Addressing Issues

Professional Training: Preparing Providers for Systems Change

Overcoming Barriers to Guideline Implementation

Health care professionals working in the area of clinical improvement need to understand how behavior change occurs and the potential barriers that exist to those behavior changes. The usual sequence in changing behavior moves the person from acquiring knowledge about a change, to changing their attitude about the need to change, to ultimately changing the behavior itself.3

• Knowledge Barriers. The volume of information that health care professionals are expected to process can be overwhelming. This leads to a lack of familiarity and even lack of awareness about the existence of particular guidelines. Many offices lack "decision support" information systems that can make guidelines available in "real time" for health care professionals. Further, confusion about which guideline to follow often exists. It is important to involve health care professionals in the adoption and maintenance of guidelines in their facilities and work to make them accessible.
  
• Attitude. Familiarity with a guideline does not necessarily lead to a positive attitude towards its implementation. Health care professionals may have justifiable reasons for not agreeing with the guideline, particularly if its scientific base is limited. There may be doubt that performance of the guideline will lead to the expected outcome, such as smoking cessation counseling leading to a patient quitting smoking. The inertia of previous practice is difficult to overcome unless there is good knowledge of, confidence in, and a positive attitude toward the proposed guideline. It is productive if health care professionals see a guideline as important, not too rigid, practical, and not a challenge to their autonomy.
  
• Behavior. Appropriate knowledge and attitudes are necessary but not sufficient for implementation. The patient, the practice guideline, or environmental factors may create barriers that limit the health care professional's ability to implement a practice guideline. A testing phase or stepwise approach may increase adoption of a practice change.

Patients will be less resistant to recommendations such as having cholesterol levels checked if they understand why the test is important, cannot afford the medication for treatment, and have positive health beliefs about blood tests or medications.

Practice guidelines are most readily implemented if resources are available, such as having mammography facilities available in rural areas. Changing longstanding behaviors such as overeating or adopting a new behavior such as regular physical activity is most successful if rewards are apparent and support is sustained over time.

Environmental barriers are numerous. Lack of time, resources, and reimbursement are common problems. Some health care professionals may perceive practice guidelines as increasing malpractice liability by creating additional requirements that must be met.

Health care professionals who dedicate themselves to clinical improvement activities must be aware of these issues and seek ways to involve other clinicians and patients in the systems change process.

Overcoming Fear of Failure

According to human performance and training design professionals, adults normally resist changes to their routine and environment, especially changes in their work environment. Fear of failure, falling short of managers' expectations, and a reduction in their status among peers and co-workers are frequent reasons for adults, including well-educated professionals, to be less than enthusiastic about changes introduced by their employer.

When management takes steps to allay staff concerns and encourage involvement at all levels of the organizational structure, the entire process is much less troublesome for the entire team.

When employees believe they have a conduit for input and can play a role in designing system changes, they have a vested interest in seeing that the revised system actually works and is implemented according to plan.

Open Communication Enables Trusting Relationships with Employees

Open communication between employees and management will go a long way to bridge gaps in expectations and provide a foundation of understanding and common goals for success.  Those who are not consulted and are left on the perimeter of all meaningful decisions can feel resentment, distrust, alienation, and even overtly rebellious.  If staff members feel secure about the reasons for system change and understand that the overall concern is for the welfare of the patient, they are more likely to join in and contribute ideas and suggestions for further enhancing the new system.

Training professionals frequently use the term “buy-in” to describe the process of involving front-line personnel in performance modifications and job description changes.  Buy-in does not necessarily mean every employee must agree with the system change, but it does involve employees understanding the reasons behind the change and accepting the changes to their job descriptions and performance standards.

Seek Help from Human Resources Professionals

Administrators who have access to the organization’s personnel department, human resources, or staff training professionals will want to seek the assistance of those individuals in developing a complete task analysis, performance audit, needs assessment, and training program.

Administrators need to keep in mind that when a system is changed, employees' jobs are changed. Changing an employee’s workload, level of responsibility, or expectations concerning skill-set requirements may translate into changes in salary, schedules, and compensation/review schedules. When unions, trade associations, or employee contracts are involved, the process of enacting system changes takes on another dimension. The administration must allow the necessary time and budget allocations to go through the appropriate steps of that organization’s process.

If the organization has no formal procedure already developed for modifying an employee’s job description, the manager should develop his or her own strategy for a plan of action, taking care to allow adequate resources of time, tools, and training, as well as providing for the employee’s input.

The demographic and psychographic profiles of employees affected by the call for system change can have a substantial impact on the amount of resistance and, therefore, the amount of training and orientation time that will be required to adopt the new expectations. The adage that “you can’t teach an old dog new tricks” may seem absurd in today’s high-tech education environment; however, professional trainers and educators routinely allow additional discussion time, drills, and review periods when the audience is comprised of adult learners over the age of 40.

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