h2cm and clinical equipoise

The past few weeks reading the Journal of Evaluation in Clinical Practice - I've encountered the concept of equipoise: specifically the clinical form.

The Health Career - Care Domains - Model is all about 'poise'.

The model's care domains provides the perfect workout.

Medicine, health and social care constantly exercises us. We are whether or not we recognize it on a balance board. In fact if you consider that image and then factor in the complexity of health care today you realise just how much stuff (technology), how many people (subjects, agents) need to be on that same board. Who does the board belong to though? Well of course it's -

Jo (off-balance, strengths depleted, sick (and tired), prone to relapse, bank poleaxed...) Public's !

The April 2010 issue of the above journal is a fascinating read. I noticed today that some of our placement students were not aware of the recent and current position regarding health policy: that is the 'long view' of decades such as: Health of the Nation, the National Service Frameworks, Darzi ... They need to address that and I'm sure they will.

This journal issue prompts me to consider evidence based medicine anew, especially:

• How long it's been around - some 20 years.
• Its occupying the SCIENCES domain, with its weight threatening to overbalance all (you could say it's a significant singularity).
• The realization that the Emperor is short on clothes.
• Given the above it can mature. Bogdan-Lovis and Holmes-Rovner (2010)

Back to that board: and stepping onto the health care domains - all four of them so spread your feet - you can see instantly (feel that feedback) how EBM, shared decision making and (person) patient-centered care are all related. As Bogdan-Lovis and Holmes-Rovner (2010) highlight:

Equipoise is the heart of the shared decision making movement, and it embodies the problems for which patient decision aids are most often developed to explain the risks and benefits of competing alternatives. p.377.

h2cm is well suited to this task on so many levels.

The past week or two I've also noticed several mentions of the need to nudge people - here and there - both in the media and in Bogdan-Lovis and Holmes-Rovner's paper and references.

More to follow - and as you step-off take care ....

Wilson, K. (2010) Evidence-based medicine. The good the bad and the ugly. A clinician's perspective. Journal of Evaluation in Clinical Practice, 16, 398-400.
Bogdan-Lovis, E., Holmes-Rovner, M. (2010) Prudent evidence-fettered shared decision making. Journal of Evaluation in Clinical Practice, 16, 376-381.

And for the week ahead:
One mind, many minds - ONE PLANET. One need, many needs - ONE PLANET: what price stability?
http://hodges-model.blogspot.com/2009/02/one-mind-many-minds-one-planet-one-need.html

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

Prime Minister’s Commission on the Future of Nursing and Midwifery in England – 2010

Earlier in March The Prime Minister’s Commission on the Future of Nursing and Midwifery in England published its final report.

You can download the report in full.

Box 3.1.2 (on page 43) features key statistics on nursing and midwifery:

• In 2009 there were nearly 595,000 RNs on the register residing in England, 77% of them registered in the adult nursing branch.
• In 2009 there were over 31,000 RMs on the register residing in England.
• Nine out of 10 of RNs in England are female.
• There are disproportionate numbers of men in more senior nursing positions and certain specialties: a third of mental health nurses, for example, are male.
• Nearly all RMs in England are female. There are 131 male midwives.
• Well over half the RNs and RMs working in the NHS in England (57%) are aged between 35 and 54, with less than 3% under 25. Almost 70% of RNs and RMs on the NMC register in England are aged 40 and over.

Reporting on the Commission's report the RCN Bulletin (10 March) notes the need to encourage more men into the profession and people from black and ethnic minority groups. As the list above highlights, however - There are disproportionate numbers of men in more senior nursing positions and certain specialties: a third of mental health nurses, for example, are male.

From my early nurse education days (especially from mental health to general nursing) you had no choice, but be aware of gender and just w(h)ere you had landed. Upon my first encounter with Hodges' model, the model stood out in the list of theories and models of nursing.

It was not listed on the original nursing theory website.
(Hence, the initial website project)
The majority of models and theories were created by women and outside England.#

The future of nursing depends on successfully addressing* the numbers: totals, proportions, recruits, retirees*. ... We can use the numbers, quality, safety and I have to say - Hodges' model to help craft the creative and innovative messages needed. We really are in for a fascinating and exciting 20-30 years in nursing; here in the UK, EU and Internationally. There is much more in the Commission's report to reflect upon which will follow here. ...

http://cnm.independent.gov.uk/

* Note the use of 'addressing' not balancing - that's why this is also challenging.
# This is not a complaint, just an observation.

Additional link:

Sciences care domain: Nursing theory and models of care resources

Major survey: Training and education for the developers of databases in research and clinical practice

Dear Colleague,

We are writing to invite you to take part in a major survey supported by the Wellcome Trust and the MRC. The survey is part of a programme to increase the capacity of the UK to support clinical research by exploiting the growing quantity of high quality data held in clinical databases.

The survey can be found at http://www.survey.leeds.ac.uk/eprresearch

The project behind the survey has been funded to develop training courses for researchers and information specialists in the health and NHS research community on how best to make effective and secure links between routine clinical databases and research collections.

It follows on from reports from UK CRC, NHS Connecting for Health and other sponsors highlighting the potential for such linkages but which recognised the considerable technical and organisational barriers.

This survey is a first step in our project. We hope you will spare the few minutes taken to complete it. Apologies if you have received multiple copies of this message which has been widely distributed through numerous channels.

Yours Sincerely,

Dr Rick Jones/Mr Mark Hawker
Yorkshire Centre for Health Informatics
University of Leeds
-----------------------
Many thanks for considering this.

Best Wishes,
Mark Hawker
Teaching Development Officer

Leeds Institute of Health Sciences
University of Leeds
Charles Thackrah Building
101 Clarendon Road
Woodhouse
Leeds LS2 9L

My source: The NHS-HE CONNECTIVITY PROJECT - forum

Squaring circles: Compressed patient care pathways = rich(er) patient experiences?

The use of Lean and Six-Sigma, their combination and other service improvement approaches has resulted in much more effective patient care pathways. A shining example is that of diagnostic medicine and subsequent out-patient appointments, apparently patients can attend for diagnostic services such as imaging and on the same day also attend for their first out-patient appointment. This saves time for all, with expensive imaging technology also proving its worth and RoI by working from 0700-2200.

Trust Boards are well pleased with such progress, but there is no such thing as a free lunch. Managers and execs know the lunch (diagnostics and imaging) isn't free, but quantitative aspects aside what does does this mean in terms of quality and assurance? Quality in the sense of:

• patient (and carer) experience;
• staff capacity to find and take advantage of patient learning (self-care, patient health career management) opportunities;
• assessment and evaluation of patient (carer) comprehension;

There is a circle to be closed by relating quality to quantitative aspects; such as, re-referral rates, re-admission, medication / treatment concordance, plus the infusion of intelligence from local and national patient related outcome measures [PROMS] to new patient journeys.

In information science there is the concept of information compression, taking out the redundancy - repetitive data in an image or text to save on processing, transmission, and storage. As Lean Six Sigma assists teams to remove tasks, processes that do not 'add value' then the result is a richer experience. The patient journey has in this sense been compressed. The patient has fewer hospital and clinic visits with fewer bus, taxi journeys, or they pay less in car park fees. Health personnel and specialists are primed to help and deliver services that really count.

What does this compressed - 'denser' experience - mean though? Does it mean that:

• patient's are exposed to more information (2-3 significant interviews / leaflets / instructions)?
• there is less time available for education, health promotion, info Px giving?

- or alternately:

• does this 'value packed' patient journey help by providing rapidly successive hooks - experiential threads to integrate patient (carer and staff!) learning?

It will be interesting to see answers to these questions and how extensive the scope of benefits are of these patient experiences across different care contexts.

Is there an optimal number for 'clinical encounters' before things start to go awry?

PROMS are quite specific (as they need to be initially), but amid richer and varied patient journeys there will be a need for other (national and local) measures. What about the extent and level of 'care complexity' and 'holistic care'?

Additional links:

Lesley Wright on lean thinking and respecting NHS staff, HSJ, Dec 2008.

NHS ready for PROM date. NDS News Distribution Service.

Image source: http://www.navyenterprise.navy.mil/knowledge/tools/sixsigma.aspx

Two vacancies students - young professionals @ WHO Geneva

Marvellous opportunities. ...

Dear colleagues,

Please help us in disseminating two vacancy notices issued by the World Health Organization for opportunities for promising students and young professionals in our Geneva headquarters.

In particular, we are looking for persons with quantitative skills to work on global health workforce information, monitoring and research. We are currently looking to recruit one full-time professional (as per the vacancy notice HQ/08/HQ/HRH/FT861 - see link below).

We are also continuously open to offering (unpaid) internship opportunities.

Full details can be found at: http://www.who.int/employment/en/

Thanking you in advance,

Neeru Gupta

Demographer-Statistician, PhD
Department of Human Resources for Health
World Health Organization
Avenue Appia 20, Geneva 1211, Switzerland
Tel.: 41-22-791-1066 / Fax: 41-22-791-4747
Email: guptan at who.int

My source: ESDS Government mailing list

BBC R4 Today - NHS productivity

Following the post yesterday - Don't waste energy - use a care plugin... - there was an item this morning on BBC R4 Today:

0815
A report published by the Office for National Statistics suggests that NHS productivity has been falling by 2% a year. Martin Weale of the National Institute of Social and Economic Research, and Shadow Health Secretary Andrew Lansley discuss the efficiency of the NHS.

There's no transcript of the interview so maybe I was (still) dreaming? At some stage though this a.m. a point was also made about the public (as tax payers and patients) either wanting to go into hospital to be treated and cured (quickly and efficiently) OR have a 'good' (positive) patient experience.

Why can't the two go hand-in-hand -
especially with all the emphasis on 'partnerships'?

Martin Weale highlighted how efficiency is not everything - people may have other requirements. If a patient is treated very efficiently and quickly - all evidence based, latest and greatest interventions - but their experience is at best neutral, or at worst negative, then how will that experience affect their recovery, staying well - relapse prevention - and any future care episodes and admissions? Complex indeed ...

- and Remembering...