One of the questions to be discussed at the up-coming Salzburg Seminar I will be attend July10-15 is, “What elements of an improvement are transferable, and what adaptations are needed?” I have written this blog for the attendees at that seminar, but wanted to share it with others who are interested in healthcare, particularly in developing countries.
“Transferable” implies moving the knowledge that was gained in one place, to another place. The term “adaptation” acknowledges that the improvement must change to fit into the new context. It is the process of adaptation that I want to focus on in this blog. The issue is, who does the “adapting.” The customary approach to accomplish adaptation is a two step process, 1) the originator tells the receiver (often in a presentation format) what his/her team did and why, and then engages in a Q&A with the receiver to explain anything further that is needed, and 2) the receiver takes those ideas back home, then adapts them into his or her own context. In this format the responsibility for adaptation lies with the receiver.
I suggest that a more effective format is to give the responsibility for adaptation to the originator. In this format the interaction is not a presentation but is a group discussion, what I referred earlier as collective sensemaking. Rather than starting with the originators explaining what they did, the conversation starts by the receivers outlining their context, what they are trying to accomplish, why that is important to them, and what they have already tried. During this explanation, the originators ask questions about the context to be able to put themselves in the shoes of the receivers as much as possible. Then the receivers ask the originators what they have learned from their implementation that could address the receiver’s specific context.
The receivers are not asking the originators to start with the actions they took, rather to start with, what Perry et al. calls, the core concepts. However, the task of the originators is not to recite the core concepts, but to think how the core concepts would apply to the receiver’s situation. The actions that the originators took may not work in a new context, but the reasoning behind the actions should be of help. This adaptation activity provides deeper understanding not only for the receivers but for the originators as well. By striving to apply what they have learned the originators come closer to understanding why it worked.
Because this adaptation activity is collective sensemaking, it is most effective when engaged in by a collective, that is, several members of the receiver’s team are present to engage in conversation with several members of the originator’s team, providing the needed diversity of perspectives. The six principles discussed in the previous blog are applicable in the adaptation discussion:
1) Set aside the time required to reflect together,
2) Include multiple perspectives,
3) Create a psychologically safe space,
4) Connect people through circles,
5) Connect before content,
6) Make ideas visible.
The adaptation format can be made even more powerful, if the originators are each from a different group that has successfully implemented the intervention. If multiple originators are present, both they and the receivers can begin to ferret out the core concepts from across their different experiences. The goal then is two fold, to understand the core concepts and to adapt the intervention to the receiver’s context.
This format of giving the originator responsibility for the adaptation is effective because of the nature of our tacit knowledge. When working in a complex system, much of what we are learning is tacit. Although we skillfully call upon that tacit knowledge to take action, we are often hard pressed to articulate the reasoning behind those actions. A story told by Gary Klein in his book, Sources of Power, provides a useful example of this paradox. He recounts this incident of the lieutenant of a fire crew acting in a dangerous situation.
It is a simple house fire in a one story house in a residential neighborhood. The fire is in the back, in the kitchen area. The lieutenant leads his hose crew into the building, to the back, to spray water on the fire, but the fire just roars back at them. “Odd,” he thinks. “The water should have more of an impact.” They try dousing it again, and get the same results. They retreat a few steps to regroup. Then the lieutenant starts to feel as if something is not right. He doesn’t have any clues; he just doesn’t feel right about being in that house, so he orders his men out of the building… As soon as his men leave the building, the floor where they had been standing collapses. Had they still been inside, they would have plunged into the fire below.
Klein reports that in an interview with the lieutenant it was only after persistent questioning that the lieutenant was able to name the thinking (tacit knowledge) that led him to the decision that saved the lives of his men. The best he could do in explaining was to offer pieces of the pattern he had unknowingly put together; “For example, the room was hotter than he would have expected from a small fire, and the fire was very quiet. He unconsciously deduced that there must be an unsuspected basement beneath the living room, and that was where the main fire was; he then “intuited” that his men were in danger.”
As with the lieutenant, much of our tacit knowledge is so deeply embedded that we require the stimulus of a real situation for us to surface it. As Dave Snowden has said, “We only know what we know when we need to know it. It is for this reason that bringing originators of successful interventions to a real situation where they must figure out how to solve the problem, allows them to surface knowledge that they would otherwise not be able to articulate. Berwick, quoting Tiller explains, “Experimentalists have pursued too single mindedly the question of whether a [social] program works at the expense of knowing why it works.” I suggest this adaptation format as a process that focuses on “why it works.”
It would be too much to expect the first originators of a successful intervention to travel to every site that requires the originator’s knowledge adapted. But imagine if every group that became successful, perhaps through engaging in this adaptation activity, was willing to “pay it forward” by themselves engaging in an adaptation session with others. Soon there would be many conversations and a wealth of knowledge growing about the core concepts. All would be researchers as well as implementers!
- Gareth J. Parry, Andrew Carson-Stevens, Donna F. Luff, Marianne E. McPherson, Donald A. Goldmann, “Recommendations for Evaluation of Health Care Improvement Initiatives” Academic Pediatrics, Vol. 13, Number 6S, 2013
- Gary Klein, Sources of Power: How People Make Decisions, MIT Press, 1999
- Dave Snowden, “7 Principles of Knowledge Management”, Cognitive-edge.com
- Donald Berwick, “The Science of Improvement”, JAMA, March 12, 2008