Nearly thirteen years ago, in an often cited article in the Yearbook of Medical Informatics, Balas and Boren¹ described a shocking reality. In the field of medicine, the average time to move from an idea, proven efficacious at the basic science level, to general adoption in medical practice is seventeen years. A common explanation for why is that medicine, as a specialty depends on natural diffusion to get good ideas into practice – in most places. While this explanation is a good one it fails to consider the status quo. It assumes a passive or even receptive set of environments to spread into. I would argue this isn’t the case and while some environments passively accept change, others actively work against it. Niccolò Machiavelli wrote as much when he penned The Prince nearly six hundred years ago.
“There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new…”
Machiavelli was succinct and in my opinion is still correct today. I’d like to dig a little deeper and explore why this is the case. Frequently the ideas we have about what might work to transform the performance of care fail to consider two key elements of the status quo: an appreciation of the system and an understanding of psychology, especially with regards to change. When seemingly good ideas are instituted by leadership, they frequently fail to consider the current design of the system. This includes everything from the process steps that the process leaders are hoping to impact, to associated processes likely to be affected by the change to resources (time, money, human capital) that are necessary for improvement initiatives to work successfully. In the majority of cases Leaders do not consider or are unwilling to confront the culture of the organisation they direct. Rarely does leadership pause to ask: Are the frontline staff, middle managers and other stakeholders ready to adopt the change of interest? They may forget or be unaware of a need to think through ways of preparing their staff psychologically for any permanent changes they want in their system. It is easy to forget that even though people can adapt quickly to new ways of doing things, they are currently used to doing things in very particular ways. The status quo persists, partially because it brings a sense of predictability to their day to day work, so that even though they may not like every aspect of the day, they are not stressed with constant surprises.
When we have a good idea, proven to provide the intended impact on a small scale, or in another environment or organisation, there are steps we can take to avoid the pitfalls described above. Leadership can take time to first appreciate the system and work with the frontline staff to understand what the process(es) looks like. Leaders can develop process maps in the form of flow diagrams or linkage of process diagrams, to help see the steps of the system. This is important because it can be the first indication of systems barriers that may work against the success of a change. Including supportive details such as how long a process takes, where bottlenecks occur, who is involved or where an activity happens, can all bring insight into what local adaptations will be needed to make a known change a success.
Preparing staff for the change is also critical. In Diffusion of Innovations² Evert Rogers describes several factors to consider and several strategies to help make change palatable to the workers in a process undergoing improvement. This includes things like communication, letting people know a permanent change is coming (i.e.avoiding surprises), describing how things will be different, helping people to see how their day to day work will be affected and providing time for people to prepare emotionally for the change. Rogers also describes attributes of change ideas that make them more attractive. Top of the list is trial-ability, the opportunity for people to try out what will be expected of them in the future. The Model for Improvement, as described by Langley et al³, provides an excellent mechanism for this. Local teams can try an idea, in a way that allows them to explore what works and doesn’t work locally, culturally or systematically. Teams can make local adaptions, find local solutions and do so in a way that is not a threat to their regular day to day work. They can build the evidence they need to adopt change when the time comes, either in the form of a deadline or because the workforce sees the benefits of the new way.
Langley et al, in The Improvement Guide³, go onto describe a set of contextual factors that must also be addressed when striving for permanent change. They suggest improvement teams with leaders prepared to change supporting dimensions of the system. Documentation will need to change, in the form of standard operating procedures, data collection mechanisms and job descriptions etc. Standardisation is a frequent aspect of permanence, with a focus on removal of the old system as an option. Training must be updated for new and existing staff to provide the relevant knowledge as to how things will work. Often there are financial changes that must be made, changes in line item budgets, allocations for new or different equipment, resources, people, or supplies. Measurement may also need to be updated or changed depending on what process changes have been made. Each of these requires leadership and the quality improvement team to reach beyond the clinical environment to work with other disciplines of the organisation.
It is easy to see that while testing a change for efficacy and impact on a process is difficult, the work of implementation and the creation of a new status quo can be equally challenging. There is a lot to consider as teams move toward transformation.
¹Balas E, Boren S., Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT (eds). Section 1: health and clinical management. In Yearbook of Medical Informatics: Patient Centered Systems. Stuttgart, Germany: Schattauer Verlagsgesellschaft; 2000:65-70
²Rogers, Everett M., Diffusion of Innovations, fifth edition, Free Press, 2003
³Langley et al., the Improvement Guide, second edition, Josey Bass, 2009
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