10. Managing change and performance

Managing change at scale is key to achieving integrated care outcomes. A combination of the following must occur:

  • A compelling reason for change – like recruitment, there must be a burning platform that resonates with the target participant. Often it is not the macro issues (e.g. health system running out of money, pressures on hospitals, ageing population etc.) but the more personal challenges that a person faces daily. These can be the pain points of working as a frontline clinician (e.g. lack of follow-up, late discharge communications, inadequate pay, too much paperwork etc.) or having a chronic health condition (e.g. pain getting out of bed, confused with too many medications, can’t get to pharmacy, no one to drive me to next appointment). Linking the reason for change to these specific issues, and communicating this effectively, is key to building relevance and motivating action
  • Help to learn new behaviours – whether it is proactively adopting a population health view instead of reacting to individual patients, using health coaching to activate self-management instead of providing passive education, or providing team-based care planning rather than individual consults, new ways of thinking and working is required. Adequate training and feedback on progress is important to facilitate change. This can be formal learning (e.g. courses, specialist talks) or informal learning (e.g. buddy groups, mentoring)
  • Appropriate incentives in place – positive or negative reinforcement is important for cultural change and performance. These can be financial (e.g. salary bonuses, payments at risk, penalties for complications, shared surpluses) or non-financial (e.g. research grants, equipment purchases, conference leave, publications and public recognition). Participants of change must have adequate ‘skin in the game’ and have feedback mechanisms to reward or penalise appropriate behaviours. The quantum must also be adequate – for example, studies show GPs need at least 20 percent of remuneration at risk to devote enough attention to a program or outcome
  • Change agents mobilised – moving participants up the change adoption curve requires role models that can demonstrate the change (and its benefits vs lack of downside risks) and carry enough gravitas to be influential and credible. Behavioural economics note that people will follow suit if they realise others are already doing it, especially if they are people they know. Change agents can be deployed on an informal basis (e.g. sharing forums, dinners, publications) or formally (e.g. paid Ambassadors, marketing videos)
  • Measuring progress and feedback – Reporting on progress is important to reinforce change. Feedback can be quantitative or qualitative, identified (e.g. league tables) or de-identified (e.g. bell curves), linked to rewards or not, and delivered in many ways (e.g. self-serve platform, regular publications, during performance reviews. Defining the measures from the outset of the change (so clear visibility and no surprises) and providing accurate data sources, opportunity for Q&A to interpret and internalise data correctly, and being sensitive to ‘poor performers’ and how they may be presented to their peers are all important aspects to get right.