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

General practice is seeing some of the most challenging times, not least with the Covid pandemic, but also just delivering day to day care with what appears to be a tsunami of demand. What can often get lost in this scenario is how people respond to one another and inadvertently create 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.

Giles Kingsley-Pallant

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 environment the individuals work in. By 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.

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

Fifteen years ago, Maureen began scanning with a single page scanner and was incredibly proficient. One day the practice manager asks Maureen to move to a multipage scanner, but Maureen is very keen not to do that. 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 uncooperative. 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 her fear of change. The way to overcome this is simple: provide her with the knowledge and skills to use the new equipment.

This is one particular scenario typical of those found in general practice that 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.

Individuals also need to know what they are required to do. They need Clarity of task or activity. 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. So, 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.

To understand what has happened here we need to appreciate that there was no clarity in responsibility, no clarity in protocol or expectations around meeting the 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: i.e. the nurse is responsible for the ECG and when that 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 and yet 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.

Moving on to Environment or what we are working with. Lets look at another scenario.

In some localities in order for referrals to be processed through Choose and Book, the administrative team need the patient’s BMI recorded on the referral form generated by the GP. Unfortunately, it’s not always recorded at the point the GP sees the patient and this can result in the hospital rejecting the referral.

So, the administrative lead, Sarah, goes in to see the GP and says “I’m really sorry, but you haven’t filled in this box here for the BMI. Would you mind filling it in?” And the GP, very keen to do the right thing says “Yes. No problem at all” and she goes back into the admin office where she bumps into the Practice Manager. The practice manager is annoyed pointing out they have had 10 rejected referrals. “Yes, yes, I know that.” says Sarah. “Well, have you thought of telling the GPs?” the practice manager asks. Sarah feels exasperated and replies “Well yes. I have told them repeatedly until I am blue in the face.”

We can keep asking the same thing and we can keep failing to get the response we need and we can keep getting cross with other team members or we can try and understand where the problem lies. The question is what is breaking down in this situation?

The system the GP uses does not automatically flag up the BMI or prompt for height and weight to be recorded, so this information is not readily to hand when the referral request is raised. But there is a relatively simple solution: by using the technology available you can create a form that auto extracts from the patient record the height and weight data to generate the BMI on the referral form. If the data is not there you can also design into the process a flag to alert the GP of the need to capture the patient’s height and weight before they leave the building.

There are a lot of things that work against us in the environment we work in and combined with lack of clarity, knowledge and skills this can increase stress, undermine performance and lead to people feeling like they are not part of a team.

And that leaves you with Behaviour. And behaviour in the BECKS models really looks at recalcitrant behaviour, where people absolutely don’t want to do something and ‘come to work, not to work’. It provides a constructive framework which you can use to check that you are supporting individuals to change. By noticing difficult behaviours around change or just within day to day working, be aware of how the environment, clarity, knowledge and skills may be impacting the individual. The BECKS model is an effective way to support teams to change within a safe non-judgemental process.