New Tools Wiki - a stunning set of resources

The newtools workshop wiki is the most amazing set of resources I have come across for months - and those of you who know me well know that I don't use "most amazing" very often. I'm at a loss for words on how to describe it so you need to go and have a look for yourself.

Be prepared to spend some time exploring it...

How to implement 7-30-90 Day projects

“Being busy does not always mean real work. The object of all work is production or accomplishment and to either of these ends there must be forethought, system, planning, intelligence, and honest purpose, as well as perspiration. Seeming to do is not doing. “ - Thomas A. Edison

The purpose of this blog is to set out some ideas on the how of a 90-day improvement project within the context of healthcare. This project process is evolving so please add comments to this post so everyone can learn from your experience.

Principles:

• Having more time doesn’t mean getting more done
• Manage the tasks not the time
• Deliver incremental value
• Deliver results within a defined timeframe
• Honour the concept of organisational learning and continuous improvement
• Discover a rhythm of change and implementation that balances risk with results
• Use these ideas as ingredients and make your own recipe
• Ensure a focused, targeted and committed action process

      “Absorb what is useful, reject what is useless, add what is specifically your own.“ –Bruce Lee

There are a variety of approaches. The choice of your approach will depend on your strategic aim, the timing that best suits you as well as the nature of your improvement process.

STEP 1: Create your format based on your timescale

“Once you have mastered time, you will understand how true it is that most people overestimate what they can accomplish in a year - and underestimate what they can achieve in a decade!” - Tony Robbins

It is possible to deliver changes in 3 days (see Kaizen methods for further information). 

Consider your desired results, the amount of people who need to be involved in the process, the team and organisational culture as well as the nature of the problem to be solved / the solution to be implemented.  With this in mind, look at the options below and see which most closely matches your needs.  Where possible make your task

 smaller and the timing shorter.

All of the timescales contain a basic strategic rhythm of

a) diagnostic steps

b) implementation focus

c) review and next steps

 It is possible to design a 90 project so the phases are sequential, or it can be built up from a series of smaller 30 day cycles.  The choice depends on your strategy for change:

“Hell, there are no rules here - we’re trying to accomplish something.” - Thomas A. Edison

Why 90 days?

• Scope is more complex though is manageable within the timescale
• Sufficient interdependencies that will need to be followed through with conversation and negotiation
• Good if have high energy people working on the project who can also maintain their focus

Why 30 days?

• May be easier to commit to than 90 days or 18 months
• Deal with the now; plans remain relevant
• Long enough to see an improvement (or not, so can then change the strategy)
• Scope is such that one individual or a small team can make the changes with no further resource to committees or individuals for permissions

Why 1 week?

• Good for those who are too time / task pressured to commit to improvement
• Able to test an improvement-through-learning process
• If used as part of a longer project the 1 week cycle can provide a mechanism for involvement (different people different weeks)
• Good for working with those with a low energy

	Diagnostic	Implementation	Review
12 week (90 day)	4 weeks	6 weeks	2 weeks
8 week (60 day)	2 weeks	5 weeks	1 week
4 week (30 day)	1 week	2 weeks	1 week
1 week (5 day)	1 day	3 days	1 day

A diagnostic phase includes, to varying degrees, some of the following (remembering that diagnosis is part of the change process as individuals discuss and assess their own situation):

R  What is the current situation, including baseline measures; this needs to be localised to the context of those making the changes. Process and value mapping, relationship mapping and other techniques are useful here.

R  Creating ideas for change and improvement; being creative rather than just implementing known tasks (otherwise we end up with low energy projects)

R  Understanding any interdependencies and carrying out appropriate negotiation

R  Planning, designing, getting in the resources that may be need (like equipment) etc.

An implementation phase includes, to varying degrees, some of the following

R  Action, with measureable results

R  Learning, from personal and team reviews

“Words may show a man’s wit but actions his meaning.” - Benjamin Franklin

A review phase includes, to varying degrees, some of the following

R  Working out what is going well, and why

R  Figuring our and being honest about the problems, and then working through some ideas to resolve these

R  Capturing personal learning as well as team and organisational learning, specifically noting those things you would like to do / feel more of

A project of any length can be constructed from a weekly pattern of activities.

“If we did all the things we are capable of, we would literally astound ourselves. “ - Thomas A. Edison 

Misusing numbers to sell project results

The more I know about statistics, the less confident I am about my own use of numbers and the more suspicious I am of any publicised data. The oracle on this topic is Dr Ben Goldacre, author of Bad Science, one of my favourite reads.  A new book out by Charles Seife called Proofiness; the dark art of mathematical deception is along similar lines.

When it comes to scaling up the results of improvement work across a wider population, the danger of inflating the opportunity is significant. These are some of the numerical problems that have come my way in the past few week:

1. Hospital a got a 30% improvement, therefore if we multiply this across the whole county, this 30% improvement will give us a £1.3 billion saving.  Humpf? So I need to know how representative of the national picture was Hospital A. I need to know the numbers and not the percentages behind this statement. I need to know how generalisable the improvement process is. And that is before we get to understanding how the savings are calculated.
2. Pathway b is delivering 212.3 more patients in a shorter time of 8 days.  Humpf? More than what and shorter than what? The 212.3 gives me the wobbles because I've never seen 0.3 of a patient. Seife discusses the art and deceptiveness of the specific number in his book - see a relevant excerpt.
3. 87% of hospitals have adopted the use product y. 87% of what population - national, region, the city? What counts as use - have they used it once or are they using it all the time. Did they try it out or have they made it part of their regular routine? Did just one ward test it once or have more (all?) wards tested it and are using it all the time?  These questions are important in understanding the true nature of what has, or has not, been spread throughout a system.

Are there any headlines of numbers that make you wonder?

Connection is key for innovation

A little luck and a lot of perspiration is no longer the prerequisite for innovation. Nowadays connections, relationships and networks are key.

Steven Johnson's next book is about Where Good Ideas Come From. You can watch him in action on this TED video (which starts with a picture and talk about the Grand Cafe in Oxford).



A couple of key points include:

1. Innovation is the result of the brain making new connections and these connections mirror workplace connectivity.  The better the networks and more complex the relationships then the more likely it will be that good ideas arise. His premise is that innovation is an interactive process.
2. The architecture of space is important if ideas are to be generated and spread - he has looked into what environments have contributed to innovation. If we want innovation we need to design spaces that enable connections.
3. Great ideas that appear to spark from nowhere are most likely the result of a long period of incubation which may not be obvious and are most likely cobbled together from a variety of existing ideas.. He argues that ideas are networks and the way of thinking about them as sparks, illumination etc is no longer relevant.

Patient Experience; report to help Boards build patient and public experience into quality fo care

If you are steeped in the healthcare quality improvement methods you will know how important it is to understand the patient experience. Scaling up project results to a wider audience does not mean the patient's views are no longer important. While the theory is obvious the practice is not. It can be difficult to engage non-executives and Board members with the patient experience and a new report on the Patient Experience  issued by Dr Foster in the UK covers the following:


Foreword 
Key messages 
The scope of this report 
What is patient experience? 
Good intelligence guide: The basics 
Good intelligence guide: Measuring what matters 
Good intelligence guide: Building an intelligent report 
Good intelligence guide: Advice from the sharp end
Board briefing: Intelligence types and uses 
Board briefing: 2010 policy directions 
Board briefing: Glossary 
Board briefing: The current state of play 
References 
Acknowledgements 

It provides advice on how Boards can produce a meaningful intelligence report on the patient experience. I particularly like the checklists and the brevity with which it is written.  They have nicely avoided the temptation to burst into theoretical concepts.

I found this report via Jocelyn Cornwall's blog at the Kings Fund - another good source of information.

Learning networks or social movements? Which is best for large scale change?

I'm not sure there is a specific answer as to whether learning networks or social movements are best for large scale change.  However, my personal preference is for learning networks and these are my reasons:

1. learning networks connect the people who are interested in solving the problem, and they do so in an interactive, participative and empowered way. In comparison social movements have the image of someone wanting to make something happen and in manipulating the joining in process and to an agenda they have set.
2. learning networks are about the exchange of information, discussion and both personal and group learning. Personal behaviour may change as a result of learning about something new from within a peer group. When a group discovers new knowledge and feel the creative process of doing so, they may become quite committed to then implementing changes.
3. learning networks can be direct and specific. They can be topic based or professional grouping based.
4. there is a sense of an output with learning networks. Social movements are useful in that they are purpose driven, however, learning networks to me are more concrete, pragmatic and easier to associate with outcomes and results.
5. we know learning networks work in healthcare while social movement theory is in its infancy. I am a proponent of using the existing knowledge we have to best effect.

This doesn't mean social movements are not useful, rather that I am sceptical about their ability to deliver results, especially when we know learning network can have an impact.

There is an excellent paper on Learning networks for sustainable, large scale change which is worth a read.