipping backwards to the old way is not an option. Transformation is something we recognise after the event. Thousands of books and papers have been published describing the experience of others and their own summary, meaning making and production of frameworks and models. However, underlying all the noise of methodology lies the premise that all transformation requires a behavioural change of significance. In addition, to transform usually requires a high degree of emotional commitment, trauma, distress and joy. Transformation is touted by "those at the top" as a process and outcome that is positive. However, for some it is necessarily an unpleasant process.

An alternative concept is "metamorphosis". This focuses on the striking change in appearance, in form and function, of an organisation or system. Individual may transform their behaviour, organisations and structures may morph into new, innovative and maybe even shocking forms. Morphing can happen slowly, the result of an incremental drip by drip process. Then we look back and see it now looks totally different. The changes around Mental Health Care in England from the 1970's to date are an example. Experience a deep depression in the 1970's and you would find yourself in an open ward of a Victorian building, treated (in a rough sense of the word) as a curious, complex and perhaps untreatable patient. Nowadays, you'd be cared for in the home by multi-disciplinary teams who recognise you as an individual with a family and personal set of circumstances. While drugs may be used, talking therapies also abound.

So what is it you are wanting from your quality improvement work? Are you requiring the sorcery of personal transformation or the magic of metamorphosis? Is the aim a behavioural one or a structural version? Of course both overlap and are dependent on each other, though a focus on form is different to a focus on individual behaviour. The resulting process and consequential outcomes will also differ.

One way to use these concepts is to think of transformation as a bottom up behavioural approach and metamorphosis as a top down structural and form based strategy. The two are related, differently.

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.

Resources to understand tragedy of the commons

At the Institute for Healthcare Improvement's National Forum today, Don Berwick used the example of 2tragedy of the commons" in his Opening Plenary. His pitch was to encourage healthcare leaders to cooperate and work for the wider and more common good and to beware of continuing to work on a self-centred and healthcare industry basis.

For those interested in the concept of "tragedy of the commons" I have put some links in here where you can get more information.

The original article by Garrett Hardin in 1968 which introduced the concept can be found here.

A special issue of Science magazine provides not only all the critical papers you need to read but also links to excellent web resources. You can find this here:

Some games you can play to simulate and understand what is meant by ToC (though anyone trying to get onto the conference wifi will know just what it feels like!). You can access these here:

One of my favourite bloggers covered ToC a while back. You can read his post and associated comments here:

I've been a fan of Systems Thinking for years. There are loads of tools and techniques to understand how ToC occurs and how to work with it. I'm looking forward to healthcare improvers adding systems thinking techniques into the regular and perhaps rather technical improvement techniques. You can learn about ToC using causal loop diagrams here, and discover resources at Pegasuscom.

Any more - please add in the comments below.

Improvement Projects: Do no harm

A common issue raised by project managers who are trying to implement existing good practice with individuals and teams is one of resistance to change. I am constantly seeking ways to reframe the term "resistance" as a means of moving away from a potentially obstructive and destructive frame of reference.

I've been wondering whether one of the reasons people appear to "resist" adopting even what is well evidenced as good practice is because of a natural and at times perfectly reasonable conservative attitude towards risk. The medical profession has the theme of "do no harm". My feeling is often we are asking professionals to take on the solutions designed by others and in different contexts without providing the potential adopters with the evidence that the results are both relaible and generalisable. Reliable in the sense they can be repeated int he same context with the same results. Generalisability is what is proved when the intervention (improvement process) can be done in a different context and obtain similar results.

Without this evidence of generalisability in our improvement work I feel professionals will continue to be suspicious of changes.

In additon, do we ever publish the knock on consequences and the adverse effects of improvement work? A quick trawl of improvement projects published in high impact journals in the last 2 months demonstrates the attitude that improvement work is all good. None fo 12 papers that I looked at provided (or even hinted) at any negative consequences. Without honesty abotu improevemnt work and results I suspect we will continue to encounter "resistance" to change - and I will consider this an appropriate response to any solution being touted for implementation where there is no demonstartion of generalisability and no discussion about identified adverse consequences.

Disseminating guidelines using MBTI Style

One of the eternal difficulties in the dissemination and application of clinical evidence is what I believe to be the " style gap".

Either they are researched and written so generically it is difficult for any individual or team to see how they apply to them. Or they are written so specifically that individuals and teams are so constrained to the detail and working out how they apply to themselves, they don't implement.

Different groups and organisations have developed their own ways round this problems. At a National or Regional level, boards and groups develop guidelines that are generic and then disseminate with a covering letter urging local adaptation of these guidelines. They know there will need to be local differences and contexts taken into account so they acknowledge this. This raises some questions for me:

• to what extent does turning the generic into the specific mean the intended benefits remain?
• are there different bits that can be adapted in different ways? Do the authors suggest how different bits can be adapted?
• what are the systemic links with other pathways, clinical areas etc that need to be taken into account?
• what are the contextual variables that are necessary for the generic guideline to be implemented (things like resources)?
• Where to start? Something practical?

For those guidelines which are so specific as to be overwhelming

• how do all these details scale up into themes and topics?
• what are the patterns and links to systems that will be useful to know about?
• which if the details are most important? Which ones can be left out and the main benefits are still reached?
• is there a specific order to implementation?
• how to the parts integrate with other systems like IT and HR?

I don't know the solution to this. What I do know is that many clinical and process guidelines are written in the MBTI (Myers Briggs Type Indicator) N/Intuitive style. This is the big picture, system and pattern way of seeing things. In contrast many of those required to implement these guidelines are more comfortable working with details (MBTI S/Sensing) and make sense easier of instructions if they are practical and specific. Sometimes the reverse is true - S's develop guidelines for N's to implement.

All the other parts of the MBTI styles could be a factor in the adoption of messages that change personal behaviour.

Perhaps one way round this is to use dissemination processes and content in a way which best suits the style of the potential adopters rather than the comfort of the authors.

Keeping track of progress; learning from DHL

It's a long story, but the short version ends with my handbag needing to be sent from Stockholm to Buckinghamshire in England. This experience has left me wondering why it is we find it so difficult to keep track of patients within a hospital, let alone across systems.

From time of pick-up to signature at home I could watch the 24-hour journey unfold (one click on a weblink, no data entry). I could see what action was being taken at each stage. If you're interested you can see the detailed information below (it's not the greenest of journeys...). It took only 2 minutes from the time of signature for the information to appear on the system.

Yes, patients are not parcels. Patient information also requires a certain degree of confidentiality management. However, I wonder what it would be like if within hospitals (let's start somewhere simple) we were able to keep track of the inpatient, figure out in which corridor they are now, how long they have been waiting for their scan, whether they have had their meal etc. This information will provide insight into the systems and the patient's experience. Maybe we could start by monitoring blood samples in this way as they are already bar coded. Maybe we could start with a system to help keep track of patients in the hospital for who speaking is difficult, such as those with dementia, stroke or some other disabling condition.

I wonder what else we can learn from DHL about how to monitor and improve pathways using technology?


585907200 - Detailed Report
Date Time Location Service Area Checkpoint Details
Oktober 18, 2009
11:59

Arlanda - Sweden Försändelse hämtad
Oktober 19, 2009
18:04

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
18:28

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 19, 2009
18:49

Arlanda - Sweden Anlänt till DHL i Arlanda - Sweden
Oktober 19, 2009
19:48

Arlanda - Sweden Lämnat avsändare
Oktober 19, 2009
19:55

Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
22:16

Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 20, 2009
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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?

Stories and Examples are different

We know that stories engage hearts and minds more than bullet points on a PowerPoint or a three page proposal. I believe there is a very important difference between stories and examples.

Stories are personal. I know a story when the person telling it comes alive with the emotions attached to the story. I can feel their passion, enthusiasm, sadness, delight - whatever. I am drawn into their personal experience. It is stories like this that engage me.

When someone stands on a stage and tells someone else's story - then for me that is an example. No matter how much we resonate with the other person's story their passion, enthusiasm, sadness, delight - whatever - is unlikely to be captured by the example-teller. Examples are helpful, though I suggest they are no different from the paragraphs in papers. They are second-hand and no longer associated with the context and emotions that go with them.

I am sometimes asked if a story I have used can be used by someone else. I usually recommend they find a way of developing their own reservoir of stories. This is sometimes difficult. Those who develop and advance theories may find their work disconnected from the reality of practice. The best way to both test the theories and develop your own stories is to test them out on a small scale. Not only will this provide self-confidence, it will also demonstrate the practicalities of your theory or suggestion and increase your personal credibility as you have a personal story to tell.

In the event you are unable to experience your own story, then I suggest capturing someone else's using a short video. Then allow their story to be told as they wish.

In the next week, try to focus on gathering, maintaining, treasuring your own stories. If you find yourself giving an example - telling someone else's story - then take a breather and see how you might do something differently to get the outcomes you desire from your listeners.

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