Helping Change Spread

If you’ve managed to get this far, you have probably assembled a successful quality improvement team that has managed to meet its aim and you are looking to share your success with colleagues in other departments. This article discusses how you can improve your chances of successfully achieving this.

Theories on Change

Understanding how change spreads is important for ensuring your improvement project helps more than just your immediate team. There are many factors that influence how successful a change will be. These include the use of different staff, processes, equipment and available resources. Familiarising yourself with theories describing the spread of change will help you to integrate human behaviour into your quality improvement journey and overcome many of the barriers to spread. Use this understanding to get adopters on your side! Below we explore two theories.

Kurt Lewin’s Three Stages of Change

Kurt proposed that people must be loosened from their old way, transitioned and then moulded into a new way. In our case, this would involve preparing for change, managing change and then ensuring change remains in place. There are three stages:

Unfreezing: This involves helping people adapt to change. Loosen their attachment to their current attitude or practice. Help them understand why change is necessary and clarify how change will be accomplished. This involves communication, training and sharing resources to help understand the need for change.
Change: The process of change itself. This may be a difficult time, so support is needed to help those who may struggle.
Freezing: This enables individuals to continue operating as designed in the new state and ensures people do not naturally return to the old way of doing things. It may involve new protocols and procedures, periodic checks and reinforcement through communication or timely reminders.

Everett Rogers’ Diffusion of Innovations

This is a book that explores how innovations are spread through a given population. An innovation is defined as “an idea, practice, or object that is perceived as new by an individual or other unit of adoption”. He noted that there are five groups of users to adopt a new method. At first adoption begins slowly but then advances rapidly once opinion leaders have accepted it (the tipping point). After this, adoption slows as the most resistant people embrace it. You can belong to any of the five groups and more than one depending upon the idea at hand. The five groups are:

Innovators: They take risks and experience setbacks when ideas or improvements are unsuccessful. They may be far removed from the average person in a system and can be seen as deviant. Innovators introduce new ideas into a system but may not have large influence on overall adoption.
Early Adopters: They are among the first willing to try the idea. They are more data driven than innovators and less likely to take risks. Early adopters take away some of the uncertainty associated with change and may also be opinion leaders. They evaluate ideas from the innovators and look for confirmation that the ideas make sense.
Early Majority: Adoption by the early majority indicates the stage when the innovation is becoming accepted by the masses. They are established in the social system and interact frequently with their peers. Although not opinion leaders, they will embrace the innovation earlier than average. They rely heavily on early adopters for confirmation that the idea is beneficial but may deliberate quite a bit before committing to it. Once they commit, they will willingly adopt the change.
Late Majority: They are sceptical about a given innovation. The late majority are driven to change by economic need, peer pressure or policy rather than personal interest. They may hold onto the old way of doing things because it has been “good enough”. They may not adopt the change until the process they use disappears completely or it truly offers no advantage.
Laggards: They take a long time to understand and accept innovation. Their opinion is important as they may be opinion leaders who can stop innovation spreading throughout an organisation. The old way may need to be eliminated before laggards adopt the new way.

Read more from NHS Improvement on working with resistance to help spread your change.

Spreading Improvement

Establishing a new system as the norm and removing the old system will help individuals adopt change. You can improve the chances of successful adoption by delivering training before switching, ensuring someone is available to offer support during the transition as well as explaining the pros and cons of the new and old system. In the following two sections we discuss the characteristics of a spreadable innovation and then how to achieve results at scale.

Characteristics of a Spreadable Innovation

Some innovations spready more readily than others. What is it that makes them so much more favourable? Often it is because they improve the lives of those that adopt them, or perhaps they are more convenient to use than the old way. Below are five characteristics of spreadable innovations:

Relative Advantage

The degree to which an innovation is perceived as better than the idea it supersedes.

Simplicity

The degree to which an innovation is perceived as simple to understand and use.

Compatibility

The degree to which an innovation is perceived as being consistent with existing values, experiences, beliefs and needs of potential adopters.

Trialability

The degree to which an innovation can be tested on a small scale. Is there a safe environment in which they can test it?

Observability

The degree to which the use of an innovation and the results it produces are visible to those who should consider it.

Everett Rogers’ Innovation-Decision Process

Within the Diffusion of Innovations, Everett Roger defines five stages in the change adoption process. Provided all five elements are met, the implementation will be successful. Often the early two stages are missed, and this can have a detrimental effect to the adoption process. Ensure you address all of the following stages:

Awareness
- The individual becomes aware of the innovation’s existence and would like to understand how it functions.
Persuasion
- The individual ascertains the potential value of adopting a new innovation and further explores its capabilities.
Decision
- This stage determines whether an innovation will be adopted or rejected. While the main deployment decision may be made from above, the individual also must decide whether they will actually use it.
Implementation
- The innovation is put into practice. There is still a degree of uncertainty about whether it may work, but efforts are made to ensure it will.
Confirmation
- Individuals seek confirmation that the adoption has resulted in a positive change. Consider what you will measure to evaluate if this is the case.

Achieving Spread

Adoption does not come naturally to most individuals. Communication plays an important part in raising awareness and shaping behaviour. It is not easy, but there are several tools you can use to assure the spread of your improvements. Attempt the following:

Develop a communication plan

Address the methods, the messengers and the message.
Who will you communicate with? What will you say? When will you say it? Where will you say it? How will you say it? What does your audience need? What will your audience respond to?

Identify early adopters and opinion leader

These are often people that have worked on the PDSA cycle. Encourage them to use your improvement and use them to showcase the benefits it brings.

Identify transition issues

You can often predict what they will be. Discuss how to overcome the barriers to adoption.
Work out how to track the number of adopters over time.

Scaling up

Look for and address structural issues that arise during spread.

Read more from NHS Improvement on supporting people through change.