Crossbills, evolution and quality improvement

Today I have been thinking about Crossbills.

You know, the finches with the funny crossing-over beaks; perfectly designed to eat the pine nuts they find irresistible. (Who doesn’t love a pine nut?) The idea being that they evolve over time into that niche in the ecosystem and thrived.

I see NHS hospitals a little like Crossbills, and probably any animal that has participated in parallel evolution – this is similar creatures – birds are an easy example, e.g. finches, although you could look at bears, rodents or big cats and how they have adapted to life on different continents. Common ancestors, varying environments and voila, you have a panther in Ecuador and a tiger in Tamil Nadu. Just add-in a thousand generations.

(Biologists out there – I haven’t researched the facts of these species in detail, so don’t break my balls if I am a little out with genus and family).

This perhaps goes some ways to explain the similarities and differences you see between hospitals.

There are of course national guidelines that try their best to create standards of practice and thereby equivalent outcomes – Sepsis Six, primary PCI and stroke thrombolysis are a few that come to mind, although even within these pathways (and, most folk know what I think of those) there will be variations – the name of the drugs used, the titles or numbers of staff involved.

We try hard to achieve consistency, as, after all, this is the essence of quality. Ask anyone working for Toyota.

Yet, the more you look, the closer you scrutinise the detail, you will find not only quite significant variation in practice between hospitals, you are also likely to find this difference in the same organisation; ‘We do it this way because doctor ‘A’ likes things like that…’ This is culture pooping on strategy.

The differences in many instances are understandable – the numbers of doctors, nurses and therapists available to work in rural hospital A will be different to big metropolitan hospital B; budgets will vary, demographics, environments.

How do you arrive at any form of consistency?

It is interesting; doctors, nurses and pharmacists when training often rotate through different hospitals and consequently have to adapt to paperwork, standards and terminology that are different; what is particular about this group of staff is that they are usually at the bottom of the barrel within organisational hierarchies. Few sit on important groups or boards. Most don’t have the ear of the chief executive or chief strategy officer.

And this, is my proposal to subvert evolution, to turn it to our purposes. (Assuming that evolution is what happens when you let things sort themselves out.)

First, get rid of the hierarchy. Names, as Bruce Lee said back in the sixties cause fear – they don’t help us collaborate (job titles that is, first names are always important) and, secondly, use the eyes and ears of the youngest (and, probably those who are most disadvantaged) in your networks and departments to gain perspective, to determine what is right and what is failing. They, after all will often have the most acute sense of good and bad – old guys like me are too unfit, can’t see or hear for anything; this is teamwork – utilising the experience of those who have been around and blending it with those who see differently.

Back to the big cats and the Crossbills.

I remember my friend Harry questioning the position of schoolchildren creating the rules and determining which teachers should be promoted to positions of leadership; I can see this as the only way ahead. It is democracy; sure, you need to account for the super-packs, the situations where the good of the few outweighs the needs of the many;

Would a tiger if given the option have chosen its stripes? Surely; how about a Crossbill? – It can’t be easy for them to kiss, blow a balloon or pout.

Diversity and variation are what make life on earth beautiful, what makes life worthwhile, and within this is the sense that we can always do better.

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