Being an Agent of Change – less of the mystery and lessons in resilience.

Dr Melanie Benson

NICS-VQC Fellow

Palliative Care Physician

• ‘According to Darwin’s Origin of Species, it is not the most intellectual of the species that survives; it is not the strongest that survives; but the species that survives is the one that is able best to adapt and adjust to the changing environment in which it finds itself.’

(Megginson, ‘Lessons from Europe for American Business’, SouthwesternSocial Science Quarterly (1963) 44(1): 3-13, at p. 4.)

Agent of change

Change agents are those people within an organization who are leaders and champions of the change process.

- B Net Business Dictionary

http://dictionary.bnet.com/definition/change+management.html?tag=content;col1

• Development and publication of evidence regarding best practice does not ensure improved patient care Lenfant C. NEJM 2003

• Most quality improvement or change management interventions are currently designed intuitively and their results are often disappointing. Van Bokhoven

MA. QSHC 2003.

• Evidence based medicine should be complemented by evidence based implementation. Grol R. BMJ 1997

Implementation or KT

A planned process and systematic introduction of innovations and/or changes of proven value; the aim being that these are given a structural place in practice, in the functioning of an organisation or healthcare structure.

Zorg Onderzoek Nederlands 1997

Knowledge to Action loop

Graham ID et al. 2006. Lost in Knowledge Translation: Time for a Map? The Journal of Continuing Education in the Health Professions, 26, 13–24.

Agent of change characteristics• Leadership style

• Vision

• Dissonance

• Creativity

• Stamina

• Relationships

• Experience

• Delegation and Teamwork

Being a diagnostician - Problem assessment

• Identifying the gap in practice

• Review the literature, speak to colleagues

• Contextualise it

• Identify target group of practitioners

• Barrier analysis

– Target group

– Organisation

Van Bokhoven MA, Kok G and van der Weijden. Designing a quality improvement intervention: a systematic approach. Quality and Safety in Healthcare. 2003; 12: 215-220.

The 5 P’s of Change – Changing an organisation

• Pain

• Process

• Politics

• Payoff

• Persistence

Craig McAllister . "The 5 P's of Change: Leading Change by Effectively Utilizing Leverage Points Within an Organization“.Organizational Dynamics. Vol. 33, No. 3, 2004, pp. 318-328

Changing Clinicians Behaviour

• Clinical uncertainty• Sense of incompetence• Information overload• Lack of motivation to change• Professional territory issues• Criticism of quality improvement and guidelines• Environmental/organisational resistance to change• Competing demands

Grol R, Wensing M and Eccles M. Improving Patient Care – Implementation of change on clinical practice. Elsevier. 2005.Michie S, Johnson M, Abraham C, Lawton R, Walker A. Making psychological theory useful for implementing evidence based practice. Quality and Safety in Healthcare.. 2004;14:26-33.Oxman A, Flottorp S. Overview of strategies to promote implementation of evidence-based healthcare. In Silagy C, Haines eds. Evidence-based practice in primary care, 2nd edn.London: BMJ books. 2001.Grimshaw JM, Eccles MP, Walker AE. Changing Physicians’ Behaviour: What Works and Thoughts on Getting More Things to Work. The Journal of Continuing Education inHealth Professions. 2002; 22: 237-243.Grol R and Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. MJA Supplement; 2004;180: S57-S60.

Is there evidence for change?

http://www.cadth.ca/en/resources/rx-for-change/database

Sustain the change

• Plan for the project to become a process.

• Use rapid PDSA cycles initially then strategic PDSA cycles built into QI/Clinical governance activities

• Use existing roles but build capacity.

• Roles rather than individuals are important

Key lessons

• Clinical teams can and should be agents of change. Use all of your strengths.

• There are no magic bullets - Understanding your organisation and target group is key to the success of any projects.

• Change is incremental.

• Think of sustainability when designing an intervention (program not project)

• Sharing of knowledge and experience is essential.

• Knowledge sharing of what works AND what doesn’t is essential.

In the realm of ideas everything depends on enthusiasm... in the real world all rests on perseverance.

Goethe