Why is it not working?

Why is it not working?

Change is not easy. We often can get stuck in the mud as a result of beliefs and values (Transforming Your Organization Global Organizational Development White Paper Series

By John B. McGuire, Charles J. Palus, William Pasmore & Gary B. Rhodes) that constrain our thoughts and actions. This story starts with a clear need to act, follows a well honed process with great results. But then the wheels fall off. The article describes how Michie's COM-b model was used to understand what happened and why. It recommends that you also use Michie's tool so your change story can speed over the sticky ground to a successful future and avoid some of the pitfalls and traps that human nature can place in the way.

The need for change

This story started with a phone call to the CEO of an acute hospital within the National Health Service (England). It was not a pleasant call and it put to the centre of the CEO's attention the failure of one of their service teams to meet patient waiting time targets.

The CEO responded by creating a crack team that brought together expertise with the badges of seniority, performance management, informatics, operational service and change expertise.

Rolling out the standard change process

A well honed approach was followed; The current state was reviewed, mapped against its value stream, baseline cycle times and lead time were measured, waste identified and the root causes diagnosed.

A suite of products were created with the team members to address the root causes and build an improved future state. Members of the service were involved and preferred learning styles were built into the products. The crack team sat back and monitored the impact. After 6 months, the numbers of patients not treated on time fell from over 700 per month to just over 10. At the heart of this were the following improvements:

1. Better planning; The service rota was now created 6 weeks in advance rather than than 1 week.
2. Patients received more notice of their appointment; 6 weeks rather than less than 5 days.
3. The lead time to allocate an appointment to a patient, complete the administrative work and send the patient a letter was reduced from 3 days to 30 min.
4. Technology was used; 45% of orders now used a new electronic ordering system up from under 5%.
5. Increased utilisation of the service from 50% of available capacity to almost 90%.

Problems brewing...

Wow, what a great result! The organisation drew a collective breath and focus shifted to other area in the hospital. Then, almost three months later the data showed a blip, just a small one but, it gnawed at me. I couldn't leave it be and returned to the service for a walk about on the shop floor within the administrative team offices and also the clinic area. What I saw shocked me.

1. The daily team huddles where the day's targets were shared and tasks allocated to the team were in disarray.
2. I observed the work and saw huge variation; the staff who had undertaken the plan, do, study, act cycles had all been temps and had now left. Old ways were returning.
3. Staff spoke of their confusion caused by their different interpretations of waiting time and booking policy.
4. Staff were open about issues they were having. But, the process for capturing, learning from and dealing with these was not being used.
5. Vigorous and aggressive finger pointing was used to illustrate where the problems lay.

What now?

The root cause of all this was something deeper then simply a learning style problem and the approach to change that had been used. There was something else going on.

Professor Susan Michie is Professor of Health Psychology at University College London and has developed a robust evidence based model for evaluating interventions to change and assessing if they have worked. It was to Michie I turned to dig into this issue. From Michie's literature, I used a questionnaire she has used to evaluate a change in GP practice. The questionnaire evaluates three key concepts within the COM-b model that are important for adherence (positive behaviour) to change. In a little more detail these concepts are:

1. Capability; having the knowledge, skills, aptitude and confidence to undertake the task.
2. Motivation; developing a vision and plans, positive decision making and positive emotional impulses to drive the right behaviours.
3. Opportunity; the right tools and physical environment is in place along with a supportive and accepting culture to encourage and catalyse adoption.

What had happened?

The administrative and clerical team was selected for interview because this team was where the majority of the interventions had occurred. Three levels of staff were interviewed; the team manager (a mid-level manager in the organisation), a supervisor and three team workers. The questionnaire covers these three areas in depth. The key findings from the questionnaire are collated in Table 1. What they illustrate is the team are stuck in no man's land between old state and the vision state. The manager has lost focus and has not got a roadmap or plan of how to move forward. Training is not complete. The team do not own the changes and keep looking elsewhere when there are problems and are not taking responsibility for their work. Relationships are breaking down and the administrative team feel they are being hung out to dry because they are not getting feedback on news about the service and have lost touch with how they fit in.

Table 1. Collated outputs from the COM-b questionnaire

	Strengths	Weaknesses
Capability	The staff, supervisor and manager all had some knowledge of the new products and changes required in their daily tasks. They also understood why changes were needed. All staff reported a high confidence in using the new approaches and that adoption was easy.	The staff and supervisor reported a wide variability in the completeness of their training in terms of covering all the products and tasks they undertake. They also recognised they needed further ongoing support. The manager reported a low confidence in their skills and knowledge to lead the team through the change.
Motivation	The staff, supervisor and manager all felt positive around the changes and a belief that changes would help the team improve. They also felt that the changes were compatible with how the team functioned.	Interestingly, an old and experienced member of the team who returned during the improvement process was not happy, not relaxed, felt pessimistic, and agitated by the changes. The leader reported that they had no vision, mission or plan to guide actions to complete adoption. This was acutely identified by the returning experienced staff member. The staff reported that the manager was not carrying through with support for ideas for continuous improvement generated by the team. All members believed there was not enough time to make the changes. The team reported that they were often distracted and lost focus in undertaking the new ways. The processes were not yet automatic.
Social Factors	All the staff reported they were happy with the support provided during the diagnose and implement phases	The staff believed they needed more resources; more people and a better system. They believed there was a silver bullet and expected the 'Organisation' to bring it. The team reported the environment was not assisting them and the physical locations inhibited their work. The teams comments illustrated a feeling in being isolated, left behind and a frustration with the 'Organisation' and their colleagues in the clinical teams. The team did not get feedback or progress reports from their speciality. Medical colleagues were seen not adhering to an array of standards and the team believed this was unhelpful. The team believed that all training was provided by the 'Organisation' only and reported the Organisation was not providing the right training. The team felt they did not own the work. They functioned in a task orientated way. They believed their role was to accept and deliver a task. Making the service better was clearly not something they needed to be involved in.

Next steps

A number of actions have been created to address the key issues of variation in task and the culture of detachment and lack of full ownership. These are described in Table 2. Actions that are considered priority areas are highlighted in green. These aim to standardise the skills and reduce variation in how tasks are carried out, develop ownership across the work and generate clarity in the improvement journey. The actions also focus on developing relationships across the service and create a deeper understanding of the work and how it impacts on patients.

Table 2. Actions to address the issues identified in the COM-b questionnaire.

	Actions in process	Actions in planning
Capability	Take all staff through the revised, standardised induction process and complete the training of staff. Record level of competence using the skills matrix. Brief the senior management on the new processes and how this impacts on their tactical requests.	Vision to be clearly and repetitively communicated to the team. Training, coaching and support for the Manager around leading change All staff to attend the organisation training on patient waiting times and patient administrative system.
Motivation	Create measures and feedback progress and service issues to be formally cascaded to the team and views returned. Reintroduce the morning huddle to remind the team of the days goals, the allocation of tasks and identification of issues to be addressed.	Create an 'owner' from the team workers for each of the major task areas whose role is to maintain the process and identify opportunities for improvement. Manager to create a road map describing the dates for all elements of improvement to be automatic and integrated. Create a standard day for the team. Create an electronic diary schedule for the 5 standard activities and allocate team members to create a sense of ownership. Process for regular (monthly) staff feedback to be created and acted upon.
Social Factors	Lunch and learn sessions to increase understanding of the service and how the administrative elements impact on patient.	Team coaching to address the communication and cultural issues and get consensus agreement on how to move forward. Move team members to form small multi disciplinary cells supporting their clinical colleagues. Senior management walkabout from the Clinical Lead, Head of Nursing and General Manager. General Manager to provide permission to manager for them to act on the improvements identified by the team. Example; support the development of a well organised working environment, establishing an owner from within the team workers.

Getting out of the mud

Interestingly, the way forward is not dramatically different from where we picked up the story. Mud from previous battles had stuck and brought the original plans crashing down. The COM-b questionnaire is a sensitive tool that revealed where the mud was sticking. As mud rained down, everyone had taken refuge in different safe places impacting on communication and standards. Everyone was looking for a hero to save them, not realising that they are the only ones who can get them out of the mud. We are now busy cleaning down the mud and preventing it build up again. Getting everyone into the same boat, agreeing its direction and getting the crew to align tasks and work together across the difference disciplines will help them lift above the mud.

Next time you start a change project, consider if the COM-b model can help you avoid the mud trap.