Service improvement and change: it’s the simple things that get in the way – part one

Valerie Amie and Giles Kingsley-Pallant, PCC associates, describe how to use the BECKS model to deal with the dynamics of your team

How can practices rethink how they engage with change? General practice is seeing some of its most challenging times – not least as a result of the COVID pandemic – but also in just delivering day-to-day care in the face of what appears to be a tsunami of demand. What can often get lost in this scenario is how people respond to one another, inadvertently creating difficulties within the practice and with colleagues. This article introduces the BECKS model to help you begin to unpick the dynamics that are behind some of the more frustrating behaviours you see in your organisation.

The essential premise of the BECKS model is that recalcitrant behaviour we encounter in organisations often has its origins in the knowledge and skills individuals have, the clarity of the processes, procedures and tasks that they are working with, and the environments in which the individuals; using this framework you can gain insight into why people do the things they do, and why you experience increased friction within the team.

Let’s start with knowledge and skills

One individual who is embedded within the practice team has been there for over 30 years. Let’s call her Maureen. She is a senior administrator.

Fifteen years ago Maureen began scanning using a single page scanner, and was incredibly proficient. One day the practice manager asks Maureen to move to a multipage scanner, but she is very keen not to do this; in fact, she puts up a number of opposing arguments as to why it is not a good idea. Now you might ask what is causing Maureen to be so un-co-operative. You may be thinking that she is being obstructive, negative, stubborn, or is fearful of change.

There is a clue, however. Fifteen years ago, Maureen started scanning, so we know she is not a technophobe; so what is the cause of her resistance to using the newer technology?  How can we begin to understand what may be behind her reticence to change?

Often in these situations it is the lack of confidence, knowledge and skills to use the new equipment that drive the fear of change. The way to overcome this is simple; provide the staff member with the knowledge and skills needed to use the new equipment. 

This is one particular scenario typical of those found in general practice which occur on a day-to-day basis. We need to ensure that knowledge and skills are front and centre when trying to move individuals towards change.

Clarity of task or activity

Individuals also need to know what they are required to do. Let’s take another scenario.

During a consultation the GP recognises that the patient needs an emergency ECG, so they message reception to book the patient in with a nurse that day. Despite the nurse’s list being completely full, with no space for any additional patients, reception squeeze the patient in. The nurse – who is working flat out – is furious that reception have added this patient to their list; they message reception to say that this is ‘Really not on’, and they can’t do it, so could somebody else do it? The receptionist messages back to the GP to say the nurse can’t do the urgent ECG because her list is full. The GP, who is now running behind, is infuriated because he just wants the nurse to do it.

The GP is now annoyed with both the nurse and the reception team for not sorting it; the nurse is annoyed at the reception team and the GP for asking her to do it – and the poor reception team are in the middle thinking that they can’t do anything right!

The way this scenario plays out is nothing to do with the individuals involved; each one of them is trying to do the right thing for the patient and the organisation, but all of them are overrun by the constant demand on the service and, in order to cope, they try to push things to another part of the system.

In order to understand what has happened here we need to appreciate that there was no clarity in responsibility and no clarity in protocol or expectations around meeting an urgent request. This starts with an agreement that an emergency ECG is just that, and should override routine work. However, without an agreed process, up front, that specifies which person carries out the ECGs, that the urgent overrides the list, and what happens to their work when this type of event occurs chaos ensues. The nurse is responsible for an emergency ECG and, when one comes in, he or she knows that is what is expected of them and the support they can expect from the rest of the practice team. 

In this scenario lack of clarity of process causes friction between three separate groups of people, who are all creating bad feeling against one another even though they are all trying their best to run the system smoothly. So, there is something to be said about working towards clarity from the outset, getting all your processes aligned, early on, to reduce unnecessary friction in the organisation.

Valerie Amie and Giles Kingsley-Pallant are PCC associates. PCC can work alongside practices to implement changes successfully, and embed learning and skills along the way. Contact [email protected] for more information.