Table 1

Recommendations to approach adaptive challenges

Recommendation	Explanation	Practical example
Be unwavering in your goal and invite everyone to help you reach it.	Choose a goal you are confident can be achieved and focus on reaching this goal. Recognise that you cannot reach this goal alone—you need the wisdom, skill, and passion of others to help achieve the goal.	If some clinicians resist efforts to reduce CLABSI, clarify that your goal is to reduce infections, it has been done by others. Yet, be sure to enlist the help of others, such as ICU clinicians, infection prevention experts, quality improvement staff, and senior hospital leaders.
Surface the real and perceived losses.	People resist change because they fear a real, but more often a perceived, loss.	Some junior doctors and nurses resisted change because they feared looking incompetent in front of others. Senior staff may fear perceived loss of control or autonomy.
Communicate the need for change.	Clearly explain the need for change so staff understand why instead of guessing motives or resisting the change.	To engage staff in the effort to reduce CLABSI, stories were told of patients harmed from these infections; staff were given data of their current infection rates, and estimates of the number of people predicted to die from those infections.
Tune into what's in it for me.	Identify what staff care about, then maximise the perceived benefits and minimise the losses.	When interdisciplinary rounds were first implemented, some doctors feared it would take too long. So, the number of pages per day was estimated. When the number of pages was shown to drop significantly with rounds, the doctors pushed to do this in other areas of the hospital.
Seek to understand rather than judge.	Talk to dissenters; it is most likely a barrier or concern causing them to resist.	A physician who was resisting a QI intervention was labelled by administration and QI leaders as obstructive, stating “he will just need to tow the line”. When I spoke with him, he noted a previously unidentified risk from the intervention. When steps were taken to minimise this risk, he became a local champion.
Monitor the organisational pressure.	Assess the ability to take on initiatives, monitor the burden on you, staff and the organization, and adjust workloads accordingly.	A hospital was in the middle of implementing a new computer system, and being pressured to implement QI programs required by regulators. When I talked to staff about implementing a new QI effort, it became clear that their workload was too high and the project would have to wait.

CLABSI, central line associated blood stream infection; ICU, intensive care unit; QI, quality improvement.