Dr Mark Charny discusses strategies for maintaining long-term change

The previous article in this series (Guidelines in Practice, October 1999) discussed some very common, early patterns which monitoring may reveal. To some degree, they reflect failure of the implementation plan to capture the imagination and loyalty of clinicians.

Someone who does not initially use a guideline may do so because he/she:

Does not agree with it

However good your initial consultation with clinicians, there may be some who agree to the guideline on the surface, but internally do not accept what is being proposed.

If you think that this is the problem, you should take the clinicians concerned through the evidence and explain the importance of following the guideline.

This should be done in a way that encourages them to express their views openly, and allows you to take appropriate steps. If, for example, they have had a recent experience with a patient which makes them feel that the guideline is misplaced, it may be helpful to go through the case notes with them.

Does not realise that the guideline is important

The clinicians concerned may not object to the guideline, or to its recommendations, but it may not be as high priority for them as it is for you, or the organisation.

If you have followed the suggestions in earlier articles in the series, you will have established early on whether this is a low priority for some of your colleagues. But however well you do this, you may find that some clinicians have other things on their minds.

In such cases, you should explore the concerns of the clinicians who are not cooperating, and try to persuade them of the importance of following the guideline, or, possibly, accept that there are other priorities which are so pressing that the guideline cannot be made to work across the board.

Is hampered by external constraints

Here, the clinician may be happy with the guideline and accept its importance, but may be unable to implement the recommendations because of the circumstances in which they work.

For example, referral letters may be delayed or incomplete because of difficulties in recruiting a secretary; a consulting room may have inadequate space to carry out interviews in privacy; or equipment may be defective or unavailable.

In these circumstances you should help your colleague to solve the problem, rather than pressurise him or her. In general, when managing change, it is as important to diagnose the barriers to change before deciding what to do as it is to diagnose the patient's condition before prescribing treatment.

Is a laggard

In The Diffusion of Innovations,1 Everett Rogers studied the uptake of new ideas in American farmers in the Mid-west (see Figure 1).

Figure 1: Adoption of change over time in a professional group
graph with s-shaped curve

He found that there were people who were very keen to try out any new idea; he called these enthusiasts 'innovators'. These were people who thrived on change: they brought their home computers into work in the early days and spent their spare time programming them.

'Early adopters' are are very flexible and like to adopt new ideas – once a few others have blazed the trail. They were the ones who volunteered to have computer terminals when organisations were looking for volunteers.

'Late adopters' are those who are willing to change when the majority has adopted new patterns of behaviour. These people grudgingly accepted computer terminals when they were rolled out to the whole of the organisation.

Finally, there are the 'laggards', the mirror image of 'innovators'. Laggards are so conservative that they will put much more energy into maintaining an unsatifactory status quo rather than changing to a better way of working.

Laggards locked their offices when computers were being installed, and when they had to accept the presence of one in an office they refused to turn it on.

Underlying Everett Rodgers' analysis of the uptake of ideas is a spectrum of personality types from those who so love change that they may adopt harmful new ideas to those who so hate change that they may not adopt clearly beneficial ways of working.

Figure 2: Relationship between adoption of change, personality types and conservatism
graph with normal curve

Figure 2 shows the same information in the form of a normal curve. Laggards are at the 'trailing edge'. Everett Rodgers' advice to representatives selling fertilisers to farmers in the Mid-west who spotted a laggard farmer was to turn round and drive away to visit another prospect.

It is an option, and one you should consider, but it may not be possible to allow an individual to opt out of a new way of working that has been adopted by a practice or a PCG.

It is important to understand, however, that resistance to change may be a deeply embedded fact of someone's personality, rather than 'bad behaviour' or ignorance.

As with other aspects of introducing guidelines, you need to diagnose the problem before applying a remedy. This calls for flexibility on the part of the implementation team: there is no point in sending another copy of the guideline to a laggard just in case he or she has missed the point.

Bear in mind that:

Knowledge isn't enough – Ignorance is sometimes a significant factor, but not as often as we tend to think. Most problems can be traced to the physical or organisational environment in which people work or to their personality.
Enthusiasm evaporates. Enthusiasm is very important in getting your project off the ground, but a different personality is required to sustain change when it is under way. As part of your plan it is important to select colleagues whose own talents and personalities are suited to the various phases of introducing, implementing, and sustaining change.
New working environments and new systems help. As earlier articles in this series have pointed out, changed systems (new forms, new computer systems, new booking systems) may make it very easy to do the right thing and hard to carry on with inefficient practice.

In sustaining change, you must first explore whether your initial efforts have influenced the behaviour of your target audience.

If not, you need to consider carefully where the problems lie: has everyone in a PCG failed to take on board the new proposals, or only some practices? Within a group practice, perhaps one partner has not changed – if so, you need to establish the reasons for this.

  • This series will run to the end of the year. The next and final topic will be:
    • When to review a guideline and when to move on to something else.

  1. Rogers EM. The Diffusion of Innovations, 4th edn. London: The Free Press, 1995.


Guidelines in Practice, November 1999, Volume 2
© 1999 MGP Ltd
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