Guideline into a succinct checklist based

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guideline into a succinct, checklist-based implementation guide; providing an outside systems consultant (i.e. a coach) with clinical expertise and experience; actively involving clinical staff (including primary care physicians, nurses, and physician assistants) in the implementation process; giving participants the ability to customize in- terventions (rather than using a one-size-fits-all ap- proach); and providing tools, such as the walkthrough exercise, Plan-Do-Study-Act change cycles, the nominal group technique, and flowcharting, that promote problem-solving and rapid, incremental improvements. Theoretical foundations The SCS rests on established theories of organizational change from systems engineering [29,31] and diffusion of innovations [14], as well as recent empirical research on quality improvement [1]. Deming established a num- ber of canonical systems engineering principles in his in- fluential book, Out of the Crisis [29]. Of these principles, the following are most important for the current proto- col: (1) quality problems are almost always caused by poor processes and systems, and thus lie outside the purview of individuals to change; improving quality re- quires systemic approaches rather than singling out indi- viduals, and (2) measuring and understanding process variation is critical to improving quality. The goal of the SCS is to reduce variability in opioid prescribing practices. Even though a clinical guideline for opioid prescribing has been in place for several years [32], most clinicians do not make adoption decisions based solely on scien- tific evidence. Rogers s work on diffusion of innovations [14] provides a theoretical framework for understanding why some ideas diffuse throughout systems while others do not. Although characteristics of ideas are important in diffusion, social factors largely supersede them. People (and organizations) are more likely to adopt an idea if they know of others similar to themselves who have done so already. Diffusion of innovations theory stresses homophily between change agents and those whose behaviour they seek to influence, that is, the similarity between individuals on characteristics such as education and social status, suggesting that consulting intended to affect physician prescribing practices should be done by consultants who are physicians. The idea of systems consulting rests on self-determination theory [15]. The theory holds that satisfying three funda- mental needs (competence, relatedness, and autonomy) contributes to individual high functioning. Conditions that foster meeting these needs lead individuals to move from extrinsic to intrinsic motivation a change that s Quanbeck et al. Health Research Policy and Systems (2016) 14:8 Page 3 of 10
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necessary for organizational improvement efforts to suc- ceed. According to self-determination theory, extrinsic motivation encourages people to regard the cause of their actions as being outside themselves rather than thinking of themselves as agents of change. Extrinsic motivators (e.g. tangible rewards, deadlines, threats, di-
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