The only Constant is Change…but How?

1. The only Constant is Change…but How? Wrightington, Wigan and Leigh Foundation Trust Dr Chandrashekar Shetty Consultant Chemical Pathologist, WWL NHS FT, Wigan Background As an effective leader one has to have a certain vision and to bring this to fruition there is a need to bring about changes in existing practices or enhance them in any way. During this course, I had opportunities to bring about change, big or small, a few times. Some changes are ongoing but during these processes I am constantly discovering elements of myself, my colleagues and something about the whole dynamics of change. I have tried to highlight my experiences with Change in the 3 examples given below. Change 1 Change 2 Change 3 • Aim To stop using GGT enzyme estimation as part of the Liver test profile in all routine samples from both GPs and from within the hospital. However the test would be available at all times as a separate request if needed. Methods • Evidence base for this change researched and confirmed validity for the change • Cross-checked with peer and specialist user groups like the Gastroenterologists and regional hospitals • Stakeholders : GPs, practice nurses, Hospital doctors, laboratory staff, laboratory managers, IT staff • Analysed the impact on clinical services if the test is withdrawn through a departmental audit including cost savings if any made. • Departmental discussion re: impact on stakeholders • An email prepared with complete explanation of the proposed change and the procedures that would be put into place to auto request the test if clinically warranted. • Email/letter posted to all the stake holders (GPs, practice nurses, Hospital doctors and managers) • Proposed change to be enforced after a lead out time of 3 months. Upside • Change resulted in significant savings for the department in terms of reagent cost. • Clinically more appropriate use of the test was noticed • After initial teething issues current practice is unaffected and Downside • Few complaint letters were received mainly from GPs stating their concerns. These were attended to with a satisfactory response through letter and telephone conversations. • Some time spent in dealing with these complaints. • Aim To bring about a merger of Pathology services across three Trusts in the North West sector of Greater Manchester region Methods • Trust directive given out to consider the possibility of streamlining Pathology services across the three trusts with the aim of reducing costs and enhancing quality. • Various subsections of the department started meeting with each other • Focus group discussions started and results to be analysed • Conflicts of interests to be dealt with. • Evidence base for the change to be clearly presented • Project leads appointed and overall Project manager appointed midcourse. • Revision of plans for project given out to subgroups Updates • Ongoing meetings and proposals • No clear end in sight • Changing end goals • Revised plans Upside • More involvement of stakeholder groups through discussion and QA sessions. • More democratic process • Ownership of the resulting change could be satisfying Downside • Lengthy delays • Uncertainty re: direction of proposed change • Stakeholder discontentment huge mainly because of uncertainties and suspected redundancies • Lack of overall vision • Aim • To bring about a change in the Troponin testing protocol, brought about because of a new test introduced by the manufacturing company. • The old test would be phased out and no kits would be available. • Methods • Stakeholders identified to be mainly laboratory staff, Cardiologists and AE staff. • Evidence base strong and uncontested for the proposed change • Proposal put forward to Cardiologists and discussion re: clinical benefits of the change started. • Issues re: financing the new protocol (more expensive) discussed • Further involvement of Finance managers. • Business case drawn up for the proposed change and impact on the dept/hospital finances elucidated • Updates • Business case to be presented finally in a couple of weeks. • Change to be rolled out probably in 6 weeks • Upside • More inclusive approach with the stakeholders involved in actually bringing about the change. • Anticipated to cause less resentment when the change is finally rolled out. • Downside • Lengthy delays as a result of getting all stakeholders to agree to a timeframe. • Disagreements re: costs involved and taking responsibilities. • Seemingly unending chains of correspondence to get things moving • Project started with no clear structure to begin with as regards to allocating responsibilities • Learning points • Dictatorial type of change as in Change 1, works more quickly and effectively but could bring about discontentment esp. if change is not fully justified and evidence-based. • Involving more parties in the process of change leads to delay and frustrations if no common goal is clearly elucidated at the start. • Big changes as in Change 3 should be initially conceptualised and managed with a proper project structure and team and any further changes to the direction of the change could be slowly introduced • CHANGE IS INEVITABLE BUT NOBODY LIKES IT!