What About Managers as Change Agents?

     Another source of energy to power public sector reform could come from sector managers. Managers have a privileged view of system operations and considerable insider information. Being one step removed from the provider-client interface, managers are often the first level of employee to have a systems perspective. To adequately fulfill their basic administrative responsibilities, managers have to develop a systems overview, not only on local operations but also on how the sector operates as a whole.

By virtue of their position so close to providers and clients, considerable responsibility for any improvement implementation will fall to managers. To meet these expectations mangers must learn the basics of implementation science: engaged leadership, local adaptation and user buy-in.

     These implementation lessons are completely generalizable across sectors and change programs but are very often ignored in the unfounded hope that a reasonable idea and individual good will are sufficient to produce desired results. Even big-name outside endorsement is insufficient in the absence of diligent work by site managers to make the improvement idea work locally.

     The effect of violating implementation rules can be seen in the experience of trying to improve surgery outcomes by using checklists. After impressive initial results, infections fell by more than one-third and death rates dropped by almost half, the World Health Organization (WHO) recommended widespread adoption of surgery checklists. Many hospitals attempted implementation, but many found no significant reductions in complications or deaths.* Writing about these failed implementations, Dean Fixsen, co-founder of the US National Implementation Research Network at the University of North Carolina at Chapel Hill, writes: "It doesn't matter how good the innovation is, it doesn't matter how much has been invested. If we don't have the implementation savvy, we're going to get the crummy outcomes that we have seen decade after decade".*

     You don't get implementation results agitating from the outside. System participants have to actively engage in their own system changes. And they have to learn some implementation science to do so effectively. Savvy managers are central to developing and sustaining improvement efforts locally and beyond.

*Nature 523, 516-518 (30 July 2015) doi:10.1038/523516a

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