Discussion (3)

1. Excellent review and with views I agree with too. The ideas of process mapping and process modeling are often difficult concepts to grasp, certainly when I’ve tried to discuss with people, and would benefit from an example.

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   • Here is a link to an illustration I produced some time ago to show the difference between process mapping and modelling. It’s a bit intense but I hope that it is of some help. It’s part of a series call ‘Brining the tuning fork diagram back down to Earth’. https://catmalvern.co.uk/nhs/PM01.html

2. Thanks to Tom for sharing his perspective and expertise on this topic. I wanted to add a note to share some of the other insights that came out of the discussion at this event. Some of the points made resonate closely with Tom’s concerns – there is often insufficient ‘study’ in PDSA cycles (at every stage but especially before intervention); and that people sometimes only apply parts of an approach, or mis-apply approaches – perhaps because of time constraints or local pressure, inexperience and so on. This can result in a good deal of ineffective action or disjointed change, and a lack of sustained change. A set of analogous concerns were raised about ‘lip service’ being paid to issues but without these being sufficiently reflected on and followed through. This includes, for example, the importance of inclusion and collaboration in the design and conduct of improvement which can be interpreted in partial, or even token, ways and which is one of the ways that improvement might exacerbate (rather than tackle) inequalities. Another example cited was the fact that being mindful of ‘unintended outcomes’ was something written into key approaches but – given that this is actually a demanding requirement – was often passed over too quickly in practice.

   In a sense the whole focus of the meeting as we introduced it was about the problem of ‘unintended outcomes’ – that improvement activities can sometimes be ‘bad’ because of their side-effects (e.g. be burdensome to already burnt out staff); because they can waste resources i.e. have an opportunity cost; because they can have the ‘wrong’ aims (ones we think are too limited or even take services in directions we would want to critique); because staff are sometimes not well placed to practise it; and because they can use models in the wrong ways or places. The discussion, which ranged around all of these matters, showed that they had resonance with participants, many of whom illustrated them with concrete examples.

   This raises three questions which the meeting only started to grapple with, but which seem to be of great importance:

   1. How might we encourage a more careful study of current processes and their outcomes before plans are made to ‘improve’ them?
   2. How might we better avoid, or at least take into account, the kind of large-scale unintended outcomes that result from the way improvement activities are currently embedded and enacted in the health service?
   3. Whether, when and where might we want to decide that improvement activities (or some sub-set of them) are actually a bad thing? Or would we want to insist that, at least on balance, improvement efforts are good but could be improved?

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