While we are discussing them in the context of general practice, they are all transferable if you work in a different setting. We will also discuss them in the context of Lean – one of the most prominent improvement methodologies. Finally, and also in the previous post, we looked at the how the 22 factors split between process factors and enabler factors by considering the factors against the Sustainability Iceberg.
1) Time / capacity
Time is a crucial consideration before any change starts. Leaders often show a level of naivety when it comes to the length of time organisational change takes.
A general practice needs to be willing to invest time and also to be clear that substantial improvement can take years to implement and sustain. As small businesses, general practices generally don’t have much exposure to change theory in terms of the time required. They also don’t tend to have the level of infrastructure around them that permits the investment of resource that other parts of healthcare have; for example the hospital sector. So when considering the time requirements, the question for a practice senior team often turns into ‘am I willing / able to put the time in’.
Practices should look to achieve early wins but also not fall into the trap of not viewing change as a continuous process, i.e. viewing change as an unfreeze, change and re-freeze process. Of course, in general practice, much of the pressure on time comes from matters external to a practice. So it is useful to think of time at a number of different levels, including at the individual, team, organisation and system, to think about time in. This means regional stakeholders have a roll to play in providing general practice with the right conditions to put the time in.
2) Ability to adapt
Adapting, not copying, Lean, or any large-scale improvement methodology, to your context is essential. Transformation involves changes that are too fundamental and deep-seated to be transferred by a copy and paste approach.
Don’t just copy others, think through your approach based on what you are trying to achieve.
As general practice is made up of small businesses there is little standardisation of working practice across different practices. Different general practices serve very different populations. Different population demographics have different needs and so what constitutes value and the demand profile can differ greatly between practices. A general practice needs to adapt improvement methods to their context, not copy others.
A good place to start is to consider the level of demand variability. Or the way the amount of work we have to do varies. Just blindly using a technique from the automotive sector (where demand is very heavily smoothed) is unlikely to work in the world of general practice where demand varies a lot.
3) Constant input
Improvement is not temporary, it is not something a general practice can start and stop. It requires constant maintenance and is something a general practice is committing to for the foreseeable future. The trap is leaders and managers tend to close programmes – remove the Hawthorne effect and then performance declines. A humbling example of this message can be seen when considering how one of the greatest Lean success stories was brought down. At Wiremold (a complex small to medium sized manufacturing company) their Lean transformation took 10 years to build and only 3 years to destroy (by a change of management not sharing the same values).
For a general practice to sustain a Lean based change it needs to avoid a ‘fire-fighting’ or short term approach to management and maintain a constant input over a long period of time.
4) Mechanisms to exploit change
General practices need to identify what they are going to do with any gains and also create a process for exploiting gains. A common mistake in any setting is to concentrate on creating an improvement without first having a plan on how to exploit the improvement to produce a benefit. 
For example a practice may be able to release capacity but it will not see a credible benefit from that unless it has considered what it is going to do with the capacity. Further staff training, going home on time, reducing the resource profile, increasing the practice list size are all options.
A general practice needs a strong sense of urgency to be able to challenge convention and ‘old ways’ of working. A practice needs to be able to communicate that urgency to all members of staff in a way that answers the ‘what is in it for me?’. General practices, as with healthcare in general, have had in previous years less urgency for change than in a more market driven sector such as manufacturing. The format of general practice has not changed in many decades and for general practitioners to contemplate a change using a method such as Lean, they need a strong sense of urgency. This urgency is now pressing down on general practice creating a compelling business need for change. It is just the remarkable resilience of general practitioners and other general practice staff that is stopping many practices failing.
Next time: We unpack the factors 6 to 10 – Staff turnover, engagement / buy in, focus on the customer, vision / direction and stakeholder engagement.
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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)