Friday, 30 November 2012

Book Review: Arbesman - The Half Life of Facts: why everything we know has an expiration date

I don't why I never thought of knowledge as decaying over time. Especially when knowledge acquisition and transfer / spread is my specialist topic. Arbesman provides excellent examples and a logical argument to support his hypothesis that facts die out at a predictable rate. This is a fascinating thoguht, especially as in healthcare we believe that we constantly press against "old" facts which are stuck in the system. A reframing to think about what their "half-life" might be, is a useful and inspiring one.

Arbesman has come up with new vignettes rather than trotting out the old favourites. This is not a new take on an old subject, but rather a new subject requiring some disconfirming thinking.

Monday, 26 November 2012

Review of iPhone apps for patients in England

I chose to find and check out apps that patients in England can use – though I did find some excellent ones for patients in other countries  We have some catching up to do…. This is not a comprehensive list and I looked at those that interested me. I've avoided ones that are specifically disease related as I will review those separately. I've also not repeated the apps in my review of iPhone apps for the NHS.

All apps are free, unless specified, and I have no links or specific benefits from any organisation listed in this post.

RCP Stroke Guidelines 2012 – Patient and Carer
Another great title. This is patient specific advice from the Royal College of Physicians and I LOVE the fact it is based on the Guidelines published in 2012. This is a proper app, with a proper evidence base, doing something proper. It would be great to see apps like these for all clinical guidelines. It’s well designed and easy to navigate. And includes links to stroke clubs and other services. Why this works is it is not just a sales pitch for one service or organisation – it is designed around the patient. The first truly patient centred app that I've come across.
This is an information based app with all their leaflets on health, conditions and diseases.  You can also find services close to you. Useful, though I’m not certain about the advertising. Others have reviewed the app as having some technical difficulties and the disadvantage of not being able to store a leaflet for viewing offline.

Communicating with foreign language speaking patients (in English, German, French, Japanese): A guide for doctors and nurses
Wonderful title that explains all. Although this is targeted at doctors and nurses, the app is also useful for patients. Of course there is Google Translate which is probably the best app for language translation as it includes all known languages – though this app does cover some of the more complex medical terminology.

GP Ratings £0.69
A simple app locating GP surgeries and giving you their ratings by using the open data available. It’s a useful way to make data useful, though as the data is made available free of charge some may prefer not to pay. What I liked is the way I could see the details of ratings for my own practice. But would I want to pay 69p to see this once, as I would be unlikely to use it again, as I have little option for changing to another GP.

Sunday, 25 November 2012

Redisorganisation in healthcare: the theory and the practice

A good friend, Bill Russell, tweeted a link to "A surrealistic mega-analysis of redisorganization theories" published in the Journal of the Royal Society of Medicine, December 2005.  Yes, it's a Christmas edition spoof, however, there is some unnerving truth underlying the splendidly irreverent - and creative - paper.  I share it nervously, as I wouldn't be surprised to find it turned into a PowerPoint and a half day course being run to teach people the theories.

The paper got me thinking about the tendency of Healthcare Improvement Leaders to grasp at the latest theory that comes their way, further confusing the people they are expected to serve with their "leadership".  Recently I have encountered an exhortation about the need for consistency and a single model for change in the NHS; countered by the push of new ideas and theories, which dilute this message.  As well as new concepts being presented as though they are the next best way to make an improvement / support change; the concept is a concept - it has not been fully tested.

The frivolousness and scattergun approach for supporting healthcare staff and their organisations is unlikely to be a useful one.  My concern is the endless search for the quick fix is confusing people. In addition, when one theory ends up not working in practice, then I'm not seeing the evaluations, reviews and sharing of lessons (as in role modelling learning and improvement). Therefore each new concept is being built on an ever-weakening foundation.

The value of of those who lead improvement and change in healthcare  I believe, should be based on the depth and pervasiveness of change they support, rather than on the number of new concepts of pilot projects they put into the system.

Friday, 23 November 2012

Feedback needs to be both ways, especially for patients

Feedback is important, in almost any context I can think of. In quality improvement we are continually asking staff and patients for feedback about their experiences. I make a point of completing feedback forms that are sent to me because I believe that my opinion will - somewhere down the line - count.  Mostly this is on trust as I never get any feedback to me as to whether my involvement has been worthwhile.

Asking me, the patient for feedback is giving me the impression that you believe my views are important  Not letting them know me results of my feedback is, sort of, forgiveable (it would be nice to what "what happened later").  But what is really difficult to get to grips with is on-line feedback which is then not answered. NHS Choices runs an excellent on-line feedback scheme where patients can leave their notes about their experience.  In many cases the organisations respond with an explanation. And for many patients this is enough - to know that someone cares about their experience.

For my own GP practice there are a few pages of negative comments from patients whose experience is an issue. The fact there are no recent replies to these comments leaves me feeling like wanting to leave a note about there being no feedback...

Feedback: it works both ways.

Thursday, 22 November 2012

Five iPhone apps the NHS can learn from

Many healthcare organisations are getting on the “app-wagon” by repackaging some of their regular website material.  In most cases, the “innovative” bit is the use of the iPhone’s GPS function for maps. Is this innovation? Not for me.

I’m on the lookout for apps which redesign interaction with health services, that support patients in caring for themselves and their families – and basically, ones which have an underlying brilliant idea that can only be implemented on a smartphone. 

In the end I didn't find any apps that lit me up – though I did find some that gave me ideas for apps that could be developed.

Wounds by BSN Medical Ltd, May 2012, UK only, FREE
You use your iphone camera to take a snapshot of the wound, then use the symbols to categorise it by wound need, depth and exudate level (for the non-clinical this means how bad, deep and weepy it is).  Then the appropriate dressing is suggested – and of course, this is their own brand of dressings. I’m not into promoting one type of dressing but this app is IDEAL for the NHS. Why hasn’t anyone produced this for the reduction of pressure ulcers – linking to the NHS Supplies dressings?  What I like about this is no improvement project is required – implementing an app will redesign the process of assessing and treating wounds/ulcers in the most fundamental way.

iScrub Lite, Free, May 2010
The premise is good hygiene and this app records observations and lets you email those observations. Whilst I am sure this is for audit folk, I can imagine that in the hands of patients (maybe lend them an iPhone while they are in hospital) it would have a big impact.  This would be fabulous if it was populated with the addresses for the contacts in each healthcare organisation in the NHS.

MedCrowd, Oct 2010, Free
This is an app designed to crowdsource medical opinions. I suspect it’s not really taken off but the concept is excellent.

Patient Journal, Free, June 2010
I like this because it is a place I can keep all the notes about being in hospital. The only problem is it really needs to be managed by the carer as the patient may be too ill to use it.  I think this would be good for longer temr patients or just for patients in general to keep track of their interactions with healthcare.  It works because it provides a structure only and doesn’t try to give me advice.

Mixed Messages, Free, June 2012
This is a training app aournd doctor-patient communication. I like the concept and it makes sense for much of the training programs that go on in the NHS to be put into a format like this. It’s simple, focused and not overworked.  No more books, manuals, workshops or PowerPoints!

Wednesday, 21 November 2012

Review of NHS iPhone apps

A number of NHS “innovators” are up there with their iPhone apps. I say “innovators” loosely as most of the apps are no more than websites in an app – useful but hardly innovative.  What’s more interesting is the lack of apps, even the most basic ones, from one of the world’s largest systems.

The NHS brand is one of the most well known in the UK, and using it and looking after it is important. There is now even a Brand Manager (c.£90k post) on the National Commissioning Board. From my days as the advertising manager in Esso, I know how important it is to make sure logos and accreditations are used properly.  My review of apps discovered many people using the NHS brand when they are not the NHS, and others in the NHS are not using their brand at all.

I chose the apps that appeared under a search for “NHS” on iTunes AND where there was NHS in the logo or title of the app.,The apps listed are all free.  
NHS Direct’ health & symptom checker
One of my favourite NHS apps and one I have used. It feels like the whole of NHS Direct is in my pocket. The feature of finding, for example, a pharmacy nearest to where I am standing is very useful. Comprehensive, easy to use and a flag bearer for app quality.

NHS Drinks Tracker
Not entirely clear but I think this is from NHS Choices (they could use their branding on the app logo perhaps?). Interesting to play with but it looks like it lacks flexibility to suit a wide range of users – as verified in the comments for the app.  Maybe an update is required? There’s also a Dept of Health Change for Life Drinks Tracker (do we need duplication?).

NHS Quit Smoking
Branded in the app as NHS Choices. I like the way it counts the amount of money saved according to the number of days you go without smoking.

NHS BMI healthy weight calculator and tracker
Another NHS Choices app. Clear and easy to use. Like the other apps in the series, it looks from the comments, like it could do with an upgrade.  There is stuff competition in app-world for BMI calculators and food intake / exercise trackers, so there needs to be a good reason for someone to use this one.

NHS Give Blood
From the NHS Blood and Transplant service, though confusingly the app logo doesn’t use the NHS branding. It’s a map function of where to give blood locally. I can see this being very useful in a crisis.

NHS 24 MSK help
Hmmmm, pink logo and very strange branding. Developer is NHS 24. Looks like an exercise app. Didn’t inspire me to download it and try it.

UK Clinical Trials Gateway (NHS Institute for Health Research)
Nice – I like it when the name of the app says what it is about and who it is from. As they say in their blurb, it’s for everyone, patients included, and covers the portfolio of clinical trials registered in the UK. I expect I can also get this off a website somewhere, so the innovation here is packaging it all up – a but like NHS Direct.  There is evidence of the app being updated which also enhances its credibility with me.

NHS Moodometer
This one took some detective work to understand. It’s an app to measure your moods. Useful if you’re in the process of understanding your own moods. It has the NHS logo on it. It comes from 2together NHS Foundation Trust – which I found out is in Gloucestershire – not obvious at all who they are and what they do from their name!  If they are using this app with staff then we need to know about this innovative use of it…

NHS Bristol and NHS Yorks & Humber
This is a well-designed organisational app that looks like it can be a standard one for many NHS areas. It’s more than a replication of their website and it is wonderfully designed for us.  It covers ICE (in case of emergency), your personal reminders and notes, where to find which service and cleverly uses the clour coding of the campaign to reduce A&E attendances (the thermometer). This app has a purpose which goes beyond advertising services.   Will need an update after all the structural changes.

My visit to Guys’s and St Thomas’ NHS Foundation Trust
Excellent. Designed for the patient, this app covers appointments, hospital information and maps.  I like the fact the name of the app says what it is for, and the integration with GPS on the phone is useful.

NHS Tameside and Glossop
Not certain about the logo use but the app is one that has broken away from the regular brochure / map / information approach.  Instead it is disease based giving information about conditions and pathways. I am not sure who is the intended audience? The name of the app left me thinking this was about the organisation but the contents are something different.

Welcome to St George’s Hospital
Another one with an app name that is useful. This is another information type app. I found some of the colouring a bit difficult to read and the design is rather poor. There’s a nice facility for providing feedback to the Trust – though I haven’t tested this.

NHS ActiveME
An app from the Royal Hospital for Rheumatic Diseases NHS Foundation Trust allowing the monitoring of daily activity levels.  Nice. Nice. Nice!  Beautiful design, easy to use and I love the graphic reports.

Hmmmm apart from the rather short hand title, I’d not know this was an NHS app. The app logo is coloured stripes – which become obvious when you look at the app – it’s another one of the “ where do I go for what” apps”. 

Northumbria Healthcare’s GP Clinical Information Exchange
OK, so this is something different. Also has CiiX on the app logo. Says it gives real-time infomration about services, clinics and consultants  Not sure what it means by real-time, but what I like is it moves beyond being an directory to adding in some information about what to do if certain thing happen – and that’s good. I’m just not sure we need to add another acronym to the business.

NHSSC Health & Safety Awareness
Logo alert here, if only for adding SC to the NHS. It’s South Central (will need to update (or delete) app when the structural shifts happen). Seem to be aimed at staff though not entirely clear. I like the content but the title, logo and framing is poor.

Friday, 16 November 2012

Resources for Lean in Healthcare: 1 - Free Templates

This is a gathering of resources for those who are implementing Lean techniques in Healthcare.

The list below is a selection of the freely available templates for various Lean techniques. These haven'#t been tested so do carry out a PDSA to test them before using.

Rapid Improvement Event
Running an event

Process Mapping
Drawing a process map in Excel

Fishbone Diagram
Fishbone & problem solving - Excel

6S Alphabet Game
Excel Template
Excel lesson plan
How to flowchart

Paper plane exercise
Powerpoint template

Will Improvement be the new Nokia? An open letter to NHS Improvement Leaders

An Open Letter for NHS Improvement Leaders

Look around you - how many people are using a Nokia phone?

My first mobile phone, in the 1990's, was a Nokia. I wish I'd kept it as it sells on eBay now for more than it cost at the time. However, it's now perceived as an art form, not as a workable option for making phone calls.The demands on mobile technology have also moved on - I use my smartphone less for making calls and more for reading email and playing Bejewelled.

What happened is the context changed. The markets developed, the customers upped their expectations. Nokia, very successful in the early days of mobile technology got comfortable with their success. They became blind to the shifts and the need to dump their favourite (and no doubt hotly promoted in-house) technologies.

The basic concepts of mobile technology has not changed much - but the products have changed significantly.

The basic concepts of what we understand as quality improvement have not changed much since the days of Deming - what hasn't developed much are the products to implement change. TQM has been rebadged, with minor modifications into Lean, which has been rebadged, again with minor mods into a variety of corporate improvement programs. And so on.

Now, I'm not suggesting we throw out all the good things we know about improvement (I can't bring myself to call it improvement science" - it isn't a science.)  We can keep the basic concepts. However, I do feel strongly that retaining "legacy products and programs" is lazy. If you feel the need to say "we need to retain what works" then think through how that sounds to NHS staff - and what it reminds you of.*

Every improvement product designed in and for the NHS has been a consequence of the context within which it was designed, then implemented. The NHS is making enormous changes  both structurally, conceptually and clinically.  Retaining "legacies" doesn't feel like support to this new context.

Be brave, NHS Improvers. Match the pace and scale of the changes in the NHS around you. Let go of your outdated models, methods, tools and products, in just the same way as thousands of NHS staff are having to do on a daily basis for the practises they believe are useful and good.. Design for the future.  Practise what you preach and get innovative - from within.  And I mean truly innovative. I don't mean coming up with an edited version an existing product, or a new framework for something. Instead, create the breakthrough applications that not only fit in the current context, but reset the whole discipline of "improvement" in healthcare. The NHS has an enormous amount of improvement experience and brainpower - use this to good effect.

Nokia missed the boat. It's trying to turn around, but playing catch up in a fast developing market is far more difficult than leading the market by designing the market - think Apple.

In April 2013 the NHS boat will sail. New structures will be in place, along with new demands that will change the face of the NHS for both staff and patients.  My hope is for "improvement" to be on the same boat, and not one of the tugs pulling in the opposite direction.

Note: * Improvers often talk about wanting others to adopt new practises and when these people don't want to, they're labelled as "resistant to change". I'm just saying...

Thursday, 15 November 2012

Reframing patient empowerment

It's good to talk - and following a chat with friend and colleague Bill Russell. I've been thinking about why it is "patient empowerment" doesn't seem to work in practice.

Firstly, it is an irony (check here for a definition and more info on what irony is). There is a dissonance between its implied meaning and what it literally means. Just thinking of the term assumes that someone other than the patient has power - and by creating a program or concept called "patient empowerment" comes across as them with the power trying to give them without the power, some of their power - ultimately the ones with the power are still power-full.  Hence the irony.

Secondly, who thought you in healthcare had the power anyway?  As a patient I am the only person who has power of my health  I may need help from health professionals, the gym instructor, my mother, advice from the bookclub ladies, thoughts from the parish priest etc.  The issue is that I may be seeking a way that health providers do not take away the power I have when I access them.

Thirdly, maybe thinking it is all about power is the problem.  Power itself has no use unless it is applied, employed, or used. This process is called influencing. Some people, with little obvious power can get a lot done through effective influencing - and vice versa. So I wonder what would be different if we thought about the relationship/s and the influencing flows between patients and healthcare providers?

Please add a comment if you have any reframing propositions for "patient empowerment"

Tuesday, 13 November 2012

Social Media and Emergency Planning: What is your policy and procedure?

There's a good blog post by Ben Proctor on how Emergency Planning can/might/does work as part of Emergency Planning strategies. There are some good references in it to more academic reviews and publications. Lots for the NHS to learn about, I think.

Monday, 12 November 2012

Innovative changes to care pathways can increase hospital admissions

Innovative changes to care pathways can increase hospital admissions - really? Well, a report from the Nuffield Trust in March 2011 suggests there is little or no evidence that community interventions lead to a reduction in hospital use.

The report is a good one with a firm research founding - in the absence of any randomised control data. It points out that redesigning pathways can discover unmet need which may account for an increase in hospital attendance.

What caught my attention was that using their own data, each of the eight interventions assessed demonstrated a reduction in hospital use. However, when compared to control groups, there was in fact an increase. This leads me to one of the ongoing issues I have with "innovation" or "improvement" projects. It's easy to come up with a measurement system and set of goals and sample size that has inbuilt biases to ensure good results - and win prizes. But in the end, improvement needs to be tested against control groups.

I recommend you read the full research report, if only to grasp the seriousness of this issue.

Friday, 9 November 2012

Book Review: Crucial Conversations by Patterson, Grenny, Mcmillan & Switzler

This book has the subtitle "Tools for talking when the stakes are high" and I found there was not a single page that disappointed me. Part way reading through the book I thought this is all common sense, and of course a lot of it is. However, the authors are showing and telling in an extremely compelling manner that you just can't help going "aha", oh-yes", "of course" every few minutes. My copy is full of notes, highlighter marks and pages turned over.

So what's the meat in the book?

At its heart is a dialogue model which is about me and the other and how we each act, feel, tell a story and see/hear. In our dialgue we are aiming to create a pool of shared meaning and there are a number of factors that impact this, such as safety, and silence (withdrawing, avoiding, masking) and violence (controlling, attacking, labelling). All this sounds cold in this description, what brings this book alive is the way the authors develop the model with the use of various tools and stories. It's impossible to read it anot feel connected yet at the same time feel empowered to do something about your next high stakes conversation.

You can download book chapters and sample MP3 audio from . There is also the stress test to discover your style under stress.

Friday, 2 November 2012

Book Review: Time Traps by Todd Duncan

You can't manage time but you can manage your thoughts, actions and tasks - that is the underlying premise of this powerful book. I read the book a couple of years ago and in a rare moment, I decided to read it again as I found I was often using the mantra of its premise and was seeking to find more ways to satisfy my desire to get a grip on the slippery slope of the balance between time and tasks.

The book is written with sales in mind though I didn't find this detracted at all from my personal context and I expect anyone who deals with many interactions with others will find it helpful.

The author talks the reader through a number of traps. The first is the identity trap. This is how when time is monopolised by our work we become our work - and thus how important it is to rethink time, to rebalance as part of regaining our personal identity. Secondly there is the organisation trap where the author suggests that most sales people are disorganised, out of control and say they lack the time to catch up. Well, that sound like a lot of the stories I hear from many people! And what I say sometimes as well!!! He suggests learning to stop all unnecessary tasks before they steal time, admit legitimate tasks onto your list of things to do, and make sure you know the difference between necessary and productive tasks. Then take action and assess how you're doing.

He also talks about the Yes trap, and then how to say No, or sacrifice more sales for the benefit of others. He has some interesting things to describe on the value of saying no. Then there is the Control Trap and the issues of letting go and learning to delegate. The technology trap should be familiar to those caught by their email, and for sale people he discusses the Quota trap. And if you're not trapped out yet, there is also the Failure Trap and the Party Trap.

I know this book changed how I felt about time and the management of it the first time I read it and certainly, the second time around, I was reminded to take some more detailed action steps.

Go to here to download a chapter or to carry out the self assessment on the eight traps.