Implementation

This is another blog in the series linked to my second book which can be found here:

Part two focuses on the theories and concepts described in part one and explores how we can turn these into practice i.e. how we can practically use them to improve the safety of patient care.  It explores the methods for studying daily work – often coined as ‘work-as-done’.  

The different approaches here help us actually notice the things we don’t notice and reflect on the non-events and things we take for granted every day from morning to night because they work just as they should.  

Part 2 shares the work of Erik Hollnagel, Steven Shorrock and Jessica Mesman and others who are exploring the different approaches that can bring the new safety concepts to life. Its starts off by delving into the world of implementation.

Part of my doctorate in patient safety focused on implementation. This was in part because I wanted to explore how we could help people turn policy into practice. Implementation is a complex process with multiple steps required to take a piece of research or a good idea, or good practice and turn it into action.  If the good idea is picked up or adopted by individuals and then used on a day to day basis it is then said to be embedded or engrained.  If the good idea is then shared across to other individuals it is described as spread.  If the good idea sticks and people continue to be different as a result it is said to be sustained.  

Implementation therefore is the combined process of dissemination, adoption, embedding, spread and sustainability of good ideas.  It surprised (even shocked) me when I found during this work that it takes, on average, 17 years to turn 14% of original research findings into practice and there is a sustainability failure rate of up to 70% of organisational change (Woodward 2008).  We definitely need to reduce that length of time down!

At every stage of the process people can and do get it wrong.  It is not nearly as simple as people think.  Implementation needs dedicated resources, funding and time and a shift away from the short term approach to change and implementation.  It is a fantasy to think that an idea can be implemented through to sustained change in just three to five years.  This is in part because implementation requires a culture shift; a culture whereby the embedded idea it still used even when politics, or policies or people change.  Understanding the simple reality that implementation takes times is an important step.  

In healthcare the traditional approach to implementation is to simply disseminate the good idea and expect the ‘audience’ to pick it up and run with it.  The approach with guidance or alerts is mainly one of distribution to a passive group of people who may not even notice that it has arrived.  The approach of relying on passive diffusion of information to inform health professionals about safer practices, is doomed to failure in a global environment in which well over two million articles on clinical issues are published annually.  

In patient safety there are lots of good ideas about keeping patients safer or reducing harm.  There are the large top down interventions but implementation is not always about making a large change; in fact it is often about making small incremental changes that can make things easier, better, more effective and safer.  

it is said that making changes after a major incident or a catastrophe has a stronger chance of success because of the motivation caused by the incident itself.  The harder thing to do is to convince people to change without something major happening.  Visible outcomes are always great motivators whether you want to lose weight or reduce the number of falls or pressure ulcers.  Seeing the graph go down or the weight go off are great way in which to convince people to continue.  What if you can’t see them?  Most change is not an earth shattering improvement that everyone will want to talk about and share.  Some change is invisible – how do you show that you have saved lives or prevented harm.  

National bodies in the UK in particular love to create standards, alerts and ‘must do’ notices and targets.  There have been repeated alerts published and disseminated in relation to the same topics in healthcare.  This should tell us that the method of ‘telling people just to do it’ isn’t working.  The people on the receiving end are expected to implement these quickly often with very little resources to help.  What implementation scientists tell us is that guidelines or standards or alerts issued in isolation rarely change people’s individual practice.  They are, at best, complied with, but they have not been found to drive sustained improvement.  This is the gap between what we assume improves patient safety and what is actually done in practice.

Subsequently in healthcare we are drowning in ways in which we could improve; numerous interventions and solutions, lots of research and guidance.  The volume is challenging with a constant barrage of guidelines which lessens their impact and reduces compliance with the more important ones.  There are multiple polices and guidelines for the same topic which are hard to access and have confusing titles as well as being extremely long and wordy.  

Those designing the interventions or guidance that they want to implement must be aware of the impact that they are making.  The must seek to understand work-as-done and get beneath the surface of what is going on every day.  But, every day the ‘every day’ gets in the way of noticing anything new.  How do we help people to notice the things they need, when they may only have five minutes in their day to sit down and look beyond their daily activity?  

One key way of doing this is to be much less directive.  

There is no one size fits all.  Contexts differ and as a result people need to vary their actions from place to place. Instead of prescribing steps people could be left up to themselves to adapt and own the intervention or solution.  Fit the intervention within the system rather than force it.