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.

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?

How do we know that what gets spread is of value?

I thought I was being radical in my last book, "Undressing the elephant; why good practice doesn't spread in healthcare" (2007) www.undressingtheelephant.co.uk when I wrote about the problem of the idea bias. Of course Everett Rogers and others have researched the issue over many years. I tried to be a bit more in your face when I wrote my chapter, challenging how egos, organisational politics and indeed, governmental Politics all let to inappropriate and questoionably poor value practices being implemented.

I'm still worrying.

I came across an organisation where a team leader proudly shared that his teams "best" practice in a safety issue had spread "virally" to all wards round his hospital. So I asked him some questions. I leave you to imagine some of the conversation we had.

How do you know it was "best" practice?
If it was proven as best for you, how did others who adopted it, know it was best for them?
How will they continue to know it is the best practice?
If it is not the best practice for some wards, then what should they be doing?
How can you use the dynamics of how this spread, to spread what you would prefer to have spread?
What really matters - the spread of the practice, or the improvement of results?

We retired for top up of coffee and both agreed that there is something very scary about self-organising systems, though perhaps not quite as scary as when one person tries to impose their value laden idea on a system that opposes it.

(c) 2008, Sarah Fraser