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Discussion

Leading change: 3 - implementation

How to pilot, implement and review a change and make sure it is sustainable

In this article…

  • When to implement a pilot project
  • How to measure success
  • Ensuring the project is sustainable


Author

Joanna Kerridge is practice educator at Sue Ryder Nettlebed Hospice and associate lecturer at the University of West London.

Abstract

Kerridge J (2012) Leading change: 3 - implementation. Nursing Times; 108: 6, 23-25.
The potential for all staff to contribute to service improvement, irrespective of discipline, role or function, is outlined in the 2011 NHS leadership framework. This advocates developing the skills of the entire workforce to create a climate of continuous service improvement.
As nurses are often required to take the lead in managing change in clinical practice, this final article in a three-part series focuses on implementing and reviewing change.

Keywords: Change management/service improvement/sustainability

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article

 

5 key points

  1. Before implementing change, check your action plan is complete and resistance has been dealt with
  2. People adopt change at different rates - there are innovators, early adopters, early majority, late majority and laggards
  3. Use PDSA - plan, do, study, act - cycles to gauge whether your change will work and adjust plans accordingly
  4. Monitor and measure your success in terms of the organisation and the individual
  5. Ensure sustainability through engagement, aligned priorities, routine feedback, and support from senior management and clinicians

 

The potential for all staff to contribute to service improvement, regardless of discipline, role or function, is acknowledged in the recently published NHS Leadership Framework (National Leadership Council, 2011). This framework advocates developing the skills of the entire workforce in leading innovation and creating a climate of continuous service improvement in the health service.
However, although most people have the potential to lead in a particular situation, they may not have the confidence to do so. They may lack the knowledge of the theory and tools available to help them when the opportunity arises.
This final article in a three-part series aims to help nurses at all levels to develop the knowledge and skills they will need to function as change agents within their organisations. It is aimed at those who find themselves in a position to influence practice by leading their colleagues in implementing change, and focuses on implementing and reviewing the change to ensure sustainable service improvement.

Implementing and reviewing the change

Once you have planned your project, there are three steps to ensuring the best chance of success.

  • Get going: pilot the change;
  • Monitoring and measuring success;
  • Sustainability.

Get going

It is often difficult to decide when the planning of a change should end and implementation begin.
It is important to check you have your action plan in place and all preparatory work has been completed. Within that plan, look at whether the key milestones have been reached. Other aspects to consider are whether the baseline measurements have been used to identify any progress or positive effects. You also need to ensure you have reconsidered or resolved areas of resistance.
Once all these tasks have been done, you can start piloting the change. If you do not get going, other things could take priority and the project that you, and others, have invested so much time in will be at risk of disappearing from your “to do” list.
It is important to understand that people do not adopt change at the same rate. Moore (2007) identifies five groups of adopters:

  • 1 The innovators make up 5% and may seem to be your most important allies, as they will be keen to adopt new ideas. However, they can be perceived as too radical and may actually be counter-productive.
  • 2 The early adopters (10%) are key innovators as they tend to be well connected and respected within the organisation. They will be open to change and should be identified and engaged to help with implementation as soon as possible.
  • 3 The early majority (35%) must support your change if it is to succeed. This group will contain people of influence and authority who lead others through power based on skill, competence or social accessibility. If you gain the support of this group, the support of the late majority will usually follow.
  • 4 The late majority (35%) prefer the status quo but, if you can engage them early in the process and address their resistance to change, they will usually support change.
  • 5 The final group, the laggards, make up 15% of the total. This is a substantial proportion and they should not be ignored. They may never be interested in change but, if you keep them informed and take care not to alienate them, they may eventually accept it.

Piloting

PDSA cycle

When you have engaged your early adopters, you can begin trialling your change on a small scale and assessing its effectiveness.
Through use of the plan, do, study, act (PDSA) cycle (Langley et al, 2009), you and your stakeholders can gauge whether the change will work (Fig 1). This cycle also enables you to identify any snags or risks that were not previously apparent, and to make any adjustments if the change is not working before repeating the cycle.
If your change is complex or involves multiple departments, you may want to run more than one pilot. Learning from these test cycles will increase chances of success when you implement the change fully, as you will already have identified and addressed any areas of difficulty or conflict. If you are able to involve other colleagues in this cycle of testing and development, you will also reduce resistance and break down barriers to change.
Once you have trialled your change and reviewed its effectiveness, and are confident that you have identified the change with the greatest benefit, you can begin to implement it fully.
Return to your action plan to review it and make any necessary changes; continue to update it as you progress so that your record of implementing the change is current and accurate.
It is vital to ensure that all stakeholders know what you are doing and what you have learnt from piloting the project. Langley et al (2009) suggest producing a brief interim report on the pilot to show clearly that you have taken notice of any risks or conflicts, and that there is evidence that the change will achieve what you want it to.
The change can then be implemented using the PDSA tool in continuous cycles. If you are implementing a change in a number of areas, you can stagger it by implementing it in the same way as you did for pilot sites. In this case, it is often most effective to return to the original pilot sites first, as this is where you will have the most support if the pilot was successful. If the project was not successful the first time round, you will need to show that you have learnt from the experience and made changes to reflect this.
Once the implementation is under way, provide regular feedback to your teams to ensure they see the progress being made and continue to support the change (Langley et al, 2009).

Monitoring and measuring success

Once the change has been fully implemented, a review period should be fixed to ensure that the new arrangements continue to meet the original aims, and that there has been no reversion to previous methods that were causing problems or not working efficiently.
The following questions should be asked:

  • Are we meeting our targets?
  • Are we attaining the desired level of quality?

In part 1 of this series, three questions were identified to help you determine whether your proposed project or change would be likely to achieve what you set out to achieve. Returning to these questions will help you to quantify any improvement:

  • Do we do more work in the same time (improve efficiency)?
  • Do we do our work better (improve effectiveness)?
  • Do we save money (improve economy)?

The NHS Institute for Innovation and Improvement (2008) suggests breaking down this analysis into benefits for the service (organisation or NHS) and benefits for the individual (patient or staff).
You can identify service benefits by looking at the input, process and output from your project. For example:

  • Input - have there been any changes in the use of staff, equipment or buildings? Are we using less or more? Is this more or less efficient?
  • Process - are we processing things faster or slower? Have turnaround times improved?
  • Output - have quantity or quality outputs changed for the better or stayed the same? Outputs may change for the better by going up or down. The same output with less input or improved process means greater efficiency. Seeing fewer patients may mean that treatments have improved or there have been fewer readmissions.

Individual benefits can be measured in terms of quantity and quality (NHSI, 2008). For example:

  • Quantity - have time frames been reduced (patient journey, waiting time or delays in discharge or treatment)? Has the number of visits been reduced for patients or health professionals? Is this a good thing?
  • Quality - has the service improved by being of better quality or through more timely intervention? Has the patient or staff experience improved? It would be a good time to revisit patient or staff satisfaction.

Adverse results may require a root cause analysis or re-mapping of the process to identify why the improvement has faltered. There may be a simple solution that can be implemented through another PDSA cycle, or there may be a more fundamental problem: the sustainability of the improvement may not have been secured.

Sustainability

Around one in three improvement changes within healthcare services fail after implementation (NHSI, 2008). This happens for a wide variety of reasons but it will be disheartening for those who have invested in the change to see it flounder.
Sustainability should not be left to chance, and much of the guidance in these three articles has been designed to embed sustainability into the project from the start.
Sustainable changes are undertaken with the involvement of stakeholders. Engaging others in developing and implementing the changes will result in them taking ownership and having an interest in keeping them going (Anderson, 2010).
It is important to ensure that the project has obvious advantages for all concerned. People will put up with some disadvantages if they can also see some improvement for themselves or those they are most concerned about. Aligning the change to the values or vision of the organisation so that everyone can clearly see how it links in with their own goals will make it more meaningful to them personally.
It is important that there is a commitment to ongoing training to support the change, including sufficient resources secured for new staff (Maurer, 2010). A potential danger is that there will be a initial flurry of training, with resources and funding provided for the implementation of any improvement but, over time, other matters will take priority and resources may be diverted elsewhere.
Maurer (2010) identifies senior management and leadership support as the vital component for ensuring sustainability until the change becomes embedded in the organisation and is no longer seen as “the change”. Everyone in the organisation needs to know that the most senior people fully support the project, and that there is sufficient funding to cover the costs of sustaining any improvement.
Embedding the change in working practices is likely to involve changing policies, protocols or pathways of care to reflect the improvement or new way of working. These can then be used to set new standards or benchmarks to measure against. The ultimate goal of any change agent is to implement the innovation to the point where no one can undo the changes made (Moore, 2007).
At this point, your role as the change agent is to continue the improvement, celebrate the change and share it with colleagues. You can also use your skills and experience to help others to implement a similar process.
Once you have completed the process, it will encourage others to change the things they want to change too and, if you and your colleagues help them, you will be less inclined to let your improvement fall by the wayside.
Take time to reflect on your success and positively reinforce the team’s efforts. Also, identify whether there is even more room for improvement but do not make more changes for the sake of it. It is easier to be brave and tackle more difficult targets once you have a success under your belt.
Do not become a victim of your success. Once you have proved how good a change agent you are, you may be swamped with new ideas for service improvements, and it is easy to be flattered into accepting more projects before you have fully implemented your original one. The danger of doing this is that nothing will then get finished as you drown in a sea of new initiatives.
At the end of a successful change, just remember that today’s sustained change becomes tomorrow’s resistance to change. Change should only be sustained until a better idea comes along and you can start all over again.

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