Thursday, 24 December 2009
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:
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.
Tuesday, 8 December 2009
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.
Monday, 16 November 2009
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.
Thursday, 29 October 2009
- 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?
- 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?
Tuesday, 20 October 2009
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
Arlanda - Sweden Försändelse hämtad
Oktober 19, 2009
Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 19, 2009
Arlanda - Sweden Anlänt till DHL i Arlanda - Sweden
Oktober 19, 2009
Arlanda - Sweden Lämnat avsändare
Oktober 19, 2009
Arlanda - Sweden Processed at Arlanda - Sweden
Oktober 19, 2009
Arlanda - Sweden Skickad från Arlanda - Sweden
Oktober 20, 2009
Leipzig - Germany Anlänt till DHL i Leipzig - Germany
Oktober 20, 2009
Leipzig - Germany Processed at Leipzig - Germany
Oktober 20, 2009
Leipzig - Germany Skickad från Leipzig - Germany
Oktober 20, 2009
London-Heathrow - UK Skickad via London-Heathrow - UK
Oktober 20, 2009
London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
London-Heathrow - UK Anlänt till DHL i London-Heathrow - UK
Oktober 20, 2009
London-Heathrow - UK Processed at London-Heathrow - UK
Oktober 20, 2009
London-Heathrow - UK Skickad från London-Heathrow - UK
Oktober 20, 2009
Gatwick - UK Anlänt till DHL
Oktober 20, 2009
Gatwick - UK Ute för leverans med kurir
Oktober 20, 2009
Gatwick - UK Signatur
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
Wednesday, 23 September 2009
Monday, 14 September 2009
Wednesday, 2 September 2009
- Problem 1: where is the good practice and who is doing what?
- Problem 2: how do I get to hear of good practices?
- Problem 3: how do I share what I am doing?
Tuesday, 1 September 2009
- 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
- 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.
- 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.
- 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?
Monday, 17 August 2009
Friday, 14 August 2009
- zero is too difficult a target to achieve in healthcare (try telling that to the patient who has just had their wrong kidney removed or the suicide that happened when on 1-1 watch and using non-collapsible rails). Admittedly in some healthcare processes zero may be a tough tartget, however, Never Events mean never.
- we may not meet the target (fear the failure and the knock on consequences for individuals, teams and project work); when I encounter this I realise I am working with an individual or group who fear the failure of improvement greater than they feal the failure of harming a patient.
- it's not worth all the changes for zero (the costs of the change outweight the cost of full redeuction of a never event); this is, of course, a judgement call and my hope is it is made with full data analysis and consultation of those involved. Some never events happen so seldom it may be difficult to justify the changes required.
- we don't believe the research is good enough; the NHS in England (National Patient Safety Agency) have streamlines a varietyof Never Event lists to determine a core 8 which are well proven in all aspects. More research I suggest is not required.
- we will take a while to get to zero; that's ok, then let's see a desired outcome of zero and some leeway to reduce over time. The trick is perhaps not to design for a 20% reduction in year 1 but rather to design for zero in year 3 and monitor progress over time.
Monday, 10 August 2009
Thursday, 6 August 2009
Tuesday, 4 August 2009
- There seems to be a confusion between performance management and measurement for improvement. Yes, the organisation may need to report on the % of x - done mostly so someone in charge can make a comparison. However, this is no reason to replicate this measurement in the project. For instance, if you're working on length of stay (LOS) then you may find mode (most frequently occurring number) is more helpful in demonstrating a change consequent to your improvement activities and it has the benefit of indicating the experience for most patients.
- When a nurse pointed out to be that they do not have .32 of a bed then I took notice. Of course she was right. So some stats that showed an average of 12.32 beds were to be shifted each month (a specific project) I could see this was nonsense. Statistically it could be argued this made sense, though as a mechanism for engaging staff, working in whole numbers, whole beds, whole patients, tends to make more sense.
- So ward A delivers a 4.18 average length of stay. Management now want all wards to achieve this (let's assume most are higher than this). So the processes and procedures underway in A is replicated to others (or attempted). The difficulty is their case mix may be different, their problem may be one where only their long stayer need to be addressed (they have the same mode but ave stats skewed the total figures) etc. In aiming for an average do they figure out the mathematics of LOS - x number can be 4 days, y number can be 5 days etc? For this is what the average leads them to - to game.
- An average, is, by definition, an abstract concept that assumes half the values will be above the line and half below the line. Do you really want to have half your experiences, interventions etc be more than the agreed number?
- One more measurement challenge. What happened to the 100% (or 0%) target? The common version is 98% of y or 95% of z. My logic suggests we are designing systems for a percentage failure. This is a tough call in healthcare. Which 2% of patients will you choose not to have optimal care for their diabetes?
Tuesday, 28 July 2009
- Relationship building: sometimes I share something because I am aware it is part of continuing a relationship with someone. This can range form the more formal paper I've read that I hope someone else will also find useful, though to something more random like a video clip on You-tube that I thought someone in the family might find amusing. My sharing isn't something planned - it just sort of happens and when I see something I will trigger a "share". This made me think whether "relationship building" is something we consider or design with in mind when developing change programs.
- Unknown sharing: this is a bit like the blindspot in the Johari window. I realised that I am on many social and business networking sites. It is possible for me to share a message, say on Twitter, and then this is retweeted (forwarded on to others). I have no idea who the people are, though Twitter is useful as it is possible to track the sharing - not so with email. Sometimes the only way I know something has been shared is when I get an email form someone I have never heard of yet they are commenting on something I said. This is a very powerful dynamic at work and I wonder how much this is taken into account when developing communication strategies? I've learnt how random this process is. Got to be in there and involved to have any sense of how the internet can generate both velocity (speed) as well as scaling up of a message.
- Problem shared is a problem halved: I have found sharing problems and looking for support and answers from others is an important strategy for me. I use LinkedIn to pose questions and also reach out to colleagues. This means I have to describe my problem - this process of sharing usually means I end up part solving the problem as I do the definition! So I wonder whether in our change efforts we spend too much time requiring solutions to be articulated when one strategy may be to help people both find words to their problem as well as find someone to whom they can reach out.
- Random sharing: ever found yourself telling your life story to someone sitting next to you on the bus and who you only met 30 seconds ago when you sat down?! Well, not quite as extreme, though I have found myself sharing all sorts of things with people which don't fall into relationship building (except perhaps very short term) or as precisely as problem solving. There is something opportunistic here. So I wonder whether we can help more of these opportunistic meeting happen in the workplace?
- Good idea promotion: yes, I did do some promotion activities, sharing good practices I have seen elsewhere and which may be useful to the person or team I was working with at the time. However, this was only a very small percentage of my "sharing" time. Standing on a stage and telling stories also counts a bit of good practice sharing, though again this was a small part of my sharing activity. So I wonder whether we are over cooking the need to share good ideas?
Monday, 22 June 2009
Tuesday, 2 June 2009
Sunday, 3 May 2009
- widgets; a whole variety to suits your own needs
- mobile information
- online videos
- rss feeds
- twitter link
- image sharing
- as for social networks you can find them on Facebook, mySpace, DailyStrength
Monday, 27 April 2009
It was announced this week that the NHS in England will have a prize fund of £20 million pounds to go to individuals, teams or organisations who come up with innovations that make a substantial improvement to services. So what I am wondering, is whether this is helpful, or in fact whether prizes and the ongoing emphasis on innovation is helping deliver long term, sustainable, effective and efficient improvements in the delivery of healthcare?
Disconfirming question #1: Why develop more innovation when the current good ideas, innovations etc are used by so few? I wonder what the impact would be if £20 million pounds was up for grabs if you could demonstrate you have implemented an existing evidenced good practice? Do we need more activity on research and new stuff when we have lists and lists of practices that can be of benefit if actually implemented? If an innovation comes up with an idea to get evidence into practice across whole systems and large groups of people, without them really noticing it, then yes, I am behind it. But I am not behind single, one off innovations which are so off the wall that the normal healthcare population can't conceive of ever implementing them.
Disconfirming question #2: Why emphasise innovation and not research? Though a part of me is frightened that any more research will go over old ground - so maybe that is why an innovation focus may be better?
Disconfirming question #3: Why focus on starting something new when stopping something that doesn't work might have more of an impact. The BMJ published in 2004 a list of "bad ideas" or practises in general use which are no longer considered "good practice". These sorts of practices continue to mean large variations in care. So if the innovation rewarded is one which erasing the use of "bad ideas" then I'm all for it.
Disconfirming question #4: Why focus energy on creating new ideas when the same energy could be focused on activity around implementing known and evidenced good ideas. Before I turn entirely into a "grumpy old woman" I do see that innovation and creativity is good. However, as a taxpayer in our system I want to see action on what we know already can work. I suspect tough times like a recession will enable the natural innovators to do their stuff - and they will do this regardless of prizes or focus. It's the greater norm population that doesn't regularly do innovation that bothers me; how can we get action underway there?
Disconfirming question #5: What is innovation anyway? This could leave to a philosophical debate. It could be that anyone implementing an existing known-elsewhere practice will feel it is like an innovation when they implement it in their own context. I suspect this is not what the prize organisers have in mind.
Yes, I do understand innovation and the need for it. My feeling is the innovating population will innovate anyway - that's their nature. I want support, profile and focus on getting existing known practice into place and in stopping known "bad ideas". We could start with hand washing - or someone could come up with an innovative something that means hand washing is an irrelevant activity in the drive to reduce hospital acquired infections.
Friday, 24 April 2009
(Photo by Goodshoot Photos)
The term "alignment" is often heard in leadership groups, team meeting and in programme documents. Do we mean alignment when we use it?
I came to this question of alignment vs attunement on reading a review on the book "Enterprise-Wide Change; superior results through systems thinking" http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0787971464.html and the review is here: http://articles.directorym.net/Business_Alignment_and_Attunement-a1128711.html
Most of us working in the Public Sector and in healthcare will recognise that we are working within living systems. The nature of people interacting, interfacing, creating and constantly altering interdependencies - all creates a perpetually shifting culture - with the consequence of perpetually shifting performance.
Dictionaries suggest the meaning of "alignment" is to arrange to in a straight line or in parallel lines. It is a term that comes from a mechanical and industrial age and is an important one in engineering.
In contrast, "attunement" means to bring into a responsive or harmonious relationship. I like this term. For your large scale change or mechanism to spread good practice, are you conducting a quartet, a 12 piece orchestra, a 120 piece orchestra or even a series of large orchestras all required to play the same tune in different places at the same time? Imagine helping each member of this orchestra to perform their best. They are professionals and know how to tune their instruments, the great music will come from arranging their performance in a way that it harmonious.
How do we lead professional individuals and teams so they use their skills and capabilities to their maximum, yet do so in harmony with others around them? I like to think of the attuning process as including:
- future orientation; you may call this a vision, it may be a picture of what the future looks like, it may be taking time to feel what the end results needs to be like. An orchestra may listen to a previously recorded version. A programme team may visit a place where similar results have been achieved. It is about creating a collective sense of possibility
- a high level plan; for the orchestra this is the score. This may look like detail though there will also be a high level interpretation of the score by the conductor. The leader cannot do the playing for someone else, they can only guide their interactions with others, to create the overall result
- using individual excellence and surrendering this to the collective experience. By this I mean that it is essential for individuals to do their best, to work at their optimum, yet do so as a servant to the group. An individual may have a soloist part, though this is a contribution to the whole and is not the result in itself. In my experience we have many soloists playing well and being praised for their individual achievement with little leadership effort placed on containing these performances
When I am working with individuals, teams, organisations and systems in enabling large scale change my focus is not on seeing them in organised rows, neatly lined up. Instead my aim is to help them identify their tune, make conscious their personal capabilities and to discover ways to build responsive relationships and work in a harmonious way.
Thursday, 9 April 2009
Whether the project is small scale or large scale, there will be a varying degree of predictability and certainty when implementing projects within people-based systems. For large scale change where multiple projects will be run, the complexity increases. There are many different project management systems, some of which are specifically designed to cope with this messy process.
A linear version of project management assumes a sequence of steps, taken in a logical and predictable manner.
The diagram above gives an example of the stages and the effort over time. Reflecting on my own experience of implementing large scale change projects in healthcare I would plan for more effort in the conceptual phase and know that the time spent in each phase is not equal; it will vary according to each project and context.
While part of me would love to work with teams and organisations in an emergent way, to help improvement be revealed and new behaviours learnt and applied, I know that some project management is required when working within the structure of an organisation. One project management model I use is the following:
While this version starts to show some of the interdependencies of each stage in a project, there is always room to draw more lines. However, I like how this model shows the reporting / evaluating stage and how this feeds back into the planning stage. Namely this is an ongoing cyclical process rather than a linear step-by-step approach.
This model also works for me when the project is about implementing existing good practice in a different context. This model allows for the process and solution to be adapted so it work within the next context most effectively.
Monday, 6 April 2009
Plenary 1 — What patient-centered care really means
Plenary 2 — Medical success leads to medical error: how health professionals accept responsibility for safety
Plenary 3 — Transforming whole systems: in search of theory and method
For all poster details and other resources: http://internationalforum.bmj.com/multimedia/multimedia-resources
To discuss the plenaries and posters: http://doc2doc.bmj.com/forums.html?slPage=overview&slGroupKey=f1ee0d38-22c5-450d-9f33-40bf110975f7
Friday, 3 April 2009
Obviously new norms can’t be “set” as such. Where does our current norm come from? I think of a norm as the sum of all the behaviours actually at work in a system. A different norm therefore requires a different set of behaviours – not only (if at all) a planning meeting to decide and list these behaviours but an actual change in the behaviour of one, then two, then three, then four and so on people in the way they act and interact with each other.
More about this norm approach in forthcoming posts. In this post I am thinking more about why we end up with the norm we have. For example, what is the norm at work in an organisation where 400 or more patients are harmed or die inappropriately (for a series of reports / investigations on UK health organisations http://www.cqc.org.uk/publications.cfm?widCall1=customDocManager.search_do_2&tcl_id=2&search_string=&top_parent=4513&tax_child=4574 ) or where one nurse is able to harm and kill a number or patients http://www.nytimes.com/2009/04/03/us/03nurse.html?_r=1? No doubt there are many causes involved in each and every event. However, I’ve been asking myself the question “Why is it so difficult to shift the norm?” Allied to this is the question for me of “How can professionals reach the stage where they become part of a norm that seems to go against their stated values, yet do nothing – their behaviour continues “as normal?”
There are procedures for the NHS in England to manage whistleblowing http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4050929 and again, there will be many reasons why people don’t step outside of a norm and take action. So why is this norm “pull” so strong?
One reason I have been dwelling on is the abuse of power. Not so much a conscious step but rather one which is part of our human condition. And when enough people behave in ways where power is being abused, then a norm develops so others, who may not be inclined to do so, end up part of the problem.
How is abuse of power part of our human conditions? We know from a number of experiments that stated values, professional promises and personal beliefs can go out the window if the circumstances are right. For example, the Stanford Prison Experiment in 1971 (http://www.prisonexp.org/ for a slideshow / discussion guide on the whole process) demonstrated in laboratory conditions that when put in a position of power (the guards) about a third of the “guards” showed sadistic tendencies, meting out punishments and inventing ways to humiliate their “prisoners”. The famous Stanley Milgram experiment http://en.wikipedia.org/wiki/Milgram_experiment in 1961 showed how when participants are morally distanced from the consequence of their actions and when they believe in the power of the authority demanding action, they will continue behaviour even when they can see it is physically harming another person. Around two-thirds of participants showed this behaviour. There are many other examples as well, not least of which come from politics and wars.
So what does this mean for raising the standards of healthcare? Imagine working in an organisation where a critical mass of people (clinical professionals as well as managers and administrators) feel distanced from their actions, feel the need to respond to authority figures, are in a stressful context and feel they can act in ways that are driven by their own very personal demons. The sum of the behaviours exhibited become the norm culture.
So when I encounter really good examples of clinical or administrative practice and I am asked to help with spreading this to other places, then one of the key things I am thinking about is the underpinning behavioural dynamic. What is it about the team and the behaviour of the individuals in the team, that contribute to their identified quality / safety improvement performance? What is their norm? To what extent is this about how they manage the power dynamics? And if others are to adopt their work, what will this do to their use and abuse of power within their own systems? How will they break free of their current norm? Whose behaviour will be critical in this shift of norms?
I’ve been through the process of listing, rather objectively, the behaviours required for good practice to be adopted. Maybe this is helpful in working out just what needs to be done to effect the change. What I know now is a list of behaviours is not the same as the behaviour itself. I am also a great deal more aware of the context in which behaviours are played out and I am open as to the impact of power dynamics in a system.
This is messy stuff that doesn’t lend itself to the predominant method of change in healthcare, namely the issuing of a “how-to” guide. I think it requires conversation, dialogue, self-awareness and attentiveness. There’s no quick fix.
Thursday, 2 April 2009
Theory is often interesting and sometimes useful. Practice is usually difficult and never quite what you expect. Thinking about "push" vs "Pull" I decided to run my own 90 day project to see what I could learn about enabling "pull".
This blog is both about Twitter as well as about a 90 day project process. If you don't know what Twitter is then check out this video: http://www.youtube.com/watch?v=ddO9idmax0o
With Twitter http://www.twitter.com/ you share information, 140 characters at a time, with those who follow you. You also get to "listen" to those who you follow, and if you like, you can forward on their messages to your own followers (called retweeting). It is easy to follow someone; do a search for names or keywords you're interested in and then click on the "follow" button. You may also see a message someone has put up and then decide to follow them.
But how do you attract followers? How do you get a pull? This was my project question.
90 Day Project Aim
To get my profile in the top 100 of England and top 100,000 of all Twitterers (of a population 2 million and growing). I chose a ranking rather than a number of followers as I felt this is more aligned with my intention and context. A bit like choosing to reduce hospital costs by having no infections, rather than counting the number of infections. One of the complications of measuring ranking is you have to keep up your position in an ever increasing pool (the denominator is increasing rapidly).
On 27th December 2008 I had 7 Followers. On 2nd April I had 347 followers. Average growth per day was 8 and the current trend predicts 536 followers within 30 days. I have used http://www.twittercounter.com/ to measure progress. My ranking worldwide is 79,492 and within England it is 79th http://www.twitterholic.com/
- It really does work to learn from where other have gone before. I was 45 days into my 90 day project before I realised I hadn't practised what I preached, namely discover the existing good practice. Only then did I search for other's experiencing of generating a pull and adopt some of their ideas. This helped, though it was not enough.
- It is possible to get started (on Twitter and I believe anything else) without knowing exactly how you're going to do it. For me, the act of the 90 day project meant I had to learn how the technology and system worked. It focused my attention.
- Measurement is crucial. I check on a regular, sometimes daily basis to see whether my actions where having an impact. Ok, so this is easy when there are systems in place to do the measurement, though I would find it hard to know what was a successful strategy without this. After a while I began to see pattern in the data which matched my Twitter behaviour. Quite amazing really...
- A "pull" is about adding value. No-one is going to follow unless they have a reason to do so. Equally, they can unfollow at any time (and I had one wobble when the graph slipped back due to unfollows - largely due I think to me unfollowing a lot of people - we sort fo went into a negative slide). So I have started to learn how to create a pull through a virtual medium communicating only 140 characters at a time. So if this was a non-Twitter project I would still think about what value am I adding for others and how succinctly can I communicate with them in a way that works for them
- The social process of retweeting is important. I am valuing others' messages and sharing - then they do the same. As humans we are inherently social. Encouraging trust, openness, enabling and allowing connections and networking seems to be fundamental. Why should I expect anyone to follow me if I don't share, put others' messages forward (always attributed) etc?
- I put my Twitter link on my email signature, added a button to my website, integrated it with my three blogs. What I am seeing is the links between these online activities and how they feed one another. Using a variety of tracking software I can see which ones are triggering followership. Maybe for other 90-day change projects it is important to think widely and outside the direct scope of a project in order to influence change.
- One of the scary things about a pull vs a push is you're not in control. Yes, I can see who follows me and I can then choose also to follow them or not, I can also block people. However, by letting go I have discovered some new contacts, new people that I would not have encountered before. Yes, I have also encountered some fairly random followers who I see no reason why they should follow me. But who am I to judge? And that is the point.
- When it came to updates I tried to be regular and consistent (something every day or two), aimed not to overwhelm at any stage and to tread lightly.
What will I be doing in the future
I will continue with Twitter as I find it useful. I've now set a different goal which is about quality rather than quantity. I want to test the next stage of "pull" - where something gets acted on as a result of a "pulled" tweet. This won't be easy to measure. I was fascinated by the recent example of this type of "pull-action" from Stephen Fry and Twitter. At the time he had around 352,000 followers (he is in the worldwide top 20). One day he tweeted a link to an Open University website / game. This OU page / game then got 52,000 hits in a single day. Around 15% of his followers acted instantly on a tiny fragment of a message. And the numbers were big.
If 15% of clinicians, professionals and managers in healthcare acted almost instantly on a message they had pulled, I wonder what might be the impact? Scary, huh...
Follow me on Twitter: http://www.twitter.com/sarahfraser