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Challenging operations: implementing medical reform in surgery (continued)

Recommendations for medical providers

  • Think collectively
  • Established roles and long-standing authority relations are difficult to overcome individually. At the three hospitals I studied, reformers were successful only to the degree that they acted collectively.

  • Identify allies
  • Reformers should actively seek out others to support change, paying particular attention to those who receive fewer rewards and opportunities for training and promotion under the traditional system, since they are more likely than others to be potential reformers.

  • Find spaces apart from defenders of the status quo for new practice creation
  • In organizing their efforts, reformers must find spaces where, isolated from defenders, they are comfortable talking about new ways of doing things. Face-to-face interaction is also crucial, as is the inclusion of reformers from all work positions.

  • Minimize visibility of lower-status reformers during new practice creation
  • Coalitions are vulnerable to the degree that their lowest-status members are exposed. Keep them out of the limelight.

  • Enlist transients to help roll out new practices
  • Since activism entails significant risk, those moving through organizations—the less committed transients—may be the most effective change agents.

In sum, healthcare organization members who would benefit from reform (and their supporters) must understand how to effectively engage in collective change processes, on-the-ground in everyday work, if they are to successfully accomplish it. To bring to fruition the opportunities hard won by external reformers, reformers inside organizations must successfully find relational spaces apart from defenders of the status quo to coordinate their efforts across diverse work positions and social identities. They must stand up to aggressive attempts to divide their coalition. And they must enlist transient reformers to put themselves on the line for change. Only by engaging in such robust collective action can internal reformers accomplish the reform that those outside have fought so hard to promote.