Thinking differently

Thinking
Institute for Innovation
and Improvement
TD_00_COVER 31/10/07 12:17 pm Page 1

In the middle of difficulty lies opportunity.
Albert Einstein
TD_00_COVER 31/10/07 12:17 pm Page 2

Thinking Differently
TD_00_CONTENTS 6/7/07 3:04 pm Page 1

Introduction / Concepts
Introduction
N How to Use This Guide
N Thinking Differently? Why Should I?
Concepts
N What’s Involved for Thinking Differently
N A Process for Thinking Differently
33
40
46
50
58
63
70
78
86
94
102
108
113
120
128
136
140
148
153
155
171
185
207
209
211
Tools Phase 1: Stop Before You Start
Introduction to Phase 1
Tools:
N Others’ Point of View (OPV)
N Reframing by Word Play
N Pause, Notice, Observe
N WWTTCA (We Want To Think Creatively About...)
Case studies
Practical Examples of Thinking Differently
N Award Winning Thinking Brings Better Care to a Diverse Community: the North East London experience
N Thinking Differently About Delivering Primary Care: an example from the United States
N Mission Impossible? Or Just Another Mountain to Climb: learning from Luton & Dunstable NHS Foundation Trust
Appendices
Linking Thinking Differently Tools to Improvement Work
Advice for Facilitators
References for Further Study
Tools Phase 2: Generating Lots of Ideas
Tools:
N Fresh Eyes
N Breaking the Rules
N Random Word, Picture or Object
N Stepping Stones
N That’s Impossible
N Mental Benchmarking
Tools Phase 3: Selecting and Testing Ideas to Make a Difference
Tools:
N Harvesting by Criteria and Dot Voting
N Six Thinking Hats®
N Enhancement Checklist
N Testing New Ideas on a Small Scale
Implementing Change: making ideas a reality
5
7
10
20
20
30
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Introduction / Concepts5
Introduction / Concepts
Introduction
N How to Use This Guide
N Thinking Differently? Why Should I?
Concepts
N What’s Involved for Thinking Differently
N A Process for Thinking Differently
TD_00_INTRO_01 12/9/07 9:15 am Page 1

We need to have imagination and courage in order
to seize the opportunities there are to transform the
provision of care in the NHS.
David Nicholson, Chief Executive of the NHS
TD_00_INTRO_01 12/9/07 9:15 am Page 2

Introduction How to use this guide
How to use this guide
The book you have in your hands is a practical, introductory guide to thinking differently. It is not a
comprehensive blueprint nor is it designed to make you an expert in thinking. But it will get you started on
a journey of thinking differently, and therefore doing things differently, that we hope continues well into
your future.
We have selected concepts and thinking tools that have proven their value, ease, and applicability in a
variety of industries and in over five years of experience with front line teams in various NHS organisations.
We’ll provide you with just enough background theory to help you see why the various thinking tools ask
you to do certain things that might seem a bit odd at first. But the emphasis here is not on dry theory or
abstract concepts. Rather, it is on developing new thinking that leads to new ways of doing.
If you’re sceptical of the value of guides such as this in light of heavy work pressures within the health
service, then we invite you to begin with the section: Thinking Differently? Why Should I?
I
It will
only take you a few minutes. If, after that short section, you are not convinced of the value of reading
any further… well then, fair enough, pass on this guide to a colleague and get back to work.
If, on the other hand, you are intrigued, then we suggest you read the short theory section entitled
What’s Involved in Thinking Differently?
I
which will give you some of the basic concepts. Follow this
with a quick read of the introductory pages of the three sections that describe the overall process:
N Stop Before You Start
I
N Generating Lots of Ideas
I
N Selecting and Testing Ideas to Make a Difference
I
With this small investment of about 15-20 minutes you will get a good overview and can decide for
yourself about whether to invest more of your time.
Concepts: 20
Introduction: 10
Tools Phase 1: 33
Tools Phase 2: 63
Tools Phase 3: 113
7
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You should then let your learning style dictate next steps. If you learn well through examples, you
might want to read the section on case studies
I
. Use these as a starting point from which you can go
back and read the details of the specific tools used in each case.
If, however, you are more of a “learn by doing” person, identify a current problem or challenge that
you’d like to think differently about and dive directly into the tools. Quickly skim the first few paragraphs
for each tool in a section and select one that seems like it might help with your issue. Assemble a small
group of colleagues or friends, or simply work on your own, to follow the directions given and see where
it takes you. Don’t be discouraged if the first tool you select doesn’t seem to give you any new insights;
simply select a different one and give it another go. The only strong advice that we would give you here is
that you follow the three-phase process in sequence, as described in the tools section of this guide. Specifically,
resist the urge to jump right into Generating Lots of Ideas
I
(phase 2) before you first, Stop Before You Start
I
(phase 1)… and resist the urge to jump prematurely to Selecting and Testing Ideas to Make a Difference
I
(phase 3) before you have generated lots of ideas.
If your primary job role involves service improvement, you might want to read the appendix:
I
early on in your exploration of this guide.
If this is not your main job role, consider this section optional reading.
Finally, if you are the sort of person who wants to learn in more depth, you’ll find some
recommendations to start you on a learning journey on the subject in the appendix: References for
Further Study
I
.
Case Studies: 153
Appendices: 207
Appendices: 211
Tools Phase 2: 63
Tools Phase 1: 33
Tools Phase 3: 113
I can’t understand why people are frightened by new ideas
I’m frightened of the old ones.
John Cage
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Introduction How to use this guide9
The only limits to our realisation of tomorrow will be
our doubts of today.
Franklin D Roosevelt
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Thinking Differently? Why should I?
You are a busy, hard-working staff member, clinician, manager, or leader. You may sometimes wonder if
you have time to think at all. Now, along comes this guide encouraging you to think differently. Isn’t this
just the latest set of buzzwords; yet another fad?
We don’t think so.
Those who have dared to think differently have changed the face of many industries, and society in general.
N Thomas Edison thought that the streets of New York could be lit at night by electricity, but he had to
persevere against tremendous opposition (including attacks on his character and death threats) from the
then thriving gaslight industry.
N Watson and Crick won a Nobel prize for being able to think differently, in three dimensions instead of
the two dimensions of traditional chemistry, about bonding structures in DNA.
N A development team at CitiBank thought differently about bank buildings and queues at the teller
window and hit upon the idea of the now ubiquitous Automatic Teller Machine (ATM).
N The innovators who have started various low-cost airlines in the US and Europe (e.g., easyJet)
re-thought service delivery in that industry and have made travel accessible to significantly more people.
Apple, one of the most innovative companies in the world, has virtually made a brand out
of thinking differently. They have transformed themselves from a computer hardware
company to a service business that has challenged nearly everything we ever thought about
how music is distributed. Forget record stores, cassette tapes, and even CDs… where is your
iPod and broadband connection?
Now that's thinking differently!
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Introduction Thinking Differently? Why should I?11
It was also thinking differently that gave birth to the NHS nearly 60 years ago. Thinking differently led
to the creation of NHS Direct, increasing access to care for millions of people. Thinking differently led to
the transition from traditional surgical methods to keyhole surgery, dramatically reducing lengths of stay
and discomfort for patients. Thinking differently freed engineers from the concept that a telephone
needed a wire, giving birth to the mobile phone and a host of subsequent wireless products that are now
routinely used within the health service. Numerous other innovations from private sector industries such
as pharmaceuticals, diagnostic equipment, and IT, have also led to significant improvements in healthcare.
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Equally important, at the front line of care, is the fact that every day some members of NHS staff take
the opportunity to think differently about their work. For example, a receptionist in a GP surgery notes
that patients sometimes do not turn up for appointments and wonders if sending text message
reminders would help. She finds that it does indeed help as several patients tell her that they were both
surprised and grateful for the reminder. After a search on the internet and a conversation with a mobile
phone provider, she learns that there is software that can link to the practice’s appointment calendar on
her PC and send out the text messages automatically. She has simultaneously helped reduce the Do Not
Attend (DNA) rate, reduced her workload, and pleasantly surprised the patients! Often, when we think
differently, everyone wins.
In every era, those who have cared passionately for the ideals of the NHS have seen the need to think
differently to meet the challenges of an ever-changing environment. Today is no different.
The recent reforms in the health service have given us different structures and different points of focus
that we need in order to thrive in the new world. For example, NHS teams are striving to change services
in order to reduce or eliminate unnecessary waits and delays, provide care in the most appropriate place
for the patient, reduce waste and increase safety. However, it is thinking differently - the necessary
prerequisite for doing differently - that will, in the end, determine whether these reforms actually make a
difference for patients and the public. If we - the staff, clinicians, managers and leaders within the NHS -
continue to think as we have always thought, we are likely to get the same results we have had before,
regardless of the new structures and priorities that surround us.
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Thinking differently is the only real and sustainable bridge to get us from where we are now, to where
we would like to be.
Further, it is the extent to which we are willing to think differently that determines how great a difference
we can really make. We can make incremental improvements, which of course are good, but if we stand
back and challenge more deeply how we do things, the gains could be much larger in terms of
effectiveness and efficiency.
NHS Reform is creating a different world which is more
about prevention than delivery, where patients drive
their own care, and services are delivered closer to
home. In this brave new world, Thinking Differently will
be a core capability of every NHS leader.
Helen Bevan, Director of Service Transformation, NHS Institute for Innovation & Improvement
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For example…
Receptionists in GP surgeries have been booking appointments over the telephone for years.
But are there ways, other than the telephone, to interact with patients?
A Surgery in Cheltenham already has the facility to allow patients to book appointments via a
website. Now, it is making the most of new technology by giving patients the opportunity to
book GP and phlebotomist appointments through their TV set. The facility is available through
the local authority microsite, which provides interactive public services on digital television.
This service can be accessed via SKY, NTL, Telewest, Netgem (Freeview), Kiosk and also on
mobile phones.
‘We currently have over 750 patients who book appointments online and patients have
commented on how much they like it and that it is easier than making a telephone call.
We hope that this new facility, (booking appointments through the TV set) will benefit those
who have not got ready access to a computer at home.’
Dr Martin Nicholas, GP.
Now that is thinking differently!
And now that we have stretched our thinking to include interactive TV as a potential tool in
care delivery, how else might we use it? For example, could we more effectively and efficiently
provide patient and carer education for chronic conditions? Could patients complete evidence-
based assessment questionnaires before they even book an appointment, thereby perhaps
reducing some unnecessary visits? There are lots of possibilities.
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1
For examples of how to use Thinking Differently tools to help achieve 18 week target,
see www.institute.nhs.uk/nodelaysachiever and go to section: An Overview of Creativity Tools
Thinking differently to use new technology such as interactive television to change care processes…
It’s so obvious… in hindsight. Good ideas are always obvious, after someone thinks of them. Before that
happens, we are stuck with our thinking… just doing what we have always done and getting the same
results we have had before.
Reflecting on the example above, and all the examples from other industries, raises the question: how
many more possibilities for thinking differently might there be in health care?
Using the approaches outlined in this guide, NHS teams are beginning to realise that if they fundamentally
rethink pathways of care and service delivery methods, they could provide access and diagnosis in a matter
of days for many conditions. We should not see the current 18-week target1
(Department of Health 2006)
as a constraint; rather we should set our improvement ambitions higher. For example, practice-based
commissioning teams are realising that if they commission voluntary sector organisations and local
handymen to improve safety in the home for the vulnerable elderly, they might reduce the likelihood of
falls and save millions of pounds as well as improve quality of life for those people. Front-line staff and
teams are finding many ways to make work life better and safer while improving care for patients by
simply asking, “Why do we do it this way?” and not accepting “Because we have always done it that
way!” as an answer.
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Leisurely Health in a One Stop Shop!
Get your dental check-up, see a demonstration of the latest home aids for your arthritis, make an
appointment to quit smoking, take your prescribed exercise class in a dance studio… and then relax
in the pool!
A vision to provide Burnley residents with better access to healthcare services while simultaneously
encouraging a more healthy lifestyle has become reality with the opening of a state-of-the-art
facility in the centre of the town. The new centre is the result of an innovative partnership
between the PCT, local council, resident and patient groups, a construction firm and Sport England.
A comprehensive range of medical services – including some previously provided in hospital –
shares accommodation (and even staff!) with a new sports and leisure facility, thereby switching
the focus of care from sickness to health and wellbeing.
As the NHS evolves and changes to face the new
realities of the 21st century, it puts stresses and strains
on our staff. But it's good to know that many of our
health professionals will walk that extra mile to achieve
their dreams.
David Peat, CEO, East Lancashire PCT
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Thinking Differently? Why should I?17 Introduction
Too shy to face your GP or your local GUM
clinic? Log on to DrThom.com!
DrThom.com, founded by a doctor specialising
in sexual health who realised that traditional
clinics don’t suit everyone, is a new service that
uses the internet, post and telephone in care
delivery.
The web based service aims to make it easy for
people to get information, testing, and treatment
without the embarrassment and inconvenience
many people associate with going to a genito-
urinary medicine (GUM) clinic or to their GP.
In June 2006, DrThom.com became the first
‘online’ medical service to register with the
No More Blushes…
Healthcare Commission. All the doctors
involved are sexual and/or reproductive
specialists.
The website provides information and advice on
a range of conditions. You can also order tests,
post onto a message board to share experiences
with other patients, obtain contact details for
NHS and private clinics, and even receive
anatomy lessons!
Tests, treatments and emergency contraception
are dispatched by post, and consultation and
counselling are also available by email or phone.
Treatment is even available in some cases
without the need to see anyone face-to-face.
TD_00_INTRO_01 12/9/07 9:15 am Page 13

So, thinking differently is here to stay. It is both an immediate and an on-going need. Further, it has
something for everyone…
N Thinking differently can help clinical staff focus on the most rewarding work of patient care.
N Thinking differently can help the busy chief executive and finance director support better services
and achieve financial and service targets.
N Thinking differently can help reduce the stresses of daily work for NHS staff, while actually improving
the care they deliver.
N Thinking differently can bring more energy and satisfaction in work.
N Thinking differently can mean better care and greater well being for patients, carers and members
of the public.
Why would you want to just keep thinking the way you always have?
Thinking differently has contributed enormously to
the success of our trust over the last few years.
The techniques have helped unblock barriers and, as
importantly, the approach has supported our culture of
continuous improvement. It has also been hugely
rewarding for staff as well as patients.
Stephen Ramsden, CEO Luton & Dunstable NHS Foundation Trust
I
Case Studies: 185
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Thinking Differently? Why should I?Introduction19
Everyone thinks of changing the world, but no one thinks
of challenging himself.
Leo Tolstoi
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Before you can effectively use the tools we describe in this guide, it is important to understand some basic
concepts behind both usual thinking and thinking differently.
Natural thinking as mental valleys
While there are many complex explanations of how we think, Edward de Bono’s simple model of mental
valleys and streams of thought provides a good illustration. Hills and valleys in nature organise the rain that
falls randomly over an area into flowing streams. In a similar way, the mind organises words and phrases -
“language” - into streams of thought.
The terms mental models, assumptions, paradigms, simple rules, the way we do things, mental boxes, and
similar words and phrases are roughly equivalent to what we are calling a mental valley.
Edward de Bono’s Mental Valleys Model for Thinking
Streams of thinking
Purposeful channel
Random jump
Valleys
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Concepts What’s Involved in Thinking Differently?21
Tools Phase 2
Mental
Benchmarking: 108
Random Word,
Picture or Object: 86
As we learn the language of the world we live and work in, a metaphorical valley is created in the mind to
hold concepts that tend to flow together in our thinking. For example, in the mental valley of “A&E” we
hold and link together the concepts of a physical space… with a car park and separate ambulance bays…
with a main entrance and reception desk where you must register… with waiting areas… with
examination rooms … where the nurse does an initial triage and tells you that the doctor will see you
later… etc. We have learned that all of these concepts naturally go together. They flow in what we
sometimes call a stream of thought. That is just the way it is; it is the “usual” way to think about A&E.
Simply saying “A&E” naturally puts us in this mental valley and activates the stream of thought. The same
thing happens when we think of a “GP Surgery”, “Patient”, “Medical Record” or any other of the many
words that are common in the language of health care.
We spend most of our time thinking as we have been taught to think. The mental valley is comfortable.
It is also very efficient in that all one has to say is “A&E” and all these other thoughts just come streaming
along. There is nothing wrong with that. That is, there is nothing wrong until we need to think differently.
We might ask for new ideas for A&E redesign, but if everyone remains in the usual valley of “A&E”
all we are likely to get are slight variations on existing themes (for example, “let’s put a television and
drinks machine in the waiting area”).
Thinking differently is about making “creative connections”. It involves challenging, connecting and
rearranging information in our mental valleys. We might challenge the usual stream of thought that uses
reception and triage as control gates before gaining access to a doctor, and simply have a process where
a doctor sees everyone who comes into A&E immediately, in order to begin the process of care. We might
connect to the valley of “fast food restaurants” and rearrange our thinking by borrowing the idea of a
drive-through window as a way to provide some hospital services.
I
Or we might imagine some sort of
hand-held GPS device to guide patients through our physical space because someone has suggested that
we think for a moment about the randomly selected word “automobile”.
I
Note that laughter is a natural physiological reaction to a novel connection in the mind.
In fact, someone initially laughing at an idea is often a good signal that it is, indeed, creative!
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The difference between first-order and second-order change
Another set of terms that you may hear is first-order and second-order change. First-order change occurs
when we make an improvement, but stay firmly within, the current mental valley; for example, a voluntary
worker to greet patients in the A&E waiting area or reducing the time it takes to register at the reception.
There is nothing wrong with that; first-order change is good.
Having a doctor as the first person you see when you come to the A&E, providing some hospital services
via a drive-through window, or providing patients with a hand-held navigation device instead of relying
on signage, are examples of fundamentally different approaches: second-order change. In general,
second-order change often has more impact, creates more satisfaction, and has more beneficial effects than
first-order change.
Underlying
mental model
Specific way we
do something
Relationship to
improvement
Example
First-order change
Unaltered
Changed
Predominent current approach to
improvement
Counsel high-risk patients on complex
medication regimens on the importance of
remembering to take their tablets correctly
Second-order change
Altered
Changed
Enhanced approach; thinking differently
to make things even better
Work with specialist pharmacy to create
individualised multi-dose calendar packs
for high-risk patients
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Thinking differently requires: Attention, Escape and Movement
In his book Creativity, Innovation and Quality
I
, Paul Plsek notes that the process of rising out of and exploring
mental valleys to get more ideas for second-order change relies on three deliberate mental activities:
Attention, Escape, and Movement. Thinking differently involves managing these three mental processes.
While usual thinking involves mental movement, it rarely takes the time to pay explicit attention to
underlying assumptions, and rarely challenges “the way we do things around here” or escapes from the
comfortable mental valley. You will notice that all of the tools for thinking differently that we present in
this guide involve some combination of these three mental activities.
Attention - When you take the time to list some of the
current mental valleys, assumptions or simple rules in the
system, you are practicing mental attention. (“Patients who
come to A&E must first report to reception”). Attention
involves looking closely, observing with fresh perspective, and
really noticing things.
Escape - When you challenge or block an existing rule, you are
encouraging escape from the current mental valley.
(“The government has made it illegal to have a receptionist
and desk in the A&E!”). We often describe this as “blue sky
thinking” or “thinking outside the box” that purposefully
moves away from the existing situation.
Movement - When you then play imaginatively with this
suggestion and generate several ideas from it without
judgement or criticism, you are encouraging mental movement.
(“Let’s try to generate at least seven ideas for ways to manage
patient arrivals in the A&E without a receptionist and a desk”)
Mental movement is free association that is just allowed to flow
in any direction it wishes without constraints for the moment.
Appendices: 211
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Thinking is of better quality when we put some structure around it
Often, our mind becomes a jumble as we try to think, particularly when we try to think differently. We are
trying to come up with new ideas and we can see some benefits from that… but there is also the
downside and risk… and we wonder if there is any data or experience to support the idea… and perhaps
we feel that this is scary, and we each wonder what others will think of us… and so on.
This jumble occurs whether we are thinking alone or in a group. Some people are their own worst critics,
while others experience the worst criticism in groups. Some people are naturally positive in their outlook,
while others are naturally more negative. Some people are naturally analytical (“The facts are…”), while
others are more intuitive (“I feel that…”).
When you want to think differently, it helps if you minimise the mental jumble and focus on one aspect of
thinking at a time. For example, you might want to loosely structure your individual thinking, or that of a
team along the following lines:
N Generate new ideas and possibilities without judgment. (Imagination)
N Think first about the positives and benefits of each idea generated or
selected for further consideration. (Positives)
N Think about the negatives, risks, and pitfalls. (Negatives)
N Review or consider gathering facts, data and information to either
support or rule out the ideas. (Facts)
N Express feelings and intuitions about the ideas. (Feelings)
These five aspects are essential to comprehensive thinking. The
important point is that it helps to take them one at a time, rather than
allowing them to become a jumble.
While this structure may at first seem limiting, it has been shown repeatedly to lead to better thinking -
both in individuals, but especially in groups. The structure is formalised in Edward de Bono’s Six
Thinking Hats®2
, a tool that we will describe in a later section
I
.
2
© The McQuaig Group. For more information contact: www.holstgroup.co.uk
Tools Phase 3: 128
Six Thinking Hats®
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Appendices: 211
Simple rules for better idea generation
The seemingly paradoxical notion that thinking differently benefits from a little bit of structure applies even
to times when we want to be our most free-thinking - during idea generation.
In the 1930s, psychologist J. P. Guilford identified characteristics of individuals and groups that were able to
generate the best new ideas. Advertising executive Alex Osborn, in whose industry effective idea generation
was particularly important, built on this work and coined the term “brainstorming” to describe the process
of deliberate idea generation. Osborn suggested that idea generation sessions would be more successful if
everyone agreed to a few simple rules. These have since been restated and enhanced by many others (for
example, Tom Kelly, the chief executive of IDEO and author of The Art of Innovation
I
) and can be stated as
follows:
N Criticism is ruled out There are no bad ideas at this point. There will be plenty of time to
judge later.
N Go for quantity Don’t settle for 3 or 4 ideas; aim for 10-20.
N Encourage wild ideas It’s the wild ideas that often provide the breakthrough insights.
These insights might lead to further ideas that are not so far fetched.
N Build on the ideas of others What can you add? What else? What other ideas does it bring to mind?
N One conversation at a time This way all ideas can be heard and built upon.
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Perceived
issue
Different
ways of
looking at
it all
Reframed
issue or
need
Lots of
creative
ideas and
approaches
Criteria
applied to
select a
few ideas
Creative
refinement
and
combination
A few
prototypes
to test
Diverge
Converge
Converge
Converge
Converge
Converge
Converge
Diverge
Diverge
Diverge
Diverge
Diverge
Diverge
Diverge
Divergence / Convergence cycles
Cycles of divergent and convergent thinking
A final important concept for thinking differently is another one of J. P. Guilford’s insights involving the
importance of deliberately alternating between divergent and convergent thinking.
N Divergent Thinking: Expanding the list of possibilities; purposefully looking for more, or looking at the
issue from a variety of directions. Divergent thinking stresses quantity of thought, imagination, long lists,
and many different ways. Divergent thinking is necessary in order to challenge “the way we have always
done it”. The downside of divergent thinking is that it can go on forever and we end up with lots of
new ideas but never actually do anything about them.
N Convergent Thinking: Reducing the list of possibilities; purposefully looking to condense, summarise,
focus or select. Convergent thinking stresses quality of thought, good judgment, short lists, and a few
selected ways. Convergent thinking is a necessary prerequisite to action, and without action ideas are
not valuable. The downside of convergent thinking is that we might miss a possibility, or prematurely
discard one and end up being very focused on an idea, but not on the best one.
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Appendices: 211
Concepts27
You may know individuals who tend to favour one mode over the other, or you may work in an
organisational culture that tends to emphasise one over the other. For example, some people are naturally
full of ideas when faced with challenges and offer lots of alternatives (divergent thinkers), while others
prefer to select a single idea and start to work on it (convergent thinkers). However, cycling between
both divergent and convergent thinking is more effective when we want to think differently.
As illustrated in the figure, we might start with a specific issue, but it is useful to spend some time looking
at it from a variety of angles. This may bring a new perspective, which leads to a different statement of the
issue and a refocus of our work rather than the same old way of looking at it. We might then generate
lots of ideas, initially without judgment, but in the end we will need to apply some criteria to select those
ideas that we wish to take forward. And so it continues, alternating cycles of divergent and convergent
thinking that get the benefits of both while avoiding the pitfalls of either.
This is a practical guide to thinking differently. It is not our intention to make you an expert on thinking.
However, if you keep the few concepts described above in mind, you will have better success in thinking
differently and guiding others to do so. From time to time as you use the tools
III
described in this guide,
return to this section on concepts for a refresher. It will help you understand better what is working and
what is not; why it is working and why it is not. If you would like to explore any of the concepts
presented here in greater depth, refer to the appendix, References for Further Study
I
.
Tools Phase 1: 33
Tools Phase 2: 63
Tools Phase 3: 113
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If we can occasionally be prepared to let go of our
cherished beliefs about the rules and hierarchies of
healthcare we may find there's a better way of doing
things. In our case, accepting patients as equal partners
in designing services has opened up a repository of
knowledge and experience that would not otherwise
have been available to us.
John Pickles, Consultant Head & Neck Surgeon, Luton & Dunstable NHS Foundation Trust
TD_00_INTRO_01 12/9/07 9:16 am Page 24

NotesIntroduction / Concepts29
TD_00_INTRO_01 12/9/07 9:16 am Page 25

A Process for Thinking Differently
In using the tools for thinking differently, the only strong advice we would give is that you should follow
the three-phase process in sequence, as shown in the flowchart below. Specifically, resist the urge to
jump right into Generating Lots of Ideas (phase 2) before you first, Stop Before You Start (phase 1)
in order to really understand the issue you want to work on… and resist the urge to jump prematurely to
Selecting and Testing Ideas to Make a Difference (phase 3) before you have actually Generated Lots
of Ideas.
The main point is to not race ahead. But, on the other hand, it is fine and quite natural to loop back in
the process. For example, after a few rounds of generating lots of ideas, you may want to take a quick
step back to the reframing tools in the previous step just to see if you can generate even more ideas.
And, you will often find that as you get into testing your ideas you may need to both reframe the issue
and generate even more new ideas to meet the challenges that will inevitably arise. If thinking differently
were easy then we wouldn’t be stuck with some of the problems we are currently facing.
TD_00_INTRO_01 12/9/07 9:16 am Page 26

Perceived challenge or issue
ToolsPhase1
StopBeforeYouStart
ToolsPhase2
GeneratingLotsofIdeas
ToolsPhase3
SelectingandTestingIdeastoMakeaDifference
1
2
3
Others’
Point of View
Choose your tool(s)
Should follow sequence
Fresh
Eyes
Breaking
the Rules
Random Word,
Picture or Object
Stepping
Stones
That’s
Impossible
Mental
Benchmarking
Reframing
by Word Play
WWTTCA
Pause,
Notice, Observe
Harvesting by Criteria and Dot Voting
Six Thinking Hats®
Enhancement Checklist
Testing New Ideas on a Small Scale
Return to tools from previous phases to help think
differently about any challenges you encounter in
developing and testing ideas
A Process for Thinking Differently
Use this framework to guide you through the Thinking Differently process from your challenge or issue
through to making ideas a reality. Note where you have a choice of tools and techniques
and where we recommend you undertake specific actions
TD_00_TOOLS_FLOW DIAGRAM 12/9/07 9:36 am Page 2

Tools Phase 1
Stop Before You Start
N Others’ Point of View (OPV)
N Reframing by Word Play
N Pause, Notice, Observe
N WWTTCA (We Want To Think Creatively About...)
Tools Phase 1: Stop Before You Start33
TD_01_TOOLS_ALL 12/9/07 9:20 am Page 1

An idea is a feat of association.
Robert Frost

Concepts: 22
The mind is wonderfully efficient. Give it a topic to think about and the mind quickly and
effortlessly creates a stream of thought. Try it. Without reading any further, ask your mind to think for
a moment about providing access to care in a GP surgery.
See how easy that was? You could easily visualise a typical GP surgery… patients coming through the
door… being greeted by reception staff… giving their name and what they are there for… being invited
to take a seat in the waiting area with other patients who are also waiting… and so on. This stream of
thought is activated by the words “providing access to care in a GP surgery” - it is simply what we usually
mean when we say or think those words.
If we asked you now to come up with ideas to improve patient access and experience of care in a GP
Surgery, your mind would similarly rise to the occasion. You could easily think of ways for improving the
receptionist’s greeting, changing the layout of the waiting area to increase comfort and privacy, reducing
the wait before being called to see the doctor, and so on. These would all be very good things to do.
Your mind has no problem at all thinking about the current system and how to improve it. Simply saying,
“Let’s come up with ideas to improve patient access and experience of care in a GP Surgery” is all that
is needed to start the thinking process. The mind is a marvellous thing.
However, if you stop for a moment to reflect, you’ll notice that in all those ideas for change, quite a lot
remains fundamentally unchanged. There is first order rather than second order change
I
. Patients must
still physically travel to get care at the Surgery. They must first speak to the receptionist, when actually
they came to speak to the GP. Even though they might have an appointment at a specific time, they may
still have to wait. They cannot go into the doctor’s room until their name has been called.
Tools Phase 1: Stop Before You Start Introduction35

At this point, you might protest. “You asked me to come up with ideas to improve flow and experience
in a GP Surgery and all those things you just mentioned are simply part of what a GP Surgery is”. Of
course, that is true. These things are what your mind has been trained to think of when it hears the
words “access to care in a GP Surgery”. Your mind is simply journeying through its mental valley down
the stream of thought on which we set it.
Equally effective is the mind’s ability to journey down an entirely different stream of thought when asked
to do so. Suppose, for example, that we had stopped and taken the time first to think about what we
really mean when we say the word, “care”. We might suggest that one aspect of care is giving
information to patients, upon request, that is relevant to their health issues. Now, if we ask you to come
up with ideas for improving the flow of information to patients about their health issues your mind might
journey down an entirely different stream of thinking. The words “flow of information” trigger thoughts
about websites, television, IT networks, telephone conversations, or email exchanges.
Think about this… Maybe some of those patients who have had to travel to come into the surgery,
chat to the receptionist, and anxiously wait to hear their name every time the door opens, don’t really
need to be in the surgery at all. A website, phone call or email would be just as good in meeting their
needs. Perhaps these alternatives would be even better for some patients, and have the knock-on effect
of improving access and reducing waiting for those who really do need to be seen face-to-face.
Think about this… If what we mean when we say that we will “see” a patient is literally that all we
really need to do is to see them or see a test result, then perhaps setting up video and telemetry links
from a rural village to a GP in the town would result in just as good care. It would also reduce
unnecessary travel for both patients and doctors.
Now that is thinking differently!

The examples above are what cognitive scientists - people who do research on the mind and thinking -
would call “reframing”. By describing the issue or challenge in a different way than normal, different
ideas naturally emerge. This of course also means that describing (or “framing”) the issue in the usual
way naturally leads to the same ideas that we have already had before.
That is not to say that there is necessarily anything wrong with the ideas we have already had before.
They may well improve things. However, when you are struggling to achieve financial balance and meet
targets; when you are already working as hard as you can and it still doesn’t seem to be good enough;
when patients, politicians, and the public are asking for more… only making things a bit better might
not be enough. By thinking differently you can create many more opportunities to achieve significantly
better health care and more efficient use of resources.
Learning to think differently must therefore begin before you start thinking too much. Our advice is: first,
stop before you start. That pause before rushing ahead to generate ideas is about paying attention to
how you are framing the issue, and considering ways to reframe it so that you can think differently. It is
about finding different words and images to have in mind as the building blocks and triggers for your
ideas. The tools we describe for this first phase will help you to do this.

Others’
Point of View
Reframing
by Word Play
WWTTCA
Pause,
Notice, Observe
1
ToolsPhase1
StopBeforeYouStart
Perceived challenge or issue
Choose your tool(s)
Fresh
Eyes
Breaking
the Rules
Random Word,
Picture or Object
Stepping
Stones
That’s
Impossible
Mental
Benchmarking

Starting to think in the usual way is the quickest and surest way to generate a list of the same ideas you
have had before. Stopping before you start - in order to rethink and potentially reframe the issues at
hand - is the quickest and surest way to generate new ideas.
Don't be afraid of new ideas. Be afraid of old ideas. They keep you
where you are and stop you from growing and moving forward.
Concentrate on where you want to go, not on what you fear.
Anthony Robbins

Tool: Others’ Point of View (OPV)
Synopsis
Before you simply dive into an issue from the usual thinking perspective of
someone who works within health care, describe the issue, opportunity or
theme from a variety of perspectives. How might other people view or
describe the situation?

Tools Phase 1: Stop Before You Start Others’ Point of View (OPV)41
In health care we should always consider:
N Service users
N Families and friends of service users
N Clinicians
N Staff
However, there is no need to limit ourselves to these traditional points of view. To help us think
differently, it may also be beneficial to consider what perspective an observer who knows nothing about
health care might bring. For example, how might the following describe the issue?
N Manager of a fast food restaurant N Airline flight attendant
N 6-year-old child N Stand-up comedian
N Formula 1 mechanic N Politician
N Librarian N Newspaper distributor
N Sales and Marketing representative N Hotel manager
N Leisure Centre manager N Accountant
N Parents of small children N Head chef of an organic, vegetarian restaurant
The aim is to generate 5-10 alternative ways of framing the issue, while avoiding getting locked into the
usual way we look at it. We are seeking to describe things from many different angles, using different
language than what is typical. This is not about trying to find the “right” or “best” way to state the issue.
We are simply striving for variety, as this may stimulate a creative connection.

Example
The manager of a mental health service writes the statement ‘improve service user satisfaction’ at the
top of a sheet of paper. She then works on restating the issues in a more focused way, using the
perspectives of service users and their families. Some of this information has been drawn from
conversations with clinicians and staff and from complaints and comments received from service users.
The new statements reflect this:
N Access is too difficult
N Medical records are often incomplete or unavailable
N We could be more empathetic to patients
N Family members need emotional support as well
Selecting a few items from the list of more unusual perspectives, the manager wonders what other
people might say about the mental health service and what language they would use to describe some
of the issues…
N 6-year-old child: “I’m really frightened.” Hmmm, she wonders… What could we do to explain
things better and dispel myths and misconceptions about the service?
N Stand-up comedian: “It’s not fun to be here!” What might we do to make the experience less
anxiety-producing? How does what we do and what our users experience either enhance or
interrupt their enjoyment of life?
N Airline flight attendant: “What’s our destination?” Do our users and carers really know where our
treatment plan is taking them, and is that really where they want to go?
After filling a page with statements that help reframe the issues, she realises that she can use some of
these later with her team to help generate new ideas. For example, she might ask for creative thinking
about “fright”… or explore what feelings and life needs (beside fun) are impacted by mental health
treatment and ask for creative ideas about minimising or avoiding this… or focus on creative ways to
help people improve goal-setting or to better understand the expected course of their condition and
treatment.

While it is, of course, important to address basic issues such as access, medical records, empathy and
emotional support, many of the answers to these challenges can probably be found in good practice
already used elsewhere in the NHS. However, in addition, by thinking differently, this team now has the
opportunity to make their service and care even better. We need both to improve our usual thinking and
to think differently. Better usual thinking helps set the minimum standard; thinking differently
helps us stretch beyond that.
The greatest danger for most of us is not that our aim is too
high and we miss it, but that it is too low and we reach it.
Michelangelo

Tools Phase 2: 63
2Introduction
Tools Phase 3: 120
Dot voting
Tools Phase 2: 70
Fresh Eyes
When might I use this tool?
This is a good tool to use very early on in the process. It is simple to explain and use and it immediately
stretches people’s thinking outside the norm.
How do I use this tool?
It’s simple really. Prepare a list in advance of “other people” that you will put forward to the group (see
the list above as a starting point; you might also want to read about the related tool, Fresh Eyes
I
).
Suggest someone (e.g., a service user, a man from Mars) and ask for thoughts from the group as to how
that person might describe some of the issues in the service, process, or topic area on which you want
to focus. Ask team members to express things in the language of that person: how would they say it?
After some time brainstorming
I
(divergent thinking), you may need to review the ideas to clarify or
remove any duplicates. Then, as a group, select 5-10 statements that cover the range of things you might
want to explore more creatively when you move on to idea generation. You might do this through simple
discussion or voting
I
.
Did You Know?
OPV is one of a collection of three-letter abbreviation tools developed by Edward de Bono as part of his
CoRT Thinking Programme. (Ref: de Bono E. de Bono’s Thinking Course. London: BBC Books, 1982. CoRT
stands for Cognitive Research Trust.) The CoRT programme is taught in schools around the world to
students from children to adults.

Tips
N Spend about 20-30 minutes on this tool. Take 3-5 minutes per “other view point” and you might do
6-8 rounds of this in that time.
N Keep up a good pace. Try to avoid long explanations or problem solving at this stage; we are just
seeking a variety of ways to restate and reframe some of the issues here.
N Start with something easy and obvious, such as the patient’s point of view; but then intersperse some
more “wacky” perspectives (e.g., comedian) as you go along. Alternating between usual and unusual
points of view helps to free up thinking on the usual ones.
N If you see that team members are struggling with “why are we doing this?” take one of the more
unusual examples and explain how you might use them later in idea generation, as illustrated in the
examples above.
N While you do not want to get into full idea generation at this point, you also don’t want to dampen
spirits or lose an idea if it comes up. Have a flip chart sheet available as a “car park for creative ideas”.

Tool: Reframing by Word Play
Synopsis
Take existing statements of the problem, issue or opportunity that you want to
work on and substitute synonyms and other words or phrases. These must
communicate the same thing, but in plain language, without all the jargon.
The goal is to stimulate non-traditional or unusual thinking.
What on earth are you talking about?!?
Words are the shorthand we use to signify our mental valleys. If I say, “I want to design a new GP
surgery” you will be tempted to go immediately to the mental valley of “GP surgery” and begin
imagining a building, with a car park, a reception desk, a waiting area, and so on. In this way, my
new GP surgery will end up looking very much like all other GP surgeries. Not very creative!
What if I played around with the words “GP surgery” and said instead “I want to design a new
way for people to get information that will help them stay healthy”. Images of Internet
computers, a book kiosk, or a new television show more easily spring to mind. Now, that might
be thinking differently!

Tools Phase 1: Stop Before You Start Reframing by Word Play47
Example
‘Access’ could be reframed as - “getting people with health needs (patients) together with those who
can help (providers).”
‘Medical record’ could be reframed as - “specific information about individuals’ health history and
needs.”
Statement before: “We want to improve access to care!”
New, more stimulating statement: “We want to think creatively about ways to link up people who
have questions about their health with people and resources who might provide answers.”
Statement before: “We want to move to a patient-held medical record… but every time we try to talk
about this, we get into endless discussions about the practical problems associated with having patients
carrying around large folders with their information in it.”
New, more stimulating statements: “We want to think creatively about ways in which members of
public could better provide certain specific information about their health history and needs when
required.”
Or “We want to think creatively about how certain bits of information about patients’ health history and
needs could be instantly available when required.”
After you have identified the list of issues to work on. This might be a result of using some of the other
tools in phase one: Stop Before you Start, or could be your original list of issues. This tool is really
helpful in creating simple statements and in identifying very specific areas to work on. A signal that this
tool might be useful is the presence of “jargon” or over-used terms (e.g., access, secondary care, etc.) in
your initial statement of your issue.

Tools Phase 1: 40
Others Point of View
Tools Phase 2: 70
Fresh Eyes
Tools Phase 1: 58
WWTTCA
Begin with your list of previously generated statements of the issue that you wish to address. Either in
discussion with your team, or alone, pick out health care jargon or over-used words and phrases.
Ask the group:
N “Please tell me what that means in plain English.”
N “What other words and phrases might we substitute for that?”
N “What words might someone else use to describe what you mean by that word or phrase?”
(Maybe suggest some “other” perspectives they might use).
I I
Capture these alternative words and phrases to feed into statements in the form of “We want to think
creatively about…”
I

Concepts: 20
Tools Phase 1: Stop Before You Start Reframing by Word Play
Tips
N You may need to be (playfully) hard on the group to get them out of the jargon that they are so used
to using. You might:
N Claim to be a man from Mars with only basic knowledge of English.
N Ask them if their grandmother or a small child would know what that word or phrase meant.
N Hand someone the flip chart pen and ask them to capture the group’s alternative statements. Walk
away from the group, but then come back periodically and circle new jargon or over-used words
that have appeared in their restatements and ask again “What does that mean in plain English?”
N It helps if you have previously explained the concept of mental valleys
I
.
N It also helps if team members can see where this is leading; that you are not just trying to be difficult.
Use the examples above, or ones from other teams that you have worked with, to illustrate how this
rewording might lead to the eventual end product of some really unique ideas and approaches to the
issue.
N While you do not want to get into full idea generation at this point, you also don’t want to dampen
spirits or lose an idea if it comes up. Have a flip chart sheet available as a “car park for creative ideas”.
49

Tool: Pause, Notice, Observe
Synopsis
Studies of highly creative people indicate that one of the things that they
habitually do is pause, notice and observe. While the rest of us pay somewhat
limited attention to what goes on outside our immediate sphere of interest,
creative people notice more and are relentlessly curious. Taking the time to
pause, notice and observe helps provide us with both understanding and
inspiration; and we have more to bring to idea generation sessions.
Curiosity may have killed the cat, but where human
beings are concerned, the only thing a healthy curiosity
can kill is ignorance.
Harry Lorayn

Tools Phase 1: Stop Before You Start Pause, Notice, Observe51
Approach 1:
Randomly pause, notice and observe to store up concepts for later use
George de Mestral, the inventor of Velcro™
, got the
idea for the fastener by pausing, noticing and
observing the cockleburs that stuck to his trouser leg
during a walk in the woods. Millions of people before
him had experienced the frustration of cockleburs,
but de Mestral was the first to study the mechanism
by which they clung so tightly to everything and
wonder how that mechanism might be used
productively. He wasn’t really looking for ideas for a
better fastener, but once he looked at the cockleburs
under a microscope he could see how a new type of
fastener was possible - and Velcro was the result!
We encourage you to practice similar curiosity as you go about your daily life. For example…
N As you do your shopping, or when you travel through airports and hotels, pay attention to how you
and others find your way around, how you gather information, what constitutes good and bad
service, and so on.
N Take the time to chat to staff in shops, managers, airline flight attendants, taxi drivers, and
others to understand how they do their work and, most importantly, how they think about things.
N Read magazines and books on topics outside your professional field.
You don’t have to be looking for anything in particular. Just notice and store it away in your mind.
Someday you may find yourself using that information to help you reframe and think differently about
some issue in your own work.

Tools Phase 1: 46
Reframing by Word
Play
Approach 2:
Purposefully pause, notice and observe for a given topic
1. Begin by taking the issue that you are facing and restating it in more general terms.
The Reframing by Word Play tool might be helpful for doing this, or it may be obvious
enough to simply describe. For example…
The manager of a pathology department wanted to decrease waiting time for patients who needed
a diagnostic test. Data collection and conversations with staff revealed that the longest waits
occurred when the waiting room was filled with patients and the two phlebotomists on duty,
despite their best efforts, were unable to keep up with the workload in taking blood samples.
Recruiting additional phlebotomists was out of the question given budget constraints, and the
manager could not see any obvious ways that the two phlebotomists could speed up their work
without risking harm to patients. His statement of the issue about which he wanted to think
differently was: “How can we better handle times of peak demand?”
2. List other organisations or other contexts in which people face the same, or a very similar,
issues.
A quick hallway conversation with a couple of colleagues on this topic resulted in the following list
of similar settings where systems have to handle times of peak demand:
N A sporting event
N The city streets at rush hour
N Airports at certain hours of the days, or on holiday periods
N Supermarkets.
3. Think about - or better yet, go out and observe for yourself - how others deal with issues that
are similar to yours. While you do this be especially attentive to new insights and different
ways of thinking.

The three colleagues agreed that, actually, the first three settings on their list did not handle peak
demand all that well, or in the case of sporting events and airports, peak demands were handled
simply by having more staff on duty to meet the demand.
However, the thought of the supermarket was useful. Someone pointed out that a certain
supermarket in town advertised a policy saying it would open a new check out if there were more
than 4 customers waiting in existing lanes. They agreed that it would be good to understand better
how that system worked. Importantly, where do the extra check out staff come from (noting that
supermarkets operate on very small profit margins and have to watch costs closely)?
On the way home, the pathology manager stopped in to this supermarket to observe. As the queues
grew, an announcement came on the overhead pager calling for more check out staff to come up
front. The manager noted that the fruit and vegetable manager and the meat department manager
both came out to open a new lane. The key insight was that senior staff within the supermarket took
on new roles, typically undertaken by more junior staff, as needed to help manage the times of peak
demand.
4. Think about how you could apply those new insights or ideas to your own setting.
The pathology manager took this idea back to his department to work on with staff. Now, when
the waiting room fills with patients, appropriately skilled individuals leave their usual posts and
help the phlebotomists take blood samples. When the demand reduces everyone returns to their
usual role.
You might say that this seems rather obvious and simple. But it was not obvious or simple to the
people originally involved who were frustrated by budget constraints that kept them from
recruiting more phlebotomists. And, judging from waiting rooms in many hospitals around the
world, the idea is not so obvious to others either! It is only obvious when one takes the time to
pause, notice and observe. That is thinking differently!

Example
A team at the NHS Institute for Innovation & Improvement used observation extensively while working
with hospitals looking for ideas to help reduce infection rates.
They noticed that many gel dispensers were placed on the wall and watched as visitors and staff put
down the bags and coats they were carrying, cleaned their hands with the gel and then picked up their
belongings off the floor, thus dirtying their hands again before entering the ward.
A simple observation!
The team remedied the problem by placing a table under each gel dispenser on which visitors and staff
could place their belongings while washing their hands.
A simple but effective solution!

Tips for gaining better insights from observation
Designers who create highly innovative products, solutions, and physical spaces say that observation is a
purposeful skill and art. Observation inspires new ideas and can help to redefine the problem.
Observation is a mindset that involves seeing beyond the surface to really understand what is going on
and how a system works or fails. It is an attitude of insatiable curiosity. When you are immersed within
a system, it can often be impossible to see the blindingly obvious. You need to observe because:
N People do not always do what they say they do.
N People do not always do what they think they do.
N People do not always do what you think they do.
N People cannot always tell you what they need.
N Things are not always what they seem.
(Adapted from IDEO)
If you want a definition of water, don’t ask a fish.
Chinese proverb

Observation is about looking within or outside an area of work for ideas and approaches to issues that
can be adapted and tested in order to improve the area.
N Looking within an area (for example, visiting another GP surgery or Trust to explore “good or leading
edge practice”) means going and looking at what people actually do in their work environment. This
helps to highlight potential issues and challenges that they face. By going and observing closely
yourself you might see details, critical to your ability to adapt an idea or approach within your setting,
that the good practice site takes for granted and would not have thought to mention.
N Looking outside an area (for example, visiting a supermarket or mobile phone manufacturer) may give
you even more ideas of things that you may be able to test within your area. Observing outside your
usual work area is one of the main ways to help develop really innovative solutions. You may get
insights and ideas that help you think about how you can fundamentally change a whole system or
way of thinking.

Whether observing within or outside the usual setting for your issue, here are some things to keep in mind:
N Keep an open mind and observe without judging. Don’t make assumptions about what you see - ask
questions to find out what is behind the behaviours you observe.
N Develop a set of questions to help guide your observation and questioning.
N If you are planning to interview people as well as observe them, your questions should let the other
person lead the conversation and not be directive.
N Try to get people to share their stories, not just provide answers.
N Taking photos is a really valuable way of remembering things that you have seen, and can give you
and your team additional insights once you have reflected on your observations. Be mindful of the
usual practices within a setting for getting individual consent when taking photos of people (this is
especially important in a health care setting, but is also common courtesy in any setting).
N Sit and watch. Sometimes just sitting and watching what is going on within an environment is a great
way of getting new insights that you can then talk about in your other observations.
N Ask others to think aloud. As participants perform a process or execute a specific task, ask them to
describe aloud what they are thinking. This helps uncover motivations, concerns, perceptions, and
reasoning.
N Learn to say instinctively, “Show me”. If you are in the interviewee’s environment (and you should be!),
ask them to show you the things they interact with (objects, spaces, tools, etc) instead of just talking
about them. Ask them to take you on a tour of their environment and capture pictures and notes to
jog your memory later.
The important thing is not to stop questioning.
Curiosity has its own reason for existing.
Albert Einstein

Concepts: 26
Tool: WWTTCA - We Want To Think Creatively About...
Synopsis
The previous tools encourage divergent thinking about your issues. Periods of
divergent thinking always need to be followed up with a little bit of convergent
thinkingI
to assure focus going forward.
A useful way to summarise the group’s thinking and to construct your final,
reframed statements of the issues on which you wish to focus, is to complete
the sentence “We want to think creatively about…”. WWTTCA is a shorthand
way to write this.

Tools Phase 1: Stop Before You Start WWTTCA59
Example
N We want to think creatively about ways to link up people who have questions about their health
with people and resources who might provide answers.
N We want to think creatively about how to decrease waiting times for diagnostic tests.
N We want to think creatively about ways to provide better emotional support to the patient's family.

Review all the thinking that you have been doing using the other tools in this section. Ask yourself or
a group “which of the statements we have generated seem the most on-target for where we might need
to think differently and are the most likely to stimulate new thinking?”
When the group have selected a few statements reconstruct these as a WWTTCA statement.
Generally speaking, 3-7 WWTTCA statements is a good number to end up with. However, there may be
times when a single statement really captures it all, or there may be some issues that are so complex that
you really need a dozen or more statements to cover them. Use your judgement.

Tools Phase 1: Stop Before You Start WWTTCA61
Tips
N After all the hard work that you may have done to begin thinking differently, do not allow the group
to simply choose the usual, jargon-laden statements. Insist that at least some of the statements that
you will carry forward for idea generation are provocative ones.
N This is a good time to pause and think ahead to the eventual effort to actually begin making real
changes. If your efforts are accountable to others who will need to be the sponsors or leaders of any
change efforts, it might be a good idea to ensure that they are on-board with the statements selected
and the implied focus going forward. Alternatively, you might decide that it would be better to wait
until you have some concrete new ideas to present to them. Just pause and think about this before
you rush ahead.

I find creative thinking tools invaluable both in my
own improvement work and when coaching other
improvement leaders on their projects.
They really help us stretch our thinking.
Liz Carter, Service Improvement Manager, NHS South West

Tools Phase 2: Generating Lots of Ideas
Tools Phase 2
Generating Lots of Ideas
N Fresh Eyes
N Breaking the Rules
N Random Word, Picture or Object
N Stepping Stones
N That’s Impossible
N Mental Benchmarking
63

The way to get good ideas is to get lots of ideas and
throw the bad ones away.
Linus Pauling, Nobel Prize winning chemist

Concepts: 25
Tools Phase 2: Generating Lots of Ideas Introduction65
Introduction
Stopping before you start - the topic of the previous section - helps you see your issue in a new light.
This has probably already given you a few new ideas. That’s good!
Experience has shown, however, that in order to get a few really great ideas, it is often helpful to first
generate lots of ideas and then sift out the bad ones. In this section, we will show you some tools to
help you and your team come up with lots of ideas. In phase 3, we will show you how to sort through
them all in order to take a few promising ideas forward.
First, some general tips and things to keep in mind…
1. Use the rules of idea generationI
Most people have heard of “brainstorming”. The word is generally used as a quick way of saying,
“All right then, let’s have all your ideas on this issue”. But did you know that there were actually rules
for a good brainstorming session? These include:
N Criticism is ruled out There are no bad ideas at this point. There will be plenty of time to
judge later.
N Go for quantity Don’t settle for 3 or 4 ideas; aim for 10-20.
N Encourage wild ideas It’s the wild ideas that often provide the breakthrough insights.
These insights might lead to further ideas that are not so far fetched.
N Build on the ideas of others What can you add? What else? What other ideas does it bring to mind?’
N One conversation at a time That way all ideas can be heard and built upon.
Keep these rules in mind when using any of the Idea Generation tools.
Did You Know?
That advertising executive Alex Osborne coined the term “brainstorming” in 1939…. It means: using the
brain to storm a problem or challenge… “each stormer audaciously attacking the same objective”.

These rules will actually make your idea generation more productive as they will help protect new ideas
(and the people who come up with them) from any initial rejection. Further, they encourage the sort of
divergent, imaginative, and supportive thinking that we need when we want to think differently. We
recommend that you have these rules up on a flipchart, or make copies of them for everyone to have in
front of them, whenever you want to stimulate your colleagues to think differently.
How to ‘RUIN’ an Idea Generation session…
N Invite only experts
N Ask the boss to speak first
N Write everything down in great detail
N Ban any silly stuff
A new idea is delicate. It can be killed by a sneer or a yawn.
It can be stabbed to death by a joke or worried to death by a
frown on the wrong person’s brow.
Charles Browder

Concepts: 25
2. Use the three mental activities of Attention, Escape, and Movement
These are the keys to generating lots of ideas
I
. It all ties back to that frequently used phrase to
“think outside the box”:
N We need to pay attention to the ways that we usually thinking about things. You can’t think
outside the box until you realise that your past thinking might have been constrained within a
proverbial box.
N Then we need to escape the box. This might come through a deliberate challenge to the underlying
concept, assumption, or rule that has now been called to our attention.
For Example... we might challenge a group to come up with ideas given the following scenario:
“All GPs have a highly contagious virus and are unable to work directly with patients for the next 6
months… How will we now handle patient flow to specialists?”
Idea: Develop questionnaires that can be administered over the internet or telephone to screen and
refer a percentage of patients with common and easily diagnosed complaints.
Warning - when ideas are put forward you might find some people immediately jumping in to say
that they will not work. For example: “we could not possibly have patients going directly to
specialists”. At this stage of ‘divergent thinking’ all ideas should be viewed as good ideas and must
be protected. Refer back to the rules of idea generation and remind the team that ‘criticism must
be ruled out’. Synthesis or selection of ideas is very important, but it is a stage that comes later.
The above scenario draws attention to the fact that we normally think of the GPs as being naturally
part-and-parcel of the process of getting patients to specialists. By saying that they are unavailable
to perform this function due to an illness, or anything else beyond our control, we are required to
escape that particular mental box to see what new ideas might be generated
I
.
Problems cannot be solved by the same level of thinking that
created them.
Albert Einstein
Tools Phase 2: 94
Stepping Stones

Tools Phase 2: 86
Random Word Picture
or Object
N Alternatively, the escape might be coupled with the original attention-getting process.
For example... during a session focused on improving patient flow in A&E, a team is handed a
clothing catalogue opened randomly to a page that displays a jacket and asked to use this image
to stimulate ideas.
Idea: Create a jacket with embedded sensors that make taking and monitoring vital signs easy
I
.
N Attention and escape need to be followed up by mental movement, letting the mind run free,
without self- or group censoring. Otherwise, the mind and the group dynamic will simply re-enforce
the usual thinking and push us back into that old box outside which we are supposed to be
thinking. The rules of idea generation described above aid this mental movement.
You’ll be amazed at the number of ideas you can generate when you allow these three mental activities
to flow. The tools described in this idea generation section provide various combinations, direction and
tips for bringing this about. If you stick with them, you will find that thinking differently is not really so
hard.
Ideas are like rabbits. You get a couple and learn how to handle
them, and pretty soon you have a dozen.
John Steinbeck

2
ToolsPhase2
GeneratingLotsofIdeas
Fresh
Eyes
Breaking
the Rules
Random Word
Picture or Object
Stepping
Stones
That’s
Impossible
Mental
Benchmarking
Choose your tool(s)
WWTTCA

Tool: Fresh Eyes
Synopsis
Since others will have different ways of thinking and approaching challenges,
we might be able to make a novel connectionI
by using “Fresh Eyes” and
thinking like another person, or making links to another industry.
New ideas come from differences.
Nicholas Negroponte
Tools Phase 1: 40
Others’ Point of View

Tools Phase 1: 33
Introduction
Tools Phase 2: Generating Lots of Ideas Fresh Eyes71
Summary of Steps:
1. Define the issue/problem
I
.
2. Randomly select alternative viewpoints (see box below) and think about how the associated
individuals would respond to the issue:
N What would be important to them in the situation we have described?
N What aspect of the topic would they focus on?
N What ideas and approaches might they have?
3. Reflect on these and think about how some of these ideas could be adapted for use in your own
context: Which are worth exploring further in health care?

An example of Fresh Eyes:
Issue: John is once again waiting for hours in Wednesday’s orthopaedic follow-up clinic. He thinks he
should have an x-ray but no one has given him a form. Last time he came to the clinic, he waited to see
the doctor who then wrote the form for the x-ray. He went along and queued for the x-ray, after which
he had to queue again to see the doctor. There have been some improvements in the service because John
can now book his outpatient appointment, but no matter what is done, waiting times always seem to be
the same.
Look at this issue through the fresh eyes of a child, who might ask:
N Why do we have to come to this place?
N Why do we have to wait?
N Why do we have to have the test?
N Why do we have to see the doctor again?
“Walk” through the process. Someone could even act into the role of the curious child, and make a
note of all the questions ‘why?’. Then take each ‘why’ question, (banning the easy response: “because
that is the way we do things”) and use them to stimulate thinking of several alternatives to existing
process.
How might someone from another industry look at this?
By looking at this issue through fresh eyes from another industry, we might ask: “How would a manager
of a supermarket manage demand at peak times in order to reduce waiting at checkouts?”
They might…
...promote internet shopping with home delivery
...flex opening times so that people can shop in the evenings instead of at peak times
...open a smaller store in the business district so that people can drop in for small purchases on their
way home from work and so on…

This then encourages us to make creative connections we might not otherwise have made, and to look
at the applicability of some of these suggestions to our own context.
For example….
N Internet shopping: Does all follow-up have to be face-to-face, or could we use a different method,
such as via telephone or email?
N Flex opening times: Can we run follow-up clinics at different times to reduce demand at this
particular clinic?
N Set up shops in other places: Can we agree protocols with our local GP practices to assess the
viability of patients being followed up elsewhere?
How might we describe this from a completely different viewpoint, another pair of “fresh eyes”?
If I think about skiing:
N I make sure I have all the things I need before I go out onto the slopes. For example, I might go over
a mental checklist for my gloves, skis, and ski pass.
For John, the patient waiting in the clinic, this might translate to us thinking about all the things he
might need for this visit and creating appropriate checklists and processes to support that. For
example, he might need an x–ray, blood test, and physiotherapy report. Let’s set in place a process to
get all of that done prior to John’s appointment, in order to ensure that the consultation will be
effective and comprehensive first time.
N As a skier I will always have a map of the mountain that identifies the most appropriate route for me
to go and includes ‘stop off’ points for lifts, restaurants etc. We could send a map to John, along with
the relevant test forms, to indicate in what order he should go through the clinic process. For example,
x-ray as a first stop, then the blood test, before finally seeing the doctor with all the results available.

Below is a list of “Fresh Eyes” perspectives you could explore:
Accounting
Acupuncture
Animal kingdom
Architecture
Airline
Astrology
Astronomy
Ballet
Basketball
Biography
Biology
Birds
Books
Bowling
Carpenter
Chemistry
Cardiology
Cartoons
Child
Coin collecting
Comics
Computers
Dance
Deserts
Dentistry
Economics
English
Entertainment
Evolution
Fast food
Farming
Fishing
Fine cooking
Funeral homes
Finance
Football
Flying
Geology
Geography
Government
Golf
Grocers
Garbage
Hunting
History
Hotel
Igloo
India
Inventions
Interior decorating
Insects
Japan
Jungles
Journalism
Korea
Law
Librarian
Law enforcement
Mafia
Maths
Medicine
Manufacturing
Military
Mining
Meteorology
Monuments
Moon
Monasteries
Music
Mythology
Movies
Nutrition
Nuclear physics
Oceans
Olympics
Parks
Pharmacology
Photography
Polo
Philosophy
Physics
Planets
Painter
Political science
Politics
Plumbing
Printing
Religion
Restaurants
Race team
Resorts
Sculpture
Seminars
Sailing
Skiing
Soap operas
Shakespeare plays
South America
Space
Sociology
Stars
Steel
TV news
Tabloids
Tall buildings
Television
Tennis
Transportation
Terrorism
Theatre
Travel industry
Sun
Unions
Vatican
Wine
Warehousing
Zoo

Example
N We want to think creatively about (WWTTCA)... Improvements in Primary Care.
N Perspectives randomly selected... Airline, Librarian, Supermarket.
N Some ideas generated:
N Establish "frequent flyers" club for patients with chronic or re-occurring conditions. Patients can
order prescriptions, schedule tests, or complete self-assessments with minimal staff involvement.
N Train librarians to help patients find health information and book appointments on-line using
computers in the library.
N Take patients with diabetes on a “healthy eating tour” of their local supermarket with a dietician.
Show them how to interpret the labels and make the best food choices for their condition.
Surprise! Each of these ideas has actually been implemented somewhere in the NHS.

An example of using “Fresh Eyes” on a problem….
Great Ormond Street
learns from Formula 1 Team
It was after what he described as "a particularlybad day at the office" that Prof Elliott, the head ofcardiac surgery at the Great Ormond StreetHospital for Children, and his colleague, Dr AllanGoldman, in charge of paediatric cardiac intensivecare, slumped into chairs in front of the television.On the screen was a motor racing grand prix and,as they watched, the two men became aware of thesimilarities between the handover disciplines fromtheatre to intensive care and what they were seeing inthe pit of a Formula One racing team. From thatmoment began a collaboration between the leaders ofGreat Ormond Street's surgical and intensive careunits, first with the McLaren F1 racing team and thenwith Ferrari's team chief Jan Todt, technical guruRoss Brawn and, in particular, race technical directorNigel Stepney. They worked together at their homebase in Modena, Italy, in the pits of the British GrandPrix and in the Great Ormond Street theatre andintensive care ward.
What resulted from this work was a majorrestructuring of the patient handover procedure,resulting directly from the input of the F1 pittechnicians. "It is not too early to say that, when welook at the number of critical instances we encounter,they have reduced markedly since we introduced themodified training protocol developed from what wehave learned from Formula 1," said Prof Elliott.The single A4 sheet of paper, which contained theflow diagram of Ferrari's pit procedure, becameseveral pages of twice that size when Mr Stepney andhis colleagues at Ferrari were confronted with thecritical transfer from operating theatre to recoveryroom at Great Ormond Street. “They were quiteshocked at the complexity of what we did and thekind of kit we had at our disposal," said Prof ElliottWe had all being doing our jobs for years and wethought we were pretty good at it," said Dr NickPigott, the consultant in paediatric cardiac intensivecare, who has worked alongside Prof Elliott and DrGoldman throughout Operation Pit Stop. "Then, afterwe had been with the Ferrari team, we watchedvideos of ourselves at work and it was quite a shockto realise the lack of structure in what we weredoing."There is no doubt that it is our research withFerrari that has honed our transfer from theatre tointensive care to the level of silent precision it istoday." said Dr Pigott.
Daily Telegraph, 29/08/2006

Tips on using this tool yourself or with others
N Before you try to engage others in using this tool share some of the examples given in this section on
how healthcare has used ideas from other industries. This helps people to see the connections and
application of the tool.
N The list of perspectives, on page 74, should not be restrictive. Add to, change or modify the list
as you go.
N Try not to censor the choice of perspectives, just select them at random. Obviously, some will work
better than others and some will stretch the participants more; but all are valid. Even if you can’t see
an immediate connection, others might.
N Spend around 30-40 minutes on this tool using 4-5 different perspectives.
N If you feel stuck in trying to make a connection, just select another perspective and move on.
Eliminate something superfluous from your life. Break a habit.
Do something that makes you feel insecure.
Piero Ferucci

Tool: Breaking the Rules
Synopsis
Identify the underlying assumptions, mental models, unwritten rules and
thinking that maintain the status quo, and then deliberately think around them
to create new ideas for service delivery.
Tell me more please…
In complex systems, rules or underlying mental models (we will use these terms
interchangeably) drive much of the behaviour in the system. We need to pay attention to these
rules by identifying and observing exactly what is happening.
There are no rules here, we are trying to accomplish something.
Thomas A. Edison

Tools Phase 2: Generating Lots of Ideas Breaking the Rules79
Example…
Consider the mental model that patients with long term conditions must have regular check ups and
diagnostic tests carried out in a health care facility. This generates many corresponding actions that
we take for granted. Since check ups and tests are carried out in a specific place, we therefore must
create patient flow processes that enable patients to move in and out of that place. We also need
decision-making processes to decide which professional should see the patient and how frequently.
When you think about it, a rule like “care has to be delivered in a specific place” drives many
processes and patterns of behaviour in health care organisations.
Innovation is a violation of the current rules!
To get innovative ideas, we need to think differently.
Example…
One idea is that patients could check their own blood pressure, at their convenience, without seeing
any clinicians, by using a static blood pressure machine within their doctor’s surgery, providing a print
out that can then be put in their record.
Another innovative idea is to consider enabling patients to have a check up and perform diagnostic
tests in the comfort of their own home and access services when they decide, based on information
that has been provided, rather than being constrained by a fixed schedule that might not meet their
needs. This could be achieved through near patient testing devices that are remotely monitored
through a high-speed data network connection or through the use of telephone, internet webcam
or e-mail consultations when the patient chooses.
Rules maintain the status quo. We can improve the system within the constraints of the current simple
rules (for example, streamline patient flow through clinic and diagnostics). This is first-order change.
But we can also innovate by explicitly breaking a rule and see where our imagination takes us
I
. This is
second-order change.
Concepts: 22

A way to stimulate different thinking for idea generation is to…
1. Identify the underlying rules
There are a variety of ways to do this:
N Simply list them through group discussion.
N Step through a process map and at each step ask, “Why is that step here?” or “What seem to
be the underlying mental models or unwritten rules behind what is going on here?”
N Actually spend some time in the system to watch what happens on a daily basis and ask the
questions in the previous point
I
.
N Tell stories of normal occurrences within the system and ask the questions above.
Tools Phase 1: 50
Pause, Notice,
Observe

2. Creatively challenge the rules
There are several ways to do this:
N Ask questions:
N What aspects of this rule can we break?
N What aspects of this rule would we want to keep and why?
N Propose an alternative simple rule.
3. Walk around in the “new world” and see what new ideas you can generate
Play out the scenario as to what you would do if the rule were suddenly altered: what could you do
differently? What would that look like? Draw the new process and / or capture ideas as you go.

Example…
Unwritten rule: only a healthcare professional can take and record an accurate blood pressure (BP)
Breaking the rules: A medical centre in Bewdley lends patients BP machines with printers for a
couple of weeks so they can self-test and ascertain whether or not they are hypertensive or have
another problem. This avoids medicalisation and inappropriate drug expenditure for those who
those are found not to be hypertensive. Patients who do have hypertension are offered a discounted
BP machine for ongoing self-monitoring. They can send results to the medical centre via the internet
and can also access their management plan on line. This enables patients to check whether their BP
is within normal limits, or if it is raised and they need an appointment with the GP.
When might this tool be useful?
N When things have been done the same way for a long time.
N On a topic where there are repetitive structures and processes that everyone knows about
(Example… In A&E there is always a reception desk where you have to go first. Why is that?
What is the “rule” here?)
Like lots of breakthroughs, the Fosbury Flop (now the standard in
Olympic high jumping) looked strange the first time you saw it.
Really strange.
Tom Kelly IDEO

Tips: Breaking Rules
N Give several examples of simple or unwritten rules in daily life and ensure that participants understand
the basic concept. For example:
N Traffic in a city centre. Trying to describe the movement of individual cars would be
enormously complex. But we all know that what is really going on is that individual drivers are
just following a few simple rules regarding which side of the road we drive on, what to do
when you approach a roundabout, the distance to keep from the car in front and so on.
N The Institute of Medicine in the USA has described the future health care system as a
transition from one set of simple rules to another. (See box on the next page)
N A common unwritten rule in health care is that “Patients must pass through low cost
resources before gaining access to high cost resources”. Talk this through in terms of who the
patient first sees upon going to the GP surgery or A&E. Note that many A&Es have been
innovative in putting a medically trained person closer to the beginning of the process in
violation of this rule.
N Consider also giving the group you are working with an example that you think is an
unwritten rule for their particular topic or system.
N Avoid simply being sarcastic or clever. (Example… “If the doctor is cross with the nurses he will hide
the patient’s notes.”) It is OK if there are a few such items on the list in the name of fun. However,
the point is to describe the functioning of the system, not simply its dysfunction. The test of a well-
worded rule is that when you show it to others their reaction is: “Yes, that makes sense, nothing wrong
with that.”
N Note that some rules are, in fact, formal rules in the sense of laws or regulations. But even these might
be challenged to see if there are some creative things that one can do within the limits of the rule.
N Not all unwritten rules need to be changed, but it doesn’t hurt to think about them.
N Many participants may find it hard initially to identify unwritten rules in their own work practices. We
get so used to “the way we do things around here” that it can be hard to step back and see them
more objectively. Involving people in the group who do not work in the immediate topic-area
(including patients) can be helpful as they are more likely to ask, “Why do you do it like that?”. This
can help identify the underlying mental models or unwritten rules.

Simple Rules for Better Health Care System in 21st Century
Current Approach New Rule
Care is based primarily on visits Care is based on continuous healing relationships
Professional autonomy drives variability Care is customized according to patients’ needs
and values
Professionals control care The patient is the source of control
Information is a record Knowledge is shared and information flows freely
Decision making is based on training
and experience Decision making is evidence based
Do no harm is an individual responsibility Safety is a system property
Secrecy is necessary Transparency is necessary
The system reacts to needs Needs are anticipated
Cost reduction is sought Waste is continually decreased
Preference is given to professional roles over
the system Cooperation among clinicians is a priority
Source: Institute of Medicine Committee on Quality of Health Care in America.

Tool: Random Word, Picture, or Object
Synopsis
How can a randomly selected word, picture or object possibly help me
think differently?!?
The very words and images we use to talk about a topic bring us into our usual
ways of thinking (our mental valleysI
), resulting in ideas that are not very
different from what we already have. A randomly introduced word, picture, or
object activates thoughts that we do not usually associate with the topic and
therefore gives the possibility of a new connection and new ideas.
Concepts: 20

Tools Phase 2: Generating Lots of Ideas Random Word, Picture, or Object87
Example…
A group working on improving the transport of samples to a hospital’s pathology department has generated
several ideas to speed up the process, but none are very creative. The team leader introduces the randomly
selected word “umbrella” (or sees a picture of an umbrella in a magazine, or notices one in the corner of
the room).
The group talks about “umbrellas” for a moment and someone notes that looking up into an umbrella you
see a central post with metal arms coming out from it. This leads to discussion of the fact that in some
laboratory equipment there is a sample compartment that is connected by wires to a processing computer
within the same piece of equipment that does the analysis. Why not keep the central processing computer
in the pathology lab, but place sample compartments out on various wards and connect these in via wires?
The Pathology manager approves a plan to test this idea by disassembling an old laboratory analyser,
relocating the sample compartment on a ward, and connecting it via a cable. No need to transport
the sample!
When might this tool be useful?
N This is a general-purpose tool that can be used on any topic at any time; either by an individual or a
group. Try a random word, picture or object to get you started!

How do I find a word, picture or object?
a) The best words to use are nouns and there are a number of different ways that you can
find one:
N Use the random word list below. Simply close your eyes and put your finger on the page. The
word that you are pointing to is your random word.
N Bring in a book (a report, letter, or any page of text will do), open to a random page, close your
eyes, put your finger on the page, and select the noun that is closest to where your finger lands.
Random Nouns…
tongue plastic wrench star gourmet money flashlight dice windsurfer ribbon
camera can pencil pin watermelon soda tape necklace mould gutter jewel
house gully fuel music wastebasket x-ray cup paint lamb stomach rain
telescope knee pole champagne top beans angel student lips salmon lungs
gasoline tub fox chimney bikini prison tax igloo fireplace axe smoke referee
cork stream strip jellyfish vines bomb umbrella cone flood frog rib table
flower towel window locker toy podium saucer rainbow amoebae disk
snail rice grass fence horse shed leaves bird tractor Olympics straw mirror
chapter vacuum bread cyclone gravy emerald gang pliers binoculars studio
parakeet fingernail meadow bat curb zipper gutter outlet elbow weeds
paper wig road sauna cord duck floor book announcer nappy cake terrorist
sandwich lightning candle crown jelly fossil pet ruler circus plug coach
wallpaper ham envelope actor riot clay train television garage stadium fork
detective magazine medal refrigerator sonar planet hostage car salad….

b) Old magazines, particularly ones that have nothing to do at all with health care, are good
sources of pictures. Open to a random page that has a picture or advertisement on it. Explore
what is in the picture and talk about what it makes you think.

For example…
A team working to come up with ideas for public health campaigns came across a picture of an open
fridge in a magazine. This generated discussion about healthy eating and how a professional could
tell a lot about someone's health by looking into his or her fridge. When one of the group also
noticed a picture of schoolchildren that someone else had cut out and left on the table, the idea was
born for creating a checklist for children to bring home to explore the contents of the family fridge
with their parents.

For example…
The picture of a recliner chair made
them realise that putting patients
on trolleys instantly reinforced a
certain severity of illness in the
minds of staff and patients. In
addition to this trolleys are actually
not the most appropriate seating
option for many patients.
They wondered if a more chair like
design, while being comfortable
and allowing the patient to rest,
might help retain elements of
wellness for both patients and staff.

c) Look around you for objects, bring in objects from home, or ask your partner or children to
give you an object, but don’t tell them what it is for.
This guide is full of words, pictures and images of various objects!
Use it as an immediate resource for this tool.

N Draw a vertical line on flipchart paper to separate it into two columns.
N Select a word, picture or object at random.
N Discuss in the group whatever this prompts people to think about.
N Make a note of these in the left-hand column of the flipchart paper.
N Then ask how some of these items can relate to your issue or topic and write those ideas down in the
right-hand column of the flipchart paper.
N Spend about 10 minutes on each random word, picture or object.

Tool: Stepping Stones
Synopsis
Offbeat ideas and somewhat wild scenarios can serve as catalysts or mental
"stepping stones" to help us make an intuitive leap to a really good idea.
By starting with the outrageous, we are able to suspend judgement and think
more freely, provoking connections or associations between seemingly
unrelated pieces of information in the mind.

Tools Phase 2: Generating Lots of Ideas Stepping Stones95
How might I use it?
There are two basic types of stepping stone provocations …
Type 1 - State an extreme or outrageous approach to the issue at hand
The purpose is to jolt the thinking (escape), step back and see what concepts emerge (attention), and
then return to somewhat more practical suggestions that stem from the concepts (movement)
I
.Concepts: 23

Example A
Issue at work: I can’t seem to find the time to focus on improvement.
Outrageous idea: You must do all of your work using improvement tools.
What are the underlying concepts within the idea?
N Improvement is work
N Use an improvement technique for everything you do
N Streamline tasks
N Think about things that do not need to be done at all
N Learning/improving new skills is part of everyday activities
N Challenges are opportunities for change.
Making connections between using improvement techniques and your ‘usual’ routine, how might the
above concepts be applied in the workplace?
Change ideas:
N Using improvement techniques: During the initial handover at the beginning of your shift ask your self
and the staff handing over how this process could be made more efficient without compromising the
information exchange. Come up with at least three alternative ideas at each shift change for 3 days.
N Streamline tasks: Every time you do a task think how many steps are involved (even create a rough
process map). Identify at least one way that you can simplify the process to make it better.
N Identify things that do not need doing: Be aware of things that you really do not need to do. Ask “does
it need doing at all or who else could help?” This might even be something that patients could do for
themselves. This creates more time for doing other things like improvement work.
N Learning/improving new skills is part of everyday activities: every time you learn something new about the
service you provide make a note of it and review with your team to see if it can lead to general
improvement.
N Challenges are opportunities for change: Every time something seems to be a challenge think about how
it could be different, what is making it such a challenge and how could it be overcome?

Example B
Issue at work: staff morale is very low.
Outrageous idea: send everyone on a skiing holiday.
What are the underlying concepts within the idea?
N Time out of the workspace
N Learning/improving new skills
N Presenting people with a challenge
N Doing something staff wouldn’t normally do
N ‘A change is as good as a rest’
N Energising activity
N Alternative modes of transport (skis!)
N Reward of good food after a hard day’s skiing
Making connections between the skiing holiday and improving staff morale, how might the above
concepts be applied in the workplace?
Change ideas:
N Time out: Open forum for staff to bring ideas during lunch hour; access to reading materials through
improved library service; aerobics/exercise facilities on site.
N Learning/improved skills: Improved access to educational and experiential learning opportunities.
Swap roles for a day to see a service through new eyes
N Presenting people with a challenge: How can we make this the best organisation in the country for XYZ?
N Alternative modes of transport: Look at broader issues relating to staff. Is parking sufficient? Can we
organise taxi services for night nurses? Can we get staff subsidised theatre tickets through our local
Chamber of Commerce?

It is not because things are difficult that we do not
dare, it is because we do not dare that they are difficult
Seneca
Type 2 - State an extreme or outrageous scenario that makes it necessary to completely
redefine how we approach the issue at hand
Here we are using the same sequence of escape, attention, and movement, plus we are applying the
old adage that “necessity is the mother of invention.”
a. Select elements of the system that are central to the way people currently think about the issue. For
example: “we simply must have more beds”, “we cannot possibly do this without more nurses” or
“we need another x-ray machine, Laparoscope, or BP machine before things will improve”.
b. Suddenly eliminate or drastically modify these elements in a scenario that describes a new situation
and makes it seem real.
Be imaginative! You could: pass a new law or regulation, invent a mysterious and selective virus that
means that certain people cannot be involved in the process, discover some environmental hazard that
forces facilities closure or prohibits the use of certain resources or equipment, create a crisis of any sort!
c. Include a statement of what you want the thinking to focus on in the new scenario.

Example
Creative focus: We want to think creatively about how patients access emergency services.
Elements of the system that are central to the way we currently think about the issue:
N GPs
N A&E consultants
N Nurses
N Diagnostic equipment
N A&E as a place
N Ambulances
N Etc.
Write a scenario and include a statement of focus:
N A mysterious virus has affected every GP in the UK so that they are unable to work. Everyone else is
completely unaffected.
How can we design a direct and speedy flow to A&E that sorts only those patients who really do need
the skills and expertise available in A&E and directs the rest to other resources? What other resources
could be used ?
N An inspection agency has noted the presence of a mysterious chemical in A&E and has ordered it
to shut down and be sealed off for an indefinite period of time. The nearest alternative A&E is 200 miles
away. You are in charge of the Emergency Services Network that serves this community. What are you
going to do to provide access to emergency care?
N The manufacturer has discovered an extremely serious defect in the brakes of all Ambulances in
operation in the UK. They are such an immediate danger to public safety, that they have all been banned
from the roadways - with immediate effect! Parts to repair the problem will not be available for 6 weeks.
You are the in charge of the Emergency Services Network that serves this community. What are you
going to do?

When might I use it?
When you feel that you or a group is stuck, or is simply coming up with variations on the same old themes.
Whenever you notice that the current thinking seems to depend too heavily on certain resources or assets
in the system.
Tips
N Have a good bit of fun with this tool. It is meant to be playful and tongue-in-cheek. But this is play
with a purpose. The goal is to explore the outrageous suggestion or scenario, but to come back to
reality with some new ideas on the topic at hand.
N Keep in mind the sequence: escape, attention, movement.
N This is a popular tool with health care teams because they are usually experienced in dealing with crisis.
N Stepping Stones of the first type are best done spontaneously. Either suggest something yourself off
the top of your head, or ask the group for some really far-out and outrageous ideas; then just go with
it as described above. The spontaneity of it adds to the climate of purposeful play and freethinking.
N Stepping Stones of the second type are best prepared in advance and used as a set. Take time to think
through a good list of things in the system that people think are central to approaching the issue, and
take time to carefully craft the statement of focus to avoid making the new approach too obvious.
Use several of these Stepping Stones to make sure that the ideas don’t just substitute one taken-for-
granted resource for another.
N If you are working with others when using Stepping Stones of the second type, be prepared for initial
incredulity; group members may simply stare back at you blankly and say things like, “That can’t
possibly happen”. Stick with it; insist that they deal with it: “No really, it did just happen, now what
are you going to do? You can’t just sit there, ‘you’ have to do something”. You might want to point
out to the group that this reaction is exactly what many people experience in times of crisis, but then
they have to get on with it and do something.

Tool: That’s Impossible!
Synopsis
Often, we take as a given that something is impossible. Maybe it is simply that
we were not able to do it in the past and we have not recently thought about
the possibilities. Once you think about it, it is possible to do (or at least come
close to doing) many ‘impossible’ things.

Tools Phase 2: Generating Lots of Ideas That’s Impossible!103
How often - even before we began - have we declared
a task “impossible”? A great deal depends upon the
thought patterns we choose and on the persistence
with which we affirm them.
Pierro Ferrucci

1. Make a list of things that are currently accepted as being impossible
Example… It is impossible to…. make sure everyone uses hand gel before they enter the ward. It is
impossible to… know that a patient is going to turn up for an appointment until they actually present
at reception.
2. Ask: “How could we actually make that possible?” “How could we come close to doing that?”
“How could we do that at least some of the time?”
Continuing the example…
N Make sure everyone uses hand gel before they enter the ward:
N Have a video camera and motion detector pointing at people as they walk near to the ward.
This triggers a voice recording reminding people to wash their hands.
N Only by using the hand gel will the ward door unlock. For example, wire the button that unlocks
the ward door to the hand gel dispenser.
N Each time hand gel is dispensed a coloured, timed label is dispensed with it so that people are
easily identified if they have not got the right label.
N Patient turning up for appointment:
N We ring them up to see if they are coming.
N Place large sign near a telephone in the car park asking patients to call us to let us know that
they are in the car park so that we can begin preparation for the appointment.
N Give patients a swipe card or PIN number to key in for a special car park or clinic entrance. When
they swipe the card or key the number to get in, a signal alerts us that they are on the way.

Example
Perform major surgery without making an incision? That's impossible!
Removing a brain tumour through the nose; performing an appendectomy through the mouth; removing
a gall bladder through the vagina…. It may sound impossible but it’s been done! Doctors in France, the
US and in India have all performed surgical procedures such as these using ultra-slender instruments and
tiny video cameras inserted into the body’s natural orifices. Using the body’s own channels prevents the
need to cut through sensitive tissue and muscle, avoiding major scaring, and providing faster recovery time
and less pain.
Over 15 years ago, it seemed impossible to have an operation without a large, invasive incision… until
someone thought differently and laparoscopic (key hole) surgery was born. The natural orifice approach
marks another step change and the chance of eliminating the need for any incision at all.
"Getting rid of them (incisions) completely is going to be not an evolutionary step, but a revolutionary
step," said Dr. Marc Bessler of Columbia University Medical Center.
Original story at: www.nytimes.com/2007/04/20/health/20surgery.html
The world is moving so fast these days that the man
who says that it can't be done is generally interrupted
by someone doing it.
Harry Emerson Fosdick

Example
"Get your heart to call your doctor and report how it’s doing". What?!? Don’t be ridiculous!
That's impossible!
Oh no it’s not….
Technology which enables doctors and patients to have “virtual consultations” via the internet
now exists.
For example, patients with chronic heart disease who have an implanted cardiac device can collect
their own data by holding a small antenna over the implant and transmit it straight to their doctor
via a standard telephone line. The physician can review the data on a special web site and the
patient can also check their own condition online.
Patients with diabetes can transmit their blood glucose readings to a web-based database, which
can analyse the data and provide immediate feedback to both patient and doctor, along with two
way messaging of insulin schedules, advice and reminders.
Other remote monitoring opportunities now available include brain activity, blood pressure, ECGs,
oxygen saturation, sleep apnoea… all via wireless transmission to mobile phones, PDAs, laptops
and computers!
N When you sense that people are reluctant to set ambitious goals for improvement.
N When people say things like, “Well, there is no way that you can…” or “It is simply not possible to…”

Tips
N Because you are addressing directly something that is widely held to be impossible, you should not be
surprised at stronger than usual negative thinking as you begin to use this tool. Be sure to emphasise the
rules of idea generation to suspend judgment, go for quantity, build on others’ ideas, etc
I
.
N Capture all ideas for possible later development; don’t allow laughter to result in rejection. Suggesting
that one tries something thought to be impossible always brings out laughter… until someone actually
does it!
N This tool might result in some ‘outrageous’ ideas. Be careful not to let them be dismissed. Ask the group
to ask: “how might we really make this happen?”
Tools Phase 2: 63
Introduction

Tool: Mental Benchmarking
Synopsis
Many of the basic issues we face are common to other industries and settingsI
,
if we state them in plain English and remove the jargonI
. For example, in health
care we talk about “access,” or “patient flow,” or “matching up the correct
patient with his or her medications.” But these are really common issues across
many industries. Those in other industries will have different mental models
from us – McDonald’s deals with “access” by providing a drive-through window;
Disney World deals with waiting time for its rides by providing stimulating
visual input to make the time pass more quickly; and FedEx certainly knows a
thing or two about how to match up packages with the correct delivery lorry.
If we can connect our issues and those different mental models, we might
generate a creative idea!
Tools Phase 1
Pause, Notice,
Observe: 50
Reframe by
Wordplay: 46

Tools Phase 2: Generating Lots of Ideas Mental Benchmarking109
The best innovators aren’t lone geniuses.
They’re people who can take an idea that’s obvious in
one context and apply it in not-so-obvious ways to a
different context.
Harvard Business Review

How to do Mental Benchmarking
The tool involves four steps:
1. Frame the issue in its plainest or most general terms.
Example… We want creative ideas on providing faster service to customers.
2. Select an industry or business at random, or one that also deals with a similar issue.
Example… Fast food restaurants, banks, shops etc.
3. Describe how that industry naturally thinks about the issue.
Example… Fast food restaurants have drive-through windows, a limited menu, “combos” where you just
give the menu number, etc. Banks provide services via ATMs (kiosks) or on the internet, etc.
4. Borrow and adapt concepts to your issue.
Example… What health care services could we offer via a drive-through window? E.g. prescription refills,
lab sample drop offs, flu jabs, quick consultations… How can we bundle or combine services, maybe for
those with long term conditions? What could we do with a health kiosk? Etc.
Laughter is a natural physiological reaction to a novel connection in the mind. Expect that others may
initially laugh at ideas borrowed from other industries or settings (“A drive-through window in a hospital
like the one in those fast food restaurants!?! You must be joking!) Rather than being discouraged, take this
initial reaction as a signal that the idea is potentially creative! Stick with it, really think about it, and you may
find that it is not such a crazy idea after all.
If at first the idea is not absurd, then there is no
hope for it.
Albert Einstein

Tools Phase 2: Generating Lots of Ideas Mental Benchmarking111
Service with a jab
and a smile
For more than 10 years Beatrice Zastrow has
received her flu shot.
Last year, Zastrow discovered an easier way to
get the vaccine - by pulling into a full-service flu
drive-through.
"We just drove in, filled out some paperwork, and
got the shot. It took probably a total of 15 minutes,"
Zastrow said.
It was so convenient that she and her husband,
Orville, are getting their flu shots by drive-through
again this year in Shady Grove, Md., she said.
"I can go any weekend for the next three weeks,
and I know it won't take up my whole day," Zastrow
said.
One nurse compared the process to picking up
dinner at a fast-food restaurant only "you don't get
the fries."
As patients pull into a drive-through clinic, nurses
begin handing out paperwork consisting of medical
history reviews and consent forms. Once the
paperwork is filled out, patients stop at a fee station
before receiving the vaccination.
Lisette Osborne of the Howard County Health
Department in Maryland said the vaccination process
was easy.
"You roll down the window, roll up your sleeve,
and get the shot," she said.
The Howard County drive-through was the
second largest in the country, servicing 2,100 people
in one day.
Not only do patients take advantage of the drive-
through, but the county benefits as well, by practicing
the kind of quick treatment that might be necessary in
case of a large-scale medical emergency.
Another purpose to this process is to see how
quickly we can perform in case of an emergency. We
get better at it every time because we learn lessons
about how to do it more efficiently," Osborne said.
The vaccines are the same as what you would
receive in the doctor's office. You have a choice
between the flu shot or nasal flu vaccine.
"I find it all so interesting," Zastrow said. "At the
doctor's office, I would have to wait in the waiting
room before seeing the doctor and then wait 15
minutes after the shot to make sure everything was
OK. But with this drive-through, if you've had a flu
shot in the past, there's not much of a wait to see the
doctor and you can drive off immediately."
ABC News, Oct. 17, 2006 - http://abcnews.go.com/Health/story?id=2575478&page=1
Drive-through flu jabs? You must be joking!
Actually, it’s already happening in the US and Canada….

Tools Phase 3
Selecting and Testing Ideas to Make a Difference
N Harvesting by Criteria and Dot Voting
N Six Thinking Hats®
N Enhancement Checklist
N Testing New Ideas on a Small Scale
Tools Phase 3: Selecting and Testing Ideas to Make a Difference113

It is better to have enough ideas for some of them to
be wrong, than to always be right by having no ideas
at all.
Edward de Bono

Introduction
If you have followed the process and used the tools that we describe in the previous sections you should
now have lots of ideas. The key to the previous phases of the thinking differently process was divergent
thinking: expanding your options… getting outside the box of ‘usual thinking’… challenging the way
things have always been and the ways that you have been taught to think about them… suspending
judgement… exploring widely.
Now it is time to balance all that with some convergent thinking: selecting the most promising options…
thinking more concretely about how you might adapt new ideas to your current circumstances…
applying judgement… doing something in the here and now… making something happen
I
.
It is important to acknowledge this shift in emphasis. A common pitfall for potential innovators is to go
around talking with wild-eyed enthusiasm about all the great ideas they have, only to meet cynicism from
colleagues who say things like “Look here, be practical” or “That will never work”. Perhaps this has even
happened to you?
Concepts: 20
Tools Phase 3: Selecting and Testing Ideas to Make a Difference Introduction115

100
ideas
generated
Creativity
Doing & Changing
Innovation
10
ideas
harvested
5
ideas
developed
2
ideas
tested
1 idea
implemented
Numbers depicted are illustrative only, but are based on typical ratios across a variety of industries
And so, this final phase of the process of thinking differently is just as important - and requires just as
much deliberate effort - as the other phases.
Experience across many industries suggests that the process of convergent thinking that is required to
get one new idea implemented (such as a new product, service, or internal procedure) begins with
around 100 ideas that have come out of idea generation sessions and proceeds through a process that
can be illustrated by a funnel. This process of harvesting or selecting, further developing, and testing
ideas is critical to success.
The Idea Funnel
£ £ £ £ £
Resources

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Introduction
Note especially that this funnelling process helps us manage resources better when thinking differently.
If you are truly thinking differently, then the ideas that you come up with are unlikely to have been tested
before in your setting.
It’s important to accept that not all ideas generated are equal; yet all are important to the
process of thinking differently
Sometimes ideas that “look good on paper” really don’t work when put into practice. That is simply the
nature of any innovation. It is a risky business.
So, it would be imprudent to take an idea directly from a freewheeling brainstorming session and
implement it fully in just one giant step. You could waste a lot of resources that way; not to mention
making it very hard for anyone to get support for another new idea in the future!
As the sizes of the arrows illustrates in the Idea Funnel diagram, it takes little resource to brainstorm 100
ideas (a group can easily come up with 100 ideas in a hour or two using the tools we describe in phase
2). You might then spend a little more time in selecting perhaps the 10 best ideas and thinking a bit more
about them. Next, you might gather a small team to further develop and think about both the strengths
and weaknesses of each idea. In this section, we describe some tools to help with all of this.
But with all the time and effort that you have put in to get to this point, still all you have are ideas on paper.
You won’t really know how they work until you try them out. Here is where the larger resource commitment
starts. We suggest that you first try out an idea on a small scale before you ask for commitment to full
implementation; and we’ll give you some tips to help you think through and plan all of that.
This entire development and testing process might unfold in just a few days for a small idea in a single team
or department, while it might take months to play out for a larger-scale idea such as developing a new
service or a fundamentally new way to access care. However, in either case, thinking it through and
managing the risks and resources associated with the change is critical.
117

For example...
As described further in the case study Award Winning Thinking Brings Better Care to a Diverse Community
I
,
a group of 120 people assembled to think differently about out-of-hours care in Northeast London
generated 180 ideas in just two hours. The group then quickly voted to get down to 11 ideas. These were
further subjected to a short analysis that resulted in rejection of some and combination of others into just
6 ideas. Teams were then commissioned to further develop and test these over several months, resulting in
2 being abandoned, 2 subsumed under other initiatives, and 2 going on to broad and successful
implementation. That is the typical process of thinking differently!
Because of the more step-by-step nature of this phase of the thinking differently process, the tools in Phase
3 are organised and described in a different way. Whereas in the previous sections we recommended that
you pick-and-chose tools that suited your needs - and didn’t necessarily recommend that you use them all
- in this section we suggest that you systematically work through each of the tools presented, in the order
in which they are presented.
You must decide how much time and effort to expend on each tool, depending on the nature and scope
of the ideas you are working with, but it is risky to skip any of the concepts that each tool represents.
We will highlight the main concept behind each tool to make it easy for you to see what is essential in
the process.
The critical ingredient is getting off your butt and doing
something. It's as simple as that. A lot of people have ideas,
but there are few who decide to do something about them
now. Not tomorrow. Not next week. But today. The true
entrepreneur is a doer.
Nolan Bushnell, Founder of Atari Computer
Case Study: 155

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Introduction
ToolsPhase3
SelectingandTestingIdeastoMakeaDifference
3
Six Thinking Hats®
Enhancement Checklist
Testing New Ideas on a Small Scale
Return to tools from previous phases to help think
differently about any challenges you encounter in
developing and testing ideas
Final point: If you don’t follow through on a few ideas and at least test them out, then all of your effort
up to this point is really a waste. It might have been fun. It might have provided some escape from the
pressures of the job, but ideas without action have no real value. Ideas without action accomplish
nothing for the patients and the public we serve. The world belongs to those who do something. When
those who are doing something also take the time to think differently… well, that opens the door for
something really great to happen!
Fresh
Eyes
Breaking
the Rules
Random Word,
Picture or Object
Stepping
Stones
That’s
Impossible
Mental
Benchmarking
119

Tools Phase 3: 116
Tool: Harvesting by Criteria and Dot Voting
What do you mean by “Harvesting”?
You cannot implement everything that comes out of your idea generation
sessions. Harvesting is about beginning to narrow down the list in order to
identify those that deserve a bit more thinking, and perhaps a test. (Recall the
Idea FunnelI
.)
How many ideas should we select?
Try to harvest about twice as many ideas as you think you can reasonably expect
to implement. Tip: In order to identify a consensus comfort level, ask several
people what they think: “Could we implement 2-3 ideas from among the many
we have come up with? or 5? 10? 20?”.

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Harvesting by Criteria and Dot Voting121
Who should do the harvesting?
While you or the small group of people that you have involved in generating the ideas can certainly select
a few to take forward, consider that harvesting is also a good time to get more people involved in the
process. It can be done by a relatively large group of 12-20 people, or more; including organisational
leaders, people who were involved in generating some of the ideas, and several people whose opinions
are representative of key stakeholder groups.
By involving others, you are creating buy-in and increasing the commitment to at least test out a few of
the ideas. Remember, there will be many people who will be uncomfortable with these ideas simply
because they were generated by thinking differently - they do not correspond to the pre-existing mental
valleys
I
of how things ought to be done in health care.
You will need many voices in support of at least trying some ideas; so begin recruiting those voices now.
Concepts: 20

What do you mean by “Criteria”?
If you are going to make a selection among the ideas you will need some basis - or, criteria - for that
selection. You can say, “Alright then, let’s vote on the best ideas here”, but what do you mean exactly
by “best”. Best might mean best for patients and carers, most efficient use of resources, most satisfying
to staff, most likely to get the support of key stakeholders… or any number of other things. Don’t
assume that others will define “best” in the same way as you.
So, we suggest that you first give some thought to what criteria you will use for harvesting. There are a
wide variety of things that you might consider in various circumstances. There is no particular right or
wrong; the important thing is simply to be clear about how you will select ideas before you dive in.
Two broad criteria: Attractiveness and compatibility
In general, criteria for harvesting tend to fall into two broad categories…
N Attractiveness refers to an idea’s impact on external and internal stakeholders - e.g. staff, patients,
the public at large etc. In other words, will people like it?
You must define this term more explicitly for your effort, of course. Perhaps you want something
that will really be noticed and appreciated by service users… something that is especially attractive
to staff or GPs…something that brings clear benefits to the service, what ever is appropriate for
your situation.
N Compatibility refers to your assessment of your ability to implement the idea in your context. In
other words, can we do it?
You will want to stress that we ought to be stretching our thinking about what we can do;
implementing new ideas will be hard, but we ought to stretch ourselves to do it. At the same time,
we do need to be realistic and note that an idea that will require several million pounds and
fundamental breakthroughs in technology might not be something that we can tackle at this time, no
matter how creative the idea is.
Begin your harvesting effort with a discussion of these two broad categories and then discuss what
might be the most important criteria (choose 1-4) to consider when selecting ideas from among the
many generated.

Tools Phase 3: 116
Introduction
Case Study: 171
For example...
The Team 5000 redesign group that is described in the case study Thinking Differently About Delivering
Primary Care
I
, used the following criteria to harvest from among the 150 ideas generated: potential
effectiveness in delivering high-quality care; time required to implement; resources required to implement.
What if we can’t agree criteria?
Don’t get caught up disagreements at this point. Rather, simply do multiple harvests. For example,
suppose you cannot agree whether it is more important to select ideas that will really impress service
users or ideas that doctors will support. No problem. Do one harvest where you select the ideas most
likely to impress service users and a second harvest of ideas most appealing to doctors. You might find
that a few ideas appear on both lists. If so, selecting those to work on further pleases both camps. Or,
you might take the top few ideas under each criterion and in the next step of further development say
that one of the challenges is to think of ways to make the user-appealing ideas more appealing to the
doctors, and vice-versa.
Remember the Idea Funnel
I
. Harvesting is not the final selection of what will be implemented, it is just
the narrowing down of options on which more thinking and work will be done.

What do you mean by “Dot Voting”?
In dot voting, group members simply vote for some pre-determined number of ideas from the list that
they feel best meet the criteria to bring forward for further development and test.
To use the tool:
1. Prepare flip charts with the list of ideas that were previously generated. Clarify the ideas as needed as
you write them up, and eliminate or combine duplicates. Make sure the ideas are written out in a full
sentence or paragraph rather than a couple of words, which might not mean very much to most people.
2. Review the list of ideas to ensure that everyone understands each idea. Tip: If you are bringing in new
people who were not involved in the idea generation (as we strongly recommend!) you might do some
of this briefing prior to the harvesting session.
3. Agree on the number of ideas that you would like to see come out of this harvesting process for further
development. Stress that you will always have the full list to go back to later; no ideas are being
thrown away.
4. Discuss and agree the criteria that you will use to select the ideas to take forward. Tip: Review the notes
on “attractiveness” and “compatibility” on page 122.
5. Give each participant a number of “votes” roughly equal to twice as many ideas as you have agreed you
want to see come out of this process. “Votes” can be coloured dots, small post-it notes, marks with
coloured pens or anything that is small and will stick to the flip chart easily.
6. Ask participants to place their votes next to the ideas that they feel best meet the agreed criteria. Tip:
The physical interaction of doing this is part of the consensus building process. You will find clarifying
questions being asked and some “lobbying” for ideas going on. That is good!

7. Identify ideas that received votes from half or more of the group.
8. If this does not yield the desired number of ideas, repeat the vote. But this time only consider ideas that
got at least 2-3 votes in the first round; disregard the rest. Continue this process until a consensus emerges.
9. If the first round yielded more items than were desired, discuss whether to take all the ideas forward, or
which ones to hold back on for now.

Variations on this tool
There are many different ways to use the basic concept of Dot Voting. You may have your own
experience and a method that you prefer. We say, “What ever works for you.” Some popular variations,
with tips, are given below:
N Assign each person a different colour dot so that you can see who voted for which idea.
This can be helpful if you want to ensure that key stakeholders see at least one of the ideas that they
support make it through for further development. If you have invited someone to the harvesting
meeting, but none of the ideas that they voted for make it through, that might be something that you
want to discuss.
N Give everyone fewer votes, but anticipate several rounds of voting as you eliminate items
that got no (or few) votes each time round. This takes longer, but can build better consensus. As
you proceed into later rounds of voting, the list to choose from gets smaller and the chances that
everyone can see at least one of the ideas that they voted for at some point make it through increases.
N Allow a person to give an idea multiple votes. Multiple votes allow people to express strong
preferences, but has the downside that you may end up with an item that got lots of votes, but only
because 1-2 people gave it all of their votes. You could use a restriction, such as “no more than three
of your votes on one item”. Another way is to simply ask for a show of hands of who voted for each
of the winning items and see the distribution across the group.
No matter how you do it, keep these goals in mind:
N You want the process to yield a few ideas that best fit the agreed criteria.
N You want to build consensus and support among key stakeholders that will be needed as you face the
challenge of taking these ideas forward and implementing them.

Concepts: 20
Tool: Edward de Bono’s Six Thinking Hats® 3
Synopsis
This tool enables individuals or members of a group to explore an idea or topic
from a variety of perspectives, and in ways that may differ from their preferred
way of thinking. Edward de Bono, an expert on thinking and the developer of
the concept, suggests that by metaphorically wearing different hats, we can
direct our thinking in specific waysI
.
The main difficulty of thinking is confusion.
We try to do too much at once. Emotions, information,
logic, hope and creativity all crowd in on us.
It’s like juggling too many balls.
Edward de Bono, Six Thinking Hats®
, Penguin, London 2000
3
© The McQuaig Group. For more information contact: www.holstgroup.co.uk

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Edward de Bono’s Six Thinking Hats®
129
The Six Thinking Hats®
are:
Calls for…
data, facts,
and information only
feelings and intuitions only
thinking about negatives,
downsides, risks, cautions and
warnings only
thinking about positives,
optimism, benefits, and
goodness only
creativity and new ideas
attention to the big picture,
direction, and management
of thinking process
Think of…
white paper
fire and warmth
the black robes of a judge
sunshine
new growth and vegetation
the sky above or a police
officer directing traffic
Hat
White
Red
Black
Yellow
Green
Blue

Hat Comments about one-stop clinic idea
Our creative idea is to implement a one-stop clinic in a service area where this
has not yet been explored
Beneficial for patients – only need to visit the hospital on one occasion, rapid
diagnosis, coordinated care, integrated approach
Possibly too fast for patients, particularly if diagnostic tests confirm a very serious
diagnosis. Risk of ‘carve-out’ if several professionals pulled into one clinic setting
to the detriment of other services
Additional information about protocols for delivering ‘bad news’ to patients
would be useful. Capacity and demand work to understand impact on other
services. Survey of patient views…
We are anxious about how these service changes will effect us but, despite the
disadvantages, our gut response is that this will better serve our patients
Let’s form a small team to develop the idea further.
By giving each hat and the mode of thinking that it represents an equal amount of time and consideration,
we can avoid prematurely jumping to a conclusion, or making a decision with insufficient information. In
addition, ensuring the whole group uses the same “hat” at the same time increases the speed and efficiency
of the thinking process, since everyone is thinking in parallel instead of in different, conflicting modes.
For example…
Suppose that one of the ideas that a group wants to take forward after using dot voting is that of
introducing a one-stop clinic for multiple diagnostic tests. The group might further process this idea (and
all the others selected in the harvest) through a discussion using the hats as follows:

131
When to use:
As the above example illustrates, this is a particularly useful tool during or after the harvesting of creative
ideas. Six Hats thinking helps provide a well-rounded view from a variety of perspectives. A quick run
through the hats enables us to broaden our understanding of the idea, thereby helping us decide
whether the idea is feasible to take on to further development, or whether its challenges so far outweigh
the potential benefits that it can be put aside at this point with no further expenditure of time and
resources.
While the example above describes its use in a group - where, indeed it is powerful in getting everyone
thinking together, rather than debating - the Six Thinking Hats®
can be used by an individual as well.
Thinking is the ultimate human resource. Yet we can
never be satisfied with our most important skill.
No matter how good we become, we should always
want to be better.
Edward de Bono

Case study: The Black Country puts on its Thinking Hat
The Black Country Health Review, “Better by Design”, aimed to develop models of service provision that
would meet the needs of the local population and provide the basis for financial investment. The SHA,
Hospital Trusts and Primary Care Trusts wanted innovative ideas on how best to achieve this. Keen to
“keep the NHS local”, they felt it important to engage patients, professionals and the public throughout
the decision-making process and to get these differing perspectives in a meaningful way.
Public meetings and in-depth information gathering and analysis were the starting points for a wide-
ranging review of both hospital services and the interface between secondary & primary care in several
key areas.
A series of key questions were then addressed through 5 one-day seminars attended by a total
of around 500 people including clinicians, administrative staff, managers, patients, family
members and other community stakeholders.
A professional facilitator introduced participants to creative thinking techniques. De Bono’s Six
Thinking Hats®
were used as the framework for the sessions. Participants worked in mixed
groups of 8, with table facilitators, to generate ideas for future service development in response
to the key questions provided.
The table groups first focused on the Green hat – generating as many ideas as possible, without criticism
or justification. The Facilitator introduced the Random Word tool
I
to help them do this. Participants then
used each mode of thinking (“hat”) in turn to develop and evaluate the ideas they had generated: Yellow
to determine the benefits, Black to examine the drawbacks and risks, White to establish what data was
available and needed and Red to identify peoples’ gut feelings.
These thinking tools generated nearly 2000 ideas in under a week!
Tools Phase 2: 86
Random Word, Picture
or Object

133
“90% of bad decisions are errors of perception, not logic. These sessions helped iron out initial
perceptions and concentrate on contributing a range of ideas from different perspectives to be
worked through as part of a group”.
Workshop facilitator.
Use of de Bono’s Six Thinking Hats®
as a “harvesting” tool enabled the ideas generated from the sessions
to impact on the decision making process rather than just remain as ideas. A core group from the Black
Country Health Review assessed, selected and developed a shortlist of the ideas with the greatest
potential for delivery and benefit, again using the Six Hats technique.
The most significant (and unexpected) result of the cross-community idea generation sessions was a
substantial re-framing of the review itself. Having begun with a focus on how to invest in hospital-based
services, it shifted to focus on how best to co-ordinate services between primary and secondary care, and
to generate models of care that were integrated.
This shift came from a combination of gaining in-depth information on how services were currently
performing and encouraging staff and public to think differently.
The SHA, Hospital Trusts and primary Care Trusts have now used the key themes and ideas that were
produced across the idea generation sessions to develop new models of care, recommendations for
future provision of services in the Black Country and the key steps towards implementation. (For more
information see: www.dudley.nhs.uk/sites/board-papers/documents/0404/Enclosure6.PDF)
“These ideas come directly from our staff who work with patients every day and our customers
in the wider community”.
Paul Maubach, Review Project Director, Birmingham and Black Country SHA

How to use:
A. To use the Six Thinking Hats®
, someone in the group ‘puts on’ the Blue Hat as the leader of the session.
The blue hat leader explains the overall plan for flow to the group. We highly recommend the
sequence of hats in the previous example for use on harvested ideas. The main role of the leader is
then to manage the time and keep the group focussed and actively participating in the thinking
associated with just one hat at a time.
“Excuse me, we are on the yellow hat now, so only positive comments about benefits and good
points are allowed… we’ll go on to the black hat where you can bring up those cautions soon”.
B. Work through the hats in sequence. Remember that the whole group must wear or focus on the same
colour hat at the same time. De Bono suggests about four minutes per hat to keep the discussion lively,
focused and flowing.
C. Since, as Harvard Professor David Perkins points out, “most of us are better critics than we are creators”
experience in the NHS suggests that it is useful to block the critical thinking of the Black Hat initially and
instead begin with Yellow in any sequence. After a period of focussing only on the positives and benefits
of an idea, the criticisms and cautions are naturally somewhat tempered. Tip: NHS teams have found it
useful to set ground rules that balance positives and negatives; such as “spend equal time on Yellow and
Black Hat”, or “your list under Black Hat can be no longer than that under Yellow Hat.
D. Consider quickly returning to the Green Hat to further embellish the idea or to think of ways to enhance
the benefits (yellow) and reduce the drawbacks and risks (black).
E. Return to the Blue Hat for a final vote on the idea as to whether, all things now considered, it should
continue in the development process or be put aside for now.

135
Tips
N You don’t have to actually wear hats; it is only a metaphor. However, some teams in the NHS have
found it good fun to actually have a supply of inexpensive coloured caps to remind them to stay on focus.
N The Hats have natural pairings; Yellow is positive whilst Black is more negative; Red is emotion driven
whilst White is data-driven. In general, if you use one hat of a pair, you should also use the other one as
well for balance.
N All participants must “put on” the same colour Hat at the same time, and everyone should participate
equally. The idea is to think together; what Edward de Bono calls “parallel thinking”.
N Discourage people from characterising themselves as being a particular hat (“Oh, don’t worry about me
being quiet… I’m saving all my comments for when the Black Hat comes round”.) Whilst people will have
preferences and natural ways of being, we should encourage them to become more balanced in their
practice of different modes of thinking.

Tool: Enhancement Checklist
Synopsis
Edward de Bono suggests that we explore a series of questions that, in his
experience, are often not asked, nor thoroughly addressed before people press
on to test new ideas. Thinking through such issues early on, before testing an
idea, enhances the chances for success.
An idea that is developed and put into action is more
important than an idea that exists only as an idea.
Edward de Bono

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Enhancement Checklist137
Based on some of the questions suggested by de Bono, we have constructed our Enhancement Checklist
in the familiar format of a SWOT analysis. The items in the checklist direct our thinking to consider
emotional and people-related issues, the strengths and weaknesses of the idea, systems-effects and
consequences, and the need for small-scale tests and prototypes.
The Enhancement Checklist is the necessary next step after harvesting your ideas. It will help you to:
N Enhance an idea enough to make it attractive to key stakeholders whose support you need in order to
take it forward.
N Further develop an idea in order to get it to the testing stage.
N Identify any ideas that should not, at this stage, be taken any further.
Threats
N What could go wrong when we try to
implement the idea, how can we avoid
this threat?
N Who will raise objections and what
might these be, how can we modify the
idea to reduce these?
Weakness
N Think about the weak points that you
have identified in the idea, what can
you do about them?
N What weaknesses were identified after
testing and what can we do to improve
the idea?
Strengths
N How can we enhance the idea further
to increase its power or value and make
it fit our needs even better?
N How can we demonstrate its value
compared to the current system?
Opportunities
N How can we test the idea on a small
scale, learning from this to enhance the
probability of implementation?
N What new possibilities are opened up
by this idea and how can we capitalise
on that?”

How to Use It
The Enhancement Checklist is meant to be taken as a whole. Consider multiple questions at the same
time, and be prepared to re-evaluate your work on earlier questions as you go along. When you think
you are finished, go through the list one final time to make sure you have not missed anything.
The amount of time required for enhancement depends on the complexity of the idea. You might make
it through all of the questions in an hour or two on a simple idea. A more complex idea may need much
more time assigned to thinking, exploring and working with others; perhaps spread out over several
meetings or in an away day.
Finally, please note that the question about testing the idea on a small scale (in the Opportunities section
of the checklist) is so important that it bears special attention. The next section is devoted to this topic.
For example...
The six idea development teams described in the case study Award Winning Thinking Brings Better Care
to a Diverse Community
I
, used the Enhancement Checklist as their guide over several months of work
to develop the ideas further. They learned that time spent looking honestly at the items in the Weakness
and Threats section either strengthened their idea or made it clear that further investment of effort and
resources was not likely to be fruitful.
Case Study: 155

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Enhancement Checklist139
Tips
N Do not rush the work of enhancement! Many creative ideas go down in flames in the rush to try them
out before they have been thought through properly.
N Recall the Idea Funnel
I
concept and keep in mind that it is OK if the outcome of this process is to
recommend that the idea not be taken forward. Such a decision is not a failure of the process of thinking
differently; rather, it is successful outcome that indicates that you are managing appropriately the risks
inherent in new ideas. However, always maintain the bias that you are striving to take the idea forward
and it is your challenge to find ways to overcome potential objections and weak points. If the idea is not
taken forward, remember to capture the learning from the exercise - you will always learn something.
N Engage lots of people in this thinking process. You or your small team do not have to work it out alone.
For example, if you are not sure who will object and for what reasons, conduct a quick survey or focus
group rather than guessing. Test out your ideas with others by simply telling them what you are thinking
about doing and asking what they think. In the end, it would be great if, when you are finally ready to
test the idea, everyone is saying “Well, it is about time! We have been talking about this enough, let’s
give it a go!” rather than “You want to do what?!?”
Tools Phase 3: 116
Introduction

Tool: Testing New Ideas on a Small Scale
Synopsis
If you are really thinking differently, then you are coming up with ideas that are
unusual or uncommon in your environment. Therefore, you cannot know how
they will work until you actually try them out. But spending lots of
organisational resource and effort in the full implementation of an idea that
you are unsure will work is not appropriate.
In theory there is no difference between theory and
practice. In practice there is.
Jan van de Snepscheut

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Testing New Ideas on a Small Scale141
As noted in the Opportunities section of the Enhancement Checklist, we strongly suggest that you
consider carefully developing a small trial or demonstration of the idea in order to build confidence and
to work through any unexpected problems before you go to larger-scale implementation. This concept
of small-scale testing is integral to all improvement work. (see Improvement Leaders Guides:
www.institute.nhs.uk/improvementleadersguides).
Thinking Differently and the Model for Improvement
The model for improvement was designed to provide a framework for developing, testing and
implementing changes that lead to improvement. Its framework includes three key questions and then a
process for testing change ideas using Plan, Do, Study, Act (PDSA) cycles. Use of small-scale testing, such
as the PDSA cycle is a way of testing an idea by putting a change into effect on a temporary basis and
learning from its potential impact. This is quite different from the approach traditionally used in healthcare,
where new ideas are often introduced on a large scale, without sufficient development or testing.
The basics of small-scale testing:
PLAN: specify and agree the change idea to
be tested.
DO: carry out the test and measure the impact.
STUDY: review the data before and after the
change. Reflect on what was learnt.
ACT: plan the next change / test cycle or plan
for implementation.
Just following the Model for Improvement is not
enough. The tools for Thinking Differently will
ensure you have great change ideas in the first
place. First, you need to stop before you
start
I
, question and re-frame your initial issue to
help really focus on what it is you are trying to
accomplish. Then you need to generate lots of
ideas
I
in order to end up with high quality
changes to test (remember the Idea Funnel).
Act Plan
Study Do
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Model for Improvement
(For more on the Model for Improvement, see the Improvement Leaders Guide: Process Mapping, Analysis and Redesign)
Langley, Nolan et al,
The Improvement Guide:
A Practical Approach to
Enhancing Organisational
Performance, 1992.

Tips for Small-scale Testing:
Obviously, the details of how construct a small test of an idea will vary considerably based on the nature of
the idea itself. But here are some tips to get you started in your thinking:
N If the idea involves a process modification that would change things for all time …
N Can you get agreement to test it out for just a few hours, days, or a week? It would be important to
agree up front that if it doesn’t work you’ll put everything back the way it was.
For example…
In a hospital in the South East, an orthopaedic team wanted to introduce weekend physiotherapy to reduce
delays in discharge dates. They tested the idea on just two orthopaedic wards over two weekends and
monitored the results. These showed reduced length of stay for the patients involved in the test. The team
did another test cycle over the next two weekends - this time withdrawing the weekend service. The length
of stay went back up, showing that it was the service change, not other factors that had caused the initial
improvement. This provided them with the information and confidence to implement the weekend
physiotherapy service.
N If the idea would involve and impact lots of people, or various groups of people…
N Can you test it out on a subset of those people? For example, can you try it out with only a few
patients… for just a few days or a week… with only 1 or 2 doctors or other staff who would have to
become engaged?
For example…
At a hospital in south east London, one Elderly Care physician wanted to reduce routine follow-up
appointments in her Falls clinic in order to free up time to see new patients more quickly. Rather than
trying to influence others to do the same, she changed her own practice, collected data on the impact
and made run-charts available to her colleagues. When they saw the results, the other clinicians soon
followed suit.

N If the idea involves bringing in a new member of staff, or acquiring a new set of skills not currently
reflected in the existing staff…
N Can you “borrow” (or arrange a secondment for) someone with those needed skills from another area
for a short time in order to evaluate what impact this might have if you could get a permanent
position, or could re-train some existing staff.
N Could you send just one member of staff on a new training scheme offered elsewhere in order to
evaluate whether or not retraining others would really have the effect that you hope for?
N If the idea involves altering a physical space…
N Can you perhaps make temporary alterations, or provide temporary structures, for a test?
N Can you maybe create a mock up in some unused space and test it there?
N If the idea involves some new gadget or fixture…
N Could you create a mock up in cardboard, wood, or plastic that you could then use for a while to
demonstrate the idea and evaluate whether the expense of constructing something more permanent
is worth it?
For example…
A team from the NHS Institute for Innovation and Improvement, working on new ideas to reduce hospital
acquired infections, put together a “cardboard ward” to mock up changes to ward layout, signage and
fixtures. This enabled them to get a better feel for how these would work in practice and to iron out glitches
before testing them in real life.

N If the idea requires changes in IT systems or other equipment…
N Can you test the idea using a temporary computer program, or a mock-up of the functionality in some
commonly available program such as a word processor or spreadsheet?
N Could you demonstrate the new IT system with a paper-based system that could be automated as a
later development effort (taking into account that the paper based system for the test will obviously
be less efficient than the proposed automated system)?
N Can you borrow a needed piece of equipment from a supplier? They are usually quite anxious to be
able to demonstrate what their equipment can do.
N Can you create a mock up of the equipment that is sufficient to show how the idea would work if
only you could acquire the real equipment?
For example….
Some of the wards in a hospital in North Devon
needed immediate data on length of stay,
admissions and discharge in order to test out a
new tool they had developed to predict discharge
dates and so reduce delays. Faced with a
complicated IT system that did not seem able to
provide real-time information in the way they
needed it, an improvement advisor handed out
graph paper and pencils and showed staff how to
“plot the dot”. Soon, ward staff were recording
their own run charts and were able to use the data
to test their Predictor Tool while the IT department
worked on being able to get computer generated
information to them more quickly.

We can make our clinical results much, much better,
simply by believing that we can, and then trying
something, measuring it and learning from that.
Laurence Wood, Consultant Obstetrician, Coventry & Warwickshire Hospitals NHS Trust

The goals of testing your ideas on a small scale are:
(1) To create some confidence and momentum for the idea, if it really is a good one…
(2) To learn more about the idea so that you can further enhance it, or…
(3) To evaluate and eliminate the idea from further development without a major investment of
resources, if it turns out not to be such a great idea after all.
Key Point: The measure of the success for a test is whether or not you learned something. The test is
successful even if the idea itself fails, as long as you learn something. The only “failure” is a failure to learn.
I have not failed, I have merely found ten thousand
ways that won’t work.
Thomas Edison, inventor of the light bulb

Remember, if your idea has reached this far in the process it has already been subject to lots of critical
thinking, perhaps by many people… and it was judged to “look good enough on paper” to give it a go.
No one has a perfect crystal ball to see the future. There will always been unforeseen effects and
unintended consequences, when you are really pushing the envelope in thinking. If all you ever do is test
successful ideas, then you may not be thinking differently enough!
When you get a result that you expect, you have
another result; but when you get a result that you don't
expect, you have a discovery.
Frank Westheimer

Implementing Change: making your ideas a reality
So you’ve managed to think differently…. Now what??
It is not enough simply to have creative ideas. Ideas alone do not really change
anything. Innovation only occurs when ideas are put into action.
To put one’s ideas into action is the most difficult thing
in the world.
Goethe

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Implementing Change: making your ideas a reality149
Implementing an idea takes more than good intentions; it requires change management skills. There
is a vast literature about the implementation of change, and an important subset of that literature deals
directly with the implementation of highly innovative change. Although the focus of this guide is on the
steps before implementation – reframing the issue, generating, selecting and testing ideas - it might also
be helpful to consider some of the key points that appear repeatedly in the literature on change
management.
Keep these in mind as you think about how you will bring your ideas to fruition and make the changes stick:
N Effective change is born of a sense of urgency. You need to create or increase urgency.
N Amid the excitement you feel for your new ideas, do not forget to think about others who are not so
close to it. You will need to address the “why should I support this?” question for those who will
participate in testing or implementing the change.
N Whilst thinking differently often requires that we escape the organisation’s structure and rules,
implementing new ideas requires that we engage the organisation’s structures, processes and rules, at
least enough to gain permission to try something radically different.
N Every idea needs a guiding coalition (a group of champions or sponsors) whose members are wide-
ranging and influential enough to help with necessary resources, including participation by others.
N Be prepared for resistance in response to innovative ideas. Be patient, but focus on trying out something
new. Prototypes and small-scale tests, where others can see the impact of the new idea, often help as
people see that their worst fears are unfounded and that there are some benefits that they had not fully
appreciated.
N If you cannot state the idea clearly and compellingly in 5 minutes or less, you are not ready to proceed
into implementation.
N Over communicate. You are ready to implement only when people start saying to you “Enough talk
already, when are we going to do it?!?”
N Use feedback to keep the change on track. Information and feedback are important to ensure people
know how the change is making a difference.
N Implementation of innovative ideas is frightening to many. Leaders have the responsibility for leading the
way by their own actions in supporting and implementing new ideas.

And the journey doesn’t stop there. Once you have turned your ideas into reality and implemented the
necessary changes, you will need to continue to evaluate and re-focus. Inevitably, a change that was
innovative when implemented will, after a period of time, become part of the status quo. We see that in
healthcare and in our everyday lives: ground-breaking open heart surgery was re-thought to develop key-
hole surgery, which later brought about day case surgery; the telephone was a radical invention that
changed the face of communication… and then became part and parcel of everyday life until someone
again thought differently and the mobile phone took the technology to a totally new level.
The concepts and tools of continuous improvement (see www.institute.nhs.uk/improvementleadersguides)
will be invaluable in ensuring that your newly implemented ideas don’t become stagnant but keep
evolving. Then one day, you or someone else will stand back and ask “why do we do this at all?!”.
That’s the joy of the Thinking Differently journey: it doesn’t ever stop and so the possibilities
are endless!
How do you get your group to defy the status quo
and act on good ideas? It starts with vision, teamwork
and some fire in the belly.
Dr Jack Silversin

Tools Phase 3: Selecting and Testing Ideas to Make a Difference Implementing Change: making your ideas a reality151
Some Final Words…
This book is designed to provide you with concepts and tools to help you to stand back from the status
quo, to re-frame everyday problems and issues, and to generate, select and test new ideas for change.
In the end… it is the extent to which we are willing to challenge the way we currently do things, to take
the time and effort to think differently and to breathe our new ideas into life that determines how great
a difference we can really make.
Whatever you can do or dream you can do, begin it.
Boldness has genius, power and magic in it.
Begin it now.
Goethe

Case studies
Practical Examples of Thinking Differently
N Award Winning Thinking Brings Better Care to a Diverse Community
The North East London experience
N Thinking Differently About Delivering Primary Care
An example from the United States
N Mission Impossible? Or Just Another Mountain to Climb
Learning from Luton and Dunstable NHS Foundation Trust
Case Studies153
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Case Studies
The following case studies are included to help you see the process of Thinking Differently in practice
within three different healthcare settings.
Each example will take you through the whole process, from the focus on specific issues, challenges or
situations, to re-framing these issues (stop before you start
I
) through generating lots of ideas
I
,
and on to selecting and testing
I
some of those ideas for implementation.
As you work through and apply the Thinking Differently process to your own context and your own
issues, we encourage you to document the journey. This will help you to keep a record of the different
tools and approaches you tried, what worked well, what you learned from the experience and what you
would do differently next time. We also hope that it will encourage you to share your stories and
experiences with us so that we can build a wider cadre of case studies and help others within the
healthcare community to be more effective on their journey of Thinking Differently.
Case Studies
Case Studies171
Case Studies
Tools Phase 1: 33
Tools Phase 2: 63
Tools Phase 3: 113
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Case Studies155
TD_07_CS_LONDON 12/9/07 8:39 am Page 1

Award Winning Thinking Provides Better Care in a Highly Diverse Community
We wanted to see if we could do something to break
the mould rather than just incremental change.
Stephen Langford, Executive Director of Service Transformation, North East London SHA
Health care is typically organised to provide services during ‘normal office hours’. Patients seeking to access
services ‘out of hours’ can often experience delays and poor co-ordination of services. Such was the case in
North East London in 2003 when the chief executives of the various Trusts and the SHA commissioned the
Service Transformation, Redesign and Innovation Project (STRIP) to bring about improvements.
A small steering group consisting of SHA leaders and several key individuals from primary care and acute
Trusts met in mid-2003 to work out a two-pronged strategy. This first involved putting together an
inventory of the many initiatives already underway in order to join these up into a better, more coherent
plan. While there was a sense that many good things were happening that would certainly make a
difference, the leaders also felt a need to initiate work on a second prong: thinking differently. They
envisioned this evolving over five phases to create some new approaches to the issue of out-of-hours care
that could be added to the existing suite of initiatives.
Phase
Scoping
Fact gathering
Idea generation
Idea testing and
development
Implementing
new systems
Deliverables
Theme, goals, targets; match
with priorities; key stakeholders
to involve
Data, facts, answers to key
questions that key stakeholders
will raise
Lots of ideas
Successful efforts that can be spread
across the patch; lessons learned
Real, measurable and sustained
change that benefits both
patients and staff
Who and How
Small planning team
Small planning group, with lots of
stakeholder input
Large group (100-120) of stakeholders
across the whole system
Multiple small teams in pilot sites
Multiple organisations across the patch
Case Studies
The North East London Experience
157

The first two phases of the effort involved data collection to describe the magnitude and specifics of the
problems and to collect the views of key stakeholders. This naturally began, as it often does, as a
somewhat internally focused exercise within the health service - looking at data on A&E waits, speaking
with clinical and managerial leaders, and so on - when it was noted that Others’ Points of View might
be a useful approach to add. Specifically, what did the care system look like to service users, both during
‘normal business hours’ and ‘out of hours’? If the aim of the initiative was to help think the unthinkable
and generate new ideas that were a departure from usual thinking and practice, then who better to
question what we do and how we do it than the very people those systems are supposed to provide for?
It was powerful right from the beginning having
patients involved. Some things were contentious but it
was difficult for people to argue against when faced
with “this is what patients have told us they want”.
Stephen Langford, North East London SHA
The planning team commissioned someone to speak to members of the public and interview patients
who had turned up at A&E outside normal GP surgery hours to collect their experiences and stories.
Innovation experts point out that such efforts to Pause, Notice and Observe often yield fresh insights
into chronic problems, and it turned out that this was the case here as well. Northeast London is one of
the most culturally diverse areas in all of Europe. Mental models about health care services and how to
access them are highly variable and the experiences of different cultural groups in trying to access the
same services can vary tremendously.

The planning team saw that all of the data - the analytical facts as well as the stories of patient
experiences - could feed into the design of an idea generation session that they envisioned as the third
phase of the effort.
The culmination of the planning was a day-long event at the Excel Centre in London involving over 120
people from various disciplines and organisations across the patch, individuals from the voluntary sector,
and a dozen service users from the community.
The SHA chief executive kicked off the day with a welcome, followed by a presentation from a national
expert about the out-of-hours service delivery problem in North East London and across the country. The
speaker challenged the group to bring some new thinking to the problem. The workshop facilitator then
presented the concepts of mental valleys; first- and second-order thinking; attention, escape and movement;
different modes of thinking (Six Thinking Hats); and divergent/convergent thinking as a lead-in to a series of
interactive table exercises that would encompass the rest of the day.
The first exercise involved the Fresh Eyes tool and utilised the Others’ Point of View material collected
in the stories of patients’ experiences. Table groups were randomly assigned to read two patient stories
and asked to come up with ideas for new ways of working that might have improved the experience of
accessing care. Starting off with this exercise, and having real patients in the table groups, served to
centre the entire day around the patient.
Subsequent rounds of idea generation used the Breaking the Rules, That’s Impossible, and Stepping
Stones tools. For example, the Stepping Stones provocations included:
• A very selective virus has incapacitated all GPs in London. Now what!?!
• All our A&Es have been declared unsafe to occupy. Now what!?!
• It is illegal to have more than 10 patients in A&E queuing. Now what!?!
In each round, one person at the table captured each idea generated on a large sticky note. These were
collected as the discussion went along by roving facilitators who grouped similar items and organised the
ideas into themes on the wall along a corridor. Around 180 unique ideas were generated in only two hours!
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The idea generation during the morning clearly represented divergent thinking. So, the afternoon was
naturally devoted to convergent thinking that would begin to select ideas to take forward.
During the lunch break, each participant was given 8 sticky dots and asked to browse the ideas posted on
the corridor wall. The Harvesting Criteria to be used to conduct this Dot Voting were summarised in
the following instructions to the group:
• Use your dots to vote for what you consider to be the “best” ideas
• Best in sense of delivering service to patients and in helping staff do the work
• Don’t worry about cost or technical feasibility (that will come in later analysis and
idea development)
• You can use your dots as you wish (e.g., all 8 on one idea; 4 each on two ideas; 3 on one,
2 on another, 1 each on three others; etc.)

This led to the selection of 11 ideas (the top vote getters), which were summarised aloud for the group
and then each assigned to two tables for further discussion. Table groups were first asked to develop the
idea a bit more by focusing on questions from the weaknesses, opportunities, and threats sections of the
Enhancement Checklist. Following this shoring up of the weak points and imagining how the idea
might be tested on a small scale, groups were next asked to take the idea through the Six Thinking
Hats®
sequence of yellow (positives), black (negatives), white (data), and red (feelings). In the end, the
table groups expressed overall positive feelings about 8 of the 11 ideas and suggested that laying aside
the other 3 as having too many challenges to overcome at this point.
The day ended with expressions of thanks from senior leaders and an evaluation, which was positive.
All of the ideas and notes from the day were typed up for further review.
Several days later, a few members of the planning group met to reflect on the day and decide how to
package the output for a presentation back to the chief executives who had originally commissioned the
work. Some of the original 8 ideas were combined to yield 6 ideas, which were then documented on a
five-part proforma:
1. A headline: something that captures the essence of the idea in an intriguing way.
2. The idea: crisply stated in attractive language in just a sentence or two.
3. This allows us to…: capture how this idea linked up with other key concepts that the decision
makers would be familiar with.
4. Why we like this idea…: a list of key benefits, (yellow-hat thinking), as we believe that black-hat
thinking will come naturally without listing it.
5. How we might trial it…: a brief description of how the idea might be tested on a very small scale
with willing participants, to make it feel more do-able initially.
An example of one of these proformas is overleaf:
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Creating a pool of Service Access Guides from within a community
Idea:
To create a cadre of people from within existing ethnic minority communities, in order to
signpost the way for patients to access services more appropriately, to meet their special needs.
This allows us to:
• Bridge language or cultural barriers that prevent patients from knowing how
to access services
• Relieve current bottlenecks in the system that result from misinformation about how
to access services
• Engage the community itself in defining how it wishes to use services
• Get more focussed input from the community about their experience of accessing services.
Why we like this idea:
• Consistent with the direction of public involvement, patient choice and patient
centred care
• Potentially relieves the demand for translator services
• Builds empowerment rather than dependency
• Can be flexibly adapted to all sorts of 'communities' and is easily replicable
• Utilises existing communication channels with existing communities rather than
expensive marketing and PR campaigns
• It allows a wider range of people to signpost ways of accessing care.
How we might pilot:
Pick two specific communities who have specific health needs and find it difficult to access
services because of major language or cultural barriers.
These one page proformas were presented to the chief executives at their next meeting. They agreed to
charter teams to take all 6 of the ideas forward into the next phase of the effort involving further
development and testing. The six ideas described below illustrate the richness and creativity of the
discussion in the all-day event. Clearly, participants were thinking differently.

Insight: It was useful to have a small group of pragmatic leaders to take the free-flowing output
of the idea generation day and repackage the ideas to make them more “marketable” to senior
decision makers for the next step in the process.
Synopsis of the Ideas Taken Forward:
1. Fulfiling the needs by meeting the demand for convenient care
Idea: Offer GP surgery services (including minor emergency, chronic disease management and
rotating specialist clinics) 8am to 8pm, 7 days a week
2. Creating a pool of Service Access Guides from within a community
Idea: Create a cadre of people from within existing ethnic minority communities, in order to
signpost the way for patients to access services more appropriately, to meet their special needs
3. Pills on wheels around the clock
Idea: Partner with private sector companies for the provision and delivery of pharmacy services
24 hours a day, 7 days a week
4. Allowing the patient to become their own gatekeeper, creating an NHS ‘frequent flyer’ club
Idea: Many patients have recognised and legitimate continuing needs for specific services. For
these patients the normal gatekeeper role is a bottleneck that doesn’t add value; create a “club”
that allows direct access to required services
5. Creating capacity while working when you want
Idea: Create pioneering examples of professionals who work non-traditional schedules but have
high career satisfaction and work / life balance
6. Health Mall - A one stop shop for all your healthcare needs
Idea: Expand and extend the current trend of Walk-in-Centres by placing them in highly visible,
easily accessible, high traffic areas of the community; offer extended hours comparable to
commercial shopping; expand the range of services located in them
A champion and a small team of 3-10 people were identified for each idea. These groups met together
twice over a 12-month period to share experiences and to receive additional guidance on project planning
and testing on a small scale. Senior executives and several non-executive SHA board members attended
these sessions to lend further support to the effort.

Understanding What Constitutes Success in the Journey of Thinking Differently
It is instructive to note that over the testing and development period, two ideas were abandoned, two
were subsumed under other initiatives, and two went on to broader implementation. In terms of the
process of thinking differently, all were successful in that something was learned from each.
The “pills on wheels” project was discontinued mainly because of the context in which it was proposed.
The basic idea come from the difficulty of developing certain patient services within the framework of the
existing pharmacy contract, and was therefore hard to promote as it became clear that these constraints
would in effect be removed by the new Pharmacy contract from April 2005.
The “creating capacity while working when you want” project was also affected by a change in context.
With the implementation of the national ‘Agenda for Change’ programme this proposed local change in
working terms and conditions for a small group NHS employees was perceived as working against rather
than with the national grain. Further, the project lacked support among the professional groups that
would be responsible for testing and implementing key areas of the concept.
Lessons learned: New ideas depend heavily on the context in which they are introduced, the presence
of a sense that the problem is big enough to warrant the effort of trying something radically different,
and the active support of key stakeholders. Sometimes an idea can be a good idea, but just not in the
current context.
The “health malls” project was overtaken by similar concepts within the programme for Community
Walk-in-Centres. In essence, one could say that the project proceeded, but with different sponsorship.
The “frequent flyers” project likewise found a new home under different sponsorship within the North
East London Long Term Conditions Collaborative, where its scope narrowed to a focus on home
monitoring of patients.
Lessons learned: One path for new ideas might be to join them up with other initiatives where they
can gain access to other sponsors and resource pools. In the change management literature, this has
been referred to as “having your idea board a train that is already pulling out of the station”. As in
rearing children, sometimes the best thing is to let them go off on their own!

The “Fulfiling the needs by meeting the demand for convenient care” project group focused on
developing knowledge resources to enable GP practices to successfully maintain opening hours of 8am to
8pm, seven days a week. (The project was actually re-branded as the ‘8 till 8’ initiative.) The development
team demonstrated that this could be accomplished principally by increasing the practice list size to make
full use of the infrastructure already available, and by revising and restructuring their staff working hours
as a team. The idea champion presented the case for this to all the PCTs and waited for volunteers to step
forward to trial it.
Two practices offered to engage as pilot sites and the development team led them through the process via
a series of away-days and on-site coaching. In the first three months of the pilot test, the two practices
had generated an additional 2,200 GP consultation and 3,200 nurse consultation slots. Nearly 4,000
additional patients had been seen – over 2,500 of these were likely to have been seeking appointments
with out-of-hours providers, either through the GP out-of-hours service or at an A&E department. The
success of these pilots has led to more practices stepping forward to implement the ideas.
Lessons learned: Often, one of the biggest barriers to initially implementing an idea that results from
thinking differently is the willingness to take a risk, when lacking the evidence to know that it will work.
Volunteers signal that they have already overcome this barrier and are willing to embrace the idea
based on the strength of the theoretical case alone. Rather than expending energy trying to get
“buy in” from everyone, use these volunteers as co-developers to work out the details of the idea and
collect the data to support an evaluation. If the results are positive, the numbers will speak for
themselves and others will come along. If the results of these small test don’t turn out as you
expected, that is good too, as you will have avoided massive disruption. It is all part of the process of
thinking differently.
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Award Winning New Thinking
The final project of the six revolved around the idea of creating a cadre of people from within existing
ethnic minority communities to signpost the way for patients to access more appropriately the services
they need to meet their special needs. This project, renamed as “The Health Guides Project”, won the
Regional Health & Social Care Award (‘Improving health and reducing health inequalities’ category) for
2005 and was a finalist for the National Awards.
Guiding for Health
North East London has a high proportion of ethnic minority groups, and a growing range of
these communities are “excluded” from mainstream society and services, partly due to language
barriers (there are 200 different languages within the local population) and partly from a lack of
engagement with and understanding of ethnic minority communities. The result for thousands
of people, many of whom have long term conditions or disabilities, is difficulty in accessing the
services and care they need, thus exacerbating local inequalities in health and reducing the
effectiveness of the resources available for the local population.
The Health Guides project has been a collaboration between the local NHS, a voluntary
organisation - Social Action for Health, and local communities which aims to address the issues
and health consequences of the social exclusion.
Aims of the Health Guides projects include:
• Facilitating own-language access for excluded people to information and guidance about
health services
• Promoting understanding and awareness of self care and self management
• Reducing health inequalities
• Increasing the effectiveness of NHS resource use
• Engaging more effectively with and empowering excluded communities.
Health Guides are… local people from a growing range of excluded local communities (such as
Bengali, Somali, Congolese, Caribbean and Kurdish), trained and supported by NHS project
workers to help others in their communities to improve their health and access local services.

A Health Guide…
• Runs community based, own language group sessions to address health issues and concerns
• Represents local people and feeds back to health and social care organisations
• Guides patients in accessing services
• Promotes health and well-being
• Enables people to take a stronger role in managing their own condition.
Benefits from the project include:
• A more confident and better informed patient population
• Broader and deeper social networks within and across excluded communities
• Local mechanisms for representation of excluded groups
• Better informed local service provision
• Helping people access the care they need
• Greater involvement of isolated and minority communities.
There have also been some unexpected spin-offs. For example, the project has created new
access to employment opportunities for community members who have trained as health guides.
In fact, 50% of the original 75 people trained secured work within 6 months. This has the dual
benefit of ending long-term unemployment for many individuals and of widening participation
from excluded communities in the local work force.
Due to the enormous response to the original posts advertised, the initiative has been rolled out
more widely and now also includes mental health service users. The level of community
involvement in the Health Guides project and the range of people involved is a key highlight for
local healthcare leaders.
It is tapping a very rich vein of community interest in
health in a way not done before.
Stephen Langford, North East London SHA

Some Final Reflection on the Process of Thinking Differently
The North East London “Out-of-Hours” initiative is a wonderful example of the entire process that
unfolds when we choose to think differently. Let’s recap some of the key points…
• Thinking differently has its place alongside existing initiatives. It can complement these efforts and
be “in addition to”. There is no need to debate “either we continue to think as we always have, or
we think differently”. Rather, we can say, “Yes, let’s keep doing all the good things that our current
thinking tells us we should do… AND let’s also do a bit of new thinking as well”.
• The case illustrates the importance of thinking a bit before diving into idea generation. The refocus
on patient experiences, the deliberate collection of their stories, and the effort to plan for active
involvement of service users in the idea generation event clearly changed the course of what might
have evolved otherwise.
• The process naturally proceeded along the lines suggested by the Idea Funnel. Let’s see… 180 ideas
generated, 11 initially harvested, 6 taken forward for development, 4 actually field tested, and 2
now more widely implemented. If you refer back to the illustration of the Idea Funnel you will see
that these numbers track the general experience pretty well. The ideas that did not make it all the
way through to final implementation are not failures nor wastes of effort; they are simply part of
the natural process of thinking differently.
The way to get good ideas is to get lots of ideas and
throw the bad ones away.
Linus Pauling, Nobel Prize winning chemist
• Finally, the case illustrates the point that simply having a brainstorming session is not enough when
it comes to thinking differently. Generating the ideas is actually the easiest part. The hard part -
and clearly most important part - comes after that and involves the courage and conviction to stick
with it to see some of the ideas through to implementation.

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How Can a Primary Care Doctor Be Expected to Cope With a Three-Fold Increase
in Number of Patients?
The Virginia Mason Medical Centre, a hospital and primary care delivery system in Seattle in the US, faces
financial pressures from declining revenue streams associated with the on-going issues of health care
funding in the States. Projections by the finance department suggested that primary care operations
would run massive deficits unless the status quo assumption regarding the number of patients on a
primary care doctor’s list was challenged.
Primary care lists in the US normally range from 1200-1500 patients per doctor (they are called “panel
sizes” in the US and this ratio of patients-to-doctor is about the same in the UK). Without getting too
deep into the details of US health care funding, suffice it to say that total annual revenues into a primary
care practice is roughly correlated to the size of the list. That is, in order to double revenues, the practice
would need to roughly double its list. But if delivering care to twice as many patients using the current
thinking means that twice as many doctors, staff, and facilities are required, the net result would still be
financial shortfall.
Clearly, this presented the need for thinking differently!
The organisation is heavily engaged in using “lean thinking” - a concept adapted from general industry
that emphasises attention to flow in all processes, and the dramatic reduction of waste of all kinds. In
additional to using this new thinking borrowed from other industries to help increase efficiency, senior
leaders recognised that they needed some fundamentally new models for primary care delivery. So, they
asked the organisation’s Innovation Centre to help design workshops for groups of staff to generate new
ideas. The Centre’s director, along with an outside consultant who had been appointed as chair of the
Centre, used a process similar to the one outlined in this Guide.
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Stop, before you start
The Innovation Centre director worked with executive and operational sponsors through a series of four
planning meetings to clarify the problem and identify the desired output of an idea generation event to
bring together clinicians, front-line staff and leaders to brainstorm.
They recognised that they would get little buy-in - and might even get open hostility - if the initiative was
framed solely as a “work harder, be more productive” dictate. Instead, the sponsors assembled
background information on trends that were clearly in progress, but that also were clearly beyond the
organisation’s ability to do anything about except to find ways to adapt that would be good for both
patients and staff. Quality of care, effectiveness and safety were brought front and centre in briefing
documents and presentations. Sponsors also took the time to engage opinion leaders throughout the
organisation in dialogue about the situation in order to identify champions and gauge potential readiness
to think differently.
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In short, rather than rushing directly into idea generation, they took two months to carefully build the
compelling case for the need for some new thinking. While one can only imagine how it might have
gone had they not done this, as you will see, when the session with front-line clinicians and staff was
finally held, assumption-busting ideas flowed quickly and easily.
Over the course of these planning meetings and conversations, the following ‘We want to think
creatively about (WWTTCA)…’ statement emerged:
WWTTCA… How to develop a health care delivery model that delivers high-quality care to
a 5000 patient panel, without increasing the direct patient care resources needed.
The somewhat arbitrary goal of 5000 patients was selected on the basis that it would satisfy financial
needs under most projections about future payment schemes, it was a nice round number, and it clearly
signalled a need for radically new thinking (i.e., it is not simply a 10-20% workload increase over present,
but 3-4 times the workload!). Innovation research has shown that declaring such “stretch goals” often
stimulate more creative thinking than the more usual “let’s be reasonable” targets. The effort was
dubbed “Team 5000” and this provided a simple, engaging message to spread throughout the
organisation to start everyone thinking about how things might be different.
About 40 people representing a cross-section of clinicians, staff, managers, key opinion leaders, and
individuals who were seen as naturally creative thinkers were asked to mark their diaries for a future away-
day, and to attend a 1-hour preparatory meeting to learn more. The preparatory meeting featured a
concise presentation by senior clinicians and executives of the compelling reasons for new thinking;
summarised as “the 10 myths of primary care”. This was followed by examples from the organisation itself
that reminded participants of small-scale innovations that had successfully challenged current thinking in
the past. The idea was to create both the feelings of “we must do this” and “we can do this” among the
participants. Sponsors also saw this short meeting as a way to gauge readiness to think differently prior to
the investment in a longer away-day.
Insight: This is a great example of how leaders can manage the risks and uncertainties naturally
associated with thinking differently.
Questions were challenging, but appropriate and positive, and several clinicians and opinion-leaders who
had had the opportunity to mull things over following their previous conversations with sponsors offered
supportive comments. This preparatory meeting was videotaped and copies were sent to any invitees who
were not able to attend.
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The final 10 minutes of the meeting featured a quick explanation of the concept of mental valleys and a
request for participants to do some Pause, Notice and Observe and Mental Benchmarking prior to
the away-day (see box).
Exercise to be completed prior to the upcoming away-day for Team 5000…
Please pause and notice during next two weeks an industry that went from a low volume model to
a high volume model, or high per unit cost to low per unit cost, and note what changes in their
model made them successful. You will be given the opportunity to report back at away-day.
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The away-day began with kick off comments, introductions, and a brief recap of the background
information. Participants then broke into table groups to discuss the Pause, Notice, and Observe
(or Mental Benchmarking) exercise and report key findings. Based on past experience with away-day
pre-meeting exercises where only a handful of people actually do the exercise, the facilitators hoped
nervously that at least 1-2 people per group might have done the work in advance and that would be
enough to stimulate others to add additional examples spontaneously. In fact, many participants pulled
out notes and magazine articles that they had brought with them to describe their insights from other
industries that had faced similar challenges. This was a pleasing result that reassured the sponsors that
the two months of effort in preparing for the brainstorming session had indeed been a good investment.
There was a high level of engagement and openness to new ideas. An example of one of the seven main
themes that emerged from the report back was:
Consider self-service as service
• Train the customer to do the basics; e.g., pump your own petrol, check in yourself for the airline,
scan your own groceries
• Customer manages and sorts their own information
• Security that allows the customer to self-manage even very sensitive information 24 x 7 x 365;
e.g., bank account
• Make self-service a desirable “want”
As the groups reported back, two facilitators wrote ideas on sticky notes and posted them on a blank
wall. This allowed the facilitators to introduce what they called the “Wall Mart of Ideas”. This is
humourous play on the name of a retail superstore chain in the US and created the image of a place
where one could go “shopping” for ideas later in the session (we will say more about this momentarily).
The facilitators then divided the group into 6 multi-disciplinary teams of approximately 7 participants each
for several rounds of idea generation. After a short presentation about mental valleys; the principles of
attention, escape and movement; convergent and divergent thinking; and the rules for idea generation,
each team was handed a card to guide them through a specific tool for thinking differently. Example of
tools and idea generation exercises are described in the table overleaf.
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Tool to stimulate
Reframing by Wordplay
Fresh Eyes
Stepping Stones
That’s Impossible
Example of specific instructions given to a team
Take each word in the “We want to think creatively about (WWTTCA)…”
statement and talk about all its possible meaning and connotations. Using
these alternative words to trigger your thinking, capture new ideas for
how we might handle a panel size of 5000 patients.
If you gave a team of movie theatre managers the task of delivery
healthcare to 5,000 patient panels, how would they go about it?
How would you provide primary care without doctors - they have been
banned by law.
How would a care team with only one doctor provide care for a list of
15,000 patients!
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In each of three rounds, each team generated 10-30 ideas. At the end of each round, teams were asked
to choose the top two or three ideas in several categories that the sponsors wished to highlight—for
example: most innovative, ideas that emphasise team delivery of care, new ways to access care, and so
on. Top ideas were written on post-it notes and added to the Wall Mart (an idea could be selected in
multiple categories). In this way, each round combined both divergent thinking (via the idea generation
exercise) and convergent thinking (via the harvesting criteria).
As the teams worked, the facilitators and sponsors organised the Wall Mart by grouping similar ideas
under themes, eliminating duplicates, and going back to teams to clarify what they had written so that
the ideas would be understandable to anyone who read them. In the end, the Wall Mart contained
around 150 ideas. And that was just the morning’s work at the away-day!
Insight: With proper preparation and some tools, front-line clinicians and staff are quite capable of
thinking differently about the challenges they face.
In the afternoon, new teams were formed and given 90 minutes to “go shopping at the Wall Mart”
in order to design an overall model of high-quality primary care for 5000 patients, using the ideas
generated in the morning as elements. Teams then gave 3-minute reports, which were videotaped
to allow details to be captured later. An excerpt from one of the reports is provided on the next pages.
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The Motorway to Health
The basic concept for this model is a motorway - lots of lanes, with each lane having a different
importance or function.
The model starts by assuming that the system is very patient-centred and self-care oriented.
The main lane on the highway is self-care. While travelling down the motorway lane of self-care, it
may be necessary to move into another lane temporarily for acute care, or hospitalisation, but
eventually the goal is for the patient to return to the main lane of self-care.
The key point is to ensure that the patient can get easily and safely from lane to lane – that is, from
one type of care to another. By the way, the term self-care in this model implies that the patient has
access to his or her own portable medical record, and all manner of health care information.
As the patient needs to access other types of care they might move into the “team care” lane. Here,
care would be provided by a doctor-led team. The patient will not necessarily see the doctor at each
visit, but only as needed. It would be important that the doctor, by his or her behaviour, transfer
credibility and trust onto the various members of the team so that the patients always felt that they
were in the best of hands.
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As a patient moves through the system, for example, with a chronic disease such as
hypertension, the patient might move into the “credentialed patient” lane. Here, the patient
receives training and a sort of “certification” that allow him or her to do some health care items
themselves, such as order their own lab tests (haemoglobin A1c levels if they are diabetic, or
basic metabolic profile if they are hypertensive).
The patient would move in and out of self-care, team care, and credentialed patient lanes on
the motorway of health as they go along their journey.
Another concept in our model was the “community care” lane. For example, one aspect of
community care might be the elderly patient who is in and out of the hospital with heart failure.
A family member or friend who takes on the role of care giver can become credentialed by the
primary care practice to do a variety of checks and report results into the practice. Another
aspect of this lane on the motorway might be establishing community clubs (for example,
diabetes support groups) that meet and are supported with knowledge resources by the
practice.
In summary, the idea is that of dipping in and out of various types of care as needed, with the
real drive - the main lane on the motorway - for the patient being self-care.
Insight: Allowing the teams to concentrate on designing their models and embellish verbally, rather
then having to fuss over capturing details on flip charts, made the group work lively and kept the
creative side of the brain, rather than the analytical, more fully engaged.
After all the reports, each team did a Six Thinking Hats®
exercise on their model to identify both positive
points and issues or barriers that would need to be addressed in taking them forward. Sponsors offered
final comments and thanked everyone for a good session. Evaluations of the session were very positive,
with several participants commenting that they now thought it was entirely possible to get to the goal of
5000 patients per doctor.
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The facilitators and sponsors met the following day to review the output of the session and begin the
process of planning next steps. A review of the videotaped reports identified nine general themes
and several ideas that were repeatedly selected by the various teams in their models (an indication of
a potential high level of acceptance and readiness to test these ideas if they were to be taken forward).
The leadership group constructed a high-level model by combining the best elements from the various
reports, identified three sites that had come forward to serve as test sites for some of the ideas, and
selected two physicians to champion the next phase of the work. Following the meeting, the facilitators
compiled all the ideas generated into an “idea notebook” that was 42 pages long - it had indeed been
a productive day!
The two physician champions worked with the facilitators, sponsors, and pilot sites over the next several
weeks to clarify the overall model and further harvest specific ideas to test. The main harvesting criteria
that emerged from these discussions were:
• potential effectiveness in delivering high-quality care for 5000 patients
• time required to implement
• resources required to implement
A total of 43 ideas were identified and put into four categories:
• Foundational elements:
ideas and processes that need to be in place first in order to support the more innovative elements
of the model
• Tier One:
Ideas to be tested immediately
• Tier Two:
Later, medium-range ideas to be tested over the next 6-18 months
• Tier Three:
Future developments requiring significant resources.
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The facilitators developed a table on one side of paper that captured the 43 ideas and could serve as a
“traffic-light system” for the three pilot sites. A green dot would indicate that the idea had been fully
tested and implemented, a yellow dot would indicate that the idea was currently under test, and a red
dot would indicate that the idea was not yet planned for testing. This simple table became an on-going
reporting vehicle for the project and was reviewed frequently by the sponsors, champions, and facilitators,
in concert with the teams at each pilot site. The facilitators also worked with each of the sites to coach
them through the concepts described in the section in this Guide on Testing New Ideas on a Small
Scale.
At the time of this writing, this is a work in progress. The pilot site teams have met for another away-day
one year on from the original one to share progress. During the session, additional ideas were generated
by the use of the Breaking the Rules and Stepping Stones tools focused on generating new thinking
on some of the challenges that the pilot sites reported were holding them back from even more progress.
Insight: The tools and various stages of the process of thinking differently can be used flexibly over
time. During testing of ideas new ways to frame the original issue or entirely new ideas might
emerge - thinking differently often begets further thinking differently as individuals get more
comfortable with breaking out of what once was their comfort zone.
The teams and leadership of the organisation are confident that they are well on their way to the goal of
panel sizes of 5000 patients per primary care doctor and they are already turning attention to planning
for the spread of new ways of working to other sites, and for sustaining the gains.
(for more detail on spread and sustainability, see www.institute.nhs.uk/improvementleadersguides)
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Case Studies185
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Thinking Differently: Mission Impossible? Or just another mountain to climb!
The Luton & Dunstable NHS Foundation Trust has a history of embracing new ideas and experimenting
with different ways of thinking and working. When they weren’t chosen as one of the four pilot sites for
the experimental whole systems initiative, Pursuing Perfection, in 2002, they decided to “do it anyway”
and learn alongside the official sites. They have been involved in a range of national programmes and
collaboratives and were one of the first sites for the Safer Patients Initiative. The Trust’s commitment to
making improvement mainstream is demonstrated by its Changing the Way We Work (CWWW) team of
improvement facilitators, led by a full time Associate Director. As a consequence, many members of staff
have been involved in service improvement activities.
Fertile Ground:
There is a very strong Board-led modernisation culture throughout the Trust, and it is difficult to come
across a member of staff who does not use the current language of healthcare improvement. They have
a genuine desire to push boundaries.
Bedfordshire and Hertfordshire SHA
In 2003 the Trust joined a national pilot to test creative thinking tools and training materials in a
healthcare setting, with a view to helping teams and individuals build new thinking into their
improvement activities and optimise the potential to achieve significant change.
The expert facilitators took them through a process similar to the one described in this guide.
Case Studies Learning from Luton & Dunstable NHS Foundation Trust
187

Getting Organised to Think Differently
Leadership Team
A leadership team, formed to support the initiative, included the Chief Executive, Director of Nursing,
Director of Operations, Associate Director CWWW, and Emergency Services Collaborative Programme
Manager. The team was joined by an active patient representative along with members of the SHA and
two Primary Care Trusts, as partner organisations.
Frontline Teams
Three frontline healthcare teams came together to learn more, each chosen to think differently for a
reason and with some distinct characteristics:
Imaging: Eight members - two consultant radiologists, ward sister, receptionist, radiographer, service
redesign co-ordinator, patient representative, general practitioner.
The imaging service had a real issue with waiting times. A wait of more than six months for
MRI scanning and a traditionally hierarchical team meant that the service needed some fundamental
change and was ripe for different thinking.
Patient safety: Five core members - head of nursing practice, matron, patient safety manager, head
of quality development, doctor with expertise in reducing mortality rates. Pharmacy, theatres and
intensive therapy unit staff were also engaged in discussions.
This project brought together a group of people who were not yet a team. Newly signed up to the
Patient Safety Initiative and with a Patient Safety manager appointed but not yet started, here was an
opportunity to think differently right from the outset of the work.
Paediatrics: Six members: senior paediatric sister, two consultant paediatricians, clinical nurse
manager, booking project co-ordinator, matron.
A very inclusive, non-heirarchical team with a history of trying to improve services and strongly linked
into the Pursuing Perfection work within the trust. Learning new thinking tools would enable them
to go even further.

An initial full day workshop was run in September 2003 by expert facilitators and attended by the three
project teams, the leadership team and representatives from the partner organisations. The teams were
asked to do some preparatory process mapping to help identify some of the issues they wanted to address.
The workshop was opened by the Chief Executive who showed his own commitment to creative thinking
by playing the opening sequence to the film, “Mission Impossible”, which depicts Tom Cruise scaling an
impossible-looking mountain top! The analogy to what the teams were doing (it’s a big challenge but it
can be done) helped set high energy levels for the day.
The facilitators gave a brief overview of the evidence from other industries on why innovation – thinking
differently – is important, and showed its links with healthcare improvement work. Participants were then
introduced to the key concepts behind thinking differently: mental valleys; first- and second- order
change; the three mental processes of attention, escape and movement; different modes of thinking and
divergent / convergent thinking cycles. Participants were also given an overview of the Thinking
Differently process: framing and re-framing the issues; generating lots of ideas; harvesting, enhancing and
testing ideas.
The three teams were then asked to discuss at their tables their initial perceptions of the problems they
wanted to address. After a few minutes to jot down the seemingly obvious statements of the problems
from the traditional point of view of health professionals, teams were introduced to the Others’ Point of
View (OPV) tool and asked to restate the problems from the perspectives of service users and other staff
not represented in the team. The facilitators circled health care jargon words and phrases and asked the
teams to Reframe By Word Play to come up with more “plain language” descriptions of the problems.
After about an hour of this work, teams were instructed to select what they felt were the most
stimulating statements of the problems and to phrase these as ‘we want to think creatively about’
(WWTTCA…) statements. (See the left column in the box “Example Patient Safety Team” and note the
broad reframing of the last three examples provided there.) This generated a lot of discussion about some
of the underlying dimensions of the problems and helped teams tease out the key issues on which they
wanted to focus.
189

The rest of the day was spent by the project teams in interactive table exercises, using a variety of
divergent thinking tools to help them generate ideas relating to the issues they had identified. The teams
were asked to observe the Rules of Idea Generation - suspend judgement, accept wild and whacky
ideas, build on others’ ideas. Laughter and fun was encouraged and the teams were given the objective
of generating as many ideas as possible.
The Thinking Tools used included:
Fresh Eyes:
What ideas would someone from another sector bring? Who does that well? What advice or
ideas would they give to us?
Random Word:
Nouns chosen at random (battleship; scaffolding; market): What does it make you think of?
What ideas can we take from that to address our issues?
Stepping Stones:
Start with a wild proposition, and create solutions. E.g.: All doctors and nurses have contracted
a debilitating virus that makes them unable to work; how do we continue to provide service?
All hospital buildings have been declared unsafe to occupy; how do we continue to treat
patients? Then… Why can’t we do some or all of those things now?
Breaking the Rules:
Identify rules that govern behaviour and practice (example: all mandatory nurse training sessions
must be booked one year in advance). What would be the implications of breaking those rules?
Do we need the rules? What other approaches and solutions does this suggest?

Example: Patient Safety team
Ideas from each of the exercises were captured on post-it notes and, after each round, were added to
individual team wall charts. At the end of the idea generation session, each team did a clustering
exercise, re-organising the post-it notes to eliminate duplications and identify key themes around the
ideas. The teams had generated more than 90 new ideas by the end of the day!
We Want To Think Creatively About…
• Infection control
• Drug errors
• Mortality rates
• How we can break bad habits for everyone
• Getting the right things in the right place
• Ensuring patients are informed about
infection and help staff to prevent it
Examples of ideas generated
• Surveillance, like the police
• Team rewards for low infection rates
• Specialist lead on each ward
• Feedback following bad behaviour
• Community service; staff obliged to work in a
different area, supervised
• Control the flow, as supermarkets do with
bread always at the back of the store
• Make hand wash smell nice and moisturising
• Alcohol gel on notes trolley
• Purpose-built design to ensure right things in
right place
• Formally enrol patient as part of the team, as
market research focus groups do
• Decontamination chamber
• Red aprons for isolated patients
• Each bedside has supply which relatives and
patients use
Case Studies Learning from Luton & Dunstable NHS Foundation Trust191

In the final hour of the workshop, the facilitators presented Dot Voting, Six Thinking Hats®
, and the
Enhancement Checklist. Teams were asked to quickly select the 1 or 2 ideas that they thought they
could try immediately. These were then assessed in a quick run though of de Bono’s Six Thinking Hats
to consider the perceived benefits (yellow), drawbacks and risks (black), any information they needed to
gather (white) and their gut feelings about the idea (red). This was done to build confidence in the idea,
or to help reject it quickly, before a quick team discussion using a few of the Enhancement Checklist
questions. The leadership team then challenged the teams to go away and repeat this harvesting and
enhancing process on more of the ideas generated, communicate more widely to their clinical teams, and
try out at least one idea in the coming months.
A second workshop, four months later, re-visited the project team issues and the ideas generated at the
first workshop, along with reflections on the learning that came from the tests of the ideas selected in
the previous workshop.
The teams generated some more ideas but the main emphasis of the workshop was on convergent
thinking: selecting more ideas to go forward and enhancing those prior to testing and implementation.
Facilitators again used Six Thinking Hats®
and the Enhancement Checklist as the main tools to help
the teams do this.
This process enabled a significant number of creative ideas to be assessed, with some dropped as
inappropriate, some put ‘on hold’ for future consideration, and others developed further for testing.
This mirrored the ‘funnelling’ effect typical of innovation initiatives.

Imaging Team
The Imaging team wanted to provide a ‘delay free’ magnetic resonance imaging (MRI) diagnostic
scanning service. Several key ideas were considered for further development:
The idea of a touch screen internet kiosk with access to web-based information on MRI scanning
procedures was developed further and integrated into a mainstream service. Patients can now use the
PALS patient information screens in the hospital’s reception to access the Royal College of Radiologists
website explaining the MRI scanning procedure.
The one-stop back pain clinic with same day imaging got to the testing stage but was not implemented
as not all staff were behind the change.
This wasn’t a “failure”; the whole point of testing ideas is to identify issues and problems to work on
prior to wider implementation. The timing was not necessarily right for this idea at the time, but it may
well provide a seed that will flourish when conditions change.
Involvement in the initiative has had a wider reaching impact for the team too. Having somewhat
resented the “external” change facilitators, the Imaging department has now set up its own Change
Team and have continued to develop new ideas and test improvements themselves. Their success in
thinking and working differently has seen major reductions in waiting times. And they now play a key
role within the Trust in piloting new approaches, including a Lean Rapid Improvement event that led to
significant improvements in ultrasound services.
Ideas selected for development
• One-stop back pain clinic with same
day imaging
• Touch-screen internet kiosk giving patients
access to website information explaining the
MRI scanning procedure
• Patient self-diagnosis using photo-booth-style
and mobile MRI units
• 24-hour scanning
Anticipated benefits
• Reduced MRI waiting list
• Fewer orthopaedic outpatient appointments
• More effective resource use
• Shorter waiting time to diagnosis
• Fewer hospital visits
• Reduced patient anxiety
• Increased multi-disciplinary teamworking
193

Patient Safety Team
This group aimed to reduce hospital-acquired infections and adverse drug events. Key ideas included:
One of the initial ideas that came through selection to testing and then implementation was an
interactive CD-ROM on hand washing to help fight health care acquired infections (HCAI). The team
borrowed concepts from computer games and from the online, multiple choice theory test for UK car
drivers to help develop the idea. The CD presents a series of facts about HCAI, takes the user through
the steps of proper hand washing, provides a multiple-choice questionnaire and a “click on” hazard
perception test, and produces a certificate for the member of staff if successful. The content of the CD
has now been integrated into the Trust’s intranet and has had a high uptake from ward staff.
• Interactive CD-rom with multiple choice
questionnaire and ‘click on’ hazard
perception test
• Nominate one ward ‘where no patient will
receive a hospital acquired infection’ and
learn how to achieve this
• Boxes of gloves by every bed and hand rub
available on trolleys
• Intensive staff and patient information
• Tabs that change colour on hand washing
• Using bright orange gels
• Reduce cross-infections
• Increase staff and patient awareness
• Reduce drug errors

Another idea was to designate one ward as ‘a ward where no patient will receive a hospital acquired
infection’ and to test a series of measures to achieve this. These included boxes of gloves by every
bed, hand rubs on every trolley, intensive staff and patient information and hand gel dispensers at the
door. Uncommon in 2003, these and many other safety measures are now standard across every ward
in the Trust.
This initial work of the Patient Safety team to think differently paved the way for the ongoing success of
the Trust in the national Safer Patients Initiative.
Paediatric Team
The aim of the Paediatric team was to simplify the care pathway for children with chronic conditions,
such as asthma and diabetes. The team held an ‘appreciative inquiry’ session and listed the changes they
had implemented over the previous couple of years. These became the foundation for further ideas.
They focused on four in particular:
• 24-7 nurse-led prescribing
• dedicated paediatric consultant across
primary and secondary care
• introduction of paediatric ‘care bundles’ for
asthma and diabetes
• paperless record using patient-held ‘smart
card’ (CD or floppy disk), providing
a shortcut to an emergency care pathway
when necessary
• reduced pressure on pharmacy
• reduced number of carers returning to collect
drugs
• reduced length of time to dispense drugs
• improved linking of primary and secondary
care
• co-ordinated guidelines across several
departments, most without paediatric
specialists
• up-to-date patient information available
to patient, family and professional carers
• improved communications between all those
involved in a patient’s care
Case Studies
Learning from Luton & Dunstable NHS Foundation Trust
195

The team used the concept of the ‘bundle’ to help them work on a variety of related issues, incorporating
co-ordinated guidelines across several departments, most of which do not employ paediatric specialists.
The ‘care bundle’ identifies the key diagnostic, admission, vital signs, and discharge procedures for all
patients, giving a clear structure to care.
This gave the team a basis for further innovative changes around one of the projects on which they were
focusing for the Pursuing Perfection initiative - Childhood Asthma:
1. The team developed an integrated care pathway for children with asthma, standardising various
admission, management and discharge plans and developing information packs for children and
their families to support this.
2. Asked to test an education pack for Asthma UK, the team thought laterally about how to do this.
They chose a cohort of the children who most frequently attended hospital and identified their
care team – including family members, a variety of healthcare professionals and a school teacher
as well as the child – and trained them all in using the pack.
3. The team took the concept of “co-production” and involved school children in redesigning their
own care. Testing ideas with one school, they worked with a group of 11-14 year olds who:
- process mapped having an asthma attack at school and going to the GP about their asthma;
- wrote an asthma policy for all schools in Luton;
- developed a series of “promises to children” to help direct the Pursuing Perfection work;
- designed an information leaflet for other children on having asthma.
The team definitely got braver. They began to be more creative
and adventurous about what they might do.
Cathy Adcock, Changing The Way We Work facilitator
In a presentation on their achievements and lessons learned, the Paediatrics team answered their Chief
Executive’s “Mission Impossible” challenge with a rendition of “Ain’t No Mountain High Enough!”

197
Spin-offs from Thinking Differently
After the involvement of the three frontline teams in testing processes and tools for thinking differently,
the Trust wanted to incorporate this work into its mainstream commitment to improvement. A selection
of change agents and service improvement staff from the Trust and from some of its partner
organisations were therefore trained as facilitators in order to develop local competency in the use of
creativity tools. Members of the Changing the Way We Work Team in particular now use the Thinking
Differently tools as part of their general “toolkit” for working with frontline staff.
For Example...
Need Pain Relief? A Random Word Provides the Answer!
The pain team were stuck in a rut. They had a long-running problem of trying to reduce pre-
operative pain for their patients with fractured neck of femur (FNF). The Pain Nurse had spent
much of her time educating colleagues in a variety of departments – A&E, wards, orthopaedics –
and everyone understood and agreed that patients needed fast, effective pain relief. In practice
however, delays in providing analgesia continued, with some patients waiting up to 290 minutes
and a lot of variation in the system. The team was stuck for ideas. Previous attempts to find a
solution had always produced variations on the same theme – further education and feedback to
staff - with no consistent and sustained improvement for patients.
There was clearly a need to think differently.
One of the hospital’s Changing The Way We Work Team was asked to help. She introduced the
Random Word tool at one of their meetings to help them to generate new ideas. Using a table
of random verbs, the group played with the 5th verb on the 5th row. It happened to be the
verb “dissect”. A few ideas were thrown around but nothing really flowed so they randomly
picked another verb. This time, it was “eliminate”, a word that really got them thinking.
“Eliminate… fractured neck of femur…”
“Eliminate… box number 3 on a drug chart” (i.e. reason for not giving
patient pain relief = the patient refused; the group realised this may be due
to the way in which patients were asked about their pain).
“Eliminate… clinicians who think it’s OK not to give pain relief to a patient!”
“Eliminate… pain altogether”

The last one really resonated with the group: “Can we do that? Can we eliminate the pain?”
They discussed the method of patient controlled analgesia, which was effective for many
patients post-operatively. Could they bring it in earlier in the patient pathway to pre-operative
care? That would be a good solution for some patients, but not for a significant number of older
patients, who are confused, and for others who are cognitively impaired. In addition, the strong
opioids used sometimes cause confusion or make confusional states worse in the elderly. Was
there another solution that would work for all patients?
What would eliminate actually mean? One of the group came up with the term ‘blocking’.
“Aha! Blocking… a pain block! What about a femoral block? Or a sciatic nerve block?”
They discussed those solutions but came up with a number of drawbacks:
• there are risks involved which means both blocks can only be administered by an anaesthetist;
• anaesthetists would not always be available to do this. There would inevitably be delays,
meaning patients still in pain.
Were there any other kinds of blocks? Something that could be administered by a wider range
of clinicians? The team left the session committed to research other pain blocks and one of the
anaesthetists came up with the fascia-iliaca compartment block. This was not commonly used for
FNF and was normally administered by anaesthetists. However, it was a quick, safe procedure so
perhaps could be used more widely and by non-medical personnel...
The team tested the new block for its ease of use and its effectiveness in eliminating pain in
their patients with FNF. The benefits were clear:
• it’s effective in relieving pain in most cases (71% patients report low pain 15 minutes after
the block, rising to 83% at 24 hours)
• it works for both children and adults
• complications are uncommon and it can be used alongside other pain killers
• it lasts up to 24 hours and can be topped up so is a great option for patients with
co-morbidities that delay surgery
• it reduces the need for opioids in elderly people, therefore reduces opioid-related confusion
• it means patients can be moved for bed changes and toileting more comfortably
• it doesn’t require complex equipment
• it’s safe and easy enough for health professionals other than anaesthetists to use, therefore a
greater number of patients can benefit.
A great result from thinking differently!

Two pain nurse specialists, orthopaedic nurses and
several A&E doctors have now been trained in the
procedure, ensuring that patients are given
effective pain relief more quickly and benefit for
longer. The pain team are rolling out training to
more personnel and have continued to audit the
effects of their innovation.
199

Thinking differently has contributed enormously to the
success of the L&D over the last few years.
The techniques have helped unblock barriers and, as
importantly, the approach has supported our culture
of continuous improvement. It has also been hugely
rewarding for staff as well as patients.
Stephen Ramsden, Chief Executive
Key learning from the Luton & Dunstable experience:
• It can be difficult to predict and evaluate the benefits from an initiative like this. It cannot be seen
in isolation from other initiatives and ways of working and often takes reflection on the wider
picture to see the effects.
• Not all good ideas will get to the testing stage and fewer will make it through to implementation.
This mirrors the natural “funnelling” effect of the Thinking Differently process.
• Thinking Differently tools are a valuable addition to improvement methods. Facilitators and other
staff can be quickly trained in their use and most people engage well with the tools.
• Thinking Differently tools can stimulate and strengthen existing teams which already have a
successful track record of improvement and innovation. The fact that problems may be well-
known, and that solutions may be already under consideration, does not prevent thinking tools
from helping to generate even more innovative ideas.
• It’s important to recognise participants’ past achievements in improvement and innovative change
and to communicate that to them.

The initial reaction of the paediatric team to their involvement in the initiative was one of
anger. Their feeling was “we’ve already done lots of good things so why do we need this?”
which prompted them to pull together 3-4 sheets of paper listing all the ideas they had already
implemented.
The fact was, this was the very reason why they were being asked to get involved – they were a
well-functioning team, open to change and so had the potential to really take some bold steps
with their service.
This indeed proved to be the case but the learning here was how important it was to actually
communicate that to them……
Start Thinking Differently and it’s hard to stop….
Once the mind has been stretched, it doesn’t snap back into the same place. In Luton & Dunstable, it was
sometimes hard to see a clear thread through the journey of learning new ways of thinking, from new
ideas generated through to specific projects and changes implemented. There were some examples of
this but, perhaps more importantly, this case illustrates the fact that the process is often not linear. The
complexity of the journey means that something that starts as a project may not deliver obvious “results”
on that particular issue. However, as we can see in Luton & Dunstable, unforeseen spin-offs and new
ways of thinking can spring up in unexpected places and times.
201

Thinking Differently is not like sowing a uniform field
with a predictable crop and harvest time. It’s more like
scattering lots of wild seeds, then watching and waiting
to see what kind of diverse meadow springs to life.

Case Studies Learning from Luton & Dunstable NHS Foundation Trust203

Appendices
N Linking Thinking Differently Tools to Improvement Work
N Tips for Facilitators
N References for Further Study
Appendices205
TD_08_APPENDICES 12/9/07 9:13 am Page 1

Appendix
The methods for Thinking Differently in this book are intended to build upon, not replace, all the improvement
work that has been going on for several years now in health care.
Q: How might I use tools for thinking differently in conjunction with my existing improvement and
modernisation work?
A: Below is a “starter for ten” to get you thinking.
Process mapping…
N Explore the use of the Breaking the Rules
I
tool by asking people to identify what are the unwritten rules
behind the various steps in the process.
N Look at how you label the steps in the process with words and phrases that are actually health care jargon
and use the Reframing by Word Play
I
tool to open your mind up to other ways of doing things.
N Use any of the thinking tools to come up with redesign ideas and then show the contrast with the current
process by constructing before and after process maps.
N Identify the steps or stages where there are bottlenecks and use a Stepping Stones
I
provocation to identify
new and alternative options.
N Review a process map using the OPV
I
and Fresh Eyes
I
tools to help you look at it from a range of
perspectives (e.g. nursing staff, patients, porters, family members…) in order to identify improvements.
Rapid cycle tests of change (PDSA)…
N Use the rapid cycle test of change approach to help you further enhance an innovative idea, or pilot test it
on a small scale.
N Use the Six Thinking Hats®I
and the Enhancement Checklist
I
tools to help you make any idea for
improvement better and more likely to succeed, regardless of its level of creativity (i.e., use these tools on an
idea which simply copies and adapts what others have already done, or an idea that comes from simple logic
or analysis).
Capacity and demand…
N In conjunction with capacity and demand analysis, try a Fresh Eyes
I
approach if you see a mismatch that is
causing queues. Think about how a supermarket, a Disney theme park, or major sports stadium thinks
about and manages queues.
Appendices Linking Thinking Differently Tools to Improvement Work
Tools Phase 2: 78
Tools Phase 1: 46
Tools Phase 2: 94
Tools Phase 1: 40
Tools Phase 2: 70
Tools Phase 3: 128
Tools Phase 3: 136
Tools Phase 2: 70
207

Measurement and data collection tools…
N Use your experience in measuring and monitoring improvement to help you evaluate the test or
implementation of an innovative idea.
N You might specifically focus on “WWTTCA
I
how to collect data”, or “WWTTCA
I
how to communicate
performance measurements”… and then go on to apply various thinking tools to these issues.
Human side of change…
N Everything you have learned about the human dimensions of change in doing improvement work also
applies to bringing about innovative change.
N You might specifically focus on “WWTTCA
I
engaging clinicians (or staff, or senior leaders)” … and then go
on to apply various thinking tools to these statements.
Methods for patient/user involvement…
N Instead of having to use your imagination in the Fresh Eyes
I
tool, actually invite service users who are
bankers, race care drivers, children, etc. to contribute their points of view and ideas about how to make
things better.
N Likewise, involve patients and users directly in Phase one (Stop Before you Start) when using tools such as
OPV
I
, or Reframing by Word Play
I
.
Process redesign projects…
N For your next redesign project, spice up traditional Brainstorming with any of the thinking differently tools.
Breaking the Rules
I
, Stepping Stones
I
, or That’s Impossible!
I
will really get team members’ creative
juices flowing.
Achieving the 18 Week wait…
N Use any of the thinking differently tools to help you generate ideas around reducing delays in the patient
pathway. See www.institute.nhs.uk/nodelaysachiever for specific suggestions on how some of these can
help and how they can be used in conjunction with other improvement tools to achieve the 18 week target.
Don’t let anyone tell you that traditional improvement methods are analytical and, therefore, could not possibly
mix well with a focus on thinking differently. Rubbish! It is not an either-or choice. The goal of both traditional
improvement work and of thinking differently is to make things better for service users and staff. If you really
want to be creative, find more and more ways to use the tools of thinking differently and traditional
improvement together. After all, it is all about novel connections that lead to useful ideas.
For detailed information and advice on Improvement Methods, see the Improvement Leaders’ Guides at
www.institute.nhs.uk/improvementleadersguides.
A full list of all 15 guides is provided in Appendix: References for Further Study
I
.Appendix: 211
Tools Phase 1: 58
Tools Phase 1: 58
Tools Phase 2: 70
Tools Phase 1: 40
Tools Phase 1: 46
Tools Phase 2: 78
Tools Phase 2: 94
Tools Phase 2: 102

Appendix
Advice for Facilitators
Those who say it cannot be done should not interrupt
those who are doing it
Chinese proverb
N As you work with groups using these tools, link back frequently to the basic concepts described in the
Concepts
I
section. People are better at creative thinking when they understand what they are supposed to
be doing or thinking about, and why. Two especially important concepts to refer back to frequently are:
mental valleys and attention-escape-movement.
N Provide an example or two as you explain a tool. Make these directly applicable to the issue they are
working on, but don’t steal the best idea. So, for example, if you are working with a team in Emergency
Services, give an example of an unwritten rule that might apply in that setting and a creative idea that
comes from purposefully escaping that rule.
N No matter which tool you are using, establish the ground rules of Idea Generation
I
: Every idea is a good one;
No judgment or criticism allowed; Aim for quantity; Build on other’s ideas. Consider illustrating these on a
flip chart to display in the room.
N You might also want to refer frequently to the Six Thinking Hats®I
and use these to maintain a positive
(Yellow Hat) or creative (Green Hat) atmosphere in the group.
N Be patient and expect that it may take a while for a group to get rolling with a particular tool. Resist the
urge to step in too soon or be too directive. Of course, answer questions and clarify instructions, just don’t
feel like you have to give them ideas. Let the creativity emerge from them.
N Get the groups to assign roles, such as a scribe, perhaps a chairperson and someone to feedback. Ask new
people to take on these roles at least once in your session. Observe the group dynamics frequently and
change roles as needed.
N Capture every idea. This is critical for the later stages of the Thinking Differently process. If working with a
small group you could offer to perform this scribing function yourself. If working with a larger or multiple
groups, assign a scribe and make sure they write everything down. If the scribe does not write an idea down
then they are, in effect, judging. Further, participants will begin to think that they must more fully explain
their idea in order to get the scribe to capture it. Either way, this violates the rules of Idea Generation and
makes whatever tools you are using less effective.
Appendices Advice for Facilitators
Concepts: 20
Tools Phase 2: 63
Tools Phase 3: 128
209

N Pause on ideas that generate laughter. Laughter is a signal of an unusual connection in the mind. Make sure
that the idea has been written down, then ask, “what is the main point behind that and how might we use
that to generate another idea?”
N Keep the pace lively. Seek to switch to another tool or provocation before the energy runs out of the one
that you are on.
N Seek physical space that lets people easily break into smaller groups with chairs clustered around a flip chart.
There should also be plenty of usable wall space to keep the group’s ideas visible as it works. Tables are less
essential and can actually inhibit creativity if they impose formality.
N Identify the core people needed to work on a particular topic - the content experts and stakeholders - then
supplement the group with some creative thinkers not necessarily connected to the subject.
N Consider how people from different demographics and perspectives can enrich the quality and depth of the
ideas. For example, will the subject benefit from the ideas of younger staff just entering the workforce, or a
certain role that will be significantly impacted during implementation?
N Constantly mix and match individuals so that the energy stays high. Ask people to switch groups… do some
exercises in trios, whilst doing others as groups of 6-8. Use your judgment, but the idea is not to let things
grow stale.
N Be aware that doing all this thinking is actually hard work for most people. They will get tired if you go on
too long. Take frequent breaks. Intersperse activities with presentations or less demanding tasks. Provide
refreshment!
N Even if you do not plan to do a formal idea harvesting session with the group you are working with, bring
some sort of closure to any idea generation session by at least asking people to note some of the ideas that
they thought were among the best.
N Be aware of your own learning style, attitude to change and willingness to think differently. Ask yourself
“Am I walking the talk here?”.
If you are not having fun facilitating the process of
Thinking Differently, you are not doing it correctly!

Appendix
References for Further Study
Paul E. Plsek, Creativity, Innovation, and Quality. ASQ Quality Press, 1997
This book takes the reader through directed creativity from first principles to application. The first third of
the book covers the theory of directed creativity, included the mechanics of mind and heuristics for directed
creativity. The second third presents the three principles behind all tools for creative thinking and reviews
the hundreds of tools available. The final third covers the application of directed creativity to re-engineering,
design, customer needs analysis, and problem solving. Practical and informative. Also visit the website -
www.directedcreativity.com.
Edward de Bono, Serious Creativity. Harper-Collins, 1992
Edward de Bono is a prolific writer on the topic of thinking in general and creative thinking in particular.
Part 1 of this text will introduce you to such classic de Bono-isms as “lateral thinking” and the “self-
organising mechanism of mind.” Though de Bono never refers directly to the research from the cognitive
sciences, you will find his work consistent with it. Part 2 covers tools and techniques for creative thinking,
while part 3 discusses issues of organisation-wide creative thinking. De Bono’s style is crisp, and the book is
fun to read.
James M. Higgins, 101 Creative Problem Solving Techniques. Winter Park, FL: New Management
Publishing Company, 1994
This is a great catalogue of creative thinking tools. Each of the 101 tools is explained in detail; the book will
provide you with plenty of food for thought. The presentation is organised around the Creative Problem
Solving (CPS) model, but the translation to the the three-step process we outline in this Guide is easy.
Robert J. Sternberg, ed. The Handbook of Creativity. Cambridge Univ. Press, 1999
This is the most up-to-date, comprehensive scholarly reference on the topic. The 22 chapters are well
written and relatively free from the repetition one sometimes finds in a collected work such as this. The
contributor’s list reads like a who’s who of cognitive scientists, psychologists, educators, philosophers, and
researchers who are currently working in the field of thinking about creativity. While the writing style is
accessible, this is not casual reading. However, if you are the sort of person who likes to dig down under the
surface of a topic, you’ll find this book a brilliant ‘one-stop shop’.
Appendices References for Further Study211

Thomas H. Davenport, Laurence Prusak, H. James Wilson, What's the Big Idea? Creating and
Capitalizing on the Best New Management Thinking. Harvard Business School Press, 2003
Major new management ideas are thrown at today's companies with increasing frequency. Only a handful
of these ideas will be a good fit for your organisation. Choose the right idea at the right time and your
company can become more efficient, more effective, and more innovative. Choose the wrong one-or jump
on the right bandwagon too late and your company could fall hopelessly behind. In What's the Big Idea?,
Davenport and Prusak introduce a largely unsung class of managers they call idea practitioners, individuals
who do the real work of importing and implementing new ideas into businesses. While gurus reap most of
the credit when big ideas take flight, their research reveals that idea practitioners actually play the most
important role: They turn the right ideas into action.
Various Contributors, Harvard Business Review on Innovation, 2001
Short chapters written by leading experts describing how creativity and innovation can give your organisation
the leading edge. Case study examples of companies such as 3M provide a practical understanding of how to
support creativity and innovation as well as illustrating managerial tools and techniques.
Tom Kelley, The Art of Innovation. Doubleday, 2001
This book is about IDEO, the organisation that has been acclaimed as America’s leading design firm.
It describes how the organisation has built an innovative culture so that creativity is part of the routine.
The book provides a valuable insight into ways of working, teams, relationships and processes.
Michael Schrage, Serious Play- How the worlds best companies stimulate to innovate. Harvard
Business School Press, 2000
Describes how the leading companies use models, simulations and pilot testing to innovate. Written with
project leaders in mind there is a focus on how to manage innovation initiatives through to successful
products and processes. The book draws on examples from companies such as Walt Disney, IBM, General
Electric and IDEO.
Frances Hesselbein, Marshall Goldsmith & Iain Somerville, Eds, Leading for Innovation - and
organising for results. The Drucker Foundation, 2002
Short chapters written to provide practical guidance for those who wish to lead their organisation to a new
dimension of performance. Suggests some of the qualities required to develop a culture that promotes
innovation and provokes thought about how organisations must abandon practices that no longer work or
are no longer useful. Includes thought from some leading CEO’s of innovative companies.

Andy Law, Experiment at work - explosions and experiences at the most frightening company on
earth. Profile Books, 2003
A story of a business which is run like no other. Using creativity as a guiding force and putting personal
development and growth at the top of its list were just two things that enabled this company to be the
most successful in its field.
Dave Allen, Matt Kingdon, Kris Murrin, Daz Rudkin, What If?- How to start a creative revolution
at work. Clapstone, 1999
Describes six behaviours, which the authors have identified within creative and high performing teams.
Contains practical ideas on how these behaviours can be encouraged within teams using illustrations from
companies such as ASDA, Virgin, ICI & Ben and Jerry’s ice cream.
Barry Nalebuff and Ian Ayres, Why not? How to Use Everyday Ingenuity to Solve Problems Big
and Small. Harvard Business School Press, 2003
Packed with real examples of how creative thinking has transformed many organisations this is a fun yet
informative read. Their approach, inspired by Edward de Bono, is a primer for fresh thinking, reframing
problems and finding creative solutions. They encourage thinking both inside and outside the box and their
inherent optimism offers novelty and surprise.
CK Prahalad, Venkatram Ramaswamy, The New Frontier of Experience Innovation. MIT Sloan
Management Review, Vol 44, No. 4, 2003
Describes the natural evolution of thinking about innovation from a focus on products and service
(producing something a customer might want), to “solutions” (creating something that solves a problem for
a customer), through to “experience space” (creating the capability for the customer to individualise and
adapt products and services to meet his or her ever-changing needs). Experience innovation shifts the focus
to the daily lives of service users. What could be more needed in health care?
John Bessant, Challenges in Innovation Management in International Handbook on Innovation,
Ed. Larisa V. Shavinia, 2003
Professor Bessant describes some of the key issues for managers and leaders who want greater levels of new
thinking and innovation in their organisations. Key topics covered include managing organisational culture,
creating continuous learning, facilitating relationships, and gaining high levels of involvement in rethinking
the ways we have always done things.
Appendices References for Further Study213

Andrew Hargadon, Robert I Sutton, Building An Innovation Factory, Harvard Business Review,
May-June 2003
Business school professors describe their research on how leading commercial organisations capitalise on
different thinking. The “knowledge-brokering cycle” that they describe includes how to capture good ideas,
keep ideas alive, imagine new uses for old ideas, and put promising concepts to the test.
Jack Silversin, Mary Jane Kornacki, Implementing Change: From Ideas To Reality, Family Practice
Management, Jan 2003
A concise, easy to read article on implementing new ideas and change within healthcare settings, written by
two Physicians experienced in quality improvement in the US. It highlights common barriers to change and
provides a helpful set of practical guidelines for building a good foundation and then applying change
management skills. Download the article at: www.aafp.org/fpm/20030100/57impl.pdf
Improvement Leaders Guides
These 13 guides, produced by the NHS Institute for Innovation and Improvement, are available as a boxed
set and in electronic format. To order or download, go to: www.institute.nhs.uk/improvementleadersguides
1. General Improvement Skills:
1.1 Improvement Knowledge and Skills
1.2 Process Mapping, Analysis and redesign
1.3 Working with Groups
1.4 Involving Patients and Carers
1.5 Evaluating Improvement
1.6 Use of Technology to Improve Services
1.7 Sustainability and its Relationship with Spread and Adoption
2. Process and Systems Thinking:
2.1 Measuring for Improvement
2.2 Matching Capacity and Demand
2.3 Improving Flow
2.4 Working in Systems
3. Personal and Organisational Development:
3.1 Managing the Human Dimensions of Change
3.2 Redesigning Roles
3.3. Building and Nurturing an Improvement Culture
3.4 Leading Improvement

Appendices215
Thank you
The development of this book has been an exciting and truly collaborative process. We would like to thank
everyone within the NHS and International healthcare systems who contributed their enthusiasm, experiences
and knowledge throughout the different sections and case studies. Specifically like to thank Lisa Godfrey
Harris for her work on the early drafts.
Core design team: Lynne Maher, Paul Plsek, Sarah Garrett, Helen Bevan.

To find out more about the NHS Institute email: enquiries@institute.nhs.uk
You can also visit our website at www.institute.nhs.uk
If you require further copies quote NHSITHINKDIFF001
Contact: Prolog Phase 3,
Bureau Services,
Sherwood Business Park,
Annesley,
Nottingham NG15 0YU
Tel: 0870 066 2071
Email: institute@prolog.uk.com
NHS Institute for Innovation and Improvement
Coventry House
University of Warwick Campus
Coventry CV4 7AL
Tel: 0800 555 550
© NHS Institute for Innovation and Improvement 2007 All rights reserved.

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