Readers of the News Blog will be familiar with the Trans-theoretical Model for Behaviour Change – it is a framework that organises over 60 individual theories of behaviour change into a usable taxonomy (see previous post). The basic framework is unpretentious – in order to change, a person must have the Capability, the Opportunity and the Motivation to adopt a new Behaviour – hence the COM-B model represented (with slight modification) thus:
Consider an organisational change under CLAHRC WM – increasing access to home haemodialysis. First staff needed the Capability to provide the service. This means that the staff had to be appointed and/or redeployed to work in the community. This required direct high-level input – HR and finance. It was also necessary to establish a supply chain to order and maintain equipment for home use. Next Opportunity. Many new skills were required; staff in hospital had to be encouraged to offer the new service so they needed regular feedback from the dialysis team to reassure them that the community service was fit for purpose; a team lead must be designated. This involved mostly team level initiative, but with support from senior management. Lastly, Motivation was required. Hospital staff needed to be convinced that home dialysis was a suitable alternative and motivated to actively support it, based on providing opportunities and regular feedback and encouragement to maintain motivation. We discovered that staff did not always feel confident in their ability to offer non-directive counselling – in other words, their capabilities needed to be enhanced in order to improve motivation.
So COM-B identifies what the barriers are and broadly what is needed – education, supply chain management, and so on. But COM-B does not provide a prescription for action. Here we can attempt a general theory, based not just on what, but how, who, and when – the WHWW framework.
First, the how. This invokes theories concerning the type of action required. For example, if education is needed, then an educational method must be selected. Do we need a didactic method of education at the one extreme, or something more subtle, such as reflective learning on the other? Similarly, there is a scientific method behind Supply Chain management and contracting with suppliers. ‘Nudge Theory’ is available when there is a need to prompt behaviour change. A number of management techniques provide methods to overcome barriers often providing social output of opportunity – these include methods such as Lean, Six Sigma, Plan-Do-Act (audit) cycles, and associated tools, such as control charts,   and the modelling techniques of Operations Research. The point is that knowing what to do is not enough; it is necessary to link theories of what change to make to theories of how to make them. The implication is that we need to create a library of methods and a scheme for the how, analogous to the COM-B model, for the what.
Then the who. Here we need to turn to organisational theory to think through the levels in the organisation that should be involved. Here we turn to models of organisational structure,   based on the idea of a causal chain running from cabinet office, through board room, then teams/clinical departments to patients thus:
This pathway helps us identify the links in the organisational chain that need to be in place. The following scheme seeks to integrate this organisational theory to psychological theory with respect to the home haemodialysis problem:
Of course, like any scientific causal pathway, this is representative of the essential elements in a complex interaction with feedback loops etc. More particularly, it is woefully incomplete. For example, regulation would form a direct link to motivation (although not necessarily in the way intended by the regulator!). Incentives would also impinge on motivation directly whereas being compared to others may act directly on motivation and indirectly through the social milieu aspect of opportunity. Some actions may impact directly on more than one facet of the COM-B model. This applies particularly to the more generic actions taken at the senior/generic service levels, such as Human Resource policies (sickness policy, appraisal), management walk-abouts, and other methods to project culture/leadership.
Lastly, the when. The order in which different actors perform different actions is crucial. In the particular case of a change in service to provide more home haemodialysis, for example, it was crucial to first get the money in the right place. This was the key that unlocked the gate. Clinic staff needed to know when the service was ready to receive patients so that they could start to offer it. The supply chain had to be established before patients could use it. Senior management had to support service chiefs when the going got tough, and so on. Ferlie and Shortell’s theory of service change  is based on the importance of different actors at different levels, and here we identify timing as a crucial variable.
The WHWW framework is offered as a ‘general theory’ of management change. It complements and includes the ‘special theory’ embodied in the trans-theoretical or COM-B models, as well as lots of other theories specific to different tasks and to how organisations are integrated. We use as a metaphor, the functioning of an orchestra. The individual instruments – the bassoon, the violin, and so on, stand in for the what. They are analogous to the types of action indicated by COM-B. The particular skill needed to play each instrument represents the how. The musicians the who; and when they each play their part is determined by the conductor, who is analogous to the individual with special responsibility for overseeing service change.
— Richard Lilford, CLAHRC WM Director
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