Lean machine(s): chasing the contexts

There is a perennial game in health and social care called assessment and evaluation: the game could also be called 'CTC' - 'chasing the context'.

Relativity lies not only in the realm of physics and philosophy.

When I say relativity I am referring of course to the influence and impact of a health and social care situation from the constantly changing perspective of each of several different players:

• the patient;
• carer;
• nurse;
• doctor;
• manager;
• medical ward;
• community mental health team;
• commissioner.

Usually, the context collapses to a specific problem (a situation) and the players set to solve a care problem presented by an individual -

• a client, resident or patient;

and their -

• relatives;
• residential care home manager;
• residential care home staff nurse and team;
• community mental health nurse;
• medical personnel.

Context directs, dictates, and shapes health and social care theory, practice, management and policy.

This relativism can also subvert, sublime, confuse and stymie plans, common sense notions, creativity, innovation and management directives.

Like a tide this relativity picks us up and re-figures, re-paints and shifts the location of everything - including measures and how they are used.

Context is all! - so the saying goes. But context never wholly reveals itself. For that is another situation, another context, another side, another coin.

For context there are key defining parameters (location, diagnoses, risk, need, physical, mental, holistic ...) all of these are couched or spring from time.

So, the game calls for us and the tide teases us to measure and evaluate. This coast is never clear, but how long is it now? Where are the pathways now? Where will they be again?

As we travel (and travail) to and from this context to that - thresholds are also altered: up and down and always around; the way of life and ..... .

Image source:
http://www.esd112.org/edtech/no_limit/rs_archive.cfm

From: Harvard Business Review - The Four Phases of Design Thinking

I came across the following post on the Harvard Business Review Blog Network - The Conversation:

10:54 AM Thursday July 29, 2010
by Warren Berger

What can people in business learn from studying the ways successful designers solve problems and innovate? On the most basic level, they can learn to question, care, connect, and commit — four of the most important things successful designers do to achieve significant breakthroughs.

Having studied more than a hundred top designers in various fields over the past couple of years (while doing research for a book), I found that there were a few shared behaviors that seemed to be almost second nature to many designers. And these ingrained habits were intrinsically linked to the designer's ability to bring original ideas into the world as successful innovations. All of which suggests that they merit a closer look.

You can read the whole of Warren's original post, while below I have taken his focus concepts CONNECT, CARE, COMMIT and QUESTION and associated them to the care (knowledge) domains of Hodges' model. Following that there is a rationale. ...

connect	question
care	commit

Connect:Intrapersonal
Placed in the intra-interpersonal domain this is the domain of concepts, thoughts, ideas, creativity and innovation. This is the essence of Warren's reference to 'connect' -

Designers, I discovered, have a knack for synthesizing--for taking existing elements or ideas and mashing them together in fresh new ways.

The INTERPERSONAL links page also highlights other conceptual 'inhabitants' here; in particular knowledge management, the semantic web and psychology. If analysis and reduction is the outcome of the hard sciences, then here as Warren writes is synthesis, integration and invention. We can see how self-belief is critical to many innovators who pursue their dreams regardless of rebuffs by the establishment, to whom - within the health career model - they are also diametrically opposed.

Question:Sciences
The ability to question lie at the heart of human activity, and although thought and mind are represented in the interpersonal domain, questions also exemplify the output of human reasoning powers in the SCIENCES. Evidence based care depends on an ongoing process-ion of questions that drive research. Problem solving with its iterative sequence of assess (question), plan, action, evaluation (question). The health career model reminds us though of the need to consider not only quantity, logic and objective measures, but the role of qualitative research and methods.

Care:Sociology
Seeing Warren's inclusion of 'care' drew me to his post. Here he concludes:

Focus groups and questionnaires don't cut it; designers know that you must care enough to actually be present in people's lives.

Health and (social!) care are social activities. Our students are socialised into the professions and disciplines as they pursue their careers. Our work depends on the effectiveness of human communication and relationships. You can read about 'counselling' and only get so far; ultimately health care is experiential. It is something to be practised.

Commit:POLITICAL
Warren deals with the way designer's view risk and committing early to an idea and the project that might follow. For me 'commit' and being committed has explicit political - power - connotations. So, Warren's reference to commit in the sense of producing a model or prototype and working through problems can be extended. Invention and design may be cognitive pursuits, but they are non-trivial in that they must ultimately and literally be negotiated. Being able to 'commit' needs to be sanctioned. Individuals need to be empowered, or recognise when to either proceed or seek advice and guidance. Furthermore, Warren notes:

The designer's ability to "fail forward" is a particularly valuable quality in times of dynamic change. Today, many companies find themselves operating in a test-and-learn business environment that requires rapid prototyping. (?)

Perhaps the recognition in health policy of the need to balance negative and positive risk taking, self-care and personalised budgets can also be discerned in the above?

Acknowledgement:
Thanks to Warren Berger and HBR

Person-centred care and semantic inflation

Time laughs at us, with us and has the last laugh. If you are ever complacent and by virtue of your years you venture to think to yourself:

Well we've been working on this now for 20-30 years look at the progress we've made. ...

Time is always there to remind you:
Hey, just who are you trying to fool?
You are a lifelong learner!

The number of personnel and services that describe themselves as person-centred is an ongoing theme of so many CVs, policies, SLAs, commissioning and consultant's presentations and lectures. ...

Whether in a ward, service, or organisation's philosophy, person-centred is a term that is being diluted to the extent that semantic inflation devalues what is supposed to be the main currency? Or are we admitting that this is the cost of the political games that people play? Whatever your view, there are insights of progress won, but also reminders on how much remains to be done.

Health and social care being multicontextual demands the existence of multiple currencies. One additional currency begs that we compare A, B, C with the evidence base.

If this is the crucible of our person-centred times then what is burning?

• Nursing ethics?
• Nursing education?
  
• Idealistic aspiration? (Yes, we will get there!)
  
• New Age incense?
  
• Policy initiatives?
• Funding allocations?
• Nursing activism (Or, are there any balls in the house)?
  
• Service infrastructures?

Although the media temperature is rising here in the UK, as health, itself economically recumbent is moved to ICU being so politicised; the Francis Report provides evidence of a dire lack of person-centred care. Recalling my basic nurse training: what can be more person-centred than ensuring that a patient has the necessary fluids and diet?

For women who suffer a miscarriage - where should they be nursed as debated in today's Guardian newspaper? What is person-centred care in maternity and gynaecology services?

In-patient provision and transitions from child-youth-adult provide other opportunities and major challenges for health and social care to demonstrate their person-centredness.

There are so many ways to be person-centred, so many levels, some may even be contradictory(?).


I wonder how many of those people highlighted in the Francis Report also had a form of dementia - whether diagnosed or not? Personhood and the need to acknowledge and sustain the person are not new.

Even if a service is person-centred in terms of the environment, meal choices, therapeutic options, belongings, personal space, proximity to home and relatives ... the crux at the center is the attitude of staff, and their having the time and space:

"to be"

person-centred

Additional links:

Mumsnet

Atkins, L. (2010) NHS 'must lessen trauma of miscarriages' Parents web forum Mumsnet calls for new code of practice to help women who lose their babies, The Guardian, Tuesday 2 March.

Image source:
http://drugsreference.co.uk/books/books.php?cat2=Caregiving

NT: Nurses urged to use checklists to reduce human error in practice

Last month Nursing Times included an item on checklists, highlighting work by the WHO in perioperative nursing and the Patient Safety First campaign. Following surgery's lead is the realisation that similar checklists have the potential to improve communication and team working in other areas such as nutrition, situational awareness and pressure ulcer care.

Checklists are ubiquitous in our day-to-day lives, the dividend for using them is fairly obvious. What is less obvious is the fact that checklists alone are dead bureaucratic adornments. Checklists are animated by situations and thinking, reflective individuals in those situations. As Lomas reports there is a need to stop at an agreed key point in the patient pathway and ask the critical - checklist - questions. In team work this co-ordinated acknowledgement to complexity is essential for comprehensive, consistent and safe care.

What is interesting here is the emphasis on human factors. While checklists undoubtedly have a demonstrated - proven - role to play in safety, situational awareness is not a product of checklists alone. There is a need for learning and for the cultivation of cognitive lists. While human memory is fallibility incarnate - hence the role for checklists - there is also the need for skilled, knowledgeable professionals with the required communication and observational skills. The need for nurses to further develop observational skills has also been highlighted over recent months.

So as checklists are checked and logged: prepare a space for the mental checklist that is Hodges' model. The model is situated, person-centered and one of the original purposes was to help bridge the theory - practice gap. Try doing that with a checklist: alone

Clare Lomas Safety checklists could cut 'human error' in clinical practice, Nursing Times, 106, 3, 26 January 2010, p.2.

Ticks in boxes and triplicate thinking

Having things in triplicate may be reassuring from an admin perspective. ...

That said, 1st year learners on wards can relax to focus on learning, not having to worry (too much) about the administration - the running of the ward 24/7.

Very soon though years 2... 3 come knocking and they must consider due process, they have to question and get to grips with the established routine that sets and keeps several plates spinning.

Of course IT has by and large (?!) removed the need for paper carbon copies (although those three copies should have three distinct purposes).

Despite that an obsession with ticks in just three boxes may not be enough when it comes to high quality multidisciplinary, holistic and integrated care - it's ticks in the mind and attitude that count.

Additional links:
Records Management Society

The Productive Ward

Image source:
Triplicate Girl - http://upload.wikimedia.org/wikipedia/en/6/63/Triplicate_Girl_LSH3.jpg

Point of care? The King's Fund - patient experience

The real 'point of care' is that there are several points with many perspectives:


Patient (person) - Care professional - Manager - Carer
Public (citizen) - Student - Lecturer - Service User Groups
Physical - Emotional - Political - Social
Patient - Inspectors - CEO information governance - Commissioners

Don't drown seeking gaps in processes. All of the P's count!

The King's Fund
The Point of Care: Improving Patients' Experience.

Hodges' model social care domain - patient, carer resources.

Image source:
Multiple Faces: Insight Management Group

The domain once removed ...

When we reflect or physically interact with the world it is easiest to effect those things nearest to us. From an early age - stationary - we learn to look and reach.

Sometimes however it is those things that are remote, inaccessible that may be significant and deserving of our attention.

Imagine yourself placed in any of Hodges' knowledge domains as if in a prison cell.

The knocks on two walls clearly come to our attention. There - is another domain that remains off-limits.

This domain is the cognitive blind-spot: which will be yours today?

Image source: Fallingpixel.com

Nursing as reverse engineering...

At Scotland on Rails last month one of the sessions included an example of Ruby code outlining a 'morning routine'. It comprised a series of tasks and sub-tasks all of which led to getting to work.

Much of the vital essentials of the code I cannot understand beyond some tentative inklings, but in the hope of learning I've re-hashed the accessible bits and turned it into a NursingRoutine. The output looks like this....

Nursing....
"Non-judgmental attitude"
"Universal positive regard"
"Basic counselling skills"
"Open mind"
"Meet person"
"Receive referral"
"assess person utilizing Hodges model"
"Create care plan"
"Meet physical needs"
"Meet interpersonal needs"
"Meet political care needs"
"Meet social care needs"
"Holistic care"
"Evaluate physical needs"
"Evaluate interpersonal needs"
"Evaluate social care needs"
"Evaluate political care needs"
"Evaluate care"
"caring..."

Something like nursing is obviously a much more complex routine than that implied above - that is because:

• nursing is not [some - 'thing'];
• nursing can be represented as a routine BUT;
• nursing seeks to transcend the routine: emphasizing the personal, unique, the humanistic;
• nursing is parallel and sequential;

In addition now we are about collaborative, multidisciplinary care that must factor in agreement (the care plan...), and patient reported outcome measures (PROMS). ...

In the meantime I need to exercise care trying to understand the program that produced the output (that could also be easily printed as a list). While this is not an example there is such a thing as obfuscated code, but surely not obfuscated nursing care?

Study the hoops, but care about the thresholds

When you are on a course you really have - quite rightly - to do things by-the-book. That is the way - they say - you learn which corners of the pages you can turnover. Students learn early on that you have to jump through various hoops in order to complete the course and earn the stripes. The art and science of caring presents its own hoops, but in addition it is thresholds that present a barrier, thresholds that need to be negotiated in order to meet need.

Suddenly this is not about one person (you) it is about a partnership. A partnership of professionals allied and directly collaborating with a 'patient' and their carers.

One of the hoops is the paper or electronic referral form. Are you still sure this referral of yours is necessary? Are those two assessments really necessary?

There are a host of thresholds that may (or may not?) shift like a tide around the local and increasingly extended health and social care community, or 'economy' if you prefer, for example:

The threshold at which a nursing home will contact a GP surgery; or mental health services?
Just exactly what is residential care's capacity to cope internally and manage with a given range of health and social care challenges? What exactly should that capacity be? Should the public have access to referral data from care homes - to accident and emergency, mental health services, primary care? What proportion of 'referral problems' are dealt with at the nursing - social work level? What is the mental health service's threshold in terms of responding to a referral? What is the threshold for relatives believing that sufficient is being done for their loved one?

As lifelong learners of course we are all perennial hoop jumpers, learning the art of scaling and re-framing the thresholds that cross our way.

Image sources:

Seed-and-threshold segmentation

hula hoop

Why health care is complex: data + process + information models...

The cover of David Benyon's (1990 & 1996) Information and Data Modelling book features the diagram below. The combination of data model and process models gives rise to a data processing model which can be termed an information model.

The processes giving context to data and thereby rendering it more meaningful hence 'information'.


Appreciating this computer science example, we can get a grasp of why health and social care is so complex.

Not all things are purely accumulative, but perhaps by extending this we can also see why creating, representing and implementing a model of care (social, nursing, ...) is so difficult.

Not only that, but we also need to consider the arrival of ICT in the care arena. This means mixing the information and care models to deliver a working 'bells and whistles' information system solution.

Since Hodges' model is composed from assumptions about nursing - health and social care - the model can also be used here through decomposition. The model's domains suggest at least four core models:

SCIENCES: the usual sense of data model in this sense physical data;
INTRAPERSONAL: a mental health - emotional care - or personal data model;
SOCIOLOGY: a social data model frequently characterised temporally as a social history;
POLITICAL: governance model, covering security, access, sharing, consent.

So it is a big order. To the informatics take on the book cover above we can add

+ physical 'care' data model
+ personal data model
+ social data model
+ governance data model

And just to think - all this needs to be done in a socio-technical harmony with the info-tech players paying heed to the four P's (PROCESS, POLICY, PURPOSE and PRACTICE) plus whatever modelling, project management, service improvement methods may be employed.

The biggest potentially confounding factor though
and the biggest 'P' of all is of course
PEOPLE
but no problem that is why we care.

Additional links:

David Benyon

The Public, Patients and Carers in Hodges' model

The table below indicates some of the main concepts and concerns that
surround the PUBLIC, PATIENTS and CARERS agenda presented using the four care domains of Hodges' model:

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

Well-being, mental (subjective) health, mood, hope, human spirit. Knowledge and understanding of condition. Literacies: 3Rs, ICT, social, visual, spiritual, health.... Diagnosis - prognosis. Psychological impact. Aware of info sources tolerance, personal choices & autonomy. Response to trauma, threat, loss. Belief systems. Coping strategies. Emotional memory Perception. 'Individual pain' Motivation. Responsibility Ability to work, disability, gender Individual engagement, personhood, dignity. Self-care, Purpose Personal Health Record Attitudes, beliefs

Physical (objective) health. Chronological - Pathological Age (of care subject, carers). 'Fitness'. Activity. Systems. SAFETY PROCESSES, structural flexibility. Pain thresholds. Measures (Pain genetics, scorecards). Systems, feedback, redesign, improvement. Complexity. Change. Research: Evidence-based care. NICE. Quantitative, Quality of Life, assessment, screening. Process redundancy. Decision making PEPIN: Professional Education Public Involvement UK Network Referral, care pathways, plans, time. Self-admin drugs. Expert patient. Health, care, eng. model(s) Ill-health - Health promotion Time for data collection. Curricula design, Courses, qualification. Standards vs Innovation Computer supported engagement*

Carer - family understanding of condition, diagnosis-prognosis. Genetic implications (if any). Familial genetics pain. Sense making. Meaning. Social articulation of individual +ve & -ve experiences. Generational (role) inversion. Engagement and Social inclusion: work, social mobility, homelessness, stigma, poverty. Access to info and comms technology The Engaged E-patient Population Medical Sociology. Sick-role. PRACTICE Effects of culture 'meanings'. Dependency. Religion, fatalism. Leisure. Volunteering. Social capital / capacity. Collaborative care, concordance. Socio-cultural reach. Communications. Media. Dialogue. Qualitiative research. Social change attitudes. Shared definitions and meanings: 'engagement', 'health', 'wellness'...

POLICY, Nat. - U.N., FUNDING, GLOBAL ECONOMICS. Legislation: Section 11 of the Health and Social Care Act 2001. Nat. programs: Health For All. Health & Local Social Service Auths, 3rd & Independent sectors. Choice, Equity, Equality, Access, Advocacy Services. Consultation, engagement. (PALs) LINks. Definitions: engagement continua, datasets, intelligence / reporting. Service planning and development. 'Localisation' - Center. NHS Constitution Scalability of concept: Grp - Ind. Organisational empathy ('x.org' <-> public, patient 'rapport, involvement'). Economic cost of prolonged 'patiency'. 'Patient Lead'. Compliance. Political priorities, strategy, continuity. Policy half-life. Consolidation. Governance. Expenses. Specificity of roles, social exclusion. Wellness. Disability. Human Rights. Invalidity. Re-training. Health outcomes, assessment. (Lay) Representation. Champions. Black, Minority, Ethinic groups. 'Citizen-Patient'? DoH INVOLVE1 Involve2 Retirees. NHS: 'Open All Hours' Dedicated centres: e.g., NCI3

The focus above is UK, but can be readily revised to reflect other countries.

1. INVOLVE: Promoting public involvement in NHS, public health and social care research.
2. Involve: Promoting public and patient involvement in policy making and service design.
3. NHS Centre for Involvement.

Additional links:

Patients' use of the Internet for health related matters: a study of Internet usage in 2000 and 2006
Healthy Democracy: The future of involvement in health and social care, Edward Andersson, Jonathan Tritter and Richard Wilson (Editors).
Dept. of Health, Patient and Public Involvement
Engage, Northern Ireland.
The Local Government and Public Involvement in Health Act 2007
LINks: individuals and community groups who work together to improve local services.
Our health, our care, our say: a new direction for community services.
Patient Information Advisory Group (PIAG).
National Patient Safety Agency

The SOCIOLOGICAL links page includes 'Seven Ages', 'Public, Patients, & Carers'...
The INTRAPERSONAL links page includes 'Mental Health', 'Psychology', 'Therapies'...
The POLITICAL links page includes 'Policy', 'Citizenry'...

*Several informatics schools: community, urban, social, health, nursing, gender, e-gov...