A Staged Approach to Implementing Change
The Stages of Change
Stage 0
ExploreDecide if there is a need for change, if a new service should be implemented, and if your pharmacy is ready for implementation.
Stage 1
PrepareDevelop an implementation plan and designate leadership and staff roles to support implementation of a new service.
Stage 2
LaunchPilot the service, revise the implementation process if necessary, and scale up implementation.
Stage 3
MaintainDecide whether the service is worth sustaining. If it is, allocate resources and develop policies to make the service a routine part of your pharmacy's operations.
Note: This framework has been adapted from the Active Implementation Framework1 and the stages of organizational change model.2You can use various strategies within each of the stages of change to support the implementation of a process.3 , 4 This module explores these strategies in more detail.
After completing the module, you should be able to:
- Identify and apply the stages of change framework to a new service in a community pharmacy.
- Identify and select strategies to support implementation of a new service in your pharmacy.
- Develop a plan for implementing a new service in your pharmacy.
To proceed:
The module is divided into a series of lessons that you can move through in any order.
Use the scroll bar to move through the lessons linearly, or use the navigation menu located at the top of your browser window to quickly access a specific lesson.
Stage 0 : Explore
Before you implement a new service, it is important to consider the following questions:
- Is there a need for change?
- Should a new service be implemented?
- Is your pharmacy ready for implementation?
Needs assessment
Your pharmacy should conduct a needs assessment to determine if there is a need for change.
A needs assessment can be either a formal or an informal strategy used to identify and prioritize needs within your pharmacy. To collect information on your pharmacy’s needs, your pharmacy might:
- Administer a survey to patients to assess their satisfaction with services
- Assess your pharmacy’s workflow and consider using value stream mapping
- Examine patients’ outcomes, such as medication adherence, over the past year
- Have a staff meeting to discuss problems related to the coordination of care with other healthcare providers
Completing a needs assessment like the one provided is helpful when more than one need is identified. Carefully review the chart and consider how it could be used in your pharmacy.
Needs Assessment Chart
Click Display to see a completed example.
Problem 1 Non-adherence to medication |
Problem 2 Inefficient prescription refill process |
Problem 3 Lack of awareness about clinical services |
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Frequency How often does the problem occur? |
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Amount How many people are impacted? |
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Importance How important is the problem? |
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Feasability How likely is it that we can solve the problem? |
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Duration How long has the problem occurred? |
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Gathering information
Before determining that a new service should be implemented, your pharmacy should gather information about both the proposed service and alternative programs.
The following strategies can be helpful when gathering information about new services:
- Research the service by obtaining information on start-up costs, maintenance costs, return-on-investment, and likelihood of sustainability. You might gather information from the organization sponsoring the service, professional pharmacy organizations, or schools of pharmacy.
- Talk with a pharmacy that has already implemented the program. Find out the steps they followed, the benefits they observed, the barriers they encountered, and the best practices they recommend.
- Visit another pharmacy that has implemented the program to observe their process for implementation.
- If you have trouble getting information from a pharmacy, consider reaching out to a professional pharmacy organization for assistance in locating another contact.
“Our owner called several other owners to learn more about medication synchronization and how it was implemented and what challenges we could expect. It was helpful to have that information going into it so we knew what to anticipate.”
Even if you know which service your pharmacy wants to implement, it is useful to identify alternatives and compare program features like the ones shown here.2
Features to Compare
How has it affected patient outcomes?
How complex is it?
How costly is it?
Why is it a better option than other services?
Can it can be modified to our workflow?
Can I try it before implementing it?
Identifying a service to implement and gathering background information are important first steps, but you also need to assess whether your pharmacy is ready to take on additional tasks. The strategies described below may prove helpful:
Assess pharmacy readiness
You can assess whether your organization is ready for change in a number of ways.6 , 7 Criteria to consider include:
- Leadership support: Leaders play a key role in supporting change by setting expectations and rewarding staff.8 Leaders could include pharmacy owners, pharmacy managers, lead pharmacists, and lead technicians. It is important to have the support of all leaders to ensure successful implementation.
- Resources: Consider the resources that will be needed for implementation and whether your pharmacy has a sufficient supply. Resources include technology, staff or staff training, relationships with patients or other key stakeholders, funding, or workspace.9
- Communication strategies: Implementing a new program often requires collaboration among multiple staff members. Consider whether your pharmacy has communication strategies in place to share information between all of the staff that will be involved with implementation of a new program.
You can informally assess your pharmacy’s readiness for change, or you can use a formal assessment6 , 7 called a SWOT analysis. (SWOT stands for “strengths, weaknesses, opportunities, and threats.) A SWOT analysis identifies the strengths and weaknesses within your organization, as well as the opportunities and threats in your pharmacy’s external environment, that might affect implementation.
Carefully consider the SWOT analysis below. How would you fill this in for your pharmacy?
SWOT Analysis
Click Display to see a completed example.
Helpful To Acheiving Your Goal |
Harmful To Acheiving Your Goal |
|
|---|---|---|
Internal Origin About Your Organization |
Strengths |
Weaknesses |
External Origin About Your Environment |
Opportunities |
Threats |
Identify potential barriers
Prior to implementing a new program, it is helpful to identify potential barriers. It is also helpful to identify strategies for overcoming those barriers.
Common barriers associated with program implementation include:
- Staff barriers: lack of training, resistance to change, lack of clarity regarding roles and responsibilities
- Leadership barriers: lack of support, lack of communication between leadership and staff
- Resource barriers: competing priorities, lack of time, lack of sufficient staffing
“Before we start any program, we think about whether we have enough staffing, what training our staff might need, and whether our management system will support it.”
Identify strategies for overcoming barriers
Identifying barriers is an important first step, but it is equally important to then identify strategies for overcoming these barriers.
- Ask your staff: Have a staff meeting to determine if anyone has ideas for solutions.
- Talk with other pharmacies: Talk with a pharmacy that has implemented a similar program to see if they have advice.
- Do some research: Conduct research to learn more about the new service and see whether others have described potential solutions. For example, you could look for information about the service on Pharmacy Times, US Pharmacist, Pharmacy Today or professional pharmacy organization websites (e.g., NASPA, NCPA, APhA, or pharmacy wholesalers). If you still cannot find any information, conduct research on a similar service that is likely to have comparable implementation barriers.
Conduct consensus discussions
Before implementing a new program, it is important to identify your key stakeholders and consider whether you have their buy-in. Key stakeholders might include your staff or other project partners (e.g., prescribers, patients, etc.).
Strategies for obtaining buy-in are described below:
- Obtain input prior to implementation: Ask staff for their opinions about the new service and the resources that will be required to implement it. Asking for input gives staff a chance to offer suggestions prior to implementation and ensures that they are aware of the service from the outset.
- Include staff in implementation planning: Include all staff that will have a role in delivering the new service in the implementation-planning process. Involvement in the planning process increases employees’ sense of ownership and buy-in.
- Educate staff: Ensure that your staff have the skills and knowledge necessary to implement the new service. Lack of knowledge and confidence about a new product can lead to resistance to change., 11
- Develop incentives: Create reward and recognition systems to support staff participation in implementation.11 Once implementation is underway, the incentives may no longer be necessary.
“We always involve the people that are implementing the program in our discussions. Anyone that's a part of the process has a right to provide input. The worst thing that anyone could do when you're rolling out clinical services is to never talk to the people who are actually going to do the work. ‘Does this make sense to you?’ ‘Can you visually see this working out in your day?’ ‘What details, or what things do we need to consider that we're not seeing?' "
- Obtain input prior to implementation: Similar to staff, it is important to get other project partners' input prior to implementation. Soliciting input gives project partners an opportunity to offer suggestions before you roll out the new service.
- Build on prior relationships when possible: It is easier to obtain buy-in from project partners for a new service if you have already worked together. For example, if you are implementing a service that requires support from healthcare providers, it is preferable to start with providers with whom you have already established a relationship.
“We have three practices that are very close to us. It’s easy for us to go over to their offices to talk. We normally take over a goodie tray, a bagel tray, a fruit tray, or something along those lines because the staff normally likes that. A gift gets you through the door a little more easily. Then we just talk with the providers. A lot of times they will say, 'What's in this for me? Why should I be doing extra work providing you with med lists for these patients?' We explain what we’re doing, why we’re doing it, and how partnering with us is not only going to help us as a pharmacy, but it will also help them as a doctor's office by getting patients compliant with their medication.”
Check Your Knowledge
Question One
Before adding a new service in your pharmacy, it is important to obtain input from pharmacy staff prior to implementation.
Question Two
ReallyRight Pharmacy is a community pharmacy in rural North Carolina. The pharmacy manager is considering adding a home delivery service for elderly clientele. What should the pharmacy manager do to determine if this service will be valuable for her patients?
- Please Select Your Answer
- A) Complete a SWOT analysis.
- B) Conduct a value stream map.
- C) Conduct a needs assessment.
- D) Develop a communication plan.
Case Study
Hear how this content has been applied to a real-world pharmacy practice.
(Watching this seven-minute video is optional.)
Lesson Progress
Stage 1 : Prepare
After you decide to implement a new service, it is time to prepare your pharmacy. Strategies for successful preparation are described below.
Develop a formal implementation plan
It is helpful to develop a plan for how you are going to implement a new service. A sample checklist for developing an implementation plan is provided.
Recruit and designate for leadership
Depending on the scope of your new service, you may need multiple staff members to help lead the program. Leaders can be pharmacists, pharmacy technicians, or other staff members. Positions to consider include:
- Implementation leader: oversees the implementation process
- Program champion: advocates for the program and provides support to staff members using the new program
- Quality specialist: monitors quality and shares feedback about implementation with pharmacy staff
“Our biggest issue with medication synchronization is getting a key person or several key people in our pharmacy. It doesn't have to be pharmacists. It can be your technicians, your cashiers who understand medication synchronization, who understand the program, who can sell it to your patients, too. I found one of my lead technicians who, when I talked about it, got excited about the program. She understood it and she was very good working with doctors' offices.“
Revise professional roles and conduct staff training
In addition to establishing leadership, it is important to identify which staff members should be involved in implementation, what their specific responsibilities will be, and whether they have the sufficient resources and training to carry out those responsibilities.
When revising roles, consider strategies that use pharmacists and pharmacy technicians at the top of their license and delegate other roles to administrative staff when possible.
Implementation Checklist
Describe the root causes of the problem you are addressing by implementing a new service.
Develop a succinct and measurable statement of your goals.
Develop a strategy for sharing information about implemention with all relevant stakeholders.
List all activities that need to be carried out to implement the program.
Describe which staff members will be responsible for which activities.
Establish deadlines for all key activities.
List the resources needed for implementation (e.g., staffing) and how these resources will be obtained (e.g., hiring new staff or revising staff roles).
Identify how you will measure success, such as the number of patients who received the service.
Determine how your pharmacy will track measures of success (e.g., pharmancy management system, Excel database).
Check Your Knowledge
Question Three
When planning implementation of a new service, it is important to clearly designate which staff members will be responsible for implementation.
Question Four
ReallyRight Pharmacy has recently implemented a medication synchronization program. Staff members are not familiar with medication synchronization and are resistant to implementation. What should the pharmacy do to improve awareness about medication synchronization and increase motivation among staff members?
- Please Select Your Answer
- A) Hire a data entry specialist.
- B) Develop an implementation plan.
- C) Develop a communication plan.
- D) Designate a program champion.
Case Study
Hear how this content has been applied to a real-world pharmacy practice.
(Watching this 14-minute video is optional.)
Lesson Progress
Stage 2 : Launch
Once you have prepared your pharmacy for implementation, you are ready to launch a new service. Strategies for a successful launch are described below.
Pilot test
It is beneficial to pilot test a program before it is implemented. You could, for example, involve only a small number of staff members in initial implementation, or you could test the program in a sub-group of patients before rolling it out to all patients within the pharmacy.
A pilot test can help the pharmacy establish a workflow and overcome barriers with implementation before delivering the program to all patients.
“We went through a two-month process where we weren't trying to add a lot of new medication synchronization patients just so the techs could get comfortable looking at a new screen, adjudicating claims, doing overrides, and just getting comfortable operating in a new system. After we got our process worked out, about 90 days in, we started aggressively trying to expand our medication synchronization program to as many patients as we could.”
Tailor strategies to overcome barriers and honor patient preferences
Once your program is underway, it is likely that you will have to adapt the service to overcome implementation barriers or make changes to the program based upon patient feedback. For example, you may have to reduce the length of time it takes to deliver a comprehensive medication review due to patients’ availability or change your recruitment strategy if patient enrollment is slow.
Tips for tailoring services
- Consider how you are framing the service to your patients. Messages can be framed in a positive light or in a negative light. The strategy that is most effective depends upon the service being introduced.12 Test different framing options to see which one works best for your patient population and the service you are piloting. An example illustrating the difference between positive and negative framing is provided.
- Consider how familiar patients are with pharmacy services. For some pharmacies, your patients may already be familiar with your pharmacy services because you have been delivering these services for a long time. For other pharmacies, you may be introducing this concept to patients for the first time.
You may need to develop educational materials and deploy other strategies to acclimate patients to the idea of pharmacist involvement in clinical care. One strategy is to educate local healthcare providers about your pharmacy’s services so that they can then recommend these services to their patients. - Consider how many services are being introduced to a patient. If you are implementing several new services at one time, it may be helpful to prioritize which ones to introduce to your patients. Patients may get overwhelmed or confused if you try to introduce too many services at once.
Gain/Loss Framing
Gain Framing
Definition: Reminds patients about the benefits that are associated with a clinical service.
Example: A comprehensive medication review can help us make sure your medications are safe for you.
When to use: For services that patients may view as unpleasant (e.g., services that require a lot of a patient's time).
Loss Framing
Definition: Reminds patients about the negative outcomes that are associated with a health problem.
Example: Getting the flu can cause serious problems for pregnant women.
When to use: For services that help patients avoid a risk (e.g., vaccines).
Stage implementation scale up
Once you have established a workflow and addressed implementation barriers, your pharmacy should be ready to scale up the new program.
Scaling up could involve training more staff, recruiting more patients, or advertising your program to more healthcare providers.
It may be helpful to revise the original implementation plan to include a strategy and timeline for scaling up the program.
Strengthen relationships with key stakeholders
As you begin implementing your program, unanticipated challenges might require additional relationship-building with key stakeholders.
For example, you might begin a naloxone-dispensing program in your pharmacy only to realize that you are encountering more patient resistance than you anticipated. To address this issue, you might get advice from other pharmacies that have experienced similar problems or talk with patients whom you’ve successfully introduced this new service to get their advice on how to introduce the service to other patients.
Check Your Knowledge
Question Five
ReallyRight Pharmacy enrolled all of their patients in their new medication synchronization program. The pharmacy is now struggling to find sufficient time to synchronize their patients’ medications. What could ReallyRight Pharmacy have done to prevent this problem?
- Please Select Your Answer
- A) Hired a quality improvement specialist.
- B) Conducted a pilot test.
- C) Developed a sustainability plan.
- D) Developed a communication plan.
Question Six
When your pharmacy introduces a new service that might be burdensome or time-consuming to patients, such as a comprehensive medication review, “loss framing” rather than “gain framing” should be used.
Case Study
Hear how this content has been applied to a real-world pharmacy practice.
(Watching this seven-minute video is optional.)
Lesson Progress
Stage 3 : Maintain
Once implementation is underway, it is important to decide whether to sustain your service. If you choose to move forward, you may need to implement strategies for making the program a routine and permanent part of your pharmacy.
Examine implementation
Not all programs are successful and worth sustaining. It is important to carefully examine how implementation of the program is proceeding and then make a decision about whether it is worth sustaining the program. It is also important to evaluate whether your pharmacy’s current process for implementation is effective or if changes need to be made for improvement.
Employees in various roles (e.g., pharmacists, pharmacy technicians) are likely to observe different barriers during implementation, so it is beneficial to solicit opinions from all of the staff involved in the process.
A number of tools are available for assessing and making changes to the implementation process. For example, the Institute for Healthcare Improvement offers guidance on how to use the Plan-Do-Study-Act (PDSA), which is a tool for quality improvement.
Obtain formal commitments and develop resource-sharing agreements
If your program relies on cooperation from external stakeholders, such as other healthcare providers, consider establishing formal commitments and resource-sharing agreements. For example, it may be helpful to establish a collaborative practice agreement for co-managing patients.
Several toolkits are available online that can assist you with developing a collaborative practice agreement. The one provided here is from the Centers for Disease Control and Prevention.
Integrate the program into pharmacy’s policies and procedures
You can also integrate the new program into your pharmacy’s policies and procedures, such as the hiring or performance evaluation process.
If you want to sustain a medication synchronization program, for example, consider developing goals for the program or rewards for achieving those goals that are incorporated into employee performance evaluation.
“Everybody has that stuff that gets them a little bit more geared up. In the beginning, we used some prizes to help get things going, and then our team got excited.”
Create centralized support systems (when possible)
If your pharmacy is part of a larger organization, it may be helpful to develop a centralized support system that provides implementation support to your pharmacy and other pharmacies within the same organization.
As an example, consider creating an implementation support or patient engagement specialist position at the central level of your organization to provide support to pharmacy staff at the local level.
Check Your Knowledge
Question Seven
ReallyRight pharmacy is trying to decide whether to sustain their medication synchronization program, given all of the problems they encountered during implementation. Which of the following actions should ReallyRight pharmacy take?
- Please Select Your Answer
- A) Elicit staff feedback about the implementation process.
- B) Conduct a SWOT analysis.
- C) Conduct a value stream map.
- D) Develop a resource sharing agreement.
Case Study
Hear how this content has been applied to a real-world pharmacy practice.
(Watching this two-minute video is optional.)
Lesson Progress
Key Takeaways
Implementing a new program in your pharmacy can be a complex process. This module has provided a framework for organizing the implementation of a new program into stages to help simplify the process and provide key implementation strategies for each stage. Key points to remember are listed below:
- Plan before implementation: Preparation is critical for successful implementation and for program sustainability.
- Reassess your process multiple times: A number of elements are required for successful implementation, such as establishing an efficient workflow or delegating roles and responsibilities to ensure staff are being used at the top of their license. You may need to reassess your implementation process multiple times and make changes in order to successfully implement a new program.
- Be purposeful about sustainability: Before implementation, consider whether it is feasible to sustain a new program. During implementation, decide if the program is worth sustaining. If you decide to keep the program, develop a strategy for making it a routine part of your pharmacy.
References
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- Powell BJ, McMillen JC, Proctor EK, et al. A compilation of strategies for implementing clinical innovations in health and mental health. Med Care Res Rev. 2012;69(2):123-157.
- Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation science : IS. 2015;10:21.
- KU. The Community Toolbox. 2017; http://ctb.ku.edu/en. Accessed January 19, 2017.
- Helfrich CD, Li YF, Sharp ND, Sales AE. Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implementation science : IS. 2009;4:38.
- Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational readiness for implementing change: a psychometric assessment of a new measure. Implementation science : IS. 2014;9:7.
- Weiner BJ, Belden CM, Bergmire DM, Johnston M. The meaning and measurement of implementation climate. Implementation science : IS. 2011;6:78.
- Birken SA, Lee SY, Weiner BJ. Uncovering middle managers' role in healthcare innovation implementation. Implementation science : IS. 2012;7:28.
- Dent EB, Goldberg SG. Challenging “resistance to change". The Journal of Applied Behavioral Science. 1999;35(1):25-41.
- Helfrich CD, Weiner BJ, McKinney MM, Minasian L. Determinants of implementation effectiveness: adapting a framework for complex innovations. Med Care Res Rev. 2007;64(3): 279-303.
- Rothman A, Bartels R, Wlaschin J, Salovey P. The strategic use of gain and loss framed messages to promote health behavior: how theory can inform practice. Journal of Communication. 2006;56:S202-S220.
Citation
Turner, K., Renfro, C., Ferreri, S., & Shea, C.M. (2018). A staged approach to implementing change. Chapel Hill, NC: UNC Center for Medication Optimization. Retrieved from: https://wp.media.unc.edu/changemgmt/stages/