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No plan, no progress it’s a simple equation in healthcare

Every business manager can lay her hands on plans and policies and can probably recite the ‘vision statement’. I like the one for Lexmark printers because I think it works for healthcare clinics:

Customers for life. To earn our customers’ loyalty we must listen to them, anticipate their needs and act to create value in their eyes.

The manager’s shelves might house annual accounts, a policy for Human Resources,  a policy for health and safety, a policy for recruitment. The practice may have a chartered accountant, a registered financial advisor, a recruiter and an HR manager. Rarely if ever does a clinic have an appropriately qualified research consultant or a five year R&D plan or policy.

Therefore the manager relies on anecdotes and other people’s data to decide if the practice is delivering accessible and effective services. The practice relies on others to advocate for them and to defend the charges that are levied on their behalf. It’s all left to persons unknown in a far away bureaucracy.

The consumer relationship starts with the brand. Before you even meet the consumer, you must fully understand your brand. If you don’t know who you are as a brand, and what makes you different, better, and special, how do you expect a consumer to? You must clearly define a brand’s product benefits to set up more intimate, emotional bonds. It is these emotional bonds that will form the basis of a lasting consumer relationship. HBR

If you are a clinician in a practice what aspects of the practices’ vision are non-negotiable and how will you know if something is undermining that vision? How reliable and valid is your understanding of the following:

  1. What is the context in which the practice is located? What drives morbidity locally?
  2. How are people greeted at the practice? What do they notice about your premises?
  3. What is the commonest reason for attendance?
  4. How long is the average consultation?
  5. What is the outcome?
  6. How many people receive less than evidence based care? Why? What are the consequences?
  7. How many people take your advice? How many go elsewhere after coming to you?
  8. Which innovation is going to be introduced and tested in your practice in the next five years?
  9. What information will guide investment decisions in the practice?
  10. Are you participating in externally funded research? Why those projects and not others?

These questions are of great interest to the better companies. Companies that are ‘lovemarks’:

Lovemarks reach your heart as well as your mind, creating an intimate, emotional connection that you just can’t live without. Ever. Lovemarks

Never let innovation for a brand be something that happens randomly. It should fit strategically under the brand. At Beloved Brands, we believe the best brands build everything that touches the brand around a Big Idea, that guides the 5 magic moments to create a beloved brand, including the brand promise, brand story, innovation, purchase moment and the brand experience. beloved brands

If these issues are of interest to you I invite you to contact me to develop a plan for your practice.

Picture by UCL Mathematical and Physical Sciences

Innovation is a product of leadership

339113868_1052c8c6a0_zInnovation is ‘a new idea, more effective device or process’. Innovation can be viewed as ‘the application of better solutions that meet new requirements, inarticulated needs, or existing market needs’. It is the fruit that appears on the branches of an organisation where every active component or member has at least what they need to thrive. Maslow identified the hierarchy of those needs. Not every ant in a colony is the queen. Not every ant has to gather food. However if the colony is to thrive every ant must play its part or work with others to solve a problem creatively.

The leader is only ever accepted in nature when the colony thrives. If the leader or potential leader has a limited capacity to facilitate the success of their colony, they are replaced or ejected. At the moment when the team faces a challenge that could impact on their capacity to be productive the individual team members must rise to the challenge. Any solution must not risk the colony. That means that foot soldiers need to live the mission of the colony, they must know the limitations of their mandate but not have to ask the ‘most senior manager’ if it’s OK to do something that brings success in their tasks.

Leaders embody the behaviours and attitudes that give the foot soldiers confidence. They communicate effectively. They ensure an adequate supply of that which underpins creativity. They ensure that the needs, as opposed to the wants of their team are satisfied.

The list of innovations produced by a company is a litmus test of the effectiveness of its leaders. The most prolific innovators foster a culture that will continue to contribute to human welfare. Their leaders have the capacity to ensure that each and every member of their team feels valued but also understand and accept the mission of the mothership. The employees learn to behave as part of the whole and yet feel empowered to boldly solve problems in their domain. A critical component in innovative human organisations is the enlightened and selfless exercise of power where relying on the natural response to chemical pheromones is not an option. If you believe you cannot be involved in any research or innovation where you work you may have a problem. An inventory of your new ideas may be a good place to start a review.

Picture by Kasi Metcalfe

The bean counters of BoGIn

5085594028_fc5d378a40_zThe bean counters at BoGIn (Bank of Good Intentions) noticed that some people came to the bank to get mortgage advice and others for personal loans. In fact there was a lot of money to be made by persuading people to borrow money. So they decided to make some reforms. A memo was circulated informing staff that customers will only be able to deposit money in the afternoons- it was to be called the ‘deposition clinic’. Similarly customers would only be able to make withdrawals on Wednesday mornings. Additionally this service would be manned by the most junior clerks who must have all their work checked by the bank manager who would also spend the day at meetings reporting his branch’s performance on key performance indicators.

Customers who withdraw their money are not good for business.

Bank tellers were ordered to ask every customer to fill out a form documenting how much they owe other banks. Customers must always do this before tellers can attend to any other reason the customer came to the bank. Forms must be completed with a black pen and the signatures witnessed by two independent adults. Bank tellers would earn a bonus every time a customer takes out a loan and would accrue points towards promotion if the customer takes out a mortgage at 5% above the cheapest rate on the market.

The bank managers and their staff were shocked. How was this to be achieved? However the bean counters pointed out that the shareholders required the staff to be accountable and there was a need to increase profits by at least 25% this year. A percentage agreed by the committee of bean counters advising the shareholders.

But we are doing so well. The bank makes a hefty profit and our customers are among the most satisfied in any industry. We offer a service. We listen to our customers. We try to help our customers achieve great things that keep our economy afloat.

The bean counters were not impressed and threatened to force managers to be recertified every year or lose their right to bonus payments. Many managers have since found alternative employment. Recently the CEO of BoGIn attended her branch to deposit a cheque. She queued for hours before she was first asked to complete a form documenting her debts and given a brochure on mortgages. Then she was informed she could only make deposits in the afternoon so she had to return the next day. The bean counters have been sacked and were last seen at the department of health next door.

Picture by DaMong Man

Health Innovation: lessons from the past

What lessons can innovators learn from the experience of a medical practitioner born in 1749? Here is a summary of what happened:

  • He was a curious and prodigious innovator who based his ideas on his observations.
  • He built and twice launched his own hydrogen balloon.
  • He published the observation that it is the cuckoo hatchling that evicts the eggs and chicks of the foster parents from the nest. Something that many naturalists in England dismissed as pure nonsense until it was proven beyond doubt in 1921.
  • He devised an improved method for preparing a medicine known as tartar emetic (potassium antimony tartrate).
  • He worked as a doctor and noted that dairymaids were protected from smallpox naturally after having suffered from cowpox.
  • In 1797, he sent a case report to the Royal Society describing how a boy who had been inoculated with cox pox subsequently became immune to small pox. The paper was rejected.
  • Many years later he published another paper outlining his hypothesis. The publication of the Inquiry was met with a mixed reaction in the medical community.
  • In the course of his life he not only received honors but also found himself subjected to attacks and ridicule.

In summary 80% of people exposed to small pox contracted the disease. Almost 1-7 died. Many thought it was innate to humans. Others thought it was an infection attributed to menstrual blood or something caused by the putrefaction of the umbilical cord. A host of remedies were proposed at the time, including special diets and enemas.  There is a remarkable parallel between the variety of proposed “cures” for smallpox and the treatments for many modern maladies foisted on a long suffering public by those looking to make a profit. The discovery of the small pox vaccine by Edward Jenner was arguably one of the greatest leaps in medical science. It was made by someone who observed the effect of the innovation at first hand. His ideas were rejected and ridiculed by many but recognised by those with sufficient insight to ensure that humankind would benefit for generations to come. How do we recognise those most likely to offer a genuine step forward in our search for a better way?

Health innovations are not always intuitive, but rather are made by innovative thinkers who are brave enough to try something new and think outside the box. Colin Farrelly

My colleague Ori Gudes drew my attention to this post by Chris Dixon. Chris brings the Jenner experience into the 21st Century. His post outlines three key features of those with a winning idea:

  1. Know the tools better than anyone else
  2. Know the problems better than anyone else
  3. Draw from unique life experience

However, having said that he points out that these characteristics are not immediately successful in getting their innovations to market because:

  • Powerful people dismiss them as toys
  • They unbundle functions done by others.
  • They often start off as hobbies.
  • They often challenge social norms.

So how do you spot a good idea? Pose one question: Does the founder have technical expertise, problem/domain expertise or experience? My colleague Oksana Burford and I observed the reaction of young women who were shown photoaged images of their wrinkled faces after a lifetime of smoking. What we observed persuaded us that this reaction would trigger determined attempts to stop smoking. Despite numerous applications Oksana couldn’t get her project funded. Potential funders couldn’t see what we had witnessed in the consulting room. So she committed to it as a self funded PhD. Oksana delivered the intervention as part of brief professional smoking cessation advice in a randomised controlled trial. As per the published results we observed 1 in 7 successful quit attempts, which is better than most other interventions. Oksana will soon be working with colleagues targeting Parisian smokers. Meanwhile Gemma Ossolinski and I are using a similar intervention in obesity– the preliminary results are also very encouraging.

Innovating for exemplar conditions

Colorectal Cancer (CRC) impacts on every part of the healthcare system. If a solution can be found to the challenges associated with CRC then they can probably be found for dealing with many other chronic and complex conditions.

  • CRC is one of the commonest malignancies in the developed world and often presents too late for curative treatment.
  • It may be related to a poor diet and is associated with obesity. The incidence is rising.
  • The vast majority of CRCs present with embarrassing symptoms.
  • Such symptoms are common and are also features of benign disease. People find it difficult to decide when they should see a doctor.
  • They often choose to consult other than a medical practitioner and there is evidence for procrastination and for inconsistent advice from the other healthcare providers.
  • [We need tools to assist those healthcare providers to signpost people to a doctor. Such tools need to fit seamlessly into their way of working]
  • The investigation of lower bowel symptoms are invasive and involve unpleasant intimate examinations.
  • Men are more likely to delay consulting a doctor than women.
  • [We need to understand why that is and what we might be able to do about it.]
  • Eventually anyone who develops CRC has to visit a doctor occasionally as an emergency. Symptoms may not correlate to the severity of the disease.
  • Those at highest risk of cancer are older people with lots of other problems.
  • They are all referred to a surgeon. Sometimes the diagnosis is delayed longer than it need be.
  • The treatment of CRC may include surgery, chemotherapy and or radiotherapy. Most people survive.
  • In a typical group of people treated for CRC a large proportion will develop long term side effects.
  • After treatment most patients will attend a specialist clinic briefly once a year, they will have unmet needs.
  • All patients will visit their GP/Family physician/Primary Care Practitioner more often than that mainly about their other problems.
  • We know the sorts of problems they present to their GP.
  • We also know that there are many problems or concerns that the patient does not voice to their GP and that treatment for CRC diminishes quality of life.
  • Primary Care Practitioners have the skills and resources to help people in these circumstances although they might need some additional guidance.
  • [We need a tool to help patients focus on these side effects and help them present this information to their GP.]
  • We need a tool that does not require fundamental reform of the healthcare system.

[A team of PhD students is working to fill in the blanks- their expertise will give us the capacity to focus on other such conditions]
In developing this program for innovation they worked with people who have been closely affected by this condition. They worked quickly, economically, creatively and in partnership with the healthcare practitioners involved in responding to the needs of patients and their families. Their work is beginning to be published.

Why innovators should learn to embrace feedback

Lean innovators often work in isolation and not surprisingly the innovator is emotionally invested in her idea. She has conceived the idea, developed it, spent time and resources on bringing the idea to life. This makes criticism of her brain-child very hard to bear.

The temptation is to be defensive. To shout down the critic. To take the view that the person offering an opinion hasn’t understood the brilliance of what has been brought to the world. The cure for this sort of pain is to begin with the end in mind.
Consider who is this innovation is for? Who needs to cooperate to make it available to the end user? Who will pay for it, either with hard cash or with their time and effort?

Another way to get a better understanding of the real problem you’re trying to solve is to write a short letter to the person you want to solve the problem for. A crucial part of innovating is to tell the story of the invention effectively, to make the people who need to care in that moment, care. It’s worth investing the time to get your story right and to seek out people you trust to give you honest feedback before you have to tell the story for real.

The anatomy of research funding

Agile, intuitive, creative and cost effective solutions must also be tested to objectively demonstrate that they work. However seasoned medical innovators recognise that most research grant applications will fail. It has also been demonstrated that many funded medical research projects fail to deliver anything of real value or to solve the problem they set out to address. While no reasonable person would expect every attempt at problem solving to succeed, it’s clear that winning a grant is no guarantee that you’ve got a winning idea on your hands. Far from it.

The anatomy of a grant application is a pyramidal structure. At the base is months of preparation, team building, strategising and review of what has already been done in that field. Conservatively grant writing takes twelve to eighteen months. Applicants consider who might be reviewing the application. Not only what organisation, but what individuals might be involved. Their likes, dislikes and prejudices. This is no different from any commercial business venture, the pitch has to take account of the competition and the people who make decisions about the future of the idea in order to have the best chance of succeeding.

What is thought to be appropriate might be based on what the grant committee is familiar with. No point proposing to demonstrate that stomach ulcers are caused by bacteria when a committee knows that they are caused by stress. When distributing limited resources risk must be reduced. In these circumstances it feels safer not to encourage innovation. Paradoxically a system that should foster innovation often ends up backing what’s already established.

Once funded, the project must be completed. Most timelines from funding to completion are between eighteen months and three years. Often at this stage the team is smaller to comply with the budget constraints from the funder. The team will produce a report and draft papers for publication in peer reviewed journals.

The publication process involves negotiating another committee. The goal is to enlighten and inform people who may think they already know the answer to the question you are addressing. What’s more, there is a significant risk that if you say things that are unfamiliar, or propose an idea that goes against the conventional wisdom you may be asked to tone it down, or discover that the journal ‘receives far more papers than they are able to publish’. Successful publication can take a year or even longer.

The grant based research model is not designed to produce agile, intuitive, creative and cost effective solutions. I’m sure that this isn’t unique to medicine.

How do you generate and then demonstrate the validity of solutions in your field?

Which ideas would never have seen the light of day if innovators were not tenacious and inspired leaders?

What problems have you identified and how have you negotiated with people who think they already know the solution, or those who feel they might somehow lose from your ideas?

Is it possible to be innovative in a world where convention and process trumps problem solving and agility?

And in a world of shrinking budgets isn’t it time that we reviewed the opportunity cost of this process?