HoW-CGA Chapter 4: Barriers to implementation
The overarching message about successful improvement shows how social relationships in organisations are key for embedding the technical features of change. A lot of time and energy in leading organisational change will require you to uncover and mitigate barriers. Part of this will mean understanding rather than judging when people resist. Reasons may include perceived losses or real barriers.
This is chapter 4 of a series. See the full series here
Engaging staff and overcoming a perceived lack of ownership are among the biggest challenges in improvement efforts13
Social Relationships
The overarching message about successful improvement shows how social relationships in organisations are key for embedding the technical features of change. A lot of time and energy in leading organisational change will require you to uncover and mitigate barriers. Part of this will mean understanding rather than judging when people resist. Reasons may include perceived losses or real barriers.
“One of the challenges was that it wasn’t […] seen as not a useful thing. So the fact that I was finding things that were important, and needed, was actually seen as being a problem because potentially I might be finding problems that people didn’t want to see.” (Physiotherapist)
Peter Pronovost, a physician and a quality improvement guru, has had a great deal of first-hand experience in dealing with what he called adaptive challenges to change. Adaptive challenges refer to people’s loyalties, priorities, beliefs and habits that may lead to resisting change. It is these adaptive challenges that “will determine whether your intervention is adopted and implemented” (p.563) (17). Some key points Pronovost highlighted to those dealing with adaptive challenges were:
- embrace and talk to dissenters rather than bully and avoid them,
- listen and understand why they are resisting – the intervention may pose some unrecognised risks or burdens
- communication, communication, communication is key to managing fears and perceived losses
- remember “WIIFM” – What Is In It For Me. Apart from doing the right thing and putting the patient first, everyone wants to maximise their interests and get something from the change effort
- benefits must be visible to overcome resistance
Key Challenges
The organisational context, culture and capacities
Staff may not understand the full demands of improvement when they sign up, and team instability can be very disruptive. Explain requirements to people and then provide ongoing support. Make sure improvement goals are aligned with the wider goals of the organisation, so people don’t feel pulled in too many directions. It is important that the organisational culture supports learning and development.
Tribalism and lack of staff engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals and use shared language. Intermediaries, such as training staff, are likely to have a role here. Protected staff time may help to secure engagement
Balancing carrots and sticks – harnessing commitment through incentives and potential sanctions
Relying on the intrinsic motivations of staff for quality improvement can take you a long way, especially if ‘carrots’ in the form of incentives are provided – but they may not always be enough. It is important to have ‘harder edges’ (sticks) to encourage change, but these must be used judiciously and are likely to require the support of senior executives, professional bodies and those designing reward structures.
The NHS Change Model
The NHS Institute's spread and adoption tool
A practical tool that synthesises the best evidence available on the factors that support the spread and adoption of innovation is now available. http://www.institute.nhs.uk/spread
Energy for Change
A YouTube animation introduces an important leadership skill to prevent burnout and disillusionment amongst staff. https://www.youtube.com/watch?v=XBwcYYy3u74
Other Resources
NHS Scotland Quality Improvement Hub on making numbers meaningful for quality improvement http://www.qihub.scot.nhs.uk/knowledge-centre/quality-improvement-tools/making-the-numbers-meaningful-for-quality-improvement.aspx
Managing the Human Dimension of Change http://www.nhsiq.nhs.uk/media/2594818/ilg_-_managing_the_human_dimensions_of_change.pdf
Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views. Quality and Safety in Health Care 2004; 13:108-114. http://qualitysafety.bmj.com/content/13/2/108.full
How to spread good ideas - A systematic review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation, 2004. http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0020/81245/BP-08-1201-038.pdf