The focus of the “classics” in this third issue of The Edge is “readiness for change”.
For any change agent in health and care, “readiness for change” is a key issue. It is the extent to which the environment in which we find ourselves as change agents is actually receptive to change and therefore, whether the change can be delivered, sustained and spread further.
This piece was stimulated by a recent blog by Adi Gaskell called “Do you really want to be a radical?” He stresses just how big a part environment plays in how we behave. In a conductive environment for change, we might be “boatrockers”, positively challenging the status quo and leading change. In a more challenging environment, we might find ourselves as “troublemakers”, full of grievances and anger and not getting very far. The system and environment we operate within therefore has to support creativity and innovation if people are to have a hope of obtaining it. It is one of our key roles as change activists in health and care to build readiness for change.
I have spent more than 30 years leading and facilitating large scale complex change programmes. Early in my career, I thought that programmatic change interventions provided “magic” for improvement. I thought that if, as a change team, we created powerful aims for change, designed measurement systems, built improvement skills and got teams to collaborate, we could make improvement happen. What I have learnt over the years is that the “magic” really happens when teams come together with a burning passion for improvement, where shared purpose overcomes power issues and the local conditions are ripe for change to happen.
I cut my teeth on large scale complex change in the early 1990s, leading The Leicester Royal infirmary Re-engineering Programme. This was the largest, most ambitious change programme ever undertaken by a single hospital system. The aim was to literally “re-engineer” all the core processes of the hospital and create big improvements for patients. This programme became so famous (or infamous!) that it continued to be quoted for another two decades, such as in Edward Peck’s book on Organisational Development in Healthcare (2005)and in this 2012 report on cost and quality in hospital by the Nuffield Trust. One of the best studies ever written on the conditions for change in healthcare was the evaluation of this LRI programme, Reengineering Health Care: The Complexities of Organizational Transformation by Terry McNulty and Ewan Ferlie, published in 2002. One of the challenges with this book is that the language it uses makes it virtually impenetrable (and therefore unusable) to a practitioner audience. None the less, I still assert that if the learning from this research study was practically applied in subsequent large scale change efforts, many fewer mistakes would have been made and the transformation of health and care would be much further forward.
Essentially, McNulty and Ferlie conclude that whilst there were notable successes at The Leicester Royal infirmary, the impact of the change programme was “uneven” and the change process was evolutionary and incremental rather than the large scale transformational change sought. This was largely a consequence of the pronounced influence of the very organisational setting that the programme sought to change. The issue of the power of the medical consultants in the hospital (and their ability to promote or block change) was pivotal. The way the change process was implemented had to be sensitive to the nature of medical work, and the need to negotiate change with the medical consultants. Despite the fact that the senior leaders supported and actively led the change programme, this was not enough to ensure change across the organisation. There are many lessons here about “readiness for change” that we will build on further in this classics piece.
The next major change programme I worked on was also the topic of formal evaluation which provided important insight on “readiness for change”. This was the National Booked Admissions Programme, initiated in 1998. Across England, 24 pilot sites were identified to test novel ways to enable NHS patients to book hospital appointments at a time to suit them. The evaluation was carried out by Chris Ham and colleagues from the University of Birmingham and published in 2002.
All the pilot sites made rapid progress in the first year but there was slipping back in some of the localities in the second year and a wide variation in what was achieved between the pilot sites. This might seem surprising: after all, all the pilots were chosen because they had strong characteristics for change, they all received programme management support, extensive training and the support of peers. A variety of factors give insight into the uneven outcomes. Pilots with a receptive context (“readiness”) for change did best. Localities with an existing history of positive change and previous booking efforts, effective leadership by a chief executive and senior clinicians, a dedicated project manager and team, and a flexibility of approach to clinicians did better than pilots without these characteristics
As with the Leicester Royal Infirmary programme, the “booked admissions” evaluation highlighted the inherent challenges involved in achieving change in a professional bureaucracy. What might seem to be a relatively incremental step –offering patients the choice of dates for appointment, instead of placing them on a waiting list – in practice entails a complex and interlocking series of actions. This study teaches us that there are no magic bullet solutions to the challenge of change in health and care. Twelve years later, the same conclusions apply: each setting for change is a unique local context; the main source of change and service improvement has to come from within and around each and every NHS organisation.
How we view “readiness for change” depends on how we define the reality of change. Many of the “change readiness assessment tools” that are currently available to us as change agents are based on the principle that there is an external “thing” out there called the system or organisation that can be diagnosed and treated in the same way that a biological system can. Therefore the questions about readiness for change are often about having all the technical capabilities for change in place. For me, the problem with these approaches is that they are too simplistic and can’t explain away or predict the human dynamics; they don’t start from the position that the system that we are trying to change is a complex set of interpersonal relationships. If we take nothing else from the previous studies, we have to take account of people with diverse needs, perspectives, priorities and power bases.
I am therefore much more comfortable with the approach to readiness for change that is suggested by Bryan Weiner in his paper A theory of organizational readiness for change (2009) He regards organisational readiness for change as a shared team property. Rather than an external reality that is “out there”, readiness for change is a shared psychological state (a collective reality) in which people in the organisation or system feel committed to implementing a change and confident in their collective abilities to do so; where changes in delivery of health and care require collective, coordinated behaviour change by many different people. Weiner’s approach has been subsequently developed into a psychometric test for measuring organisational readiness for implementing change by Christopher Shea and colleagues
Similar themes are carried into one of the most insightful studies about readiness for change in recent years; Explaining Matching Michigan: an ethnographic study of a patient safety program published by Mary Dixon-Woods and colleagues in 2013. Matching Michigan was an ambitious national programme, launched across England, to reduce central line catheter-related bloodstream infections and match the dramatic results achieved in more than a hundred Intensive Care Units in Michigan that had tackled the issues in a similar programmatic way.
The Intensive Care Units that the researchers studied were categorised as “transformed”, “boosted” or “low impact” as a result of the Matching Michigan programme. The low impact group was the big majority. What the researchers found was that these were complex, multi-factor environments at play that were not always easy to categorise or explain. However, the single most important influence on how individual units responded – either in promoting or resisting change – was the extent of consensus and coalition among the senior medical and nursing staff on individual ICUs. The commitment, characteristics and skills of local clinical leads was at the heart of how much change took place. Transforming or boosting of efforts was most likely to occur when the clinical leaders charged with making change happen were sincere and authentic in their beliefs about the value of the Matching Michigan program and the way they put that across. Other important factors were their ability to create alliances that crossed clinical disciplines, how much credibility they had among their local peers, were prepared to tolerate debate and dissent but exercise firmness, and used multiple tactics involving both intrinsic and extrinsic motivation, including role modelling, persuasion, sanctioning, reminders and constant feedback. The authors stress the importance of distinguishing technical interventions from implementation strategies, and the need for careful attention to the contexts in which improvement programs are introduced. .Actually, these are similar themes to those suggested by McNulty and Ferlie and Chris Ham and colleagues more than a decade ago.
So which tools for assessing readiness for change would I recommend? The tools I use most are those designed for assessing spread, adoption and sustainability in a healthcare context. Why? Because, as much of the research I have already quoted shows, there is a clear relationship between readiness for change, the extent to which change is likely to be sustained and its ability to spread. Here’s an Improvement Leader’s Guide that explains it further.
I often use the NHS Sustainability Model and Guide which helps us to identify the strengths and weaknesses in our implementation plans and predict the likelihood of sustainability. There are also three videos that go with the guide.
I also find this online tool to assess the likelihood of spread and adoption to be very useful. Both these tools are built on an extensive empirical evidence base. For me, the power of these tools is in the conversations that they spark between key stakeholders, and the different conversations they allow, rather than their predictive abilities.
If we look back over the past two decades we can see just how much effort we could save ourselves by considering readiness for change more reflectively and creating the conditions where change and innovation can flourish, rather than rushing into action and/or designing programmatic interventions. Of course readiness for change means putting into place all the programme and accountability systems that will build a strong governance platform for change. However, at the heart of readiness for change is the complex, interconnected web of individuals with different needs, interests, priorities, influences and previous experiences. We start from there.