Domain 5: Responding to complexity in the organisation
The project is only going to work if the organisation has the capacity to take on innovations and if there is good ‘innovation-system fit’. The tips below may help if you are trying to support an organisation to implement a new, technology-supported care model.
Assess the organisation’s capacity to innovate. An innovative organisation has strong leadership, good clinician-managerial relations, a devolved management structure, slack resources (money and/or staff) that can be channelled into new projects, good lines of communication and an ethos where it’s OK to take risks and learn from failures. If an organisation appears to lack these essential prerequisites for innovation, consider whether you need to strengthen its capacity before pressing ahead. Here are some questions to help you assess capacity to innovate:
- Is there a culture that supports innovation and change (e.g. are staff trusted to introduce new ideas)?
- Does the organization have systems and processes in place that support innovation and change e.g. effective information and communication systems, opportunities for networking and learning across departments/teams?
- Do the senior management team actively seek opportunities for improvement and encourage ideas and feedback from patients, the public and staff?
- Are the organisation’s leaders helping to create a facilitative context through providing motivation and support, creating a vision and reinforcing the change process?
- Is there a distributed and devolved style of management?
- Is there a history of introducing successful change in comparable projects at a local level?
- Are there mechanisms in place to support learning and evaluation and to embed changes in routine practice e.g. regular team meetings, audit and feedback processes, professional development opportunities and performance review systems?
Assess innovation-system fit. Even when an organisation is capable of running a successful project to implement a new technology, it might be the wrong technology to introduce in this organisation right now. Has the organisation successfully adopted similar technologies in the past? Are its strategic priorities aligned with the use of the proposed technology? Or are other projects more pressing?
Assess the implications of the technology for the organisation. Careful mapping out of tasks and processes is necessary to surface how the technology or other innovation is likely to change these. The pathway in which the technology is used directly (e.g. clinical care) may have indirect knock-ons for other processes and pathways (e.g. booking, correspondence, billing). You need to estimate costs (both initial and recurrent), and consider how money will need to flow across the system. Before signing off on a project, boards generally want to know how much will it cost up-front, what the likely savings will be, and when these savings will occur. These resources may help:
Process mapping guide from NHS Improvement. Ideas and tools for mapping the steps in a care pathway. A full list of additional service improvement and redesign tools from NHS Improvement is available here.
Using costing information to support better outcomes – a guide from NHS Improvement.
Assess the level of ‘political’ backing for the innovation. For an organisational-level adoption decision to be approved, it needs support from both top management (a ‘senior sponsor’) and the rank-and-file. Supporters of the change must outnumber opponents and be more strategically placed. People with ‘wrecking power’ can block progress and may need to be brought on board (or worked around). To assess all this, use the NASSS-CAT PROJECT tool and also:
Stakeholder analysis guide from NHS Improvement. This guide will help you construct a table or chart listing all the stakeholders who will need to accept (and, in many cases, start to use) the technology. Consider each key stakeholder’s perspective (and their potential wrecking power).
Consider inter-organisational relationships. Costs and benefits of technology projects are hard to predict, and savings may accrue elsewhere in the system. When there is no pre-existing contractual relationship between organisations, it can be hard to reach a satisfactory arrangement for how to manage these uncertainties.
Think how (and by whom) success will be evaluated. If this project is going to happen, you will need to monitor how well the change is going. You will almost certainly need both quantitative metrics (to answer the “how many…?” and “are we on track…?” questions) and also qualitative measures (to answer the “how do people feel about this…?” questions). Evaluation is everyone’s job, and data are often best collected by people doing the job. Extensive data collection can be time-consuming and slow the project down (i.e. the perfect may be the enemy of the good).
Evaluation: what to consider – A guide by the Health Foundation. This basic guide includes qualitative and quantitative approaches.
The ‘rainbow framework’ for evaluation and monitoring by Michael Quinn Patton. It takes you through 7 colour-coded steps, namely Manage (e.g. define stakeholders, secure funding), Define (set a scope for the evaluation), Frame (intended users of the evaluation, what they will use it for, what success will look like), Describe (sample, measures/metrics, data sources, analytic approaches), Understand Causes (deeper analysis to produce explanatory models), Synthesise (combining results), and Report & Support Use (publishing and disseminating).
Evaluation Works and Evidence Works toolkits to guide commissioning decisions, produced by West of England Academic Health Sciences Network and their partners.
Allocate funding. Studies of ‘failed’ technology projects often identify inadequate funding as a leading cause. You will probably need substantial set-up funding and possibly a recurrent budget line (for things like licences and IT support). Budget adequately for staff to learn and adjust as the transition occurs (see ‘Responding to complexity in the intended adopters’ above).
Manage the transition. Good change management involves a combination of ‘hard’ and ‘soft’ approaches. As well as setting goals and milestones and using agreed metrics to monitor progress, you also need to create opportunities for staff to come together and talk about the technology and new care model. As noted above, collective sensemaking, training (especially on-the-job training for both individuals and teams) and social learning from champions and super-users is crucial for building capacity. Use creative tools such as flip-charts and post-it exercises to surface people’s interpretations and concerns. Invite them to come up with creative ideas and solutions to any problems they identify. Allocate sufficient budget for this work, and consider issues such as backfill. This guide may help:
Leading large-scale change: a practical guide from NHS England.