The words innovation and improvement can be misleading

If you want an idea or activity to be judged as good, then label it as an innovation or an improvement. Correct?  Well, I'm not sure it should be, but it seems that's what happens. I've been wondering why it is that the words "innovation" and "improvement" are assumed to represent "the good".

At a high level, there is an ethics issue; to whom does the "good" belong? New ideas often stem from crises, and crises are often either sourced from or produced by competition. When one side creates an innovation, the other side loses.

At a more detailed level, what worries me is that by labelling an idea or activity using words that come with the assumption of good, is that we:

• fail to evaluate whether the idea does what it intends (fidelity; more about fidelity here)
• fail to check whether there are unintended consequences in applying it
• fail to understand the drive of the person or organisation behind it
• urge the spread of a "good" practice, without assessing its value
• just accept; and the more we just accept, the more we open the floodgates to ideas and activities which may no longer be what we need

There's a lot of talk in the NHS about the need for "innovation". It will be good when this is grounded into discussion about the problems that need to be solved and then the ideas and activities being introduced to solve them. Solutions need to stand on their own right, not be labelled to give them credibility.

Cutting the cloth does not a slimmer NHS make

The NHS in England is undergoing a fundamental change  It's driven by the need to cut the cloth - to cut the expenditure. The trouble is, if the body of the organisation is still fat, then trimming the clothes will neither a pretty picture nor a happy organisation. The body needs some work.

It's a little like telling someone who is used to living a life where they can buy designer clothes  shop for the best cut in steaks and live in the best areas - that they have to buy from Primark and live in a less desirable area.  Obviously this is not an ideal situation. But it is one where the person starts to live within their means. Yes, it means life will never be the same, but if the person doesn't make the shift then they may face bankruptcy and lose everything. Surely it's better to take control and create a new life that is sustainable.

The NHS has a lot of fat in it. There is waste, despite the doomsayers who tell of the end of the NHS due to budget cuts (cloth cutting). This fat often isn't obvious (it is hidden deep within the organs of the organisational body, often in small streaks, but there nonetheless. When I can buy a ream of paper cheaper than an NHS organisation - there is waste. When I or a member of my family has difficulty in getting discharged from outpatients - there is waste.

I'm on my personal mission not to become part of the obesity epidemic. I am pleased to have got through a number of (healthcare...) events without resorting to the biscuits and pastries. Maintaining an exercise regime in the snow is difficult - but not impossible  I know that buying clothes two sizes smaller will not cure what's lying beneath them.  A radical shift in behaviour is required from me.  And so for the NHS - a radical shift in how services are designed to meet the future needs of future patients is necessary. While I commiserate with the pain staff in the NHS are going through, I do hold out hope, as a patient, that eventually the cloth cutting will move on from losing staff to rethinking the way care is delivered.

3 reasons why UK healthcare should not copy US innovations and improvement methods

I've nothing against the US, it's healthcare system and the methods used by various US organisations to improve their outcomes and processes. I don't live there so my opinion on their healthcare system doesn't matter. What is my business is the importing of US methodologists and solutions into a different context.  At a high level, learning new methods such as the Improvement Model is helpful, but at a more concrete level, copying "what worked in the USA" into the NHS will always be fraught with difficulties.

Reason 1: The USA outcomes are worse than the UK.
The IOM has released a new report US Health in International Perspective; shorter lives, poorer health. The facts are stark. US citizens die younger than their peer countries, despite paying more. Crucially, the report suggests that 20% of avoidable mortality is due to poor healthcare (rather than system related issues or behavioural choices).  Specifically, the US is worse than many countries in infant mortality & low birthrate, injuries and homicides,obesity & diabetes,  heart disease, chronic lung disease.

So why are we copying "solutions" from a system which is providing for worse outcomes than ours?

Yes, it can be argued that some care processes have better outcomes, but even then, there are difficulties. For example, it's widely touted that men with prostate cancer live longer than men with similar condition in the UK. If you look into the detail, yes, US men get diagnosed earlier - but they die at a similar average age as men with prostate cancer in the UK; the US men just had longer with the diagnosis, the treatment and the cost. More details on this and similar topics on the Cancer Research Science Update Blog.

Reason 2:  US model is based on cash for activity
The incentive for the majority of healthcare services is to provide more activity as a means of generating more income. This leads to overtreatment. Sharron Browlee's book "Overtreated; why too much medicine is making us sicker and poorer" is an excellent expose on this topic.

I had a debate with a US improvement consultant yesterday about why the NHS may not be rushing to implement rapid response systems in hospitals. We have a different value system, we have a different set of economics, and a different culture about death and dying. Solutions that work in US hospitals may not be the best ones for our NHS. Yes, we still need to resolve some of the underlying issues - but I hope we can do so in a way that fits our own culture, social and economic constraints.

Reason 3: The opportunity for delivering change & improvement in publically (and part-private..) funded health system far outweighs the private led US model.
Even though the NHS is under pressure to privatise part of the healthcare services, the fact that we do have a publicly driven system, connected to social care as well - means we have an incredible opportunity to devise solutions to problems that are truly radical. While we fuss about the speed at which patients are supposed to get electronic access to their records, and how to link them with hospitals - at least we have electronic records. We have register of people with conditions, and many good primary care organisations use these to do their best for the health of their local population.

I sometimes feel that whilst we are in the embrace of US-led improvement and change methodologies we are not devising ones that will make the most of our specific context. A good start is the NHS Change Model, which is sufficiently bland yet comprehensive, to provide useful and reasonable guidance for change.  It's not earth shatteringly clever - but it is one for the NHS, by the NHS, and I believe will be helpful for the NHS.

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. 

New systems model to simulate spread and adoption of good practice

I've worked with Ken Thompson of Bioteams to develop a systems simulation of the spread and adoption of good practice.  Our aim has been to provide a method for individuals and teams to play about with different strategies and to model the impacts of those strategies. It's not a prediction tool, but rather one which helps you gain an insight into the complexities  It's been important to us to produce a simulation which provides an adoption curve - having an idea of the speed (or not) of spread is crucial to your planning.

The simulation is ready for testing. It's not perfect, and we'd love to demo it and take your feedback on how to make it even better. Feel free to tweet Sarah @sarahfraser or Ken @kenthompson, leave a reply to this blog, or email Sarah, if you'd like to have a go.

A screenshot of the main screen is below. You can choose your strategies and then simulate, quarter by quarter, the rate of adoption. There are other input screens where you can assess your readiness for change and where you can enter details about the strategies you'd like to use.

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. 

Leadership, Spread, Adoption & Sustainability

Here is a summary of some blog posts I've written with healthcare leadership in mind:

• Do middle managers matter in healthcare? (refers to a peer-reviewed paper)
• Why don't we search for evidence? (Importance of role modelling)
• Is the role of the organisational champion effective? (Refers to peer-reviewed paper)
• Leaders need to be productive (Video)
• Scheming virtuously: A handbook for public servants (links to the handbook)

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.

Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials

A good friend, Bill Russell, told me about a paper produced by the UK Cabinet Office calling for Randomised Controlled Trials for Public Policy. I was sceptical. When he told me Ben Goldacre (author of the excellent book, "Bad Science") was involved I was intrigued, and then wondered whether it was a spoof. But it isn't.

Hallelujah!

This paper is required reading. [update: new link] I commend it to you all and especially those I've been trying to convince for years that spreading improvements or innovations can have an ethical bias - how do you know it's a good and effective thing to spread?

And when you've read it - read it again. This has to be the best paper I've read for some years.

(I hope someone has passed it on to the Department of Health and the NHS Commissioning Board.)

An introduction to Activity Theory

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

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

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."

Is Activity Theory useful for large scale change?

There's no shortage of theories and models for how good practice can be "spread". I'm part fo the problem by generating some of them.... I've recently become curious about the use of Activity Theory as a means of large scale change in healthcare settings.   It's a bit of an eclectic theory from the social sciences - but then, PDSA cycles were once an eclectic Japanese theory.

Wikipedia has a good intro.  Basically, the benefits of Activity Theory is it combines all system levels into one model of change - from individual through to policy. And I like that.

Greg, Entwistle and Beech have a new paper which considers how AT can be applied usefully in healthcare.

Soc Sci Med. 2012 Feb;74(3):305-12. Epub 2011 Mar 1.
Addressing complex healthcare problems in diverse settings: Insights from activity theory. 
This is their abstract: "In the UK, approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and 'rolled out' across organisations. When the designated 'best practice' is not implemented, this is interpreted as local - particularly management - failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail. We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on "objects of activity" which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice. The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the 'best practice' of rapid response teams."

Why don't we search for evidence?

So I'm perplexed.

I've spent years listening to leaders at all levels - from unit, to department, to organisation, to region, to National  - all say they want "other people" (usually those "beneath" them) to adopt existing good practices.

That's all good and well.

But when I press these leaders on what efforts they've made to check the literature, search for existing guidelines or consider the experience of people similar to themselves - they all look at me blankly.  One recently told me that "that sort of thing is for the people who need to improve, not me. They need to adopt guidelines."  When I pressed him about the opportunity he has to learn from others in the design of his large scale intervention, he replied "We're different."

I shall invest a new piece of equipment - a mirror.

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.

Is the role of an organisational champion effective?

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

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

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

How does organisational context impact spread and adoption

Those who know me, know I am critical of the continued use of Roger's Diffusion Curve as a means of telling people how and how to plan for the spread and adoption of good practice. If you read Roger's work in depth you will understand its limitations.

One of these is the lack of attention to context. It's fairly obvious to anyone involved in spread and adoption of good practice that leadership, organisational culture and readiness to change etc. are all important in the process. The problem is, although many models and frameworks are drawn up to show how context is important - which is an excellent first step - there is a shortage of published work on the topic.

A key problem is that those who publish ignore the contextual factors.  A recent review paper by Emmens, Weiner & Fernandez looks at this issue.


Health Educ Behav. 2012 Feb;39(1):87-105. Epub 2011 Jul 1.
Systems antecedents for dissemination and implementation: a review and analysis of measures 

International Profiles of Healthcare Systems

A fascinating comparison of healthcare systems is available for The Common Wealth Fund.

Some highlights:

• Healthcare system financing and coverage: there's a table that shows how 14 countries finance healthcare (I thought the NHS was complicated in England, but I see it really is quite simple when it comes to financing it.)
• Selective system indicators: this is where you get to see how funding, population, numbers of physicians etc link to chronic care management, avoidable deaths etc. It's all riveting reading but I'm impressed by England's capacity for quality in Primary Care.
• There is a chapter on each of the fourteen countries: Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, Norway, Sweden, Switzerland and the USA

There's nothing like a bit of comparison to place both positive and negative aspects of our healthcare systems in context.  I thoroughly recommend at least browsing the tables, if not reading the whole report.

Systematic Review of Communities of Practice in Healthcare

I love systematic reviews. They are hard work, major undertakings and make life much easier for the rest of us. Compliments to the authors of this new paper which can be accessed online.



How and why are communities of practice established in the healthcare sector?
A systematic review of the literature.

Geetha Ranmuthugala, Jennifer J Plumb, Frances C Cunningham, Andrew
Georgiou, Johanna I Westbrook, Jeffrey Braithwaite

Australian Institute of Health Innovation, University of New South Wales, Sydney,
NSW 2052, Australia.

Does opinion leadership change over time? New Research

I'm pleased to see useful research is being done to clarify further what we mean by opinion leadership. Too often I hear people reducing what is a very complex topic to a simple slide of Roger's characteristics. Roger's initial work on the Diffusion of Innovations was researched and published before the age fo the Internet and before many staff were born. We need updates and we need to grasp a deeper understanding of the complexities.

There's a new paper out.
Implement Sci. 2011 Oct 11;6(1):117. [Epub ahead of print]
Opinion leaders and changes over time: a survey.
Doumit G, Wright FC, Graham ID, Smith A, Grimshaw J.


I've posted the conclusions to this paper below - and recommend you read the original.


"CONCLUSIONS:
Opinion leaders identified in this study were not stable over a two-year time period and generally appear to be monomorphic with clearly demarcated areas of expertise and limited spheres of influence. These findings may limit the practicability of routinely using opinion leaders to influence practice."