February 2019, Volume XXXII, No 11

cover story One

Change management

Improving outcomes in health care

“People are entitled to joy in work.”—W. Edwards Deming

n health care, where change management is often viewed with dread rather than enthusiasm, this might seem like a surprising way to begin. Change management is most often defined as the process, tools, and techniques required to achieve a certain business outcome. This includes supporting people to make changes. Yet for many reasons, change management in health care—perhaps in the areas of new clinical guidelines, evidence-based practices to integrate behavioral health and collaborative care, implementation of Triple Aim objectives, or staffing structures—often fails to provide this necessary support to health care workers before, during, and after any system change or process improvement.

When it comes to quality improvement and the transformation required to thrive in a value-based care environment, the idea of facing one more process improvement can seem overwhelming. In fact, when there’s a choice between making a change and maintaining the status quo, most people choose the latter.

So how can physicians and other health leaders not only implement change but achieve strong engagement around change (or even “joy”), particularly when many health care workers are feeling burned out and disillusioned? There isn’t an easy answer. Too often, what organizations call “change management” are actually top-down management mandates, instead of what should be an inspirational, creative practice.

The practice of medicine has faced unbelievable amounts of change over the past decade. Much of that change has been externally driven, from federally mandated electronic health records, to the introduction of the ACA and the implementation of Medicare star ratings. Further disruption has resulted from medical information being widely available on the internet. This has armed health care consumers with knowledge, but at times has created challenges when the information was of poor quality. It’s not surprising, faced with so much external change, that resistance to internal change management programs continues and may even be growing within physician ranks.

Change management or rigid mandate?

When physicians and other health leaders resist change, it can be challenging for administrators and change agents to introduce and implement new systems and process improvements. When faced with resistance, management can easily fall into the trap of issuing rigid mandates disguised as quality improvements. This often leaves organizational change agents feeling like a modern-day Sisyphus, dragging unwilling participants up the hill toward the desired outcome, only to repeat the same effort the next day, and the day after.

Obviously, there’s a problem with change management in health care. At quality improvement workshops led by the Institute for Clinical Systems Improvement (ICSI), we’re asked the same question over and over again: “How do we get people to participate in improvement?” The answer is not rigid mandates, which create defiance rather than engagement. The answer lies in creating an atmosphere that embraces collaboration and the co-creation of solutions. Simply put, the answer is a return to teamwork.

Physicians can and must be the leaders in transforming how health care approaches and manages change and quality improvements. They must embrace the idea that the responsibility for any improvement resides with everyone, not just the quality improvement (QI) staff or a designated change agent.

Most health care organizations already have a good understanding of Lean and Six Sigma principles. It’s the engagement skills that have been left behind. To truly engage people within health care, change has to be a collaborative process. Physicians should play a strong role in moving to what often constitutes a brand new mindset around change management

Embracing change is not optional, it’s a requirement to survival.

Developing the “how” through small tests of change

Redefining change management can benefit from taking a fresh look at the Model for Improvement (MFI) developed by quality experts Gerald J. Langley and Kevin M. Nolan, authors of “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.” Although most health care leaders “know” the MFI, the actual implementation of the MFI and its associated tools may not always be carried forward in its true spirit of trial and learning.

In our experience, most organizations are taking on activities that are too big for the MFI’s Plan-Do-Study-Act (PDSA) cycles. Using smaller PDSAs can further change more effectively. By involving the team in specific, smaller cycles, PDSAs can also serve as a vehicle for re-introducing a more collaborative approach. Evidence has shown that testing hypotheses on a small scale actually speeds up improvement. The cycles iterate more quickly, and knowledge is acquired more rapidly.

It’s clear that nearly everyone understands “what” needs to be done. It’s usually the “how” that isn’t planned well. The “what” is often the mandate, such as a strategic goal, or compliance to certain required metrics. Redefining the “how” can help achieve stronger engagement, by using a team approach and building a solution that reaches the desired outcome.

Steps to engaging the team in quality improvement

Most health leaders and other change agents feel they’ve tried just about everything, and many are frustrated by their inability to motivate teams to improve. What usually hasn’t been tried, however, is asking the team to participate in creating the “how.” It may seem like a leap of faith to believe that the team will co-create strong solutions, but in most cases, that’s exactly what happens. While there is some variation depending on the size of the team and the situation being addressed, most successful engagement follows these four steps:

  1. First, clearly define the non-negotiable “what.” In other words, be clear about the goal that must be achieved. Explain that the status quo is not an option and that their participation is a necessary and vital part of developing process improvements. Physicians should consider using data and patient stories that help support the staff’s understanding of the goal.
  2. Next, encourage ownership of the “how.” Gather ideas from the team in a group setting on ways to accomplish the goal, and/or to reach the desired outcome. Ask them to hold each other accountable for contributing ideas. Physicians can support the QI facilitator in this idea-gathering phase by encouraging all members of the team to share ideas. An outside facilitator can be helpful when doing this exercise with a new team.
  3. Now, focus on embracing every idea. Create a safe environment where all suggestions have a place on the table to be considered by the team. The goal is to gain a better understanding of the problem together, and then co-create possible solutions based on ideas generated from the team. Solutions may not be clear at first, but there needs to be a sense of freedom and safety to explore any avenue. Physicians are trained to be analytical and find problems, but this is a time to hold back on analyzing potential outcomes. This allows many possible solutions to be considered before choosing what to try.
  4. Finally, experiment with small PDSA cycles. As the team examines the results of each test cycle, they need to be willing to use what works, keep testing those which seem promising, and abandon ones that simply didn’t work. It’s important for new processes to represent real improvements, not merely changes. This is the phase where a physician’s strong analytical skills can and should be used.

Too often, what organizations call “change management” are actually top-down management mandates.

A major premise of improvement experts Langley and Nolan’s guide is that change isn’t achieved through the implementation of a single solution. It’s the impact of several changes that have the most effect on the whole system. Understanding this, and adopting an iterative, team-based approach, can accelerate quality improvements. Team members feel a sense of ownership around the improvements, which in turn results in more engagement in the future.

Infusing change management with collaboration

Change management may be difficult to tackle within many health care organizations where physicians and staff are overworked, overwhelmed, or even burned out. An unusual but effective tool that has proven useful involves applying the rules of improvisational arts to quality improvement. In ICSI’s “Prime the Pump” workshop series, physicians and health care staff are invited to re-engage with change management through the collaborative framework of improv.

Anyone who has watched the popular show “Whose Line Is It Anyway,” listened to jazz, or seen a performance by Stevie Ray or Brave New Workshop is familiar with improv. Watching successful improv is to see a group of people creating a safe, supportive environment where exceptional teamwork is employed to address a challenge together. Practicing the principles of improv can help drive collaboration within everyday work scenarios. Improv principles map beautifully to the process of change management, which requires an open, learning-based environment.

Improv has a performance style with many layers of complexity, but these few key components of improv can be used to effectively create a collaborative environment for change management and conducting small tests of change:

  • Always say “Yes, and…” rather than “No” or “But” to any idea. This honors and validates others’ contributions, creating a supportive environment for new ideas to develop and thrive.
  • Choose to always move forward. Embracing change is not optional, it’s a requirement to survival. Phrases like “If not this, then what?” help people consider new options when they are stuck.
  • Make your partners look good. Encourage participants to see themselves as interconnected and dependent on each other for success.
  • Genuinely listen and support others by discontinuing habits of negating, ignoring, or refusing ideas.

Physicians who have participated in ICSI’s workshop Prime the Pump: Activate the Team, Accelerate Improvement often report back that they’ve learned new ways to collaborate with their staff and lead teams to co-create stronger, more positive change. Participants feel much safer making suggestions, and the atmosphere of teamwork that improv brings presents change management in a supportive, positive, and, often, joyful light.

Conclusion

Change management in health care needs a makeover. Physicians can support this by using the four steps to engagement. Clarifying the “what,” team ownership of the “how,” and embracing ideas and testing them together builds a collaborative process for an iterative model of change. Adopting improv tools is one way to help create a team-based mindset and empower teams to change the system in a profound and meaningful way.

Claire S. Neely, MD, FAAP, is chief medical officer at the Institute for Clinical Systems Improvement (ICSI).

Sarah Horst, MA, is a project manager/health care consultant at ICSI. 

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cover story One

Sarah Horst, MA, is a project manager/health care consultant at ICSI.