Failure – likely and visible #WILTW

This is the 139th #WILTW

I chanced upon an old article on the relationship of learning and performance and how it appears to improve the former you often see transient decreases in the latter. The authors describe:

  1. The visibility problem: Collecting the data to demonstrate improvement before-and-after an intervention often shows you are currently performing far worse than you thought or reveals problems you hadn’t previously looked for.
  2. The worse-before-better problem: Learning to do new things results in performance deficits. The example given was that of touch-typing: there is a period where you are actually slower in creating a manuscript as you transition between single and multiple finger keyboard use.
Singer and Edmondson 2006 When Learning & Performance are at Odds: Confronting the Tension

A logical consequence of this relationship is that failure becomes a not uncommon event when something is initially implemented (or at least if the evaluation takes place at the nadir of the learning curve).

What really struck me is their observation that failure is not only more common than success, it is also more visible.

This visibility becomes increasingly more overt the bigger the scale of the intervention. This in some ways is inherently obvious but it really isn’t acknowledged enough. Failure is often taken as a set back, or even worse, covered up with an over-glamorisation of positive results at the expense of any real learning.

At times when system pressures are critical the ability to develop new ways of working is vital. However it becomes potentially even more likely that the innovation or improvement will come only after there have been multiple public failures. Given the challenges the organisation is facing this may be even less well received.

At times like this it is important boards, directors, clinical leads and individuals are brave and pragmatic with their interpretation of new strategies and projects.

What have you learnt this week? #WILTW

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The three curses of organisational culture #WILTW

This is the 138th #WILTW

At the start of every new year comes my annual appraisal. Despite it requiring a bit too much form filling and box-ticking I have always welcomed the chance to discuss problems and review strategies with a peer who is outside of my direct area of practice.

The day before this year’s appraisal I chanced upon a re-share of an old post by Bernadette Keefe on tribes and silos in healthcare. This is a recurring theme in many healthcare blogs and something that I’ve repeatedly returned to.

The sad irony is that perhaps I silo’d myself even making these comments.

Bernadette links to a very powerful story by the exceptional educator Victoria Brazil on how tribalism in medicine impacts on patient care and clinician moral (please click here if video doesn’t play)

Understanding the context of why people speak and act in the way they do is vital. Bernadette links to  another blog in which we are reminded of Plato’s insight:

Be kind, for everyone you meet is fighting a harder battle”.

I left my appraisal cognisant of three things, curses almost, which afflict the mindset of healthcare professional.

  1. Our point of view is shaped by the environment we work in

There is a need to recognise that all the most complex and difficult issues don’t just happen to you.

But even when you externalise yourself to see a wider picture:

2. We often only communicate in a narrative or style that we are comfortable with. sometimes we tell stories that others can’t relate to. Either because we are telling the wrong stories or the format (e-mail/corridor conversation/meeting) isn’t an effective method for the listener.  I often note always bringing it back to the patient perspective isn’t as an effective strategy as we think.

And when communication efforts have been exhausted, or are waning:

3. We implicitly acknowledge the status quo as an acceptable place to be.

This is a difficult admission but when challenges become really difficult it is easy to let things drift. Sometimes it is necessary to have  time to let ideas settles and embed. But often  what needs to be done is perceived to be too great an effort, despite the fact that the efforts needed to maintain what you are currently doing are just as great. Sadly this further embeds curse one….

I resolve to treat these three afflictions in 2017!

What have you learnt this week? #WILTW

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Is the #NHS crying wolf? #WILTW

This is the 137th #WILTW

Every winter is tougher, busier and more draining than the last with an unremitting year-on-year rise in demand:

  • Emergency admissions from major A&E departments have increased by an average of 4.3 per cent a year since 2003/4
  • Attendances at outpatient clinics have risen by an average of 3.8 per cent a year since 2007/8
  • Admissions for planned treatment have increased by an average of 4.3 per cent a year since 2003/4.

It is no surprise then that within, and without of healthcare, people are wondering how long things can continue with flatlined funding before the NHS completely collapses.

There is a slight problem though.

Because we have been here before.

For at least the past 3 winters think-tank and media reports have warned the current situation is the worst ever.  In December 2015 #WILTW responded to an article by BBC Health Editor Hugh Pym which concluded:

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

This does prompt the question of what actually is it that might ‘collapse’? The NHS isn’t going to go out of business, close its doors and turn off the lights. What I think professionals fear the most is that they will be delivering a service that isn’t safe or sustainable. There are those  who already say emergency care is out of control but we are not (yet) repeating the past when huge waits in Emergency Departments and for elective surgery were the norm. However people do fear being overwhelmed by what they need to do on a day-to-day basis to keep the health system ticking over.

Staff resilience as a whole though is incredibly strong. I wrote last year:

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.

But will this be its undoing if the 2018 headlines read: “NHS again at tipping point” or is it that the cycle of care is such that we thrive on a crisis? It may well be time to decide what our real concerns are because otherwise the NHS will remain at risk of being taken for granted.

What have you learnt this week? #WILTW

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If the NHS ran Disney #WILTW

This is the 136th #WILTW

Please read this with the Christmas spirit it was intended 🙂

In 2004 Fred Lee published “If Disney ran your hospital: 9½ Things you would do differently“.  His observations, as an American hospital executive who went on to work for Disney, are technically more pertinent to “pay-as-you-go” systems but remain relevant to all healthcare providers. His key idea is that customer experience is paramount and being obsessive about it will improve quality across an organisation. The famous example from the book highlights that healthcare professionals never say why they are drawing curtains around patients. He argues just explaining it is for the patient’s own privacy would be a small but tangible approach that would improve experience.

Having taken my daughters to Disneyland Paris this week I can vouch that the ‘Disney’ experience is certainly something special. The attention to detail in the Sleeping Beauty castle, the brilliance of the Buzz Lighter Laser Blast and the charm of the Dumbo flying ride all definitely have a ‘wow’ factor. However having completely  immersed ourselves over a couple of days I do think there are areas where the NHS might just have an edge over the corporate machine that is Disney.

  1. Waiting Experience – In both the NHS and Disneyland you need to be patient and wait in line. However while waiting in an Emergency Department to have your broken arm mended is not the same as waiting to fly through the sky with Peter Pan you can pretty much guarantee in the NHS there will be toys in the waiting room. The interaction during queues was surprisingly sparse in Disney, perhaps they need to employ some Play Specialists..
  2. Waiting Times – While a matter of great political and clinical debate the NHS does have standards it aspires to. Are there waiting time for rides that Disney wouldn’t publically be prepared to publish? What percentage of visitors get to ride Big Thunder Mountain having had to use a significant proportion of their total visit time for the privilege? The 4 hour target is a cause of great controversy but at least it’s a matter of public record.
  3. Prioritising Services – In order to maintain flow for emergencies the NHS may chose to delay elective surgical procedures. While this is clearly frustrating for some it maintains the service within a finite resource envelope. Disney doesn’t have the ability to sacrifice Mad Hatter’s Tea Cups to improve access to Pirates of the Caribbean.
  4. Managing demand – The services the NHS can provide do not match the need for care it wishes to provide. Therefore prioritisation decisions need to be made. These are difficult, and sometimes very unpopular, but aim to ensure treatments are given to those most in need of help or most likely to benefit from it. In Disney however it is possible for a group of adults to decide they’d like to have their pictures taken with Mickey over breakfast denying a couple of toddlers the chance.
  5. Knowing your environment – while many hospitals are like mazes at least NHS staff will be honest if they don’t know where ‘Clinic 23’ is. To the Disney staff member who looked like they weren’t sure where we wanted to go, but still cheerfully sent us completely in the wrong direction, we forgive you.

Have a good holiday period – whatever you maybe doing.

What have you learnt this week? #WILTW

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Jugaad #WILTW

This is the 135th #WILTW

Dependant on your source Jugaad is a colloquial Hindi word which implies a work-a-round solution to a problem. Its direct translation is ‘machinery’ but in management vocabulary it describes cheap resources which solve complicated issues. It was used in the context of ‘frugal innovation’ in a blog linked to by Roy Lilley this week. The Jugaad approach cited as a mechanism to help the NHS in this difficult period.

No immediate cash injection into the healthcare system looks likely at present. An even if it was suddenly to occur it wouldn’t solve those inefficiencies, bureaucracies and productivity challenges which are not directly amenable to financial resolution.

It is very easy to develop learnt helplessness during these challenging times:

There is nothing that can be done, or nothing I can do, so I will continue to do nothing.”

I think this phenomena plagues healthcare more than we care to admit. Having said we have strong notions of productivity and I think pride ourselves on attempting frugal innovation where possible.

There is a delicate balance here – the concept of Jugaad could easily become part of management ‘bingo’ and certainly won’t solve some of the more wicked problems we have in healthcare. Conversely falling into a cycle of despair helps no one.

I have tried where possible with #WILTW to reflect and learn with tangible solutions. I have no immediate answers this week however if there is one thing that may well keep the  balance, it is the healthcare staff themselves…. (click here if video below doesn’t play)

What have you learnt this week? #WILTW

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Don’t Multi-Task, Multi-Think #WILTW

This is the 134th #WILTW

There are very few completely original ideas.

Someone, somewhere is always likely to have thought of something before you have. Genius more in being credited for the idea rather than having it!

Andrew Tagg released a great blog post this week. He muses on there “never being enough hours in the day“. I am often challenged on how I find the time to do so much; especially considering that I am “always tweeting”.  My stock response to this is “well how do you know I am tweeting so much if you aren’t on twitter too?

Seriously though, like Andrew, I am relatively regimented about out-of-work routines and there are somethings I treat as a hobby rather than a chore. I do appreciate this is a fine line and it is important to take stock and be honest with yourself about why you are doing what you are doing (especially with social media). I share with Andrew a general aversion (or maybe more correctly an avoidance) of television and video games and also see so much kinship with this:

“I currently have ideas for about 20 blog posts in slow Brownian motion inside my head.” 


One of my greatest faults is to not always be present. My colleagues do very well to tolerate this in me. It is often because an idea or thought from 2 weeks ago  re-surfaces with a progression or solution. I am not knowingly mulling things over but somewhere in my brain synapses are firing away.

Having read the post I coined the term “multi-thinking”. I am not efficient because I am multi-tasking, it’s because my brain is simultaneously working on lots of projects in the background. Sadly after googling multi-thinking I realised I wasn’t the first person to coin this. There is actually science behind it; the more precise term probably being a variant of integrative thinking.

“..the predisposition and capacity to hold two diametrically opposing ideas in their heads. And then, without panicking or simply settling for one alternative or the other, they’re able to produce a synthesis that is superior to either opposing idea…”

The ability to multi-think is, I’m sure, impacted by state of mind or other external factors, but it’s a pretty reliable component of my productivity, especially what I learnt this week!

What have you learnt this week? #WILTW

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In googling for multi-thinking I found this post on procrastination which while not directly related is quite fun….


It’s easier to recognise wrong from right #WILTW

This is the 133rd #WILTW

While delivering a presentation at #MedX a member of the audience was taking notes in a different format than usual.

James is a healthcare designer and his visual note taking really appealed to me. He recently visited our children’s Emergency Department and had some amazing insights, both from a design point of view, but also because of his perspective from outside of the healthcare profession

One of his comments:

Kneeling down and reducing your physical size is so important. Witnessing situations where adults didn’t match the child’s eye level made it even more obvious of its importance.

Those working in paediatrics have an instinctive desire to kneel down. Jame’s statement stood out, not because it was new to me, but from his observation how obvious it is when you don’t do it.

While the message in this picture is self-evident


I think this is perhaps more powerful..


The point is maybe obvious but I am struck that it is perhaps easier to recognise when something’s wrong rather than when it is right. We are observed constantly in healthcare; what might have you been remembered for on your last shift?

What have you learnt this week? #WILTW

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