Embracing change

Most people are familiar with the sentiment, ‘change is the only constant’ and it is certainly true when it comes to advances made across health and care. We also know that change can be daunting. For those implementing the changes, whether incremental or large-scale, it can sometimes seem an uphill struggle.

The management of organisational change is the process of guiding change in organisations to a successful resolution. At Health Innovation East, our experienced team supports healthcare systems, industry and entrepreneurs and academia to implement change. Guided by implementation science and experience which emphasises understanding and collaboration, we help release the bottlenecks that hinder change programmes.

Our work alongside the University of Leicester supported trial sites with a study of the CHARMER medication review intervention. The project involved the delivery of a complex procedural and behavioural change programme for, and alongside, pharmacists and geriatricians.

Reducing medication overuse with CHARMER

CHARMER was a five-year (2021–2025) England-wide research project to develop and test an approach where older hospital patients (typically people aged 65 and over) are offered a comprehensive, geriatrician-led. medication review. The aim of which was to discuss situations where they may safely stop taking medicines that are no longer useful or could potentially be harmful.

The CHARMER team recognised they needed further support, first with involving the NHS trial sites, and secondly facilitating communication between the participating hospitals and the CHARMER trial team. The project used the step-wedge approach – where a change intervention is rolled out sequentially to different clusters – therefore it was essential  that each step was successfully implemented within specific timelines. Health Innovation East was approached to provide expert input and ensure these timescales where met.

Our intervention

Working alongside hospital doctors, pharmacists, system improvement managers and patients, the team designed strategies to remove blockers and encourage more proactive medicine reviews.

Encouraging prescribers to have conversations with patients and clinicians about deprescribing potentially harmful medicines required prescribers to first understand why the change was being requested, and second to learn and then cement the new behaviours in their daily work patterns.

Following the ‘step-wedge’ approach a targeted, sequence of activities was deployed in support of the change efforts required.

Preparation: our team convened kick-off meetings before implementation and shared some from previous stages of the project to ensure that internal conversations were started at sites and to minimise future challenges they may face.

Implementation: we supported the implementation of the CHARMER intervention with weekly meetings and ad hoc 1-to-1s with staff over the 14 weeks of the implementation phase. Four tranches of the intervention were completed.

Follow-up: a community of practice was set up for all sites, with additional support for sites experiencing challenges – enabling colleagues to share learning, common challenges and utilise the groups expertise to overcome barriers.

A number of evidence-based interventions were established which necessitated a substantive change in the ways pharmacists, geriatricians, patients and support systems interacted with each other:

• Holding workshops for pharmacists and geriatricians, using patient case study videos. These workshops helped to address concerns around potential adverse consequences of deprescribing and correcting the misconception that patients and carers are resistant to proactive deprescribing.
• Establishing regular deprescribing meetings between pharmacists and geriatricians, providing time within current working patterns to support proactive deprescribing
• Setting up weekly benchmarking reports to provide colleagues a way to compare their performance, both against other hospitals, but also to review weekly trends and help them to discuss what enablers and barriers may contribute to their reports.
• Implementing and resourcing a hospital action plan to prioritise deprescribing. This action plan outlines the steps the site must take to achieve an increase in proactive deprescribing and the impacts this will likely achieve.

The programme and its interventions sought to embed a proactive gold-standard approach to deprescribing. It also highlighted the importance of signposting health and care professionals to change interventions and encouraging engagement that leads to a change in practice.

In support of the process of implementing changes at each of the trusts, weekly calls were set up with the sites for each step of the trial. The calls supported the change momentum in implementation sites, while also providing a space in which to raise challenges experienced by the sites involved. Having all the sites in attendance allowed for shared learning and problem-solving which resolves potential barriers to change rapidly.

We also facilitated weekly calls with the CHARMER project team in support of the trial. Such calls enabled us to ensure that partners across the piece were provided the most up to date information.