• implementation of a post-acute stroke pathway for patients admitted with a cerebro-vascular accident
• development of an interim care pathway for non-acute patients awaiting transfer to a nursing home or residential care facility
• introduction of a hospital at home scheme facilitating early discharge for suitable patients with enhanced community support

All three projects were fascinating to be involved in and were completed on time, within budget and achieved some good outcomes. But rather than describing the projects themselves, what I wanted to reflect on here is the process that was adopted throughout the programme and any lessons for leadership and service improvement which may still relevant today.

I was reminded of this happy episode from my career earlier in the week when I found, amongst a pile of papers I was sorting out, a copy of the final programme report I’d prepared at the time. Now I doubt that the report itself has made much difference in the wider scheme of things and for all I know (I moved on from the hospital shortly after the programme was completed) it may have languished on a few shelves for a year or two before being consigned eventually to the ‘round filing cabinet’. But, in a way, that doesn’t bother me. The report was only ever a summary of what we’d achieved, and the fact remains that we achieved a great deal.

Looking back, I think there were three key factors which made the programme so successful.

First, the local health economy was organised (as it still is I believe) into an integrated whole. The hospital’s chief executive was also the executive officer for the local community and mental health services, making integrated work across organisations and disciplines so much easier. There were no complicated or bureaucratic contractual relationships to negotiate – everyone was on the same team, working for the same outcomes.

Second, there was very much a culture of ‘permission’ evident within the organisation. The hospital board signed off the project objectives and expected regular updates of course, but were otherwise content to let the actual work happen from the bottom up. In fact, staff at all levels were frequently told by senior management that they could do anything they wanted, as long it was (a) legal, (b) good for patients and (c) affordable. Thus, everyone was encouraged to come forward with their improvement ideas and could expect a fair hearing and chance to experiment.

The third factor was undoubtedly the part played by an inspirational nurse leader, who is now the Director of Nursing Services in another part of Queensland. His enthusiasm for improving patient care was infectious and his willingness to go out of his way to engage everyone from the medical director to the catering staff was always evident. No-one had a role too small or insignificant, for in his eyes everyone, including the patients and their families, was part of the wider system of care and therefore equally important to achieving good outcomes.

In the report, I had documented a number of lessons which we had learnt throughout the one-year programme. Some of these were generic lessons, reflecting on the success factors necessary for any improvement initiative, whilst others were more specific to bed management. Here are just a few of them (taken verbatim from the report):

Clear ownership and promotion at senior management level provides validation to a project and gives it a ‘corporate stamp’ – this has to originate from the executive level of the organisation if projects are to be taken seriously. A clinical driving force is also desirable where projects have an impact on the roles of medical staff.

Opportunities to contribute are given to staff at all levels – participation increases awareness of a project’s objectives among those affected by it, allows many new and practical ideas to be put forward, and increases the sense of collective ownership.

Recognition of the achievements of those involved in the programme – individual and collective effort was recognised at Ipswich Hospital through staff presentations, excellence awards, attendance at national conferences and seminars, and verbal communication from senior staff. More importantly, putting good ideas into practice confirms to staff that their contribution is valued.

Demonstrable changes – seeing change happening is encouraging to all participants in a change programme. Ward modifications, equipment purchases, changes to staff rosters and completed products like information packages all contribute to the sense that the programme is heading somewhere and is not just a vague idea.

Whole district approach – a continuum of care model helps break down the barriers between different elements of a service – eg primary, acute, community and private sectors. Team-working and patient-focus are both thereby emphasised.

The right people in the right place at the right time – one of the key advantages of having designated beds for particular types of patient is the ability to build teams around them. For example, an acute stroke unit is not so much a physical entity but a philosophical entity, in that it is the teams of specialised professionals that make it work.

Reasons to stay, not reasons to go – a change in mindset is required if hospitals are to focus on their core business of providing acute services. Rather than asking when (or if) it is OK to discharge a patient, the question should always be asked ‘for what reason does this patient need to remain in hospital any longer’. It is a subtle difference, but a profound one. The hospital at home scheme forces this question of every patient every day.

Make every day like Christmas – Discharge planning often works best at Christmas when arrangements to get patients home to their families are in full swing. This attitude is required all year round if patients are not to be detained in hospital longer than necessary.

Don’t get carried away – occasionally care processes can become driven by pathways and protocols, with little reference made to those caring for the patient. This should be avoided, as there is no substitute for effective, shared clinical decision-making. Pathways and protocols can only speed up the decision-making process, they cannot replace it.

OK, so it may not be rocket science and in the 15 years since this particular programme began, many of us have had similar experiences and learnt comparable lessons in thousands of clinical settings around the world.

But, my final thoughts on this particular programme, and one of the reasons I am proud to have been associated with it, are that we did it with no fancy tools, little or no special training, no fast-track development programmes, no external consultancy support and no over-bearing regulation or performance regime. We did it because we wanted to and we created the right conditions to tap into and harness the good ideas, motivation and commitment of everyone involved. All it takes is common sense, compassion, the right conditions and a one or two inspirational leaders.

by Daniel Kahneman

Hardback, 499 pages, ISBN: 978 1 846 14055 6, published in 2011 by the Penguin Group

Daniel Kahneman, described as the world’s most influential living psychologist, won the Nobel prize in Economics in 2002 for his pioneering work in behavioural economics – exploring the irrational ways we make decisions about risk. Ideas from his many years of research, which have had a profound impact on business, medicine and politics, have been brought together elegantly in this one book – ‘Thinking, fast and slow’.

Management Decision Making – view our learning module

In 2000, psychologists Stanovich and West described two cognitive systems that drive the way we think and make decisions – System 1 and System 2. Kahneman calls them Thinking Fast (System 1) and Thinking Slow (System 2). System 1 is fast, unconscious, intuitive and effort-free while System 2 is slow, conscious, uses logic and deductive reasoning and is hard work. Consider detecting hostility in a person’s voice as an output of System 1 while multiplying 512 X 248 would involve System 2. It’s not as if there are actually two physically separate systems within our brain. Instead, the names System 1 and System 2 have been ascribed to explain the phenomenon of a dual-process model of the brain i.e. two distinctive cognitive systems underlying reasoning.

The automatic System 1, which can never be switched off, runs the show when it comes to human decision-making. And human thinking has evolved such that, most of the time, System 1 gets it right. But it is prone to several cognitive biases and judgmental shortcuts or heuristics. Crucially, although System 1 can deal with stories which are causally linked, it is weak in statistical reasoning. It has a tendency to ignore the law of small numbers and the phenomenon of regression to the mean. And when making judgments about the probability of an event under uncertainty, it is guilty of base rate neglect. Consequently, it is prone to error by answering a different question to the one that has been asked. The trick, as Kahneman asserts, is to be aware of these biases in our thinking and slow down, to actively engage System 2, before making an important decision. Otherwise, System 2 will lazily endorse the flawed System 1 decision.

So how does any of this apply to medicine, healthcare or health policy?

The most well-known of Kahneman and his late colleague Amos Tversky’s experiments is the Asian disease problem which demonstrates the powerful effects of ‘framing’. Participants are divided into two groups and asked to imagine that the US is preparing for the outbreak of an unusual Asian disease which is expected to kill 600 people. Two alternative programmes to combat the disease are proposed – programme A will have a sure outcome whereas programme B is a gamble. However, the two programmes are ‘framed’ differently to the two groups. The first group is told that adopting programme A will save 200 lives whereas the second group is told that it will lead to 400 deaths – i.e. the consequences of adopting programme A are identical. Curiously, a substantial majority in the first frame chose the certain option i.e. programme A while in the second frame, a large majority chose the gamble i.e. programme B! The author adds that, more grimly, the results of the experiment were the same when tested with a group of public health professionals. The human mind, it seems, is not bound to reality.

How to explain this irrationality? Apparently, decision makers are risk averse in the face of gains (lives saved) and risk seeking when faced with a loss (deaths). This loss aversion is the basis of prospect theory that won Kahneman the Nobel for behavioural economics. People fight harder to prevent losses than to achieve gains. Could this explain the strength of opposition to the NHS reforms and desire to maintain the status quo?

The author takes the effect of framing further into the realms of health policy with the example of organ donation – countries with a policy for ‘opt-out’ have higher donation rates than those with ‘opt-in’. He claims this is because a person is likely to opt-out only if they have already thought it through carefully using System 2. Fewer people do this thus, making them an organ donor by default.

Long years of medical training are no defence against the power of framing either. Two groups of physicians at Harvard Medical School were given statistics about the outcomes of surgery vis-à-vis radiation for lung cancer. One group read statistics about survival rates (gain) while the other half received the same information in terms of mortality rates (loss):

1. The one month survival rate after surgery is 90%
2. There is 10% mortality in the first month after surgery

84% chose surgery over radiation in Group 1 as opposed to 50% in Group 2 even though the descriptions are identical in terms of outcome. Kahneman argues that a reality-bound decision maker would make the same choice regardless of the two framing versions. But that’s not how System 1 works and hence, the need to engage System 2. But he does, however, concede that doctors fall into the group of expert decision makers, just like fire fighters. It takes 10,000 hours of training in a rapid feedback environment to become an expert. Such experts become skilled at patterns of recognition when faced with similar situations, thus allowing them to diagnose correctly by instinct or gut-feeling. This Recognition Primed Decision model uses both System 1 to access associative memory and System 2 to run through the cues, all done effortlessly with years of practice. And among medical specialties, it seems anaesthetists are in a better position to develop useful intuitive skills than say, radiologists, because they benefit from good, immediate feedback of their actions.

The book contains plenty more examples of decision-making biases that apply to healthcare. Take, for example, the idea of denominator neglect which is important for communicating risks of vaccines. To System 1, the risk appears small when we say ‘this vaccine carries a 0.001% risk of permanent disability in children’. But the same risk if described as ‘one of 100,000 children will be permanently disabled’ conjures up a distressing image of a paralysed child. A more vivid description produces a higher decision weight for the same probability. Thus, the power of format and framing creates opportunities for manipulation – think tabloid vs. scientific journal reporting. And policy makers and project managers will have all experienced the planning fallacy where projects typically are behind schedule and over budget compared to the original plan. NPfIT anyone?

The author explains complex psychological and mathematical constructs in a lucid and conversational style that is easy to read and understand. However, the book falls short in some aspects. Firstly, I’m unsure as to how Kahneman’s colonoscopy experiment to determine the role of the experiencing self and the remembering self in generating happiness got past the ethics committee. How did they approve the prolongation of a painful procedure purely for a psychological experiment and not for any obvious clinical reason? You can view his TED Talk on the subject here.

Furthermore, although a relaxed, conversational style is easier to engage with, the author could have done more to describe the rigour of his study designs. What are the sample sizes for his experiments? Are they adequately powered? He talks about denominator neglect in our System 1 thinking yet never states the denominators for his own studies. And many of his experiments seem to have been conducted on inexperienced university students with the results extrapolated to rest of the population. In one episode, he describes the impromptu nature of one of his experiments as a quick survey that was handed out to students as they were leaving the administrators office – and then delights at the results because it proves his theory. Hardly a controlled study in a controlled environment. And for this reason, much of what he describes often sounds like anecdotal evidence. Such as posing a problem to one statistician in his office to prove that even statisticians are guilty of base rate neglect. Can psychologists really draw meaningful conclusions from poorly designed studies?

However, despite its flaws, this is a book I’d recommend to anyone who is interested in the psychology of decision-making. Now, did I think that through carefully or did I jump to a conclusion?

Management Decision Making – view our learning module

Here is a quick reminder of some interesting healthcare and management related webinars and webchats coming up over the summer which may be of interest. All times UK/London, unless otherwise stated.

If you know of any other interesting online web chats that readers may be interested in, please feel free to add them via the comments below. Thanks.

The Missing Link between Strategy and Performance

Find out why 70% of business failures are not a result of bad strategy but rather bad execution. Don’t miss this opportunity to take a deeper look at how the changing landscape of today’s healthcare environment is affecting strategic development and learn how to identify the keys to success and the warning signs of failure in strategic execution.

This 30 minute webinar will cover:

• Realities of Strategic Development in Today’s Healthcare Environment
• The Value of Strategic Coherence
• The Importance of Capabilities-Driven Strategy
• How to Create a Strategy Map
• Ten Keys to Successful Strategic Execution

The webinar takes place on Thursday 28th June at 3pm EST (9pm UK time).

Details here: http://hospitalmarketing.blogs.com/my_weblog/

Transparency of Care Project

This webinar presents an introduction to the Transparency of Care project. The transparency project utilises a set of core nursing care metrics combined with patient and staff experience measures to improve patient outcomes across falls and pressure ulcer care. Trusts then publish a narrative that describes both the data and their improvement journey.

Target Audience: Nursing, workforce across health and social care provision, colleagues who support measurement for improvement including analysts, patient experience leads and senior managers and board interest groups.

Date and time: Monday, 2 July 2012, 09:30 – 10:30

The webinar will then be followed by a series of three further presentations on Wed 4th July, looking specifically at the transparency project in acute, community and MH/LD settings.

Details here: http://www.institute.nhs.uk/option…211.html and http://www.institute.nhs.uk/option…213.html

QIPP in Action

For many years PCTs have sought to fight the rising tide of demand. Through the implementation of an independent GP triage capability and other actions, NHS Oldham has managed to achieve what King Canute failed to do. NHS Oldham set up a referral triage system in three weeks to tackle forecast deficits for commissioners and the local provider. This has significantly reduced referrals and allowed the local provider to take out capacity. As a result, the north-east Manchester sector saved £6m in the final half of the year 2010/11 financial year and contracts for 2011/12 are about £20m less than the previous year for outpatients and scheduled care.

The session will be presented by Stephen Sutcliffe, Director of Finance at Greater Manchester CSS and Kathryn Wynne-Jones, Deputy Director of Commissioning and Reform.

Date and time:Tuesday 3rd July 14:00 – 15:00

Details here: http://www.hfma.org.uk/hfma-tv/webinars…Section=2

What makes a good manager

We all know that line managers are key to the successful delivery of any programme and that if a manager is not engaged with the process and able to encourage staff to engage as well, the likelihood of success is severely limited.

Good managers achieve success across the NHS and assist their organisations to deliver across a range of programmes and often deliver outcomes that improve patient care and satisfaction.

The webinar speakers will be:

• Dr Tony Zarola, Director Zeal Solutions, who will talk about the key manager capabilities that have been identified in research he has carried out recently in the NHS.
• Amanda Oates and Joanne Twist from the Walton Centre NHS Foundation Trust who will be talking about the very successful manager programme that they run to improve the skills and capability of their line managers.

Date and time:Wednesday 4th July 13:00 – 14:15

Details here: http://www.nhsemployers.org/Aboutus…webinar.aspx

Engaging line managers and clinicians

This free webinar will look at practical case studies on how organisations can engage with line managers and clinicians.

Line managers have a major impact on staff engagement levels.

We will look in depth at at how Royal Bolton Hospital NHS Foundation Trust has sought to engage its line managers to help create greater staff engagement.

We will also look at emerging findings from work we are undertaking on how best to engage clinicians to meet objectives.

Date and time:Tuesday 10 July 2012, 3pm until 4pm

Details here: http://www.nhsemployers.org/Aboutus…clinicians.aspx

Making the best use of the NHS staff survey

This free webinar will look at how to make best use of the data in the staff survey.

It will feature a case study as well as the impact of changes in community services and linking staff survey data with patient satisfaction.

There will also be an update on plans for the 2012 staff survey including the optional questions that will be available.

We would also like to get your views on future direction and frequency of the survey after 2012.

Date and time:Thursday 26 July, 11am until 12 noon

Details here: http://www.nhsemployers.org/Aboutus…staffsurvey.aspx

Crafting Business Stories That Captivate, Convince, and Inspire

When you want to be understood, tell a story

Date of Event: Aug 15, 2012
Time: 12:00 PM – 1:00 PM EST / 6:00 PM – 7.00 PM (UK time)

Over the last decade, storytelling has become one of the most rapidly growing communication tools used by business leaders and executives.Instead of corporate memos, email, and PowerPoint presentations, storytelling is now being used to inspire and motivate organizations, to create a vision for the future, to define culture and values, to set goals and build commitment to them, and to lead change.

What You Will Learn:

• WHY storytelling works, and WHEN to use it
• A simple, three-part story structure that’s proven to work
• Tips for turning a good story into a great story by using metaphors, emotion, and surprises, while keeping the style concrete, direct, and engaging

While attending this program is FREE, reservations are required.

Details here: http://www.amanet.org/training/webcasts/Crafting-Business-Stories…aspx

Introduction to Health Economics – view our learning module

Working in Teams – view our learning module

Here is a quick reminder of some interesting healthcare and management related webinars and webchats coming up this month which may be of interest. All times UK/GMT, unless otherwise stated.

If you know of any other interesting online web chats that readers may be interested in, please feel free to add them via the comments below. Thanks.

Patient Flow in Care Delivery

Patient Flow Leaders: Necessity Breeds Innovation – this webinar series will show you how healthcare leaders are striving to improve patient flow in healthcare. In this third webinar in the series, which has featured both UK and Canadian healthcare systems, the Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK, discuss patient flow in care delivery. It features topics from laying the patient flow governance groundwork, to engaging front line healthcare providers in health IT. It’s great for anyone – including clinical, management and operational staff – who has dealt with patient flow issues, or those who are interested in learning more about hospital patient flow. The webinar takes place on Tuesday 17th April (time to be confirmed). Details here: http://pf.medworxx.com/webinars/

How the Best Managers Create a Culture of Belief

Are Your Employees “All In?” Date of Event: Apr 18, 2012 Time: 12:00 PM – 1:00 PM EST / 6:00 PM – 7.00 PM (UK/GMT) Adrian Gostick and Chester Elton teamed up with Towers Watson to analyze an unprecedented 300,000-person study revealing that high-performance organizations possess a distinctive kind of culture. In these environments, employees believe in their leaders and the company’s mission, values, and goals. Join us as Gostick and Elton explore a simple 7-step roadmap for creating a high-achieving culture: defining a burning platform, creating rigorous customer focus, making sure team members root for one another, and establishing clear accountability. Attend and you’ll hear:

•  Specific how-tos for inspiring belief in your mission and goals
• Fascinating stories depicting the power of culture in action
• Advice for getting your employees “all in”

While attending this program is FREE, reservations are required. Details here: http://www.amanet.org/training/webcasts/…Culture-of-Belief.aspx

Leadership Framework – A single model of leadership for the NHS

In this web seminar, Sabhia Sheikh, Board Development Associate at the NHS Institute, will give you an overview of the new NHS Leadership Framework (LF) launched last July by the Secretary of State, Andrew Lansley. The Leadership Framework reflects the values of NHS staff, embodies the NHS Constitution and represents the foundation of leadership behaviour for all staff in health and care. The webinar will outline how the LF is progressively being embedded across the wider healthcare system. Date and time:  Thursday, April 19, 2012 4.00 pm – 5.00pm Sabhia will also introduce you to the LF supporting materials such as the Leadership Self Assessment Tool which has already helped more than 20,000 people to review their leadership capability and understand their development needs, as well as pointing you to some free online resources including the leadership development module, e-learning materials and case studies from early implementer sites. Details here: https://nhs.webex.com/mw0306ld/mywebex/default…content=9681

Innovation in Healthcare

How can NHS organisations meet the cost and quality challenges through innovation and technology? This debate will explore where the NHS is at, how it got here and what can be done in the future. When: 12.30-13.30, Monday 23 April A free QIPP webinar with the Commissioning Board’s Jim Easton, the NAPC’s Charles Alessi, Rosemary Cook of Queen’s Nursing Institute and HSJ editor Alistair McLellan. Details here: http://www.hsj.co.uk/hsj-tv/

Leading the significant organisational change required to achieve SLM

True service line reporting can only be achieved if true visibility of non-pay usage is accurately assigned to the service line, and costs are fully reflective of the actual cost being incurred, including wastage, and inefficient buying Service-line Management (SLM) is not solely about service-line reporting (SLR). Optimising the benefits of SLM requires whole organisation engagement and a shift in approach. Whilst engaging clinicians is a key element, the executive and senior management teams also need to adapt their approach. This webinar will focus on the cultural change aspects of SLM, focusing on examples of how organisations have been working to achieve this. Date and time: 25 April 16:30-17:3 Speaker: Ian Renwick, CEO of Gateshead NHS Foundation Trust Chair: Kate Hall, Policy Advisor from Monitor Details here: http://www.hfma.org.uk/hfma-tv/…pageSection=2

Is bigger better?

How do mergers impact on patient care?

Why mergers fail

She: We start at 8am and work a two session day in the operating theatre. It amounts to 2.25 PAs.
Me: So you finish at 5pm?
She: No, we finish at 3.30pm.
Me: So, how does that work? 2.25 PAs, in normal time, equates to 9 hours work. Doesn’t that mean at least a 5pm finish?
She: No, we finish at 3.30pm. That’s what’s been negotiated.

Here is a quick reminder of some interesting healthcare and management related webinars and webchats, coming up this month, which may be of interest. All times UK/GMT, unless otherwise stated.

Department of Health web chat on NHS Standard Contracts

Important changes to contracting arrangements within the NHS are taking place during 2012/13 with the introduction of a single contract covering all provider types and all community, secondary and tertiary care services. Members of the DH contracts team will answer your questions about the new arrangements in a live webchat, on Friday 9 March, 2-3pm. The webchat is intended primarily for providers, although commissioners are also welcome to join in. Richard Dodds, Mehdi Erfan and Fiona Sutcliffe, of the NHS Standard Contract Development Team, will be available to answer your questions on the changes to contracting arrangements within the NHS. If you are unable to join the webchat on the day, you can email questions in advance to providerlandscape@dh.gsi.gov.uk or leave them on the web page. Details here: http://www.dh.gov.uk/health/2012/03/contracts-webchat/

Online Seminar: Incorporating Equity in Health Technology Assessment & Evidence-based Decision Making

Free Upcoming Webinar on:

•  Incorporating Equity in Health Technology Assessment & Evidence-based Decision Making
•  When is equity important? How do you address it your systematic review?

Join Erin Ueffing from the Canadian Cochrane Centre for this interactive webinar WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity March 12th 2012 at 13:00-14:45 (17:00-18:45 GMT), will be broadcast from the University of the West Indies in Kingston, Jamaica. Examples of equity-oriented reviews will be given, along with strategies and methods for considering the effects of interventions in vulnerable and disadvantaged populations. Details here: http://equity.posterous.com/online-seminar-incorporating-equity-in-health

Delivering Good Governance: preparing for turbulent times

In support of the general recognition of the need for NHS trusts and foundation trusts to deliver good governance and to demonstrate this to stakeholders, Grant Thornton has undertaken in-depth review of over one hundred NHS trust and FT 2010/11 annual reports. While there were elements of good performance, all trusts have room to improve the clarity and quality of their annual reports, particularly in preparation for the times ahead.  Date: 13 March 12:30-13:30 The report, and corresponding presentation, covers key aspects of governance including:

•  Board effectiveness
• Non-Execs and Governors
• Risk and performance
• Audit and assurance

There will be time for delegates to ask questions and get immediate responses. Details here: http://www.hfma.org.uk/hfma-tv/webinars/webinar-detail.html?id=28&pageSection=2

Mind Matters! Getting Results Through Psychology

Setting expectations, directing, delegating, enforcing policy. Date of Event: Mar 21, 2012 Time: 12:00 PM – 1:00 PM EST / 5:00 PM – 6.00 PM (UK/GMT) If you’ve been doing the same thing and not getting anywhere, listen to this webcast for new techniques that tap into the human psyche. Because understanding the root reasons of human behavior allows you to make different choices about how you manage and what kind of results you get. Thought, behavior, personality — all three affect everything from having a preference for a particular employee to how often you voice your opinions in a group. In this webcast, Dr. Boyce will give you a quick overview of three major schools of psychology—behavioral, cognitive and social — and give you insights into each one. So you can heighten your self-awareness and increase your effectiveness as a manager. Details here: http://www.amanet.org/training/webcasts/Mind-Matters!.aspx

Free online workforce webinar for HSJ audience

How can organisations best manage as the changes outlined in the Health Bill come into force and they need to protect services whilst striving to meet its challenging targets? When: 12.30-13.15, Wednesday 28 March With 70 per cent of costs related to workforce, healthcare organisations are entering a new era where financial pressures and new operational models have to be balanced with the need to provide quality care. Making efficient use of existing resources – whether those are staff or expensive facilities and equipment – will be crucial for organisations, whether NHS or independent, in this new, more commercial environment which will demand a flexible response to an unpredictable future. This exclusive free HSJ webinar, in association with Allocate Software, can help you and your organisation. Details here: http://www.hsj.co.uk/5041769.article

Heterogeneity is not always noise

Converting noise to signal: new research methodologies for improvement science The Health Foundation are pleased to announce that Frank Davidoff, MD, MACP will be delivering a free webinar about ‘Heterogeneity’. Date: 29 March 2012, 3pm In quality improvement work, results are not just about the intervention itself, therefore traditional methodologies to test clinical interventions such as randomised double blind trail need to be re-assessed in relation to improvement science. Biological variation – heterogeneity – makes it difficult to show that clinical interventions work. Context – everything other than the intervention itself – largely accounts for this heterogeneity, and clinical studies are therefore designed to control out context-derived ‘noise.’ Unfortunately, failure to recognize heterogeneity results in the ‘ecological fallacy’ – the simplistic assumption that cause-effect relationships established in populations hold true at the level of their individual members. In fact, analysis of clinical trial data using techniques sensitive to biological variation (eg ‘risk stratification’ and ‘number needed to treat’) clearly shows that study of biologic heterogeneity can deepen our understanding of causal relationships. Details here: http://www.health.org.uk/news-and-events/events/improvement-science-webinar-from-frank-davidoff-md-macp/