Strategic Facilitation and Web 2.0

Strategic  facilitation. That's what I think I do quite a lot of the time. Basically I try to help senior NHS managers and clinicians either a) to explore difficult and organisationally significant issues  or b) to identify new strategic possibilities and form useful leadership coalitions that can help these aspirations come to fruition.

All mildly interesting perhaps, but what's this got to do with Web 2.0?

Well, as people who know me are aware, I also am an enthusiast for Web 2.0 tools and applications and recently I've taken to blending the use of some of these tools into the facilitation work I do. Garlic bread, it's the future!

Two straightforward examples might help shed some light:

Example 1

A few month back I was asked to  facilitate a meeting of about 40 Health Economists, Finance and Public Health Directors. They were being pulled together to advise DH on whether a national support network ought to be formed to help PCTs make better revenue investment decisions - from both technical and allocative efficiency perspectives. I suggested that the organising group use SurveyMonkey to seek the group's views, in advance, about whether forming such a group was a good idea  (it was thought to be so surprise surprise) and, more importantly, what the key roles and responsibilities of such a group might be.

An online survey was duly run (at no cost!) and the subsequent 4 hour meeting was then focused on 3 things: a) Quickly sharing and clarifying the results; b) Exploring the 2 issues where significant differences of opinion within the group seemed to exist; and 3) Asking the group to  focus most of their time on providing detailed advice about how the top 5 roles, as voted in the survey, ought to be discharged in practice.

The point is that, without the free online survey, the group would have come together and spent alot of their time talking in generalities about the support network and what it might do. The survey 'cleared the decks' and allowed the face to face meeting to add more value to the proposed initiative.

Example 2

Currently I am helping a well established University research network to develop an accreditation re-submission bid to enable it to continue to receive a sizeable amount of research monies for biomedical research projects. We are using a tool called Ideascale to  invite stakeholders to suggest, refine and prioritise key questions that need to be addressed before the resubmission proposal gets written.  So instead of the  2 day workshop that was initially proposed, where everything is addressed in one go for better or worse,  we are now holding a half-day meeting to address the 10  most powerful questions , followed, 2 months later by a half-day session with stakeholders where a draft re-submission bid will be presented and modified.

In both examples, Web 2.0 tools (SurveyMonkey and Ideascale in these cases) are being blended into the development process, helping to create less time consuming and more focused face to face working.    Garlic bread, it's the future you know!

The Long Tail of Facilitation Questions

Image by Segozyme

Recently I was in a 5 hour meeting, planning a series of high profile workshops for civil servants and senior managers to explore the key features of a new Commissioning system. Don't worry, it wasn't in England! Two other professional facilitators/process designers were in the room, as were 4 or 5 policy people.

The meeting progressed quite smoothly. Time passed, with occasional bouts of tension and excitement and a few interesting design choices emerged. However, (and you may find this a little sad), energy levels went nuclear amongst the 3 facilitators when the question of whether or not to have appointed facilitators work with the 8 table-based groups popped up!

We (the facilitators) had different opinions and loved the debate. In fact we 'came alive'. Much better than discussing a boring old Commissioning system. The poor old policy people were bemused, perhaps rightly so? Eventually after 3 or 4 minutes of increasingly heated debate we came to our senses and suggested that we resolve our differences on this matter outside the meeting. The policy people signalled a huge sigh of relief.

For the record, three options were under discussion:

• Identify and brief competent 'table facilitators' from beyond the 40 invited participants in advance;

• Identify 8 people from the 40 participants in advance who we think would probably be competent as facilitators and ask them to do it, with a briefing before the workshop; and

• When the time for table facilitation comes, draw everyone's attention to a short list of facilitator responsibilities listed on the wall and ask each table group to  appoint someone from their table to act as facilitator.

 I was angling for option 3.  Which option do you prefer and why?

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Why is the NHS a Web-Free Zone?

photo by Jude

Guest post from Roger Marlow, Health2Works

Before I try and answer that question, let’s start with a few questions about you. Do you use IT at work, and if so is it any good? And next, do you use the web at home, and how does that compare with your experience at work? If like me you find what is available 24 hours a day, for free, on the web utterly amazing and what is available in the typical work place relatively stone age, then you are not alone.

The incredible story of the growth of the web isn’t news anymore but even the raw numbers are still staggering. You can search 2 billion web pages in a fraction of a second, read 3 million wikipedia articles, watch 9 million YouTube videos, subscribe to 175,000 new blogs every day and chat with 200 million people on Facebook. And it's not just the scale of these facilities that is amazing. They are available all day every day, never run out of space, they continually add new features, and there are literally thousands of new things to try out every day. And it all happens without any overarching management or grand-design; the web has no CIO, no mission statement and no management team. 

Compare that with the experience of IT in a typical NHS PCT or Trust. Here we have CIOs, mission statements, and management and project teams galore, but there isn’t the feeling of innovation, pace and sheer wonder that you get from the web. Why is that? Perhaps you feel like Blackadder trying to teach arithmetic to Baldrick, who gives up complaining “To you, Baldrick, the Renaissance was just something that happened to other people, wasn't it?”. Is the web just something that happens outside of healthcare?

Isn’t it time we put the web to work in the NHS? It has changed, largely for the better, key aspects of just about every other aspect of society. Perhaps it’s time to stop thinking that IT is something that happens ‘over there’, at huge expense and risk, by people with funny job titles, focused entirely on extremely complicated clinical integration projects. And what’s more we are at a crucial point in time. The web itself is going through a renaissance, creating so called Web2.0, supporting new social effects such as social networking, empowering the “long tail” and giving a global voice and power to even the smallest of minority groups. Which is all rather prescient for health. The NHS faces enormous increases in demand for more consumer friendly healthcare services and experiences at the same time as significant financial challenges. It can aid its own survival by taking advantage of some amazing technology.

Yes, the NHS has dabbled a bit with Web2.0 applications, but now is the time to embrace the full potential of Web2.0 and experiment like crazy. I and others are proposing ways of bringing, quickly and at low cost and risk, the amazing technology of the web, and in particular Web2.0, to healthcare. This is not just to give us all a better experience of IT in the workplace, but primarily to give better, more efficient care, to reach and connect with more people. 

Now is the time to act. Do you think the NHS is sufficiently curious? If you are interested in getting involved, please have a look at what Steve, Robin and I are up to at health2works and let me know what you think. 

Roger

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Summer Holiday Questions for Chief Execs

Most Chief Execs are going to be on holiday for a couple of weeks soon. Rest and relaxation hopefully, but also a chance to reflect on some deeper questions, away from the cut and thrust of day to day life in the NHS.

At the risk of ruining a few holidays, here’s my list of questions to mull on whilst lying on the beach or pottering along cobbled streets etc.

1.How can my organisation clearly demonstrate that it accepts a fair share of the responsibility for getting UK plc out of the mire?

2. How can we still keep a focus on creating our future whilst coping well with the financial uncertainties and challenges of the next few years?

3. Do I really care about quality?

4. How many staff want to work for my organisation more than any other and how can we get this number up next year?

5. If my organisation didn’t exist would local people demand that we be created exactly as we are now?

6. Am I still keenly interested in healthcare and serving people?

Got any better questions to pass the time on a sunny beach?

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The NHS and Local Communities

I met with some PCT people last week. The meeting was in a new Health Resource Centre, built under the Local Improvement Finance Trust scheme(the LIFT programme) for £7m.

The Centre is a wonderful building. It's light and airy, has 3 floors, a lovely atrium and even a half-decent car park. It houses a bunch of GP practices as well as a wide range of community services and a few specialist clinics, previously available only at the local DGH. I was so impressed I even took a couple of pictures.

But then I was taught an important lesson. Putting up a nice building and calling it a Health Resource Centre is not the same as acting as a Health Resource Centre. Whilst I was waiting at the Reception desk, a middle-aged, friendly woman came in and asked, politely, if she could leave a bunch of A5 leaflets alongside the lovely display boards promoting various local NHS services. Her leaflets were promoting a new local voluntary support group for people with Cancer. "I'm not sure let me check", said the Receptionist. A phone call ensued. Then came the reply "Oh dear, I'm sorry but we have a policy only to stock official NHS leaflets. Do your leaflets have an NHS logo on them by any chance? - No, I'm sorry then, but we can't take them".

I was reminded of this little story this morning when talking with my wife. For some reason, please don't ask why, my wife has decided to offer a home boarding service for dogs. She's produced some colourful posters and yesterday popped off to 3 local Vets to see if she could put the posters on their notice boards. All said yes, without hesitation, as did the 4 local shops, scattered around nearby villages, that she approached later the same day.

Apparantly vets and shop keepers consider themselves to be intergral parts of their local communities, but the NHS is still not sure.

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Wonky Teeth and NHS Inequalities

My son has 'wonky teeth'. My wife took him to the dentist (on the NHS). She, the dentist that is, suggested that a specialist should come and take a look at him, to decide if he needed braces . Wife and son agreed.

Six weeks later he went back to the dentist for his assessment. Turns out he could benefit from treatment but didn't qualify for free (NHS) treatment - "he's just on the wrong side of the access threshold". We would need to pay privately for the treatment. Wife asked how much. £2700 was the reply. Wife walked out in a daze.

Now I have a friend who is a dentist. I rang to ask for advice. "Who did the assessment?" he asked. "Mr X" I replied. " Well, he only does private work, why were you seeing him? You should go back to your dentist and insist on a proper NHS referral" he suggested. "I thought that was what we were having in the first place, thanks for the advice" I said.

We followed the advice. Last week my son went to the local DGH for another assessment. This time by someone who is employed by the NHS. He was still borderline but, after a bit of humming and harring, he was accepted for treatment. No charge.

My dentist friend saved me £2,500! Trouble is most people don't have a dentist for a friend, or a GP, cardiologist or social worker for that matter. What happens then?

Perhaps they might contact their local NHS PALS office? I didn't think of this, which is interesting in itself. I've just tried to contact them now, out of curiosity. According to the national PALS website, my local office is 'full-time staffed', but it only deals with written enquiries!

There must be tens of thousands of people who each day feel 'adrift' in the labyrinth that is the NHS, stoically or angrily accepting 'their lot'. Its mid 2009. We need to do better. Perhaps it's time for a professionally run national telephone and online patient agent service that can quickly source good, geographically relevant. sources of advice to help people already 'adrift' in the system review their situations,clarify options and become more assertive 'customers' ?

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New NHS 2.0 Not for Profit Start-Up - Interested?

Health 2.0 is part of the future for the NHS. The term, derived from Web 2.0, covers a large bucket of web-based applications, all designed to give patients, healthcare 'consumers' and communities more information, influence and/or control over their healthcare experience or health status.

The Health 2.0 'movement' started in the States, mostly West Coast. I went to the annual Health 2.0 Conferrence last October. About 1000 people (mostly application developers, clinicians and policy commentators) spent a lively 3 days in a Marriott hotel basement, reviewing over 100 health 2.0 applications and exploring where the 'movement' might go next.

To-date the potential of Web 2.0 has pretty much passed the NHS by. Partly because IT staff are largely preoccupied with trying to get NPfiT 'on track' and most managers aren't that familiar with net based appplications. That's going to change soon. The DH is formulating a new Digital Strategy that will, in part, embrace the experimentation with what is becoming thought of as NHS 2.0

I'm going to start a not for profit to work in this area. The basic idea is to help PCTs and Trusts to explore possibilities with talented application developers. Quick beta versions of NHS 2.0 applications can be generated and tested and those that prove to be most attractive to users can then be picked up and funded more fully. Let me know if you are interested in getting involved. It'd be good to find two or three partners who have something to offer. Also let me know if your organisaion is interested in being an early customer!

There is enormous potential here, (despite the digital divide) to help millions of people make their lives a bit easier by the use of relatively simple, very cheap and practical NHS 2.0 applications. Who knows, some may even turn out, as a by-product, to be useful in helping the NHS achieve some of it's key strategic objectives.

A few of my favourite applications showcased at the Health 2.0 Conference are:

Careflash

Limeade

The Prevention Plan

American Well

My Medlab

PatientsLikeMe

WeAre.Us

Sermo

Healthline

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Leadership Styles in the NHS

Earlier this week I ran a half-day awayday session for an executive team of an acute Trust,  titled "The Leadership Challenge for the NHS. I thought I'd share the slides I used.

Topical as ever, especially since leadership development in the NHS is being reviewed, again, at the moment - see this week's HSJ -  NHS is a Brutal Place for it's Leaders

The key point is partly expressed in Slide 15 - Leaders need to be able to make use of several styles of leadership inorder to increase the chances of getting effective results, on or ahead of time. However, most leaders either can't recognise when to switch between these styles or can't use more than one style. To make matters worse, the NHS system is led, nationally, in ways that mitigate against the most useful leadership styles being used at local level.

Do you think this is right? I wonder what magnitude of 'performance gain' might be achievable if NHS leaders at local level were consistently using the most effective style for any given situation?  Perhaps getting appropriate leadership styles in use at the right time might be just as fruitful an idea to pursue as the miriad of 'transformational service landscape' changes that are being proposed all over the place at the moment?

Btw - the ideas contained in the slides are not mine - "Really" I hear you say!

I pulled them from 3 sources (and mainly the first one):

Leadership that Gets Results: Daniel Goleman, Harvard Business Review, March/April 2000

Execution: The Discipline of Getting Things Done: Larry Bossidy & Ram Charan, Random House, 2002

The Leadership Challenge: James Kouzes & Barry Posner, Jossey-Bass, 1987

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Response to DH on New Quality Policy

High Quality Care for All – Measuring for Quality Improvement: the approach is a document that sets out the Department of Health's view about what needs to happen to make quality improvement the organising principle of everything that the NHS does. It invites comments. Here are mine.

1. Timeliness, efficiency and equity have all historically been seen as significant features of NHS quality systems. The traditional focus on these 3 issues must not be overlooked when designing a new system. The NHS needs to learn how to judiciously 'blend' these historic features into a new approach that rightly has a much sharper focus on safety, effectiveness and the patient experience.

2. Transparency is a new and important dimension that is missing from the proposals. Transparency needs also to be present in a refocused Quality system. Inviting, or even welcoming, public and patient scrutiny is probably potentially the single most powerful dynamic that can be harnessed for creating a culture that priorities quality improvement.

3. It is absolutely vital that local leaders, especially Chief Executives and Medical Directors of Trusts, feel capable and personally able to devote sufficient attention to this agenda. Partly this requires a conscious effort on their part to appreciate the 'science' of quality improvement, to prioritise quality related work, to signal this clearly to the rest of the organisation, including the Board and to communicate other Trust activities within a broader Quality 'mindset'. To find a broader 'quality narrative' if you like.

4. Ultimately leadership of successful and sustained quality improvement is not something that can be delegated to 'quality technicians'. Most clinicians, understandably, will only be persuaded that we are serious about quality when they see Chief Executives and other local leaders being obsessed with the pursuit of quality, over a sustained period of time. Leaders really do have to have to 'be the change they wish to bring about'.

5. Most organisational cultures will not become more receptive to sustained and effective quality improvement without a clear and visible shift in the leadership behaviour of leaders. The requisite shift in culture also requires the judicious use of positive incentives to reward desirable attitudes and behaviour deep within the clinical and managerial domains. Commissioners in particular can play a key role in co-designing and reinforcing such positive incentive systems. Financially penalising relatively poor performers is not the route to quality improvement.

6. The new, ambitious vision of “making quality improvement the organising principle of everything we do in the NHS” may of course mean that, over time, the 'goalposts' move in terms of what makes a successful Chief Executive, Medical Director and ultimately a successful Trust. Some local leaders will find this transition easier to achieve than others. It is vital therefore that local leaders make the time to create their own effective lateral peer support mechanisms to accelerate their personal learning about what being successful now means in a re-focused NHS. Existing leadership programmes need to be refocused to reflect this need.

7. Less is better when it comes to agreeing and using a national system of metrics. When building a national set of quality metrics the NHS should start small and build incrementally, developing and agreed a more sophisticated set of metrics (with clinicians) as people learn how to measure, interpret and act. One feature therefore of a successful national Quality System will be its' ability to balance the need for a small set of consistent comparative data at the regional and national level with the dynamic of continual adjustment of meaningful metrics at more local levels.

8. All data will be interpreted. Most data can be interpreted in multiple ways. Clinicians, managers, non-executive board members, politicians, patients and members of the public will all be interpreting quality-related data. The NHS needs to ensure that, as far as is possible, useful and timely training in data interpretation is offered.

9. Data is always interpreted in context. For example, relevant patient stories, sitting alongside 'raw' data will have a significant impact on how that 'raw' data is interpreted. Some stories might 'help' the reader see the data as more positive than might be the case. Other stories could easily help create the opposite effect. Much more research needs to happen, urgently, about the psychology of data presentation, especially in relation to sharing data with the public.

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The NHS in 2009

photo by the|G|™

Here's seven personal New Year wishes for the NHS. These are not necessarily the most urgent challenges but, for me, they are some of the most important. A bit belated I know, but I've only just managed to defeat the Man flu:

1. Get serious about recruiting for attitudes and values. Let's really try to strengthen compassion, integrity, pro-activity and respect for people's wishes;

2. Develop more integrated clinical pathways AND financially incentivise acute and primary care providers, jointly, for the attainment of certain outcomes. We've made progress on the clinical recording systems, now we need to use them;

3. Find ways to 'get a grip' on what's coming down the scientific 'pipelines' and interpret and re-present this intelligence in ways that invite managers to get into dialogue with clinicians about implications for the next 5 – 7 years. Let's not wait till we hear about this stuff on the nine o'clock news!

4. Be more proactive about reshaping or investing in (new) services to ameliorate some of the probable effects of the credit crunch, especially services needed as a consequence of likely mass redundancies. Btw, do we know which areas have most jobs at risk and who the 'at risk' people are?

5. Move social marketing into a pull/push/act cycle rather than a mass broadcast push only service. A bit cryptic I know- happy to talk more about this if asked;

6. Switch revenue investment into good 3^rd sector organisations to give more 'space' for challenging official policy direction where this seems too conservative or overly centralist in nature. The NHS, at local level, will probably never have the ability to really push back hard. This just might be a better way;

7. Finally, and it won't be all that popular, don't don't don't backtrack any further about 'making markets'. The opportunities are too great. There are millions of good, talented, compassionate people out there – working beyond the NHS – who could really help to move healthcare forward. Let's use them.
   

Do any of these strike you as 'spot on'? Perhaps some suggest that I'm living on a different planet? What are your wishes for the NHS in 2009?

Oh and happy 2009.

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