May 2019, Volume XXXIiI, No 2
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:
Too often, what organizations call “change management” are actually top-down management mandates.
Claire S. Neely, MD, FAAP, is chief medical officer at the Institute for Clinical Systems Improvement (ICSI).