Surfing the waves

What a week! Seriously, I’m sitting in the garden reflecting not only on the unusually good weather, but the most amazing week of learning and connecting about improvement research and practice.

This time last week, I arrived in Montreal for the international conference in organisational behaviour in healthcare (OBHC), (thank you, as always, Health Foundation for funding my PhD and its dissemination). It’s a super conference covering many aspects of improvement, and strategic and organisational theory. The event started for me as last time by (losing my luggage and) meeting many early career researchers and PhDs. In what can only be described as a shouting frenzy, we enthusiastically participated in a round of speed networking, fantastically facilitated by Prof. Cathy Pope, where amongst other things we were asked to discuss our superpowers and our best teacher. The best part about this is that we all made many new friends, learnt about each other’s research and we were not at risk of being lonely at the conference.

After a hike up Mont Royal, the following day the conference opened with a plenary about crossing paradigmatic boundaries. This included reflecting on the current state of the field including the need for pragmatic and real world trials, and the need for much more ethnography to develop insights to explain and influence organisational behaviour in healthcare. After this was a torrent of breakout sessions, for me the strength of this conference, with such a diversity of topics. I heard sessions about organisational change capability in Wales, knowledge mobilisation using boundary objects (I didn’t know what they were to begin with), leadership for quality improvement development programmes, the negative impact of leadership churn on quality improvement, the role of middle management in improvement, improvement sustainability, second victims in patient safety and so on. I was also delighted to present my theorisation of improvement capability.

I especially loved hearing from A.Prof Liz Wiggins and colleagues about their work to understand and develop the leadership of improvement via the GenerationQ programme (I am a former participant). This work (in press) describes leading improvement as ‘surfing the waves’ between perspectives, relationships and world’s; taking a complexity perspective to influence learning and practice in healthcare, one conversation at a time through leadership gestures and responses.

Two main highlights were a keynote from Prof. Henry Mintzburg speaking on managing the myths of healthcare; and the work from Prof. Stephen Shortell at CLEAR and colleagues to evaluate lean programmes in North America. I find this work very exciting. First, was research to evaluate the audacious lean programme in Saskatchewan province in Canada followed by a national lean survey in the USA. Shortell et al’s survey and analysis begins to demonstrate much needed research evidence of the positive [self reported] impact of lean (and other robust improvement) programmes especially after they begin to mature (warning for those looking to lean for a fast fix, this study shows impact really only starting after about 8 years of implementation). Whereas, the Satskatchewan story is rather depressing to hear, but nevertheless, there is much learning from the programme for other national and large scale lean programmes, to learn from. Not least ensuring early engagement of physicians, not being too fast/aggressive, being careful with jargon, the need for continuity and commitments from leaders particularly CEOs and being thoughtful about the personal and political risk leaders take. Thinking about our research which demonstrates a tendency of national orgs to focus on the ‘doing’, i.e. improvement tools, governance and data, the Saskatchewan story perhaps also a re-emphasises a cautionary tale, that lean programmes, particularly large national ones, must listen to stakeholders and patients from the beginning and pay as much, if not more attention to culture and leadership, and the political risks of such an endeavour.

Which brings me neatly to the end of the week, where I crossed back over the Atlantic boundary and joined the NHS Improvement (where I work) lean conference, (as far as I know, this was the first ever NHS led national lean conference). It was brilliant to reconnect with so many friends and colleagues from lean work, from the Virginia Mason partnership with 5 trusts, the NHS Improvement seven trusts embarking on the Vital Signs lean programme, and colleagues from NETS, CLIC, and from the Bolton Improving Care System (BICS). I was so proud to be there and I loved it. It was exciting, inspiring, energetic, and connected to research and practice, and so in a way for me, it felt like home.

Dr John Toussaint, from Catalysis and former CEO of Thedacare, from where Bolton learnt so many lean lessons, opened with a keynote discussing his personal lean leadership journey and shared 5 leadership lessons from organisations that he and colleagues have worked with. His keynote echoed the research lessons about the significance of culture and leadership, especially that of the CEO, from earlier in the week at OBHC. ‘Surfing’ between research and practice, he also shared Shortell et al. work and commented on the implications for practitioners and healthcare policy makers.

So after ‘surfing’ between improvement theory and practice this week – between two different world’s, associated paradigms, with seemingly different aims and remits, different communities and identities and many epistemic boundaries, there seems much to share and learn from both.

It is reported in an article by Prof. Jeffrey Braithwaite, that: only 50-60% of healthcare meets level 1 guidelines; healthcare expenditure seems to be 30% wasted; and adverse events remain stubbornly at a rate of approximately 1/10. In addition, much healthcare improvement continues to be challenged by a lack of scaling, magic bullets and a lack of evidence (Dixon-Woods and Martin, 2016). Following the OBHC research theme, more boundary crossing is going to be needed by researchers and practitioners alike to help ensure ‘we’ know how to improve healthcare. It does seem that ‘we’, improvers and researchers, might have to change and become more sophisticated, not only in how we think and learn about healthcare improvement, but also how we practice it. To me it seems much more ‘surfing’, and many more ‘surfers’, will be required to cross professional, organisational/geographical and paradigmic boundaries.

When will we be opening the surf school?

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Spot the difference: QI and OD

Last summer, I asked Twitter users, what their views were on the difference between Quality improvement (QI) and Organisational development (OD) is and I followed it up in a blog. I promised I would write another blog about it… so here it is. This blog tries to summarise the responses I got, and incorporates some reflection from me.

Many responses to the question argued there is little tangible difference between OD and QI. For example, some argued that in practice it is hard to see a difference: action research cycles that inform many action learning sets and much reflective practice, also informed Deming when he developed PDCA, and later, PDSA; and that many variants of ‘change’ approaches have the same or connected roots. Other arguments included that both are about change and both are about working with staff to resolve issues, conflicts and problems to improve effectiveness; both seek to change culture and behaviours (eg see Toyota principle respect for people, and use of behavioural routines e.g. Leadership Kata); both have specific tools and practices… eg 5S, mapping, psychometric tests, and both most definitely use measures and measurement instruments; and both are capability development approaches.

Yet, many responses also pointed out differences, such as: differences in ‘who’ can practice OD and QI, and who ‘leads’ it; differences in emphasis on measurement, relationships and action; differences in views of culture and if it is something that can be intentionally changed, or if culture is something that mediates QI or an outcome of QI, or a combination. Some said OD is about change readiness and is strategic and argued that QI is about the tactical application of tool. Some also indicated there were differences in the view of, if a so called ‘good’ culture has to be in place before QI is used for it to be sustained and successful, or if culture is created as part of QI work; and there were differences in views about if ‘QI’ can be learnt through ‘training’ or if practice is ‘the only way’. Some pointed out that perhaps there is a different audience – staff for OD and ‘the customer’ (service user, patient, citizen etc.) for QI; and that different groups tend to prefer particular approaches, perhaps contraversially, arguing that there are the strong links between the nursing profession and OD and there are growing links between the medical profession and QI. Some responses indicated a view that OD is for people and relationships whereas QI is tools, measures and processes, revisiting longstanding tensions between perceived ‘hard’ (systems) approaches and ‘soft’ (people/culture) (Wilkinson, 1992). Finally, a number of responses said that QI is for efficiency whereas OD for effectiveness. (NB: I personally don’t agree with some of these arguments… especially the last two points).

For me though, a more interesting question might be: why do so many perceive a difference between OD and QI? Some of the responses I received through my twitter question included: professional protectionism; identity and power dynamics; a lack of measurable results from OD; and poorly practiced QI that focuses only on the application of tools with little fidelity to QI approaches, sometimes leading to OD practitioners having to ‘pick up the pieces’. A strong theme was a view that there is a narrow or limited understanding and conceptualisation of QI particularly by observers, (and from my engineering colleagues, a view that when observing lean / six sigma / theory of constraints etc. being used in manufacturing in practice, many have stereotyped engineers and just assumed only mechanical tools were being ‘practiced’, failing to notice the socio-technical approaches being applied ‘in full’). Finally, I wonder if to some extent the long term ‘split’ between so called ‘soft’ and ‘hard’ approaches to change underpins many of these views; and for some a continued lingering (and imho false) perception that many QI approaches are Taylorism reinvented, taking little account of more humanistic approaches.

A friend of mine, an OD practitioner, wondered if the difference was that QI was more specific than OD. That is, she wondered if QI is OD with a purpose… with language generated through difference professional paradigms and there is strength from a combination of approaches that benefits patient care. At least, that was the only main difference she could spot, from her lens anyway.

What do you think? Can you spot the difference?

Please also note, I am most certainly not an expert here, and I haven’t read very much research in this area, particularly for OD. This is just a blog, I’m thinking this through, using the blog as a way of doing that.

Refs: Wilkinson, A. (1992) The other side of quality: soft issues and the human resource dimensions, Total Quality Management, 3: 323-9.

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Why does lean ‘fail’ in some healthcare organisations?

This was the question posed by Dr John Toussaint* on Twitter earlier this week.

Big question, and in my view the answers are probably as relevant to organisations outside of healthcare as those in it. It is also an important question, given the resources committed by organisations to ‘do’ lean, the opportunity cost of those resources and the potential learning from asking it, that might help us understand more about delivering value for patients effectively whilst being respectful of staff and the communities we serve.

So, what are my thoughts? Here are some of my reasons for lean ‘failures’ (in no particular order):

Rivers and rocks

You are possibly familiar with Ohno’s rivers and rocks analogy, where a cross-section of a river is used to illustrate how higher water levels hide rocks in a river bed and a lean approach seeks to lower water levels (inventory/waste) and in doing so the rocks become visible, allowing the rocks (problems) to be removed rather than worked around. The problem is, many seem to expect organisations using lean to have magically removed all the rocks by the end of day 2 or 3 and seem to think that problems and challenges thrown up through error identification and inventory reduction mean lean isn’t ‘working’.

Show me the money

Waste is removed using lean, in all its forms, transportation, inventory etc. But, these are not all cashable, and removing waste in itself, in healthcare anyway, tends to release capacity or reduce overburden, more so than reducing stock usage and wastage and thereby releasing cash. In industry, spare capacity can often be converted into revenue through the sales of more product on top of reduced costs from defect correction. But, in healthcare the use of fixed volume, fixed price contracts or fixed total spend across a population, can often mean this conversion is less possible for providers, meaning the only other way to turn freed up capacity into cash, (if this is an expectation rather than a safety, quality, morale or productivity gain), is through capacity reduction, thus potentially jobs. Who wants to improve themselves out of a job?

It’s too hard

It is hard, very hard at times. It’s hard to keep the energy, enthusiasm,when it at times seems so relentless, and after the initial full steam ahead, improvement can become a little more, well, boring. The attention to detail needed, the careful specific work to keep testing and adaption, the ongoing communication and influencing. It is easier to imagine sometimes to just go and do something else, something more exciting, with even brighter post-it’s or new gadgets and technology…. but then remind yourself why and it is worth it (but see reason number 5).

Leadership, leadership, leadership

Do I need to say more? The biggest risk for me, is when leaders, especially board level leaders lose interest, find other priorities, introduce another improvement approach on top of the lean approach confusing matters, don’t walk the talk, or find new jobs/retire without succession planning, not just for their role, but their successors role as well (if an internal appointment) and fail to find full sponsorship and understanding of the the lean work as they depart.

Why are we doing this again?

Perhaps the biggest reason, it fails simply because the organisation forgets why it was learning to be lean in the first place… to improve care for patients… and starts to believe their own hype and focuses on executing lean instead delivering value.

These are just my first thoughts, other reasons are failure to adapt to local context; too many initiatives driven through silos competing with lean; failure to respect staff and patients and improve together, too reliant on the internal/external change team; thinking lean is all about tools and training, failure to pay attention to organisational culture and so on.

I haven’t researched this area in any great depth, unlike Prof Bob Emiliani who has spent a good chunk of his career looking at the failure modes of lean. It is worth checking out his bookstore and blogs. What are your thoughts? Why do you think lean sometimes ‘fails’?

*Dr. Toussaint is the former CEO of Thedacare In Wisconsin, USA who set up and established lean there with the help of a number of folk using an adaptation of the Danaher business system, about 15 years ago. When I worked at Bolton FT on their lean programme, Thedacare was one of our inspirations and a group of staff went out to visit them and took part in some rapid improvement events with them. Dr .Toussaint has since set up the lean healthcare organisation, Catalysis.

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The neoliberal establishment

I first heard the word neoliberalism during an epistemology class as part of the first year of my PhD. I didn’t take much notice, frankly it was another long word that I just hadn’t heard before and in that class, it took quite a while to understand what any of the long words ending in *ism meant. Like yellow cars, however, I started to notice the word more and more, within student conversations, occasionally in an obscure journal paper, in the occasional Guardian article and increasingly on social media. This week I finally got around to reading ‘The Establishment’ by Owen Jones, which in many ways summarises a view of what neoliberalism is, how it has come about, implications and crucially who gains and thrives from it, and how they sustain it – the Establishment. He suggests that this isn’t some grand plan or group of leaders meeting in some smokey gentlemans club somewhere, but a mental model developed by a few outriders that prepared the way for a shift to the right, arguing that the post war consensus, i.e. The welfare state etc., needed reform and retrenching. As one of Thatchers children, the pattern was for me perhaps harder to notice, perhaps explaining why neoliberalism was I word I hadn’t heard before 2013, so normalised and prevalent were the arguments for privatisation and growing individualism, the need for accountability etc. during my education, early career and within general discourse.

Using this viewpoint, the book has made me think rather hard about what QI practitioners like myself do, and how that may or may not contribute to the ‘Establishment’ and what Owen Jones suggests it stands for. Quality improvement by its nature is about ensuring improved performance, measurement, and in many cases doing more with the same or less – many of the very thing that have grown during the era of neoliberalism. Some critics of quality improvement approaches suggest they just the latest in a long line of ways, most of which started, they argue, with Taylorism, to inappropriately standardise work (especially in healthcare) and exploit and control workers, gradually removing worker rights for flexibility and seeking ever more efficiencies and productivity improvements, that benefit the elite (establishment).

Most factories I worked in during my early career were on the brink of closure (often due to outsourcing activity, usually to Asia) or already in the throes of redundancies, which were often the programmes which I worked on to work out how a supply chain could keep working whilst production moved or the workforce downsized. The first time I work on a project involving redundancies I remember having a huge strop with my boss explaining how ‘I came to improve things, not help people lose their jobs’… I was sat down and it was explained to me that in the long run this was better, because without the restructuring there would be no factory at all, and surely some jobs are better than none. At the time, as a junior engineer, I just nodded and got on with it… time to grow up, it was my job, right? And I continued to work on improvement projects of all types. I do remember a sense of relief though on joining the NHS that now I would ‘definitely’ be improving people’s lives.

But the perspective offered in this book has really made me wonder if we are doing what we ostensively set out to do when improving quality in healthcare. Most improvement approaches define quality based on the patients view of quality (a few could be argued to use much more neoliberal view…i.e. stuff people will pay for). So, how much of improvement activity is genuinely for patients? How much improvement activity is genuine coproduction and working together with staff and patients? This to me is the hope that is offered by quality improvement approaches rather than the exploitation and standardisation that QI approaches can be critiqued as. My sense in healthcare is we are not there yet, and have quite somewhere to go.

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OD, QI or both?

Matthew Mezey from the #Qcommunity has been begging me to write something on OD and QI, ever since we chatted about it at the Health Foundation annual reception last year. It has been something I have been thinking about for a long time, and when I tweeted a similar question during the summer it was one of my more actively engaged with tweets. Yet, I have hesitated writing something, because I’m not sure how this might be received, and that asking these questions may not be welcomed, and maybe I am just imagining something that isn’t there. So, this is a first attempt, and there might be another one.

What is it about OD (organisational development) and QI (quality improvement, including patient safety) that seems to raise interest and engagement, why do I feel it needs talking about? Why do I think it is important? Based on many conversations and private responses to me on Twitter and over coffee, there seems to be a fault line, a schism, hidden just beneath the surface of much organisational change, patient safety, service and quality improvement work.

I hear this in many ways… different groups who talk about culture, improvement, patient safety and leadership in different and separated ways. We have separate ‘networks’ like the Qcommunity, and DoOD, arguably emphasising separate professional identities. Phrases get used to separate like ‘QI must be clinically led‘ (as opposed to whom, and where does that leave patients? Why does OD not have to be clinically led?), ‘we need to focus on the cultural work because the improvement programme doesn’t do that, it doesn’t reach enough staff‘ (why not?), ‘we don’t want to do the – where are we going and what are values stuff – just teach us the QI tools, it’s faster‘ (why?). Yet, people ask me frequently how to join up OD, patient safety and QI work as though they are mutually exclusive, have different views and underlying perspectives, or as though one is ‘better’ than another. Increasingly, I rather feel they have more in common.

So, whose job is it to lead such efforts? Who gains from creating a schism? Why? Does driving the efforts also mean a chance to control and influence the narrative, have exclusive access to the decision makers, influence the resourcing decisions and protect professional identity and groups? Yet, this is by no means everywhere, many stories I hear are of teams who bring all their skills and knowledge together and transcend the divide, so I’m wondering how they do that, and what has helped them to that, and why the schism felt elsewhere appears to not affect them. As a medic said to me in a direct Twitter message… ‘they must be synonymous’ (must they?).

What do you think? Do you think there is a difference and how are you overcoming challenges? Or am I imagining something? I’ve been trying to look through the roots of where the different approaches came from and if you have ideas please let me know, I would love to hear from you. I might try to write about that next.

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‘Which improvement approach is best?’

Without doubt, this is the question I have been asked most during the last 4 months since returning to paid up employment:

‘Which improvement approach do I think, is the best?’

I find it sometimes a tricky question to answer, because it can reveal so many different things, which depending on the context, I don’t always want to reveal.  It can potentially reveal information and clues about my professional background, and potential tribal allegiances, about my view of improvement priorities, my perspective of ‘how’ to do improvement work: top down or bottom up; frontline or corporate centre; clinically-led or patient led, internal team or external consultancy; my knowledge and experience and even my view of the world.

My view has changed.  I did used to think that…. or kind of think that, Lean was the best approach.  I think gave that impression. Not in the way many view Lean now mind, codified as: value, value stream, flow, pull and perfection (perhaps Lean has even ossified like this?).  But as both continuous removal of waste AND respect for people and society rather than any tools or techniques.  With 4 True North goals, Lean’s version of the IHI Triple Aim: quality, leadtime, cost and morale. Those to me were common to most ways of respectful problem solving, and in a way, just how you were taught to think and work as an industrial engineer and improvement leader.  Choosing the way of solving the problem and selection of the best ‘approach’ part of the skill set for each problem and context.  Sadly, I see Lean often ‘defined’ and ‘practiced’ in very mechanistic and inexperienced ways, where arguably ‘over-standardised’ tools are used [e.g. office based ‘sterile’ 5S] to ‘make it easier’, where money and results dominate whilst customers, service users (patients), people and society are barely mentioned.

When I came into healthcare I found it very confusing: why is there so much debate about which improvement approach is the ‘best’, (I don’t remember this debate in any earnest in industry), why does there seem to be so many arguments, aren’t they all really the same underneath?  With a focus on the customer (service user, patient), emphasis on flow and reducing variation and a requirement to support those doing the work, to improve the work?  [And as an experienced industry improvement professional what the h*ll is this newfangled IHI-QI approach, that doesn’t seem to be used anywhere else but healthcare, and yet seems broadly the same but just with different jargon, coupled with loads of clinical terminology and metaphors?, Yes, jargon barriers work both ways, folks.]

So what is my view now?

I suppose I have mellowed and take a view that there are many benefits of using different approaches in different circumstances, though I think it helps for improvement beginners to just use one at first, with all its jargon and peculiarities, (whilst signposting it is not the ‘only or best’ one).  I consider that learning and practising more than one overtime also important, to learn the strengths and weaknesses of each, to develop some level of mastery, to be able to cut through and translate the jargon, to recognise that the seemingly different tools and techniques on the surface in look and name, are similar in usage and to learn when and why some suit and some don’t (often through failed tests of change) in different contexts, cultures, organisations and sectors whilst working collaboratively across a supply chain (or care pathway).    

All of the approaches have strengths which can be helpful in different circumstances: lean in reducing lead time and its relentless focus on the flow of value, together with a blueprint for a ‘management method’ for organisational or system improvement; IHI-QI for its collaborative method and ability to engage folks in improvement activity; 6sigma for its focus on variation and product/process consistency.   The approaches, to me, seem to have similar ‘tools’ for similar tasks, such as the Model for improvement or the lean A3; the driver and fishbone diagram; patient safety walkarounds and gemba walks; collaboratives and yokoten (translates as horizontal deployment); to name but a few.  These improvement approaches all also have plenty of downsides, not least the lack of evidence of their effectiveness, regardless of approach chosen.

However for me, the strength of improvement approaches is in their similarity in helping folks solve problems and serve their service users and patients better. Consistency of purpose in improving care, rather than consistency of approach seems to me to be more important, (although I am mindful of potential fidelity problems). I prefer to put my energy and passion in to the ‘doing’ of improvement for this purpose, rather than using energy considering which improvement approach is best.  What’s your view?

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Finally Phinished

I finally graduate on Monday… two days time.  I have designed, researched, written, rewritten, printed, submitted, defended, corrected and completed my PhD thesis.  Some 340 odd pages and 120k of words (I count the appendices!)  Probably more like 500k words before seemingly endless revisions and the culling of pointless paragraphs and sentences, that ended up nowhere.  As well as 2 journal papers, 2 book chapters, 4 ‘formal’ blogs, 7 conferences, 2 summer schools, 1 award and 1 lost suitcase.

Just about 4 years of my life, of hard work, of realising how little I ‘know’.  Learning, painfully at times, how hard it is to write well (or even approaching something like ‘well’).  And with it, I have developed an endlessly growing gratitude and respect for supervisory teams and other academics who think so carefully, precisely and meaningfully about questions, topics and issues.  They spend so much of their precious time both formally and informally supporting students, reading and re-reading thesis chapters over and over, as well as providing as much encouragement as critique (and quite often contradictory feedback😉) and offering to both mock-examine and examine the final copy.  [Thank you, you know who you are!]

I’m now sat here, on a drizzly English summer afternoon, wondering what to do with myself, so used to am I, at getting out the PhD laptop.  Just to bash out a few more words here or there, or read a couple more papers or even just to rewrite a paragraph from the day before.  I still have a bits to do, perhaps a couple more journal papers that could be submitted… maybe (if I can bear the thought of rejection and re-writing again?).  Though now, almost without a university IT account, continued work for submission is harder, no easy library and journal access, no free citation software… and now back in the cut and thrust of managerial work, less time to think, reflect and consider potential submissions.  For me, on reflection, this ‘thinking’ time, a chance to slow down and breathe is the luxury and privilege of the PhD.  At first this time felt slow and frustrating, already now I am looking back on that protected time with some envy.

Now I have this great big PhD sized hole in my time, what am I going to do next?  Well, I have the afore-mentioned potential journal papers and the graduation ceremony itself still to do and a rather neglected family to give some time back to.  I also have returned to working in the NHS in England, working in one of the national regulatory agencies with an explicit remit to improve care.  I feel pretty damn lucky to have a role working in the exact same field as my thesis and to have the potential opportunity to use and share my learning to benefit our work and ultimately patient care.  A kind of non-post-doc, post-doc if you will, with my own variation of ethnography.  With a role where I can focus on putting my learning and contribution into practice, rather than a focus on seeking further ‘contribution’ to knowledge.  Perhaps it could even be described as the next stage for me, ensuring ‘Impact’ from my learning.  For me, ensuring patient care would – eventually – benefit from my work, was always one of my main drivers and sources of motivation.

Am I glad I did it?  Yes, yes, yes, despite the ups and downs of academic work, receiving disappointing critique, missing events because of the need to ‘write’ and temporarily losing ’employee’ identity, I have mostly loved it.  I have gained so much more than I was worried about losing.  I have been lucky enough to meet some amazing people and travel all over the world, to learn and share my work.  Now,  I am able to return to what I love to do, help to improve services and care for patients, with so much more knowledge than I had before.  What will I do differently now?  Try to keep learning, remaining open to other ideas and trying to remain a somewhat more critical thinker than I was before my PhD.   I also want try to stay connected with a research world interested in how and why services improve (or don’t), and help to connect more with a practitioner world that is constantly trying to improve services and yet has little time to actively reflect and consider those same questions.  We all have much to learn and much to share from each other for the benefit of patient care.

Am I glad I have finished?  Yes.  Am I missing it?  Well, I’m not missing literature searching, but everything else? Just a little.

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