Insights into improvement #4: Making improvements stick in general practice – factors 6 to 10

May 12, 2014

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In the previous post, we had the second installment of a discussion around the 22 factors (based on a thorough review of literature[1]) that have a huge impact on the sustainability of improvement / change.

In this post we discuss factors 6 to 10 – staff turnover, engagement / buy in, focus on the customer, vision / direction and stakeholder engagement.

6) Staff turnover

The issue of staff turnover and its impact on organisational change sustainability is one that polarises managers. On one hand it can be very damaging to sustainability[2]. This is because a high turnover of managers / senior staff can hinder a practice’s ability to learn and so imbed new ways of working.

The counter argument is that turnover introduces new ideas, and that people who have been in an organisation for a long-time are less receptive to change[3]. The greater the specialism and achievement of employees, the harder it is to engage them; especially if they are experts[4], suggesting that highly educated staff, who are be very prevalent in healthcare and general practice, can be a block.

The practical reality is a careful balance between the two. With structured and controlled staff turnover ensuring sustainability but also introducing new ideas.

7) Engagement / buy in

Many change attempts fail, including those in general practice, largely because employees feel left out of the process and end up lacking motivation, skills and knowledge to adopt new systems and procedures[5].

This staff involvement and commitment is the number one factor when considering elements associated with successfully implementing and making routine the new changes  – the defining feature of sustainability[6]. The mistake commonly made is that this lack of engagement and buy-in is commonly thought of as a ‘practice staff’ problem, but it can also be a problem in with the senior team in a practice.

Because of the pressures of everyday practice life, practices often fail to make clear what advantage is in it for the individual to participate in a change[7]. This can be more complex than often considered in general practice due to the common partnership model. It requires careful planning for partners to explain the ‘what’s in it for me’ for those staff without a personal stake in the business.

Finally, it is too simple to think that more engagement equals better. The problem is that organisations lose site of the rigour of the change in the excitement caused by increases in employee engagement. This can be seen in general practice where practices who are new to improvement see their initial successes. Through new found engagement the improvements become too organic and uncontrolled and thus steps are skipped and rigour is lost.

Peter Wickens8 argues, in the excellent Ascendant Organisation, that an organisation must achieve balance between employee engagement and control of the process. This is required for sustained change (see image right). Simply put, concentrate only on engagement and you get anarchy, too much control of the process and you get alienation.

8) Focus on the customer

“Understand customer value” is the first Lean principle[9] and vital for all improvement work. The pressure practices face from both internal and external factors can sometimes turn attention away from this – for example budget pressures. It needs a conscious effort by an organisation not to de-personalise and lose this connection with customer value. The overriding principle is to Link everything to creating value for your customers, your organisation and your people[10].

9) Vision / direction

Linked to the previous factor (engagement), practices need to go out of their way to make everyone aware of what they are trying to achieve and why they are doing that[11].

In general practice this requires a vision (or strategy) that goes beyond a high level document located in a filing cabinet. It requires a vision that is easy to articulate and that is referred to frequently.

A vision / strategy needs to contain the following elements[12]:

  • Realistic assessment of current situation.
  • Coherent vision of the future.
  • Understanding of the transition required to bridge from present to the future.

A vision for a practice needs to have a balance of the hard and the soft. As the NHS Change Model suggests, you are more likely to gain staff commitment through a discussion about a shared purpose rather than targets alone.

10) Stakeholders engaged

Inadequate engagement of critical stakeholders is a common reason cited for lack of sustainability of organisational change[13]. In general practice this is a complex task, with a complex relationship between customers (patients), commissioners (such as the CCG), regulators (such as CQC) and staff.

For many healthcare organisations the stakeholder control of an organisation does not follow traditional organisational lines. Healthcare organisations are professional bureaucracies where control lies with the professionals delivering the services (not the appointed leader[14]). The situation in general practice is not quite as stark.  As a sector that predominantly operates a partnership model, the practical reality is the professionals are the leaders and owners of the organisation.

Next time with regard to sustainability: We unpack the factors 11 to 15 –leadership, complexity, incentives, uncertainty and scientific thinking.

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

[3]Fraser, S. (2002): Accelerating the Spread of Good Practice, CHICHESTER:  Kingsham Press AND Massey, S. Williams, S. (2005): CANDO implementing change in an NHS Trust. International Journal of Public Sector Management, Vol 18, Issue 4, 330-349

[4]Fraser, S. (2002): Accelerating the Spread of Good Practice, CHICHESTER:  Kingsham Press

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

[6]Greenhalgh, T. Robert, G. Bate, P. Kyriakidou, O. Macfarlane, F and Peacock, R. (2004a): A systematic review of the literature of diffusion, dissemination and sustainability of innovations in health service delivery and organisation. LONDON, NHSSDO Programme, 2004

[7]Ham, C. Kipping, R. McLeod, H. (2003): Redesigning Work Processes in Healthcare: Lessons from the National Health Service, Milbank Quarterly, Vol 81, No. 3, 415-439

[8]Wickens, P. (1998): The Ascendant Organisation. 2nd edn. BASINGSTOKE: Macmillan Press Ltd

[9] Womack, J. Jones, D. (1996): Lean Thinking. 1st edn. LONDON, Simon and Schuster

[10]Hines, P. Found, P. Griffiths, G. Harrison, R. (2011): Staying Lean – Thriving, not just surviving: NEW YORK, Productivity Press, 2nd Ed, ISBN 978-1-4398-2617-1

[11]Hines, P. Found, P. Griffiths, G. Harrison, R. (2011): Staying Lean – Thriving, not just surviving: NEW YORK, Productivity Press, 2nd Ed, ISBN 978-1-4398-2617-1

[12]Hines, P. (2010a): How to create and sustain a Lean culture1, Training Journal, June, 28-32

[13]Kee, EK. Newcomer, K. (2008): Why to change efforts fail?, The Public Manager, Fall, 5-12Kotter, J P. and Schlesinger, L A. (2008): Choosing Strategies for Change, Havard Business Review, July / August, 130-138

[14]Ham, C. Kipping, R. McLeod, H. (2003): Redesigning Work Processes in Healthcare: Lessons from the National Health Service, Milbank Quarterly, Vol 81, No. 3, 415-439

Ascendant Organisation: Simple Model. Source: Peter Wickens