STAGE :FOUR making improvements Changing behaviors • Theories of how behavior changes help to explain the influence of the situation in which the change occurs. • Encountered in many different fields, • Education and learning, • Management, • Economics, • Sociology, • Psychology. NCCSDO (National Co-ordinating Centre for NHS Service Delivery and Organisation) summarised the change management literature and described the context of the modern NHS (Iles and Sutherland, 2001) • different socialisation processes of the professions • different needs and expectations of different client groups • the different histories of different institutions • local priorities, resource allocation, and performance management. Organisational change • Organisations can be thought of as existing in a state of quasi-equilibrium, in which driving forces are opposed by restraining forces, with the net effect that changes in the organisation are minimised. Driving forces • Restraining forces • Patient pressure Individuals • National policy • Fear of increased • Demands from referring workload general • Concern about staffing • practitioners for improved and mix access • Loss of control over work patterns Organisations • Resistant culture • Lack of resources • Rigid structure Group change • A group exerts pressure on its members to conform, and this pressure can be so powerful that individuals not only comply, but come to believe that the group view is valid and adopt it as their own Individual change • The trans-theoretical model, which was developed for management of people with addictive behaviours, such as smoking (Robertson, 1999), explains individual behaviour change as a transition through a series of five stages: • precontemplation – the individual has no intention of changing. • contemplation – change is regarded as a possibility in the near future. • preparation – explicit plans are made. • action – the change occurs. • maintenance – the changed behaviour is consolidated. Identifying barriers to change • If the barriers to change are identified beforehand, implementation methods can be tailored to overcome them. • Obstacles to change can be identified in several ways (Table 13), but generally the simplest and most practical method should be used. Some methods of identifying barriers to change. • Interviews of key staff and/or users. • Discussion at a team meeting. • Observation of patterns of work. • Identification of the care pathway. • Facilitated team meetings with the use of brainstorming. Implementing change: • A recent review of tools, models and approaches to changing management in the NHS. (Iles and Sutherland, 2001) provides a helpful overview of how change can be.implemented, addressing issues affecting the management of health services rather than just clinical care, which tends to be the focus of clinical audit. Promoting successful audit • Most health professionals have taken part in audit before, and their experiences support the more formal reviews of implementing change – it is possible to change practice, but it is not a simple process • Factors that promote the success of clinical audit include. • lack of resources • lack of expertise in project design and analysis • lack of an overall plan for audit • poor relationships between professional groups or agencies and within teams • organisational problems, such as lack of a supportive relationship between clinicians • and managers (Johnston et al., 2000). Establishing the right environment • Nature of environment is more important for the implementation than for other aspects of audit. Individual environments • Individuals need time to implementing improvements. • Giving opportunities to think, discuss practical issues with others make a change less of challenge. • Time alone is not sufficient, systems and support also available to help in improving existing skills or develop new ones of individuals. Team environments • teams must be able to meet together, to discuss their objectives and share ideas about making changes in their work. • Once meetings are established,leadership skills are needed to establish effective communication and ensure that everyone is able to contribute Organisational Environments • chief executives are accountable on behalf of trust boards for assuring the quality of services. • seeks to improve it should regard the experience of service users as the starting Point for change. • Must not fear external review by the health service or the public, • Must be able to show openness and freedom Users and the public Communication with the local public must be good, and depends on effective communication systems. • All trusts are to ask users for their views on the services they have received. • Every local NHS organisation is to publish a patient prospectus setting out the range of services available and the ratings users have given them. • Financial rewards to trusts are to be linked to the results of the annual National Patient Survey. • User versions of guidelines and other forms of information for users about the care of particular conditions are to be routinely available. • annual prospectuses, published by all trusts and Local Health Groups, that set out the services available (ministry of health and social services,2001).