A different, Learning approach to manuals

Treatment manuals that are written in stone, or even on paper, are liable to be out of date very quickly, and risk being rather "concrete" - examples of Teleological thinking rather than mentalizing.



A TiddlyManual expects some co-authorship of a manual: balancing centrally-curated evidence-based practice with locally-curated practice-based evidence.

In this way a local team's version of the manual has authors at different "levels" - a foundation of material from the AMBIT project at the Anna Freud National Centre for Children and Families, but locally authored material that sits above, adds to, or improves upon that common core.

A modern palimpsest

This is like a modern version of a "palimpsest" - a document that has multiple layers of written on top of each other. Because the different layers in our palimpsest link up, and are easily navigable, we think ours works better than Archimedes' one (which was created when someone just wrote over the great mathematician's works) even if it may not look as beautiful:



The Core Features of AMBIT includes the practice LEARNING at work, and the key element of this is what we call Wiki-Manualization. This helps to straddle two (potentially contradictory) markers of the AMBIT stance, namely:

• Respect for Evidence
• Respect local practice and expertise

A local team's Manualization of "how we are implementing these interventions" is not a static, immutable thing - instead it is a dynamic and adaptive document that the local team takes responsibility for continuously adjusting, shaping, and editing in what are generally small week-by-week "tweaks" - trying to document the kinds of specific problems "...that tend to recur in OUR specific setting, with OUR specific client group."

The Accumulation of Marginal Gains

Learning from British Olympic Cyclists

The British Olympic Cycling team dominated the sport in the London 2012 Olympics. A key part of their strategy was what the principle coach, Dave Brailsford, has referred to as the accumulation of marginal gains (see a newspaper article about this here). The point of this is that performance of a team functioning at the highest level is unlikely to be affected dramatically by a single "lightning bolt" inspiration - but that instead there may be lots and lots of elements of the complex practices, behaviours and machinery that could be "tweaked" in ways that save, perhaps 0.02 seconds each. Find 50 of these, and you have gained a second, and that is almost certainly (another) victory.

In the same way the "tweaking" of a TiddlyManual by a team that is engaged in learning about what works for whom, seeks to add multiple marginal gains to performance as a whole

Co-construction and the Learning Team

The balance between the "top-down" imposition of a structure and forms of working, and the "bottom-up" addition of a local team's expertise and creativity (and feedback from local patients/clients) is what distinguishes the AMBIT model of manualization from other approaches to treatment manualization.

We envisage tiddymanuals as functioning rather similar to a "Blog"; the "blogger" adds to his or her blog, which is presented as a "work in progress". Similarly, a local version of the AMBIT manual that builds on, bends, adds to, and adapts the Core material in pursuit of marginal gains in that setting is part of the AMBIT-influenced culture of continuous ServiceDevelopment.

An example from general medicine:

Some slides and video:

Below is some video explaining the way a tiddlymanual attempts to:

• Integrate centrally-curated evidence-based practice in the same place as locally-curated practice-based evidence that a local team gathers Iteratively
• Encourage multiple teams to Compare and share what they are each doing to support the development of a Community of Practice:

• A Wiki is just a collection of web-pages, linked around a common theme, that can be edited by users - a sort of 'work in progress'.
• TiddlyWiki are like this, except that all the "pages" (we call them "Tiddlers") are held in a single file that your regular browser reads - so you don't need any special software on your PC or tablet to make them work.
• When they are hosted online in TiddlySpace, one Wiki can include all the public parts of another.
• In this way, content from a useful wiki (we hope the ambit or the mbtf wikis, etc, are good examples) can be included in lots of other wikis - for instance the "local treatment manuals" of local services.
• See Set up your own Local Version of the AMBIT manual for advice on this, if you haven't already got your own version.
• Local teams can use the 'core' material provided by the AMBIT project at the Anna Freud National Centre for Children and Families, but they can also add their own material, or overwrite and improve upon our basic platform - manualizing their own practice as they apply ambit principles in their unique setting.
• If they over-write ambit material (to customise it for their local setting) they can always delete their "customised version", so that the original ambit version 'pops back' in its place.
• Previous versions of pages are all stored, so reverting to earlier versions is easy.
• Using the Show references and info panel, you will see some of Comparing and Sharing functions: it is easy to compare one local version to other versions, and any customised material is marked as such.
• Excellent local innovations may gain sufficient evidence of effectiveness to warrant being included in the core manual - so this is a Community of Practice.
• The ethos is about sharing best practice, and filtering the most effective innovations through attention to outcomes evaluation.

Presentation

Dickon Bevington addressing a conference at UCL back in 2008, explaining the notion of TiddlyManuals. Apologies for the video quality (these particular videos may only play on on modern browsers)

What about research?

It is possible to freeze further editing of a manual, so that in formal research (RCT's etc) the team can deliver robust outcomes measurements on a known quantity.

The local team's version of this manual should constantly develop and adapt to the local needs (determined from practitioners' experience and service user feedback) and in response to developing evidence of "What works for Whom" in the wider scientific community.

Editing a local version

This is is one of the Core Features of AMBIT - covered in Manualization.

In order to achieve this, the team needs to place active interaction with, and ownership of, their own "TeamTemplate" manualization at the centre of what they do. Ultimately, their local adaptations of this manualization should move their version towards becoming a statement of their own collective understanding, and of their local team's identity:

"This is who we are and what we do...".

How to edit our manual?

See Customising your local TeamTemplate