The difficult art of implementation

From 2005 through to 2008 I undertook a doctorate in patient safety.  The focus was on implementation; the factors that help and hinder implementation of patient safety practices, interventions and guidance.

I have yet to publish articles (I know an academic crime) following my research, partly because I would add to the 2.5 million articles produced in healthcare every year and ironically therefore add to one of the main factors that hinders implementation.  I did however produce an implementation toolkit for developers of guidance and led the implementation year of the campaign, ‘Patient Safety First’ using all the lessons I had learned.  So I thought I would produce a serious of blogs for anyone who is interested in both patient safety and the difficult art of implementation.

Implementation is shorthand for how innovations, interventions and guidance are communicated, disseminated, adopted, and spread.  For the purpose of this blog I shall just refer to these as ‘change’.  The aim is obviously to do this effectively so that the new practice or change is sustained and embedded into everyday practice.  My research included talking to and observing leaders, managers, junior doctors, frontline nurses and experts. So what did I find?

Implementation is a process not an event, it is complex and requires both expertise and concerted effort, it most definitely is not about simply telling people to ‘do it’.

The following are key to successful implementation:

1. Demonstrating that the change is better than status quo and relevant, with tangible benefits – i.e. the answer to the question ‘Why should I bother?’ or put it another way, ‘there needs to be a need for the change’

2. The change is easy to do – i.e. it doesn’t need a 100 page manual or intense hours of training and there are lots of useful resources to help reduce the time it takes such as a set of templates or presentation slides already created for you to adapt

3. The change is adapted to local conditions – i.e. something that works in another country, another organisation or even another team will not automatically work for you – you have to test it, adapt it, and test it again to get everything to feel it fits for them

4. The change is liked by people you respect, often referred to as peer to peer influence or the use of opinion / role models – i.e. you will implement changes that are liked by people who do a similar job to you, and you think are sensible, possibly even charismatic, and you want to a) be like them and c) do what they do because if they like it, it must be good

5. The change matches your intrinsic motivators – i.e. presses the buttons that make you want to do things, like your beliefs, moral compass, ethics, desires, competitive streak, positive feedback, energising activities and so on

6. Reward and recognition – i.e. people are recognised for their actions, thanked and valued for their contribution to safer care

7. Measurement and visible results – i.e. I know obvious, but you cant tell how well you are doing, you cant offer recognition and make people feel good about what they have done, if you haven’t measured it

The things that hinder are:

1. Training – i.e. didactic training with no consideration of the success factors above

2. Simple dissemination with no support – i.e. a guidance passively disseminated expecting people to notice

3. Carrots or sticks in isolation – i.e. providing incentives or punishments without thinking about the success factors above

4. Lack of awareness – i.e. no recognition of the problem

5.  The wrong solution – i.e. the change doesn’t actually address particular problem that needs addressing

5. Lack of or poor preparation

The external factors that get in the way are:

1. Volume: the huge number of articles, policy documents, guidance, interventions  published daily – coming from all different directions including your own organisation

2. Quality: or seeing the wood for the trees – trying to figure out which are the ones to pay attention to and which are the ones to ignore

Increasingly as I attend meetings events or conferences the last line seems to be, ‘the key problem with improving safety is implementation of the things we know work’ with the assumption often that surely this must be easy.  It isn’t.  If we do ‘one thing’ it is for the ‘problem of implementation’ to be owned by the guidance developers, solution designers and researchers and not those that are expected to do the implementation.