Insights into improvement #2: 22 factors that make improvements stick in general practice.

November 20, 2013

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Based on our expertise and a thorough review of literature[1], we discuss 22 factors that have a huge impact on the sustainability of improvement / change. We have decided to add a bit of context (after all, anyone can talk about these factors theoretically) and discuss what these factors would mean in general practice. We will also provide links to literature supporting the argument. Don’t worry if you work in another setting, these all transfer.

Central to general practice meeting current and future demands** is improvement. Making internal processes more reliable, more efficient and maximising clinical time. But making improvements is hard.

75% of organisational improvements fail[2]

To avoid your improvements adding to the 75% you need to plan for sustainability. Before making improvements, a practice should consider what needs to be in place to make their improvements stick.

This is because trying to change and improve ways of working is very difficult. Old ways, like gravity are always with us[3]. They are always threatening to re-appear.

The 22 factors (in no particular order):

  1. Time / capacity
  2. Ability to adapt
  3. Constant input
  4. Mechanisms to exploit the change
  5. Urgency
  6. Staff turnover
  7. Engagement / buy in
  8. Focus on the customer
  9. Vision / direction
  10. Stakeholder engagement
  11. Leadership
  12. Complexity
  13. Incentives
  14. Uncertainty
  15. Scientific thinking
  16. Communication
  17. Organisational size
  18. Method
  19. Control plan
  20. Early wins
  21. Process knowledge
  22. Standards

A practice can dramatically enhance the chances of improvements succeeding by taking a bit of time to consider these factors. Most of the factors are enablers, i.e. they should be considered before you make a change. The enabler factors are things that are often glossed over or forgotten about – but they pose the most risk to your improvement ambitions.

Below is an overlay of the 22 factors against Peter Hines’[4] useful Lean Iceburg.  All of the enablers being under the waterline, while the things we tend to consider (process factors) are above the waterline.

Just like all icebergs, it is what is below the waterline that really does come back and bite you. The secret to sustaining improvements is in the preparation (considering the enablers), not in the actual practical application.

Next time: We unpack the first five factors. Time / capacity, ability to adapt, constant input, mechanism to exploit the change and urgency.

Want help or want to discuss any of the themes in person? Contact us.

[1]Downham, N. (2011): The identification of factors that are pre-requisite to the sustainability of Lean based change and the assessment of whether they are present in the general practice of the English National Health Service, COVENTRY, Coventry University, Faculty of Engineering (a big thanks to Wendy Garner for her expert support on this project)

[2]Dawson, M J. Jones, M L. (nd): Human Change Management: Herding Cats, LONDON, PWC, P21-23

[3]Emiliani, B. Stec, D. Grasso, L. Stodder, J (2007): Better Thinking, Better Results, WEATHERSFIELD, The Centre for Lean Business Management, P287

[4]Hines, P. (2010): How to create Lean culture1, Training Journal, June, P58

**The pressure on general practice:

The focus on general practice (or family practice) and primary care is increasing as health systems around the world view general practice as the focal point for better health care. General practitioners are now expected to manage the entire patient journey across multiple providers, manage more complex long term conditions, manage greater numbers of patients with acute lifestyle related illnesses, stand up to greater scrutiny, get involved in commissioning, meet the increasing demands of the public and finally deliver all this in a less generous funding environment.Quite simply, the pressure is on general practice to deliver more for the same.