Behaviour change is core

At the heart of any improvement effort lies behaviour change. If people continue doing what they’ve always done, nothing changes. That’s why organisational change requires behaviour change. For example, changing clinical routines involves more than gaining agreement; it requires individuals and teams to adopt new habits in the context of busy environments.

Too often, managers assume that providing the right information will naturally translate into new behaviours and improved systems. While individuals need to know what to do, information alone is not enough. Lasting improvement depends on enabling people and providing a range of practical supports and reminders to shift their daily behaviours.

Behaviours are shaped by a dynamic mix of individuals’ capabilities, opportunities, and motivations. They are also influenced by broader system conditions and previous experiences. Consequently, behaviour is driven by multiple factors. A clinician might be willing to try and introduce a new product, but if they lack protected time, access to tools, or confidence in the process, change often stalls.

Even motivation is complex and contextual. It’s not just about effort or attitude. Motivation represents both individual intentions and the routines, emotions and habits that propel most daily action. Uptake of a new practice may depend on whether it aligns with a clinician’s values, their trust in the source of the change, or their sense of professional autonomy.

For all behaviour change, individuals need time and space to learn about what is required. Even when individuals know what to do, a safe place to practice and hone the skills improves their confidence and self-belief in a new pattern of behaviour. Further, these learning and practice opportunities must be enabled amidst competing pressures and time constraints in busy work environments. Too often, it is assumed that health professionals know what to do and how to do it because they learned about it somewhere else!

Without attention to these multiple influences on individuals’ behaviour, implementation efforts risk being incomplete or unsustainable.

Organisational systems influence behaviour

To complement this focus on individual behaviour change, it is important to acknowledge that organisational structures shape individuals’ actions. People behave in ways that their healthcare systems support. At the same time, healthcare systems are structured in ways that often reinforce the status quo. Policies and regulations enforce adherence. Even when new practices are evidence-based and well-intended, they may struggle to gain traction if existing workflows, infrastructure, or reporting systems are not designed to support them. Clinicians might want to adopt a new documentation approach, but the electronic system they use makes it cumbersome or inefficient.

Healthcare systems are not faceless machines that can be repaired and tuned up. They represent a unique combination of structures, processes and services, between which there are interacting and interdependent relationships. Every healthcare system has a specific combination of health professionals who interact with administrators, patients and their families. Within these systems, people act within relationships. A strategy that is technically sound may still fail if it lacks support from respected peers or alignment with team values. When clinicians see their colleagues engaged in a new practice or are invited to shape the process themselves, they are more likely to take part.

Above all, change efforts need direction and alignment. That’s why a shared purpose is so important. As individuals work towards a shared purpose and make progress towards clear goals, they understand why change matters and how they can contribute. Over time, they are more likely to stay engaged, even when things get tough. When those involved in delivering a healthcare service help co-design their new pathway, they are more likely to commit and contribute.

The promise of implementation science

Over the last few decades of implementation science research, many practical implementation strategies have emerged to support behaviour changes in complex healthcare systems. The process of implementation is built through practical planning.  Strategies need to be tested, adjusted, and adapted over time. Even with detailed description, analysis and planning, outcomes in complex systems will be both predictable and unpredictable. Therefore, ongoing monitoring and adjusting is required for sustained improvement. A phased rollout of a new clinical pathway, with feedback loops and opportunities to learn from what’s working, helps maintain momentum and build confidence.

Finally, just as no two people are the same, no two healthcare organisations are the same. An implementation strategy that works in one healthcare setting may fail in another. Successful implementation recognises that one size does not fit all. Effective change leaders adapt strategies to local needs, constraints, and relationships, ensuring that solutions are relevant, feasible, and embraced by the people they are meant to support.

Ultimately, successful implementation depends on enabling both individual action and collective alignment within each health system. The Ten Core Principles are summarised in the following table.