Dr Richard More gives details of eight principles for introducing and maintaining change and how this can help GPs and practice staff implement improvements
Clinicians who wish to see improved outcomes for patients are commencing, whether they like it or not, a change process. There is much study of the art and science of change management that tells us that there are ways of going about this that are both likely and unlikely to be successful. Doctors who wish to achieve good outcomes for their patients should choose to go about change in a manner that is likely to succeed. As advocated in one paper, ‘evidence-based guidelines require evidence-based implementation.’1
There are reviews on the relative effectiveness of different strategies for ensuring the uptake of guidelines in the NHS,2-4 but this article is aimed at providing practical advice to the individual practitioner who wishes to play a full part in supporting a change for the better in their own practice or those of their colleagues. After all, no change equates to no improvement.
Expectations and uptake of ideas
The first point for the enthusiastic ‘clinical champion’ is to manage their own expectations and the expectations of any team members around them. Not everyone, in fact very few, will immediately adopt the proposed ideas or principles. The most influential research for this comes from Rogers’ theory of diffusion in Diffusion of Innovations, first published in 19625 and repeatedly updated since then. Some of the key research leading to the development of this theory was the study of the increasing use of the then brand new drug, tetracycline, by American physicians.6
Studies of diffusion show that new ideas percolate through groups, whether they are doctors or farmers, in an S-shaped curve; initially there is a slow uptake of ideas, followed by a period of rapid uptake. Then as the majority of the group have changed their behaviour, there is a slower uptake in the final group. This is because the rate of diffusion of an innovation is related not just to the idea but also to the methods of communication, and the individuals receiving this communication.
Rogers observed that groups consist of a range of people characterised by differing behaviour that results in varied rates of uptake.5 These groups can be characterised as follows:
- innovators (venturesome)
- early adopters (respectable)
- early majority (deliberate)
- late majority (sceptical)
- laggards (traditional).
What are the implications of this for the busy doctor? First, it provides evidence to support the often implicit idea that just sending an email or writing a paper will have little or no effect on behaviour. There is no point in just writing guidelines; their incorporation and implementation needs support to encourage uptake among those who do not immediately adopt new ideas. Time for this support needs to be built in and costed.
Second, do not be disheartened that not everybody adopts new ideas immediately. In different subjects, in different groups, in different countries the numbers are surprisingly constant, with 84% of individuals not adopting new ideas rapidly. Be ready for this and manage it. Eventually you will hit what is known as the ‘tipping point’, which is the point on the graph where the bulk of individuals who comprise the early and late majority (68% of individuals) start to take up new ideas.
Diffusion of ideas
Rogers also studied factors that influence the rate of diffusion of ideas and found that individuals will adopt new ideas faster if they:5
- can be tried on a relatively limited basis initially
- offer practical advantages
- are better than existing ideas or other new ideas
- are not overly complex
- are compatible with pre-existing values.
This knowledge can advise us on how to present new guidelines and new ways of working so they are more attractive for colleagues, and therefore lead to more rapid uptake.
Resistance to change
These ideas about diffusion are helpful in setting out in general terms how to bring about change, but from time to time every leader will come across an individual who seems to be resisting what is clearly, to the advocate, beneficial change. How should one approach this issue?
Kurt Lewin suggested in his book Field theory in social science that human behaviour is a result of the effects of two opposing sets of forces, ‘driving forces’ versus ‘restraining forces’.7 Driving forces attempt to bring about change; restraining forces seek to maintain the status quo. This concept can be used to analyse a situation and how an individual may perceive the situation to produce what is known as a ‘force field model’.
On the face of it, this seems a rather simplistic approach. However, its value lies in requiring the person who is interested in change to view proposed changes from a different perspective (i.e. from the point of view of those less keen on change). After all ‘people don’t mind change, they mind being changed’. This technique can be used to assess what concerns people may have about change (the resisting forces) and allow the team to come together to reduce those problems. This is a far more productive approach than attempting to increase ‘driving forces’. The consequence of pushing ideas at people is that they tend to push back, thus decreasing rather than increasing the rate of change.
Action to implement change
Rogers5 and Lewin7 provide two academic studies of change that have led to some practical advice in how change circulates through communities, and how to approach individuals who may or may not resist proposed change. How can we convert these useful ideas into a plan of action for incorporating published guidelines into mainstream practice? The theory of diffusion tells us that in practice not all members of staff will rapidly adopt new ideas; how can we go about our business to support the change and make it more likely to be successful?
There are as many ‘how to do it’ guides as the bookselling market will stand! One of the most respected has been written by a professor of leadership at Harvard University and is pertinently titled ‘Leading change’.8 Professor Kotter begins by identifying eight errors that contribute to failures in change. These are:
- allowing complacency
- failing to create a powerful leadership team
- underestimating the need for a clear sense of a better future
- undercommunicating the vision by a factor of 10 (or perhaps a hundred or thousand)
- allowing obstacles to stand in the way of change
- failing to create short-term wins
- declaring victory too soon
- failing to embed change as the corporate way of doing things.
Following on from his research on why change fails, Kotter makes the following recommendations on how to avoid these failures.
Sense of urgency
Kotter recommends establishing a sense of urgency. In the same way as the force field analysis, this would require the advocate of change to establish and articulate the reasons why change would be a good idea. Kotter even goes so far as to suggest that manufacturing a crisis may be required.8
A powerful leadership team should be created. Powerful not just because of the position of individuals in the organisation, but because they are so regarded by others. This gives them the ability to influence and shape the thought of others. The leadership authority of this team will be required later in the change process to manage late adopters and laggards, when all the enthusiastic innovators and early adopters have taken up the new idea.8
Having a clear vision is a concept often ridiculed by the medical community but is used frequently in change management. In this context a vision is a clear and unequivocal statement of the future. When the whole team knows where it is going, all the members can go there together. If there is no agreed statement of where the team is heading, the chances of them all arriving at the same place are remote.8
Communication must be effective. Effectiveness here means both in volume, using different techniques such as email, face-to-face meetings, and lectures, but also in consistency of the message sent from different individuals. Kotter makes the point, which is very pertinent for today’s general practice, that proportionality is also important. This means that the volume of communication about new ideas must occupy a significant proportion of total communication received. General practitioners are familiar with the idea that a good new idea is buried in reams of paper concerning unimportant ideas.8
Barriers to change
In recommending the removal of blocks to change, Kotter is not just referring to individuals who do not go along with the new idea, but to other factors that conspire to resist change. Sometimes this can be systemic, such as performance-related pay rewarding old not new behaviours. Having said that, the important blocks are always human beings, and managing them is perhaps the most difficult part of leading and managing change.8
Kotter clearly makes the point that change is tiring and, without feedback in good time, teams can feel that they are struggling (early change being at the relatively flat part of the S-shaped curve described by Rogers). Kotter recommends establishing and communicating short-term wins.8
Kotter counsels against declaring victory too soon. He makes the point that the historic ways of doing things, by definition, have been around for a long time. There is a tendency to revert to tried and tested ways and so change needs to be continually reinforced. Momentum must be maintained.8
Changes should be incorporated into the rules and structures of the organisation. Kotter makes the point that it takes time for new ideas to become accepted ideas.8
Even Kotter8 accepted that his principles of implementing change were by no means the whole answer. There is much more detailed and sophisticated research, particularly incorporating the new science of complexity theory.9
The reality is that change is messy and difficult. If it was easy, everybody would be able to do it. However, incorporation of relatively straightforward techniques will increase the chances of success and lead to those improvements in patient care for which we all strive.
- Grol R, Grimshaw J. Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv 1999; 25 (10): 503–513.
- Palmer C, Fenner J. Getting the message across: Review of research and theory about disseminating information within the NHS. London; Gaskell, 1999.
- Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362 (9391): 1225–1330.
- University of York, NHS Centre for Reviews and Dissemination. Getting evidence into practice. Effective Health Care Bulletin 1999; 5 (1): 1–16.
- Rogers E. Diffusion of Innovations. New York: The Free Press, 1962.
- Coleman J, Katz E, Mentzel H. Medical innovation: diffusion of a medical drug among doctors. Indianapolis, MN: Bobbs-Merrill, 1996.
- Lewin K. Field theory in social science. New York: Harper, 1951.
- Kotter J. Leading change. Boston: Harvard Business School Press, 1996.
- Plsek P, Wilson T. Complexity, leadership, and management in healthcare organisations. Br Med J 2001; 323 (7315): 746–749.G