“Should it stay or should it go?” Making space for innovation: De-implementing old ways of working

This blog, the third in our three-part series on supporting the adoption of innovation in complex adaptive health systems, explores how organisations, services and teams can successfully retire old ways of working, this is known as de-implementation.

What is de-implementation?

In the ever-evolving landscape of healthcare, the focus has traditionally been on implementing new innovations to improve patient outcomes. However, an equally important, yet often overlooked, aspect is de-implementation – the process of discontinuing practices that are ineffective, outdated, or potentially harmful.

According to research definitions, de-implementation is the systematic process of stopping the use of medical practices, interventions, or policies that are no longer supported by evidence, are less effective than alternatives, or are harmful. For NHS managers and staff, this can be complex and they face – to paraphrase the 80s band The Clash – making decisions about ‘should it stay or should it go?’

Decisions on stopping out of date practices are crucial to ensure that healthcare resources are used efficiently and that patients receive the best possible care.

De-implementation may not mean a ‘hard stop’

There are several shades of grey to consider. The care pathway or device currently operating may only be reduced, rather than removed. For instance, changing the screening age from 50 to 65 years old or only using a pathway with a specific sub-group of patients. Complete removal of a service or pathway is possible, but it is more likely that phased removal is the safer or preferred option.

Stopping old ways of working is hard for individuals and organisations

The experience of Health Innovation Wessex (HIW) in supporting the adoption of innovation has shown that success is often dependent on stopping outdated interventions, procedures or processes that are removed or replaced by an innovation. However, challenges can arise in stopping these old practices, even when there are clear reasons to do so.

• Resistance to change and long-held beliefs: Clinicians and healthcare providers may be hesitant to abandon long-standing practices.

• Lack of awareness: There may be insufficient awareness or understanding of the evidence against certain practices.

• Cultural and institutional barriers: Organisational culture and institutional policies can impede the de-implementation process, such as reluctance to discard older equipment.
• Regulatory considerations: Existing ways of working may be linked to regulations designed to measure whether safe and high-quality care is in place. Reducing or removing services may affect how regulatory compliance is achieved and there may be a disincentive to replace the existing way of working. This can be further challenged by the absence of regulatory criteria for new devices and procedures, due to delays in updating relevant guidance. This presents a dilemma for NHS managers about whether to take on the risk of de-implementing.

A practical model to support de-implementation

HIW have identified a lack of practical guidance to support de-implementation in health and care, yet there is a pressing need for this if we are to improve patient outcomes. A review of de-implementation research models and frameworks led to the creation of the HIW practical model. Once a decision has been made about what to stop, the model recommends a series of activities to support effective de-implementation:

• Validating and assessing current activity: once a service or intervention is identified, an assessment of all related activity and interdependencies should be conducted to identify how the change will affect linked services.

• Deciding whether to replace, reduce, restrict or remove an existing way of working: an assessment of related activities can lead to an important decision about what kind of change is being enacted. Different de-implementation strategies may be required if partially or fully stopping a service or intervention.

• Assessing the consequences and impact of the decision: a range of impacts should be explored and described to stakeholders. There may be impacts of stopping an intervention on staff, patients, processes, diagnostic tools, workforce wellbeing, equality of access to treatment, economic impacts, environmental impacts, and changes in public perception.

• Creating an enabling strategy: three strategic areas should be considered to enable change. For staff behavioural change, for policy and process change, and to acknowledge any infrastructure change.

• Planning the change: a delivery plan is required to describe the activities to de-implement the service or intervention, in the same manner as a plan to implement an innovation.

• Monitoring and sustaining the de-implementation: during the delivery of the planned change, managers should be vigilant of factors that permit the resurgence of the previous way of working and mitigate these as they arise.

The practical model has been developed for experienced innovation adoption managers, to guide their support of staff engaged in change.

Enhancing the efficiency of de-implementation activities

Optimising de-implementation is achievable by using a practical model to identify barriers and assess the impact of decommissioning. This approach can mitigate risks and reduce unnecessary tasks for NHS staff. Additionally, it can ensure NHS staff are well-informed about the research-based steps necessary for successful de-implementation. The activities outlined in the model will support NHS staff in achieving a smooth transition away from decommissioned services, practices, and devices.

Further information

Blog author: Andrew Sibley, Programme Manager, Health Innovation Wessex: andrew.sibley@hiwessex.net

Interested in how our model can help you or your organisation to adopt innovation more efficiently and improve care? For an informal conversation, please contact Health Innovation Wessex at enquiries@hiwessex.net or message us via LinkedIn.