Archivi del mese: agosto 2013

Should doctors lead on sustainability? @Medici_Manager

Welcome to a new series of blogs on sustainable healthcare that will look at health, sustainability and the interplay between the two. The blog will share ideas from experts across the healthcare field, some of whom are speaking at a major European conference looking at Pathways to Sustainable Healthcare in September 2013.  More about the conference can be seen at

by Rachel Stancliffe and Mahmood Bhutta

The GMC’s Good Medical Practice states that: “Good doctors make the care of their patients their first concern.” This is of course a laudable principle, and good doctors strive to ensure that patients are seen in a timely manner, that they are treated by appropriately trained staff, and that systems of clinical governance are in place to enable improvement. Yet we all know that we work within constraints, with these most commonly relating to financial or logistical constraints on service provision. However the evidence now makes it clear that those constraints should also include consideration of the wider impact of healthcare provision on the global need to care for the environment and to protect labour rights.

The natural reaction to such a suggestion for many doctors is to say that this is someone else’s concern, or that they don’t have time for this: “Doctors should concentrate on saving lives and not saving the planet.” However climate change is already affecting human health and a growing number of doctors realise that we need to address this in our clinical practice and make it a normal part of the way that we provide good care. As Dr Donal O’Donoghue, former National Clinical Director for Kidney Care put it: “Sustainability is the seventh dimension of quality.”

Moreover, the NHS as an organisation sees this as a major issue. Five years ago it set up the Sustainable Development Unit to look at ways to reduce NHS carbon emissions by 80% by 2050, which complies with the requirements of the Climate Act 2008 that the UK Government has signed up to. Meanwhile, the BMA Medical Fair and Ethical Trade Grouphas been looking at ethical issues within the supply chain to try and ensure that no harm is done to those who make the products that we use in our everyday work life.

So how does this affect doctors? There is often such a disconnect between our day-to-day working and the global view of healthcare provision. What difference can we as individuals make? Quite a bit, we would argue, not least because we are seen as ambassadors for change. Over the coming weeks, clinicians and experts on sustainable healthcare will discuss what that might mean in practice, and how we as doctors and other healthcare professionals can engage.

We are motivated by the understanding that there is a really crucial interplay between health, the environment, and labour conditions. If we understand this interplay, and act on our knowledge in a scientific way, we can use this to help us solve some of the greatest problems of our time: climate change, social inequality, and a healthcare system which is near breaking point for many reasons.

We hope these blogs will inform, provoke and ultimately inspire you to understand the urgency required and benefits accrued to a system of healthcare that engages fully with its environmental and ethical aspects.

Rachel Stancliffe is the founder and director of the Centre for Sustainable Healthcare.She is co-hosting the CleanMed Europe conference in Oxford from 17 to 19 September.

Mahmood Bhutta is a founding member of the BMA Medical Fair and Ethical Trade Group, a registrar in ENT Surgery, Oxford University Hospitals, and a research fellow, University of Oxford. He will be speaking at the conference on Ethical & Fair Medical Procurement.


Why you should reframe your strategy as transformational @Medici_Manager @helenbevan @muirgray

In my last post, I talked about strategy as logic; that is, a system of reasoning we utilise, based on our views and beliefs, about how to achieve change.

My own strategic logic for change (and therefore my practice as a leader of healthcare improvement) has been particularly influenced by Marshall Ganz. Ganz spent decades as a community organiser, leader and enabler of campaigns and social movements before joining the Kennedy School of Government to teach, research and write about leadership of change from a social movement perspective.

It’s very helpful for healthcare leaders to reflect on Ganz’s logic and definition of strategy: how we as leaders turn what we have (resources) into what we need (power) to achieve what we want (outcomes) by focusing on clear strategic objectives. I’m concentrating on this perspective specifically in this blog and will discuss resources next time.

The Montgomery bus boycott

We can see these strategic principles in action in so many of the inspiring stories of social change. Let’s take the example of the Montgomery bus boycott which was a pivotal point in the genesis of the American civil rights movement in 1955-56. Following the arrest of Rosa Parkes for refusing to give up her seat on a bus to a white passenger, the black population of Montgomery, Alabama, boycotted the town’s buses in protest at racial segregation of buses.

By organising for civil rights, a group of largely dispossessed marginalised African Americans was able to pool resources to create collective power for change (enough people withdrawing their use of buses and payment of bus fares so that it had a profound impact). They built power both by pressing the authorities for reform through united action and growing their movement by winning other people across the nation to support and take action for their cause.

And they achieved the outcomes they sought: pressure for change increased across the country and eventually the segregation rules were deemed unconstitutional by the courts.

Ganz, along with other commentators, concludes that the leaders of social movements (“voluntary organisations”) typically have fewer levers and resources for enacting change than leaders of formal organisations have. This makes the strategic focus of leaders, to turn potential resources into power for change, even more important.

Ganz quotes James Q. Wilson:

“In most voluntary associations, authority is uncertain and leadership is precarious. Because the association is voluntary, its chief officer has neither the effective power nor the acknowledged right to coerce the members – they are, after all, members and not employees. In a business firm, the chief officer may, within limits, hire and fire, promote or demote, his subordinates…

“In most associations, power, or the ability to get a subordinate to do what the superior wants, is limited, and authority, or the right toexercises such power as exists, is circumscribed and contingent.”

Use your levers

I concur with Wilson that the kinds of levers and resources available to organisational leaders can create an easier set of circumstances for enacting change (when compared with social movement leaders who have none of these resources). However, on their own, coercion, compliance and other organisational mechanisms won’t create sustainable transformational change within and across organisations.

So I don’t necessarily agree that organisational leaders have a more straightforward task in leading change. In fact, I think that leaders of health and healthcare who are seeking radical changes across their organisations and systems in an ever more complex and unpredictable world have got more in common with social movement leaders than they have differences.

Many NHS change strategies are driven by logic based on extrinsic levers for change: incentivising payment systems, regulatory and quality assurance systems and holding leaders to account to deliver change outcomes. The strategic logic of social movement leaders is essentially based on igniting intrinsic motivation: building shared purpose, connecting with values, mobilising actions and taking meaningful action.

Transformational change across the NHS system requires both intrinsic and extrinsic factors and we as leaders need to find ways to align them and balance the tension between them. Otherwise there is a tendency to overemphasise the extrinsic factors and inadvertently kill off the energy, creativity and sense of psychological safety that people need to innovate and deliver goals for change.

Peter Drucker got it right when he advised organisational leaders to “accept the fact that we have to treat almost anybody as a volunteer”. We can learn greatly from the strategic approaches of social movement leaders who led change that succeeded because people wanted to be part of the change, not because they had to be. They have a lot to teach us about motivating, mobilising and building power for change through the assets and resources of a communitybased on common interests and a common goal, creating capacity for change from within.

Some questions to consider:

    • What is the shared purpose underpinning our change efforts? Is it framed in a way that connects with values and builds intrinsic motivation?
    • What leadership actions can we take to shift power in the system and get the outcomes we seek?
    • Think about loss and gain: what control/power might we have to surrender in a hierarchical sense to enable a more distributed leadership system and quicker, wider progress of change across the system?

For more resources on large scale change, follow Helen Bevan on Twitter @helenbevan

Learning to do more with less @Medici_Manager @helenbevan @pash22

By Christopher Moriates, MD and Andrew Lai, MD MPH

University of California, San Francisco

The daily “Resident Report” conference at the University of California, San Francisco (UCSF) started a little differently yesterday. The Chief Resident stood at the front of the room and asked the audience, “How many of you ordered labs for a patient this morning?”

Only 2 people in a crowd of more than 20 put up their hands.

Yesterday’s lab ordering restraint was not because of our focus at UCSF over the last two years on decreasing unnecessary services and costs of care, nor the fact that our Chair of Medicine, Dr. Talmadge King, has declared “Choosing Wisely” a Departmental priority. In fact, in 2010-2011, housestaff were offered an incentive of $400 each if they were able to reduce common labs by 5% — they didn’t.

At UCSF we have been exploring listing the prices of labs on order screens, much like was successfully done at Johns Hopkins. We have tried educational programs and feedback to reduce the costs of daily lab ordering, much like was described in the memorably titled research paper, “Surgical Vampires.”

So what finally got them to not order daily labs yesterday?

It was a strike by the patient care technical workers represented by the American Federation of State, County and Municipal Employees (AFSCME), in conjunction with a “sympathy strike” by the University Professional and Technical Employees (UPTE), which occurred at all University of California medical centers. This severely limited resources with virtually nobody in the hospital to collect and process labs.  This created a situation where labs, along with imaging and procedures, could only be performed under truly urgent circumstances.  As a result, our Chief Medical Officer reported that our medical center ordered less than half the usual number of labs.

Let’s be clear: this strike was not good for patient care and resulted in cancelled surgeries and chemotherapies, as well as the inability to accept inpatient transfers from community-based hospitals despite these patients needing specialized care. But if we are to find a silver lining of this strike, it did indeed serve as a teachable moment for forcing clinicians to think more thoughtfully about our diagnostic test patterns. Our medical service leadership counseled all teams to ask themselves “Does my patient need this test?” and “Is there another patient who needs this test more?”, simple questions that should automatically cross our minds every day in our daily work flows.  It is possible that this two-day experiment may provide an impetus to ingrain this sort of reflective – rather than reflexive – ordering practices into the culture post-strike. At least for a few days it seemed to break the stronghold of routine daily labs.

After all, our Chief Resident asked a follow-up question to the “Resident Report” group yesterday: “How many of you felt that not ordering daily labs this morning impacted your patient care or outcomes?”

Not a single hand.


Christopher Moriates, MD (Twitter: @ChrisMoriates) is an Assistant Clinical Professor at UCSF. He is the Co-Chair of the UCSF Division of Hospital Medicine High-Value Care Committee. He works with the ACP, ABIM Foundation, and Costs of Care on educating physicians about healthcare value. 

Andrew Lai, MD MPH is an Assistant Clinical Professor at UCSF. He directs the Division’s Case Review Committee and co-directs the Hospitalist Procedures Service. He is a member of the Division of Hospital Medicine High-Value Care Committee, Quality Improvement Committee, and the Global Health Committee.  

The Unwritten Rules of Management @Medici_Manager @helenbevan


William Swanson’s unwritten rules of management is full of pithy advice. Swanson is the Chairman and CEO of Raytheon.

Originally a part of a presentation to engineers and scientists at Raytheon, someone asked him to write his rules down.

Thankfully he listened, the result is Swanson’s Unwritten Rules of Management.

Not all of the rules are Swanson’s. Some of them were published in 1944 in The Unwritten Laws of Engineering by W. J. King. (The book was updated in the early 2000′s by James G. Skakoon.)

In The Unwritten Rules of Management, Swanson elaborates on these rules with a paragraph or two.

  1. Learn to say, “I don’t know.” If used when appropriate, it will be often.
  2. It is easier to get into something than it is to get out of it.
  3. If you are not criticized, you may not be doing much.
  4. Look for what is missing. Many know how to improve what’s there, but few can see what isn’t there.
  5. Presentation rule: When something appears on a slide presentation, assume the world knows about it, and deal with it accordingly.
  6. Work for a boss to whom you can tell it like it is. Remember that you can’t pick your relatives, but you can pick your boss.
  7. Constantly review developments to make sure that the actual benefits are what they are supposed to be. Avoid Newton’s Law.
  8. However menial and trivial your early assignments may appear, give them your best efforts.
  9. Persistence or tenacity is the disposition to persevere in spite of difficulties, discouragement, or indifference. Don’t be known as a good starter but a poor finisher.
  10. In doing your project, don’t wait for others; go after them, and make sure it gets done.
  11. Confirm the instructions you give others, and their commitments, in writing. Don’t assume it will get done!
  12. Don’t be timid; speak up. Express yourself, and promote your ideas.
  13. Practice shows that those who speak the most knowingly and confidently often end up with the assignment to get the job done.
  14. Strive for brevity and clarity in oral and written reports.
  15. Be extremely careful of the accuracy of your statements.
  16. Don’t overlook the fact that you are working for a boss. Keep him or her informed. Whatever the boss wants, within the bounds of integrity, takes top priority.
  17. Promises, schedules, and estimates are important instruments in a well-ordered business. You must make promises — don’t lean on the often-used phrase, “I can’t estimate it because it depends upon many uncertain factors.”
  18. Never direct a complaint to the top. A serious offense is to “cc” a person’s boss on a copy of a complaint before the person has a chance to respond to the complaint.
  19. When dealing with outsiders, remember that you represent the company. Be especially careful of your commitments.
  20. Cultivate the habit of boiling matters down to the simplest terms. An elevator speech is the best way.
  21. Don’t get excited in engineering emergencies. Keep your feet on the ground.
  22. Cultivate the habit of making quick, clean-cut decisions.
  23. When making decisions, the “pros” are much easier to deal with than the “cons.” Your boss wants to see them both.
  24. Don’t ever lose your sense of humor.
  25. Have fun at what you do. It will reflect in your work. No one likes a grump except another grump!
  26. Treat the name of your company as if it were your own.
  27. Beg for the bad news.
  28. You remember 1/3 of what you read, 1/2 of what people tell you, but 100% of what you feel.
  29. You can’t polish a sneaker. (Don’t waste effort putting the finishing touches on something that has little substance to begin with.)
  30. When facing issues or problems that are becoming drawn-out, “short them to the ground.”
  31. When faced with decisions, try to look at them as if you were one level up in the organization. Your perspective will change quickly.
  32. A person who is nice to you but rude to the waiter — or to others — is not a nice person. (This rule never fails.)



La tentazione è di parafrasare il titolo della celebre raccolta di racconti di R. Carver per chiedersi “di cosa parliamo quando parliamo di trasparenza”.[1] Infatti, l’evoluzione che ne ha caratterizzato il contenuto e progressivamente arricchito il significato rende necessario precisare il concetto, nell’accezione in cui può essere specificamente usato. Perché, nell’ambito del pubblico agire, la trasparenza può – di volta in volta, ma anche al contempo – atteggiarsi come disclosure dell’Amministrazione o come openness dei risultati della sua operatività.

Può, quindi, realizzarsi mediante l’accessibilità a informazioni finalizzata al controllo delle pubbliche istituzioni, ma anche mediante la possibilità di libero riuso ed elaborazione dei dati in cui si concreta la loro azione, per la creazione di prodotti e servizi che generino valore per chi la effettua così come per l’intera collettività che ne fruisce. E’ nel concorso di entrambe le connotazioni – discolure e openness – che essa trova la sua più piena attuazione fino a divenire, nella forma e nella sostanza, vera ed effettiva “apertura”.[2] Ma ogni apertura, anche giuridicamente intesa, è sempre l’essenziale preludio di un’ineludibile evoluzione, individuale e collettiva, verso nuove dimensioni. Forse per questo lo Stato è piuttosto restio a perseguirla e, autoritativamente arroccato nella statica conservazione del potere, stenta a rinunciare alla propria tradizionale predominanza. Mentre la dinamica dei rapporti tra pubblico e privato, soprattutto in tempo di crisi, evidenzia sempre più l’esigenza di una reciproca sussidiarietà i cui effetti virtuosamente si propaghino dall’uno all’altro ambito, in una paritaria interazione. Il risultato di tale sfasatura è che la trasparenza in Italia è stata solo parzialmente attuata, sia come disclosure che come openness, fondamentali canali di collaborazione e partecipazione dei cittadini alla “cosa pubblica” nel perseguimento del desiderato “bene comune”, ma anche importanti strumenti di innovazione e sviluppo economico e sociale.

Del primo versante si è già trattato.[3] Da elemento connotante l’azione e la sostanza stessa dell’azione amministrativa, rinvenibile nei principi costituzionali di legalità, imparzialità e buon andamento, oltre che di efficienza ed efficacia, con la l. 241/1990 la trasparenza è dapprima divenuta criterio volto a consentire al singolo portatore di un interesse “diretto, concreto e attuale, corrispondente a una situazione giuridicamente tutelata” di superare la segretezza quale regola gestionale della documentazione amministrativa, sovvertendo la stessa logica relazionale delle Amministrazioni.[4] Successivamente, è stata resa strumento atto a scardinare progressivamente la consolidata blindatura dell’attività pubblica, fino ad aprirne ambiti sempre più ampi rispetto all’angusto perimetro dell’interesse del singolo alla conoscenza dello specifico atto  del procedimento a lui pertinente. Dalla prima legge, il d.lgs. 150/2009, che l’ha configurata quale “accessibilità totale” – ma pur sempre limitata ai documenti dalla stessa previsti come pubblici – e preordinata a forme diffuse di controllo della P.A., al recente  d.lgs. 14 marzo 2013, n. 33, che l’ha sostanziata di sovrabbondanti contenuti, riordinando anche quelli già vigenti,[5] la trasparenza è andata giuridicamente concretandosi in un progressivo aumento di disclosure dell’attività amministrativa. La qualità dell’indubbio salto culturale così operato non ha trovato analoga corrispondenza nei modi con cui è stato attuato, tesi a privilegiare la quantità e articolazione dei dati proattivamente pubblicati[6] rispetto alla qualità e selezione di quelli che reattivamente avrebbero potuto essere concessi. Il risultato è una trasparenza tanto dettagliatamente perseguita quanto mai pienamente realizzata. Sarebbe bastato consentire a chiunque la conoscenza di quanto non protetto da esigenze di riserbo o segretezza, per non lasciare angoli bui nell’amplissimo ambito del pubblico agire. Invece, si è preteso che i suoi infiniti anfratti potessero essere illuminati con burocratici elenchi di minuziosi adempimenti, in una sorta di slalom tra legittimazione individuale vincolata e accessibilità totale, ma al contempo limitata. E così la complicazione documentale, anziché in esaustività informativa, si è piuttosto tradotta in opacità: “per confusione”. Ma tant’è.

Quanto al secondo versante, non si può dire che i risultati in termini di opennes siano più soddisfacenti. Mentre la trasparenza andava evolvendosi e sostanziandosi come sopra accennato, il progresso informatico ne portava in evidenza un’altra dimensione, di tipo tecnologico primo ancora che giuridico: perché se per realizzare disclosure basta la pubblicazione, purché sia, sui siti web di documenti e informazioni, per attuare opennes servono dati liberamente accessibili, tecnologicamente fruibili, gratuitamente disponibili, a qualunque fine riusabili.[7]Due parole: open data.[8] Un metodo, open government.[9] Un obiettivo: un nuovo modello culturale e trasversale, che dall’ambito amministrativo a quello economico affermi un’amministrazione sempre più aperta all’interazione con la collettività che della sua azione è non solo destinataria, ma anche compartecipe. Ecco allora che gli open data divengono funzionali non solo alle finalità  di controllo, collaborative, politiche ecc. che per il loro tramite si vogliono perseguire, ma anche a quelle ulteriori di tipo “commerciale” che, pur nascendo dall’iniziativa personale, si traducono comunque in innovazione e, quindi, in crescita economica e sviluppo sociale.

Purtroppo, il legislatore nazionale non mostra sempre troppa coerenza tra intenzioni proclamate e risultati prodotti. E se ha sempre meglio connotato giuridicamente, fino a renderla in una certa misura cogente, l’openness, dall’altro l’ha relegata entro gli stessi limiti delladisclosure.

Nel d.lgs n. 36/2006[10] (novellato dalla l. n. 96/2010), da un lato l’ha introdotta come “finalità” delle pubbliche amministrazioni, affrettandosi nel contempo a ribadire la libertà di queste ultime di non adottarla. Nel d.lgs. n. 82/2005 (Codice dell’Amministrazione Digitale, CAD, modificato dal d.lgs. n. 235/2010) l’ha resa oggetto di un compito da attuare, individuandone le modalità[11] ed esplicitandone il fine.[12] Nella l. n. 35/2012, in materia di semplificazioni, ha previsto la promozione del paradigma dei dati aperti (open data)[13] e nella legge 179/2012 (c.d. decreto sviluppo), modificando di nuovo il CAD (art. 52), ha disposto, ma senza il supporto di mezzi di efficace cogenza, la pubblicazione del catalogo dei dati, dei metadati e delle banche dati in possesso delle Amministrazioni. L’ha finalmente resa oggetto di un obbligo, anziché di indicazioni programmatiche, solo con il d.l. n. 83/2012 (c.d. decreto crescita 2.0), ove ha imposto, se pur limitatamente ai provvedimenti attributivi di vantaggi economici,[14] che i relativi dati siano “resi di facile consultazione, accessibili ai motori di ricerca ed in formato tabellare aperto che ne consente l’esportazione, il trattamento e il riuso” (art. 18). Infine, con il d.lgs. 33/2013 (c.d. decreto “trasparenza”) ha dettato che venga pubblicata in formato aperto (ai sensi dell’art. 68, comma 3, del CAD)[15] e sia riutilizzabile (ai sensi del d.lgs. n. 36/2006) quella massa di documenti, informazioni e dati oggetto di pubblicazione obbligatoria (art. 3). Di conseguenza, quelli che spontaneamente queste ultime ritengano comunque di pubblicare (art. 4, comma 3), o comunque fornire, restano soggetti alle norme del CAD, sprovviste di un’effettiva sanzionabilità. La circostanza che questi ultimi vengano resi come open data rimane così un mero auspicio. Né pare rinforzarlo la previsione per cui i dati e i documenti che le amministrazioni pubblicano senza l’espressa adozione di una licenza si intendono rilasciati come dati di tipo aperto e l’eventuale adozione di una licenza deve essere motivata ( c.d. open by default, art. 52, comma 2, CAD).

Per l’openness è stato in questo modo replicato il medesimo paradigma della disclosure. E’ riutilizzabile e, quindi, rielaborabile, quella stessa complessa congerie di dati che – autoritativamente e proattivamente – è sancito sia pubblica. Ciò perché il legislatore non ha – più semplicemente e reattivamente – consentito, fatti salvi i limiti del segreto e della riservatezza, la generalizzata legittimazione dei soggetti interessati al soddisfacimento di ogni loro richiesta di trasparenza: non solo conoscitiva, ma anche tecnologica. Ma quanto con complessità e discrezionalmente viene elargito è difficile possa essere facilmente compreso e, dunque, proficuamente riutilizzato. E’ evidente come la trasparenza ne risulti, in ogni sua accezione, depotenziata: essendo, innanzi tutto, il risultato della percezione di coloro i quali ne sono destinatari, essa viene rafforzata dall’ascolto delle esigenze e dal soddisfacimento delle istanze.[16] E, solo quand’è effettiva, ne genera altra, in un inesauribile circolo virtuoso. E’ così che l’informazione da pubblica diviene chiara e, quindi, comprensibile e, poi, rielaborabile e, infine, effettivamente utile.[17] E’ così che dati di concreto e facile accesso, a livello cognitivo prima ancora che tecnologico, quando variamente studiati, analizzati, messi a confronto ed elaborati anche mediante nuovi database, sono in grado di creare valore aggiunto. Dati “open”, in ogni senso: che possano cioè essere agevolmente reperiti, con semplicità capiti e, di conseguenza, efficacemente usati.

Favoriscono il controllo dell’operato della P.A., responsabilizzandone vertici e base e concorrendo alla loro accountability; consentono ricerche e analisi a fini di collaborazione e interazione tra le amministrazioni e  i cittadini utenti, nonché di partecipazione di questi ultimi alle decisioni che li riguardano, emancipandoli da una situazione di passivi destinatari a una dimensione di soggetti attivi, selettivi e propositivi; costituiscono un incentivo alla concorrenza e alla competizione tra amministrazioni che svolgano attività omogenee, facendo luce sui fattori distorsivi e aumentando la qualità delle prestazioni rese; rappresentano miniere di informazioni per la creazione di servizi e lo sviluppo di applicazioni utili all’intera collettività, fonti di impulso all’economia e di stimolo alla creazione di posti di lavoro.

Solo un legislatore miope può avere una visione di trasparenza così limitata da comprimerla in una congerie di oneri adempimentali per le P.A. e in una mole di informazioni e documenti spesso criptici e intricati, anche se in formato open data, per la collettività. Un’effettiva “liberazione” dei dati, salvo segreto e riservatezza, non può tollerare limitazioni, né tecnologiche né di legittimazione, nella piena armonizzazione tra disclosure e openess. Tanto più perché quei dati appartengono alla collettività dei contribuenti che con denaro pubblico li ha finanziati e, a maggior ragione, se essi possono costituire un mezzo per produrre ricchezza, sia essa informativa o economica, per chi li usa e li elabora e per chi, poi, dei risultati così prodotti si avvale.

Ma lo Stato, forse, non sa di cosa parla quando parla di trasparenza se, limitando normativamente l’obbligo di open data ed essendo scarsamente disponibile a fornire quanto non gli venga imposto  di pubblicare[18], ne penalizza la realizzazione. E in questo modo – non favorendo la collaborazione collettiva, la partecipazione politica, lo sviluppo sociale e la crescita economica – penalizza se stesso. Ma forse anche questo lo Stato non lo sa: del resto, la piena trasparenza genera ritorno di amplificata conoscenza anche per chi la consente. Sarà per questo che lo Stato, spesso, ignora.

Le opinioni sono espresse a titolo personale e non coinvolgono in alcun modo l’ente di appartenenza (Consob)

[1] Il riferimento è al libro di Raymond Carver “Di cosa parliamo quando parliamo d’amore”, pubblicato negli Stati Uniti nel 1981 e in Italia nel 1987.

[2] “È bene differenziare sin da subito il concetto di trasparenza da quello di apertura. Il concetto di apertura include quello di trasparenza, ma non necessariamente è vero il contrario. In altri termini, non è sufficiente la trasparenza così come definita nel nostro ordinamento giuridico perché si possa parlare di Open Data”. .

[4] In questo senso, G. Napolitano, “Manuale di diritto amministrativo”, 2008, p. 267.

[5] Al riguardo, v. i risultati di un’indagine svolta dalla Civit (Commissione Indipendente per la Valutazione, la Trasparenza e l’Integrità delle Amministrazioni Pubbliche) in ordine agli obblighi di pubblicazione vigenti al luglio 2012 .

[6] La Civit ha così schematizzato i vigenti obblighi di pubblicazione .

[7] “Make a beautiful website, but first give us the unadulterated data, we want the data. We want unadulterated data. OK, we have to ask for raw data now” (Sir Tim Berners-Lee, inventore del World Wide Web).

[8] Una definizione comunemente accettata è quella dell’Open Knowledge Foundation (fondazione no profit, costituita nel 2004 al fine di promuovere la conoscenza aperta), che definisce gli open data come “data that can be freely used, reused and redistributed by anyone – subject only, at most, to the requirement to attribute and sharealike”, specificandone poi le caratteristiche (

[9] I principi della dottrina dell’Open Government sono stati valorizzati dall’amministrazione Obama, che ne ha declinato i contenuti nel 2009 nell’Open Government directive, incoraggiando l’utilizzo degli open data e impostando l’archivio Nel maggio 2013, con unexecutive order, il Presidente USA ha imposto che i dati delle amministrazioni, qualora passibili di accesso da parte dei cittadini, debbano essere in modalità predefinita come open data e in formati utilizzabili dalle macchine:

[10]“Le pubbliche amministrazioni o gli organismi di diritto pubblico perseguono la finalità di rendere riutilizzabile il maggior numero di informazioni, in base a modalità che assicurino condizioni eque, adeguate e non discriminatorie” (art. 1, comma 4), ma dei documenti di cui abbiano disponibilità “..non hanno l’obbligo di consentire il riutilizzo (..) La decisione di consentire o meno tale riutilizzo spetta all’amministrazione o all’organismo interessato, salvo diversa previsione di legge o di regolamento” (art. 1, comma 2). Al riguardo, v. anche

[11] “Lo Stato, le Regioni e le autonomie locali assicurano la disponibilità (…) dell’informazione in modalità digitale e si organizzano ed agiscono a tale fine utilizzando con le modalità più appropriate le tecnologie dell’informazione e della comunicazione” (art. 2, comma 1), intendendosi per disponibilità “la possibilità di accedere ai dati senza restrizioni non riconducibili a esplicite norme di legge” (art. 1, lett. o)).

[12] “I dati delle pubbliche amministrazioni sono formati, raccolti, conservati, resi disponibili e accessibili con l’uso delle tecnologie dell’informazione e della comunicazione che ne consentano la fruizione e riutilizzazione, alle condizioni fissate dall’ordinamento, da parte delle altre pubbliche amministrazioni e dai privati…” (art. 50, comma 1), laddove per “fruizione” è da intendersi “la possibilità di utilizzare il dato anche trasferendolo nei sistemi informativi automatizzati di un’altra amministrazione” (art. 1, lett. t)), mentre per riutilizzazione occorre rifarsi al citato d.lgs n. 36/2006 che, all’art. 2, lett. e), la definisce come “l’uso del dato (…) a fini commerciali o non commerciali diversi dallo scopo iniziale per il quale il documento che lo rappresenta è stato prodotto nell’ambito dei fini istituzionali”.

[13] In particolare, il fine è quello della “valorizzazione del patrimonio informativo pubblico, al fine di creare strumenti e servizi innovativi” (art. 47, comma 2 bis, lett. b).

[14] Dati da pubblicarsi nella sezione “Trasparenza, valutazione e merito” di cui al citato decreto legislativo n. 150 del 2009.

[15] “ intende per: a) formato dei dati di tipo aperto, un formato di dati reso pubblico, documentato esaustivamente e neutro rispetto agli strumenti tecnologici necessari per la fruizione dei dati stessi; b) dati di tipo aperto, i dati che presentano le seguenti caratteristiche: 1) sono disponibili secondo i termini di una licenza che ne permetta l’utilizzo da parte di chiunque, anche per finalità commerciali, in formato disaggregato; 2) sono accessibili attraverso le tecnologie dell’informazione e della comunicazione, ivi comprese le reti telematiche pubbliche e private, in formati aperti ai sensi della lettera a), sono adatti all’utilizzo automatico da parte di programmi per elaboratori e sono provvisti dei relativi metadati; 3) sono resi disponibili gratuitamente attraverso le tecnologie dell’informazione e della comunicazione, ivi comprese le reti telematiche pubbliche e private, oppure sono resi disponibili ai costi marginali sostenuti per la loro riproduzione e divulgazione”.

[16] Interessanti, al riguardo, i risultati della ricerca Formez In particolare, da essi emerge la disaffezione diffusa nei riguardi di una P.A. che pecca per la scarsa chiarezza delle risposte e per gli ostacoli che frappone fra sé e i cittadini utenti: solo il 17,6% dichiara di averne fiducia.

[17] “La trasparenza implica che tutti i dati resi pubblici possano essere utilizzati da parte degli interessati. Non è, infatti, sufficiente la pubblicazione di atti e documenti perché si realizzino obiettivi di trasparenza. Di contro, la pubblicazione di troppi dati ovvero di dati criptici può opacizzare l’informazione e disorientare gli interessati”.

[18] Dal sito, “I dati aperti della PA”,  emerge che sono solo 73 le amministrazioni che attualmente hanno provveduto a liberare dati dalle stesse detenuti.

How does an organization create breakthrough performance?

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Smokers will be asked to quit before undergoing surgery under new medical guidelines @Medici_Manager

Grant McArthur

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

Leaders are made, not born (great video) @pash22 @Medici_Manager @WRicciardi @muirgray

Great video by

Many of the system-wide issues we face won’t be solved by management processes @Medici_Manager

POSTED BY  ⋅ MAY 28, 2013

If the future sustainability of the NHS means its leaders will need to make tough decisions, how can leaders make sure they are making the right ones? In my chief executive roles in the NHS, I’ve made some difficult decisions – some clinical, some financial, many staff related. All had patient and service impact.

You could probably guess at the areas they might have covered: where to invest new resources, how to structure new organisations, which of the best people to promote, whether to reduce funding for services with limited clinical value, how to tackle the viability of a service, and so on.

They were all difficult, but they mostly related to ‘tame’ problems. I’m not being flippant, I’m using language coined by academic, Keith Grint, who says that if a problem can be solved using a process, then it is ‘tame’. The problem might be complicated, but there’s a process and we know the answers. So in the organisations I’ve worked for, we engaged with patients and the public, consulted using statutory guidance and followed organisational policies and procedures. There was process and we followed it.

Then there were the incredibly difficult problems, those which were complex, longer term, strategic, multi-dimensional and with no obvious answer or process. The sort that Grint refers to as ‘wicked’.

As chief executive of a primary care trust (PCT) in Sheffield, our goal was to reduce the 13-year health inequality gap between the best and worst outcomes in the city. We wanted to work out how best to measure the impact of our investments – either unilaterally as a PCT or as part of multi-agency approaches – so that we’d make a difference 30 years from now. It took difficult to a new level.

Do you focus on housing, social care or education? Or what about the justice system, benefits, improving NHS services or health promotion? Where will the greatest impact be made? Impossible, right? These sorts of complex problems, says Grint, are wicked. We’ve not come across them before, we don’t know the answers and we can’t solve them alone. The best we can do is to come together to try.

In Sheffield, and with support from the Health Foundation and the London School of Economics, we tried a new approach that brought together clinicians, patients and managers from across the health system to work through problems, looking at how we could combine value for money analysis with stakeholder engagement.

The approach was designed to help us move forward, not necessarily to find the answers, engaging with patients, staff and data, investing a lot of energy and staunch commitment. In short, we were working it through.

When staff are looking for solutions, when boards are holding you to account, would you be bold enough to respond “we’re working it through”? It takes someone with great leadership skills to know it’s the not only the right answer but the only answer for wicked issues. For many of the system-wide issues we face today, we won’t solve them with management processes.

We need leaders who are comfortable with the journey, who want to work in collaboration across system boundaries and who know that making a difficult decision is sometimes the wrong thing to do.

If senior leaders are always dealing with problems where there’s an answer, they’re dealing with the wrong things. Finding the right question is as important as finding the right answer.

Jan Sobieraj is managing director of the NHS Leadership Academy. Follow Jan on Twitter @JanSobieraj

How To Apply For USA Residency: Tips For IMGs

Andrea Silenzi, MD, MPH, PhD

1. Apply Early. The early bird catches the worm. Most medical residency programs have limited interview slots. According to FREIDA, on an average a Family Practice Residency Program interviews 50 applicants and an Internal Medicine Residency Program interviews 189 applicants. Normally a program receives applications, reviews them and sends out invitations for interviews. Usually all residency interview slots would be filled up quickly. If you apply after this happens, chances are even if you meet or even exceed the requirements, your application will not be reviewed. So, before 1st September, you should already have finalized the programs you plan to apply. And, you should apply as early as possible in the first week of September itself.

2. (Again) Apply Early. In case you missed the above point or underestimated the importance of applying early, read on. Programs are likely to be flexible in the beginning of the application season. This…

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5 Leadership Lessons An MBA Can’t Provide @Medici_Manager @CEOcom @muirgray

First he talked about the importance of inspiration. Then he described the power of passion. Then he shared the value of vision.

Then I almost fell asleep.

The professor was describing the traits of a great leader. I certainly didn’t disagree with his list: Vision, passion, inspiration, dedication, fairness and accountability. All are important traits of a great leader.

Still, even then I knew I wouldn’t remember almost anything he said. Platitudes are hard to remember, much less put into practice. “Inspire your team,” is great advice, but how exactly do you inspire them?

As I walked away I decided most of what I know about leadership didn’t come from business schools or conferences or seminars. The best leadership lessons are the ones I learned the hard way:

1. Information comes and goes, but feelings are forever.

Data is important. Explaining the logic and reasoning behind a decision can help create buy-in and commitment. Charts, graphs, tables, results, etc., are useful—and quickly forgotten.

But make an employee feel stupid or embarrass him in front of other people and he will never forget.

An employee made a comment in a meeting, and I instinctively fired off a sarcastic comeback. Everyone laughed but the employee. (For a long time, I was like a sarcastic-comment sniper who figured that if I had the witty shot I should always take it.)

And my working relationship with that employee was forever changed. I apologized on the spot and also later, but the damage was already done.

Spend twice the time thinking about how employees will feel than you do thinking about data and logic. Correcting a data mistake is easy. Overcoming the damage you cause to an employee’s self-esteem is impossible.

2. The best ideas are never found in presentations.

Presentations are a great way to share detailed, complex information. Presentations are a terrible way to share great ideas.

After I drank too deeply from the Six Sigma Kool-Aid I started interrupting employees who came to me with ideas by telling them to “put something together.” A few would: Then we’d whip out our multicolored belts and talk intelligently about their data, their analysis techniques, their conclusions… ugh.

Most wouldn’t bother, and looking back I don’t blame them.

Great ideas can be captured in one or two sentences. Your employees have those ideas.

All you have to do is listen. And your employees will love you for listening, because I guarantee people they used to work for never did.

3. The “volunteer penalty” kills the flow of great ideas.

Your best employees tend to come up with the best ideas, and it’s natural to assign responsibility for carrying out an idea to the person who came up with the idea. Plus, if that person is a great employee it’s natural to want them to take responsibility because they’re more likely to get things done.

Of course, your best employees are already working extremely hard, so assigning them responsibility every time they have a suggestion naturally stops their flow of ideas.

As one outstanding employee finally explained to me, “I finally realized I needed to stop suggesting things to you. Every time I did you just added another responsibility to my plate.”

Sometimes the employee will welcome the responsibility for carrying out their idea. Other times they won’t. How do you know how a particular employee will respond?


4. Sharing only the positives always results in a negative.

Imagine you’re sharing the reasoning behind a decision you made with your team. Naturally, you want to describe the positive outcomes of the decision. So you whip out your pom-poms and start cheering.

Meanwhile your employees are instinctively looking for negatives, since almost every silver lining for the business has a black cloud for at least a few employees.

I once described how a change to paper dust collection would improve the air quality throughout the plant, but I left out the fact that as a result a few employees would spend at least part of each day looking like they had rolled around in a bathtub filled with flour.

Never leave out the negatives, even if those negatives may be potential rather than actual. Talk openly about any downsides, especially when those downsides directly affect employees. Show you understand the best and the worst that can happen and what that might mean to your team.

When you freely discuss potential negatives, employees not only respect you more, they often work harder to make sure potential negatives don’t turn into realities.

5. Data is accurate, but people are right.

You’re smart. You’re talented. You’re educated. Data analysis is your best friend. Sometimes your data will lead to an inescapable conclusion… and yet you should still make a different decision.

I once moved two crews of about 30 people to a different shift rotation because I knew the resulting process flow would automatically improve overall productivity by about 10 percent. I also knew, because they told me, that most of them would hate the new rotation. But I held firm because I knew great leaders are willing to make tough decisions and do whatever it takes to get results.

It turns out I had that all wrong.

Sure, my new shift rotation worked on paper. It even worked in practice. But it screwed up the family lives of a number of great employees, and I finally pulled my head out of my [butt] and shifted everyone back to the old rotation. We found other ways to improve productivity.

Sometimes a decision should be based on more than analysis, logic, and reasoning. No decision should ever be made in a vacuum, because every decision must eventually be carried out by people.

Leadership should be data driven, but great leadership is often subjective and even messy. If your employees don’t agree with you, ask why, but don’t ask just so you can defend your position. Ask in order to learn.

You know things your employees don’t know, and they know things you don’t know—at least until you listen to what they have to say.

Richard Smith: Health and social care: lots of activity, little value @Richard56 @Medici_Manager

21 Jun, 13 | by BMJ Group

My mother is a wonderful woman but has no short term memory and drinks too much alcohol. When she’s sober her language is complex and her sense of humour magnificent. “What a terrible world,” she says, watching the television news, “I’m glad I’m not in it.” In a way, she isn’t. She’s mildly disinhibited even when sober and chats to everybody. “You’re one of the sights of Barsetshire,” I say to her, “they’ll be organising coach parties.” “Well, nobody ‘ll pay,” she answers laughing. But how much have the health and social services helped my mother?

She’s clear that she wants to live on her own as long as possible. In an age gone by, but still present in most of the developing world, she would have lived with me or my brothers. It would be unthinkable that when widowed she should live alone. But those days are finished. We couldn’t stand it and nor, I’m confident (but maybe deceiving myself), could she.

It’s fascinated me how well and for how long she has lived alone despite having no short term memory. It’s been some six years. I thought an intact short term memory essential for living alone, but I was wrong. Luckily she doesn’t cook, so doesn’t leave the gas or the oven on. She forgets to put water in the electric kettle and sometimes blows the fuses, but she doesn’t blow up the house.

Every day is much the same. She gets up at about 8.30, has a cup of black coffee, looks at the Guardian (making no sense of it), puts on her shoes, and “stomps,” as she describes it, the mile into the centre of Barset. Greeting the man in the newsagent, she buys a bottle of wine, stomps home, hailing people as she goes, drinks the wine, and goes to bed. Perhaps two hours later she gets up and does it all again. And when the days are longest, she may attempt it a third time—unaware that it’s evening not morning and unsteady on her feet after two bottles of wine. That’s why I’m sat here in Barset writing this. I’m “mothersitting.” She giggles at the term but doesn’t really like it.

Back at the beginning I thought that we ought to “get her into the system.” I thought that we’d need some support and that it would be essential to be “on the books” to receive it. So we went to the GP, which she doesn’t like. The trainee said that she should have some blood tests and come back to have “the long test for memory.” That was two trips, 140 miles driving, and when we had the appointment for the long test, the doctor didn’t have time to administer it and so simply referred her to the memory clinic. There was no value added by all this as the postman could have told us that she has no short term memory.

The adventures with the memory clinic were long and drawn out with MRI scans, psychological tests, many interviews with a variety of people, and some 350 miles of driving. My mother hated it all, but in the end she was prescribed drugs to help her memory. She forgot to take them and didn’t, I think, want to take them anyway, although she said she did to please us all. Even if she had taken the drugs there was only a small chance that they would have done any good. Everybody was charming and helpful, but no value was added by all this activity—except that the diagnosis released some state benefits.  It was bureaucratic value that was added.

Social services became involved. They came and did a long assessment. Eventually, they said, she’d have to go into a home. This wasn’t surprising. They couldn’t do anything except give us a list of services. They couldn’t recommend any service even though they presumably know which are better than others. So no value in this.

We arranged for a “sandwich lady” to come three times a week to encourage my mother to eat. But that was hopeless, and eventually my mother herself told the sandwich lady that she didn’t need her anymore.

Social services assessed her again and told us the same as before. They did arrange a bath chair, which did add a little value. Unfortunately it broke down almost immediately and took a long time to fix. Now they’ve taken it away. I’m not sure why.

We arranged for carers to come in twice a day, and they have added value. But we found them and have to pay as my mother owns her house.

What about resuscitation, the care company asked. My mother is very clear that she doesn’t want to be resuscitated. We talk about death a lot. She’s not scared of death. But we can’t have a DNR in place without having the doctor approve it. So we haven’t bothered. If the carers find her in cardiac arrest they are highly unlikely to succeed in resuscitating her anyway. Having to have a doctor determine your eligibility for a DNR seems to me a process that subtracts value.

Now things have reached a crisis. With the long evenings my mother is going out late and drunk and having all kinds of adventures with neighbours, the police, and the burghers of Barset. The care company has contacted social services worried that it might be blamed if she goes under a bus. So have some neighbours. A young man from social services rings me in a state of high excitement. He asks me things that we have told social services many times. He’s rung the GP asking for an assessment. He offers us another assessment. “What good will that do?” I ask. He’s not clear. I say that we recognise she can no longer live alone even though she insists that she wants to. We’ve started finding a home.

They can’t, it’s apparent, really do anything. I ring the GP and speak to a friendly understanding doctor. They have been contacted by social services and discussed her in their meeting. But nobody knows anything about her. A doctor has visited twice but never got an answer. Somebody is going to try again. The young doctor agrees that they have little to offer. I’ve not heard from them since.
Social services keep ringing because people are ringing them. The care company tells me that they will do anything to help but in the same call, without irony, tell me that they can’t supply somebody in the light evenings.

My brother asks who social services are serving?  Are they there for my mother or the neighbours? We recognise the strain on the neighbours, and we know most of them. Some have been very helpful. Ages ago I delivered them all a letter asking them to contact any of us if they had worries. I’m not sure why they ring social services rather than us.

Then my mother has a fall. It had to happen. Indeed, it’s happened before. This time she has a scalp wound, and we doctors (and surely most others) know that scalps can bleed generously. I was abroad unfortunately, so my brother rings 111. Risk averse, as they have to be, they recommend a visit to A and E. Nobody can be sure that she wasn’t unconscious. A young doctor thinks she might have a urinary tract infection to account for her confusion and prescribes antibiotics. They can’t be taken with alcohol. He suggests a visit to the GP in four days’ time. I say poppycock to all this when I return, and we forget the antibiotics and the visit to the GP. She is fine. So again more activity, more expense for the NHS, and no value. At least she hasn’t developed diarrhoea through taking antibiotics.

A woman from social services rang again today. She’s weary. I tell her that we are in the final stages of the bureaucracy of finding a home. She’s relieved. I ask her what she might do if we weren’t doing anything. Eventually she would have to use the law to have my mother admitted to a care home. She could arrange an emergency admission to a home, but we agree that we should do all we can to avoid having to move her twice.

My mother is unaware that the phone lines of Barset are buzzing with concern about her. She’s not keen on moving to a home but will do what we advise. Seconds after we’ve had the conversation she has of course forgotten it.

When I reflect on the saga so far I can’t see that statutory health and social services have added anything but minimal value. But there’s been plenty of activity, form filling, and expense. My mother is not that unusual. We surely need better ways to get value out of the system.
I also reflect that people who have added a lot of value are those who work in the newsagent she visits every day. She likes them, and they are not only kind to her but also let her have goods without paying when she forgets her money and arrange a taxi to take her home when she’s tired and exhausted. Perhaps we need fewer expensive professionals and a revitalisation of communities.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


Five (and a half) lessons I learned at the IHI National Forum @Medici_Manager

Dr Alan Willson, 1000 Lives Plus @dralanwillson –

Several people will be on their way from Wales to the BMJ/IHI International Forum in London next month. While there they’ll see innovation and best practice from around the world. It’s an opportunity to meet experts in quality improvement and patient safety and bring new knowledge back to Wales.

I’ve recently been reflecting on the ideas and examples I heard at the IHI National Forum last December. Here are five (and a half) lessons I learned, recognising a huge debt to Brent James and others who willingly shared their presentations with me so I could fully get to grips with what they were saying.

Lesson 1 – The quality improvement mindset is the opposite of top down management – and that is important

The frontline is where change matters because this is where we interact with patients. To change NHS Wales we need to follow Deming’s principle: Organise everything around value-added processes on the frontline – i.e. focus on the bits that will really make a difference to patients. Change needs to start here to be really effective.

Lesson 2 – Improvement has more to do with left brain than right brain

Innovation is fun. We all like to come up with ideas and then see if they work. But Bellin Health’s ‘High Performance Healthcare’ model indicates that a scientific approach to providing standardised levels of care is important to improving quality.

We don’t always have to do something new – what is more important is making sure the right things are done at the right time, in the right place and to the right people. Then, valuable improvement energy must be focussed on business critical problems and within a clear context of measurement and alignment with what else is happening in the system.

Lesson 3 – Quality and cost saving can and must be delivered together

The evidence from the QUEST initiative in American hospitals shows that improved quality and lower costs (or better control of costs) go together. We’ve also done some work on this, publishing a white paper last year. However, it’s very important that we set out with a focus on quality, not a focus on improving costs – better quality helps reduce costs; just trying to reduce costs won’t improve quality.

Lesson 4 – There is now an evidence base for high performance

The 10 most important elements in high performance have been identified in the QUEST hospitals. In the past we have had intuitive opinions, but now we have evidence-based key features that we should be looking to replicate in NHS Wales. We are fortunate to have Eugene Nelson speaking at the next 1000 Lives Plus National Learning Event on Tuesday 11 June to describe this ground breaking work.

Lesson 5 – Reducing harm from sepsis and surgical site infections are winnable fights

Some healthcare organisations have seen mortality due to sepsis drop by two thirds. Infections after c-sections have been virtually eliminated in many hospitals. It shows that deaths and harmful events can be stopped in Wales – the ways we can make this happen are out there.

 Lesson 5 and a half – We are on the right track with Improving Quality Together (but there is still work to do!)

If we can reach the point in NHS Wales where everyone truly believes that they have two jobs – to do their job and to improve their job – then this will result in improvements being initiated everywhere by everyone.

Improving Quality Together is a way of delivering this mass participation – but we need training, coaching and data for actionable measures to keep track of the improvements taking place and to evaluate them.

Let’s keep talking

I’d be interested to hear your comments on these lessons. Do they reflect what you know about the work going on in NHS Wales? What do you find intriguing? What makes you pause and go ‘hmmm’? Do comment.

Or, if you are at the International Forum next month, 1000 Lives Plus will be running the NHS Wales stand. Please stop by and say hello. If you can’t make it, then we’ll be blogging throughout the week to keep you up-to-date!

Most CEO’s have a cautious approach to innovation and it’s not paying off @Medici_Manager @StephenClulow

Why Low-Risk Innovation Is Costly

Companies are finding it hard to churn out “the next big thing.” Instead of the disruptive products, services and business models of yesteryear, innovations coming to market today are typically line extensions.

Our recent survey of more than 500 executives revealed that, while one in five (18 percent) respondents rate innovation as their top strategic priority and two-thirds depend strongly on innovation for their long-term strategy success, more than half feel they have a sluggish innovation process. Despite increasing commitment, funding and organizational accountability, many companies are disappointed by the returns they are deriving from their investments.

A cautious approach to innovation is understandable, given the relatively disappointing results. At the same time, however, it is a potentially perilous strategy. Enterprises that restrict themselves to incremental innovation, on the other hand, risk unknowingly entering a vicious cycle in which they lag ever farther behind.

By putting formal systems in place to manage innovation, companies can protect themselves from such risk. Enterprises able to successfully innovate at a breakthrough level are far more likely to dominate and prosper in the new markets they create. They can also position themselves to master change.

Leadership, doubt and humility @Medici_Manager @muirgray

Do you ever feel secretly inadequate?  I don’t mean the confusion of not quite understanding what’s going on in a busy and demanding world.  I mean feeling out of your depth, bewildered and doubtful as to whether you can do what is asked of you in your leadership role?  Or more accurately, a deep-seated and yet suppressed and secret feeling that really – you’re not up to the job?

I have.  My presenting behaviour, my ‘brand’ if you like, is confident, assertive, and assured.  I’m sure some people might even turn the volume up on those words and call me over-confident and maybe sometimes even rude.  These are behaviours I’ve been working on for years where I try and manage the thin boundary between genuine passion and unfortunate arrogance.  However, my internal experience is different.  Sometimes I look at the expectations people have of me, and I think ‘I’m just not up to this!’  I don’t feel like this all the time – but when things are tough and my resources are low I can find myself rocked and uncertain.

am i good enoughIf sometimes you feel like me – that you might not have what it takes – then we’re not alone. This feeling is called the Imposter Syndrome – and it’s completely normal. During my leadership development and coaching practice I’ve worked closely with numerous managers, leaders and fellow developers.  Pretty much every one has at some point said ‘I’m only one page ahead of the others’ or ‘I feel that at any moment I’m going to get found out for the fraud I know myself to be.’

Despite apparent evidence of one’s competence, when the Imposter Syndrome hits you’ll remain convinced that you do not deserve the success you’ve achieved, dismissing this inwardly as luck or fortuitous timing.  Psychologists would call it a phenomenon where successful people fail to internalise their accomplishments, unable to believe they are themselves responsible for, or deserving of, the position they’ve achieved.

I’ve met some truly brilliant people who experience this hindering internal pattern.  One in particular comes to mind – a bright and brilliant talent who is by everyone’s estimation a deserving young leader full of real promise.  By everyone’s estimation that is, other than her own.

Almost every leader I’ve worked with as a coach has expressed this personal doubt.  I say almost every leader – there have been a few that were justifiably nervous and rightly aware they were out of their depth – living examples of thePeter Principle where employees in a hierarchy will be successively promoted until they reach their level of incompetence.  But these weren’t the worrying ones – they were usually helped to find more fitting employment – sometimes uncomfortably, but normally appropriately and with compassion.

No, the really disappointing leaders were the couple that had no qualms at all of their capability.  Is it that they were so ‘complete’ and personally confident that they didn’t need to doubt themselves?  Quite the opposite – they were the real imposters who serendipitously found themselves in positions of influence but lacked the humility and insight to work reflexively on their own practice, to seek genuine feedback and take a proper look in the leadership mirror.

So, assuming you’re one of the majority of leaders, of people, who experience (or suffer) the Imposter Syndrome – what can you do?  All I can suggest is the same as I have suggested to clients, and the same as I suggest to myself when the feeling hits.

  1. Believe that it’s normal.  Take a look around the office at those you admire, and know they’ll experience this too.
  2. Ask for feedback.  Since the Imposter Syndrome is really a denial of the realities of your own efficacy, seek out others who can give you a more dispassionate view.  They’ll probably tell you you’re not perfect – but that you deserve the success you’ve earned.
  3. Save up positive feedback – and use it when you need it.  Be it a patient’s ‘thank you’, a colleague’s ‘well done’, a manager’s recognition or a good appraisal.  Some people keep a ‘My plaudits’ file on their computer offering a mine of restorative nuggets to be excavated in times of need.

thumbs up

Oh, and one entreaty.  If we assume that most people at some time or other experience this feeling of doubt – let’s help them out.  Let’s pass praise around our worlds freely and liberally.  I’m not talking about adopting a leadership style of complacent acceptance of poor performance – quite the opposite – I’m all for challenging (fairly, compassionately and very directly) those that truly aren’t up to the job.  The majority of colleagues though are talented yet self-doubting people doing the best they can. An encouraging word and a positive stroke could be just the reinforcement they need to keep their imposter at bay.