Change'Management'in'Healthcare!

Workshop Report

June 2014

Introduction! The Change Management in Healthcare Policy Workshop brought together healthcare and business leaders, policymakers, and researchers on January 8th, 2014 in Kingston. The one-day workshop featured an interdisciplinary panel discussion and an interactive, facilitated dialogue to outline the next steps for future collaborative research projects. As part of the program, conference speakers and participants developed a vision for partner-oriented research on healthcare policy reform by:

• Mapping the landscape of existing research on healthcare change management • Identifying key research priorities for effecting change in Canada’s healthcare system • Building linkages between researchers across disciplines and creating opportunities for future

collaborative research grants addressing change management in healthcare The conference began with an opening panel discussing new movements in change management for healthcare in Canada.

Dr. Julian Barling, Professor of Organizational Behaviour at Queen’s School of Business, opened the conference by drawing lessons on change management from the leadership and influence of Nelson Mandela in South Africa. Mandela provided three key lessons that can be easily translated into the world of Canadian healthcare. The first lesson is to respect the opposition. This involves having the ability to take other perspectives into consideration and to build an appreciation for alternative views. The second lesson

considers the importance of influencing the opposition, which is often overlooked in favour of rallying supporters. One of the principal challenges in leadership is not to reinforce support from those who are already supportive, but to reach out to adversaries and force them to question themselves and their reasons for opposition. Dr. Barling also brought attention to the fact that leaders must also be learners, and to the lack of training that exists in healthcare leadership. There is now emerging evidence that a greater representation of females on hospital boards leads to a greater amount of training endeavours. The third and final lesson is that reciprocity is the first rule of persuasion. This means that givers succeed more than takers and ultimately receive a much more valuable pay-off. These three lessons build upon one another to create a platform for change management that is particularly relevant for Canada’s healthcare leaders. Paul Huras, CEO of the South East Local Health Integration Network (LHIN), introduced the principle of change management as an approach to transitioning individuals, teams, and organizations to a desired future state. The efforts of the South East LHIN focus on working with health service providers to improve access to high quality care through the development of regional integrated care. The primary challenge has been to find a balance between organizational and regional priorities. The two main drivers of change are the change in patient demand and the change in the supply of services to meet this demand. The existing system of care is fragile, as it is designed to serve an outdated patient

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demand model dominated by acute care episodes. Patients today are increasingly frail and elderly, exhibiting multiple chronic conditions that require an integrated system of care. Canada spends more on healthcare than almost all other countries, yet fails to achieve top outcomes. Ontario spends 38% of its provincial budget on healthcare. In an economic environment where debt is already persistent, a new funding formula for hospitals is needed. In order to spread change in such an environment, a vision must be built with support and confidence. The process to move towards such a vision must occur through community development practices, both internally to local communities and externally to partner engagement. Key areas for further knowledge include new models for hospital boards, moving from a single focus on organizational performance, to a dual focus that also assesses the performance of the system. Likewise, research is needed on how to shift training from organizational leadership to systems leadership in a way that involves frontline workers alongside managers. Leadership exists throughout the healthcare system, but the environment is such that many leaders are prevented from revealing their expertise. In order for a change management process to succeed in healthcare, system leadership is necessary. Dr. Richard Reznick, Dean of the Faculty of Health Sciences at Queen’s University, advocated for a reduction in the strictures of healthcare accountability, and a renewed emphasis on creativity instead. His comments shed light on the current state of Canadian healthcare, which has fallen into a sea of accountability, in part due to micromanagement, which results in counterproductive behaviours. Most evidence points to the fact that, on many metrics, Canada is not doing as well as it could, despite the 11.5% of its GDP being spent on healthcare, and despite healthcare being seen as a social pillar by most Canadians. The two biggest culprits in healthcare spending are hospitals and physicians. In order to ease spending woes, there must be a move towards patient-focused funding in hospitals. In a time where hospital executives have the flexibility to exercise creativity, this is entirely possibly. On the other hand, doctors operate differently from executives. They are strongly independent and self-regulated and therefore require significant care and maintenance within the system. Both spending on physicians and hospitals can be regulated to work towards a system that encourages responsibility rather than accountability. Accountability infers rules, while responsibility infers caring. Dr. Reznick also pointed out that accountability is still needed, but, in framing decisions, a simple approach that balances accountability and responsibility is best. Other panelists supported this notion, advocating for more bottom-up, emergent change initiatives in healthcare, and improvement frameworks that consider a wide range of factors, rather than a narrow set of accountability measures. Leslee Thompson referred to the triple aim embraced by the Institute of Health Improvement (IHI), which consists of improving the care of individual patients, improving the health of the population, and reducing costs. As CEO of Kingston General Hospital (KGH), Leslee Thompson has become familiar with the many facets of change management in healthcare. She noted that one of the most important and difficult leadership challenges with change is to create burning ambition within individuals and across organizations. In her hospital work, she has found it important to capture the hearts and minds of hospital staff in order to work together in new ways to achieve something greater. The Ontario Ministry of Health and Long Term Care has followed in the footsteps of the United Kingdom to adopt the NHS change management model to guide its transformation toward healthcare reform. The core of the model is centred on shared ambition, while the other elements of the model involve leadership for change, spread of innovation, improvement methodology, rigorous delivery, transparent measurement, system drivers, and engagement to mobilize. One of the key aspects of creating a shared system is to ensure alignment of actors and units in the system. Often in hospitals, leadership and traditional managerial skills are pitted against each other, even though both are needed. The

other essential component of change is the “spread, scale and stick” model. The notion of involving and engaging patients is required to mobilize change. Patient engagement must also be considered in research to ensure that the voice of the patient is built in upfront. At KGH, patients, doctors, researchers, and administrators are invited to discuss problems and issues from a combined lens to create an environment that can fuel change. Instead of prescribing change for people, it can be created with patients and families in order to set the expectation that no change in healthcare should be thought about, done, or delivered without the voice of the patient. Marg Alden shed light on the transformation of healthcare through her work as Executive Director at Kingston Family Health Team/Kingston Health Links. The current state of healthcare results in an elevated level of hospital visits when patients could be better cared for in the community. There are too many people who have trouble navigating the system, and too many people being readmitted to the hospital soon after being discharged. Moreover, most people in the system do not have access to a properly managed healthcare plan. Health Links is a new initiative across the province of Ontario that seeks to manage complex patients in the system suffering from multiple chronic conditions. There are a total of 7 Health Links in the South East LHIN, which consist of 104 doctors representing 132,000 patients. The system model used for managing complex care is focused on transitions between the system and awareness among partners. The aim of the intervention is to connect 90% of patients to a primary care provider through a well-coordinated care plan. The potential barriers that exist in primary care Health Links formation include the amount of time that may be spent per complex care patient, the notion of privacy with regards to a shared care model, the ability to facilitate communication between providers, and the fear of diluting resources. A major challenge will be to assess the impacts of the social determinants of health, which are the underlying environmental, social, and economic conditions that affect health and well-being. It will be imperative to understand how to engage both physicians and patients in the change management process. Any transformational agenda has to improve patient care, and if patients and providers are able to work together as a cohesive group, this will lead to coordinated care with a personalized game plan. The Canadian Foundation for Healthcare Improvement (CFHI) helps healthcare organizations across the country develop collaborative leadership. Kaye Phillips, Director of Evaluation and Performance Improvement at CFHI, highlighted the use of strategic goals as a focus on how to improve healthcare efficiency and achieve better value for spending. Her work has emphasized how to best integrate patients in the process of improving healthcare through collaboration and coordination. Using the CFHI Improvement model for change, healthcare management teams are learning strategies to build capacity and support for ongoing change processes within their organizations. Leaders are seen as champions of change, at the level of both frontline workers and executives. The aim is to support these leaders with skills training, and then work with improvement teams to spread and achieve outcomes. The monitoring and evaluation approach combines program evaluation through the use of logic models with improvement science methods, including real-time data collection. The evaluation is designed to be responsive and flexible in order to respond to the unique needs of individual organizations. A key feature of the approach is to build evaluation and performance measurement

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into the culture of an organization. In order to do this, priority measurement domains across an organization’s programs must be identified and aligned with the improvement model. It is critical for support staff and partners to reconcile the complementary features of research design and improvement methods. This will support the maintenance of on-going data collection, and the use of evidence to generate short and long-term results. There are many challenges that present themselves with evaluation and performance measurement. For example, long-term outcomes are notoriously difficult to measure and evaluations may be contextually and culturally sensitive. However, there are countless existing opportunities to achieve sustainable commitments to change and to push the improvement envelope to measure spread and scalability.

Opportunities!for!Research! In addition to surveying emerging themes in healthcare change management, workshop participants brainstormed research priorities around five themes:

• Organizational culture and leadership • Patient-centred care • Integration of care across delivery silos • Healthcare performance measurement and evaluation • Stakeholder engagement and governance

Organizational+culture+and+leadership+ Participants identified several opportunities for research on organizational culture and leadership, building on ideas raised by the panelists. The first was, “Team training –� how does it influence organizational culture?”�The group cited research by Zohar et al. on healthcare’s strengths in training individuals for success, but there are challenges that arise in training teams, especially when there can be hundreds of individuals on a team. Further, the culture of healthcare is changing rapidly, creating an urgent need for updated managerial skills. It is also critical to study the impact of leadership development and training on organizational climate. This could be studied using cluster randomization, evaluating the effects of different leadership development forms in different organizations. Alternately, studies could focus on one organization, evaluating why some groups succeed while others do not.

A second research theme would be, “Fostering leadership potential to improve team climate.” As healthcare practitioners work increasingly in teams, a better understanding of the skill set needed to create tomorrow’s team leaders is essential. Research could explore models for embedding leadership training into healthcare training. Building on the role of fear in change management, a third theme could explore,

“What are foundations of the ‘culture of fear’?” Research could explore the factors that enable organizations to move from “the burning platform” to one driven by “burning ambition,” as discussed by Leslee Thompson. In particular, those elements which drive risk aversion. The role of individual

personalities, be they risk takers or risk avoiders, in creating an organizational culture of fear should be considered as well. Fourth, it was suggested that a case review of organizational changes in healthcare, particularly one looking at both successful and unsuccessful change processes, could better inform future research. It was noted that medical teams often evaluate what went wrong in a process, but seldom assess what organizational and team factors were right. Patient4centred+care+ The identified “patient-centred care” is the driving force behind many new healthcare reforms, and yet there is little agreement on what “patient-centred care” actually means. A research study could address meaningful definitions of the term, in particular, looking at patient perspectives on the issue. This could engage a range of stakeholders, including patients, advocacy groups, and healthcare providers, as well as researchers in health policy, leadership, ethics, and law. A second study – “Optimizing the delivery of value” – could investigate what patients and providers value in healthcare. This would assess how these two groups understand “high value care,” determine their underlying values, and analyze the degree to which these two value sets align. Drawing on perspectives from psychology, marketing, and ethics, this study could provide insight into better meeting patients’ health quality expectations. A third study could explore closing the gap between practice guidelines and delivery. Quality of care could be improved by assessing where clinical practice falls short of standards. In addition to engaging policy researchers as above, such research should also involve information technology experts. Final studies proposed included an economic analysis of patients’ priorities, and addressing the priorities patients place on the investment of both their own personal resources as well as broader social resources for healthcare delivery. A study that would contrast patient wants and needs, particularly in terms of managing expectations in end-of-life care was also proposed. Such research would provide a valuable opportunity to involve patients alongside experts in ethics and law. Integration+of+care+across+delivery+silos+ Two studies were proposed relating to improved integration of care. Dr. Jean-Baptiste Litrico suggested a study entitled, “Loosing the bounds,” to explore those factors which prevent healthcare delivery organizations from innovating and integrating. In particular, such a study could determine what changes to the policy/regulatory environment are required to free leaders and organizations to integrate across silos, while still maintaining the level of accountability expected for publicly funded organizations. Global success stories could be of particular help in this case. Dr. Michael Green proposed, “Connect the Dots,” a study to investigate how health services provided by specialists can be coordinated for patients with co-morbidities. Drawing on case studies, collective learning, and network analyses, the project would identify the factors and processes that facilitate or hinder provision of care across providers to allow patient care to appear seamless.

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Healthcare+performance+measurement+and+evaluation+ Kaye Phillips, Dr. Elizabeth VanDenKerkhof, Dr. Kathryn Brohman, and Dr. Doug McKay suggested, “Identifying the Dark Side of Metrics,” hinting at the unintended consequences of metrics on organizational performance. In particular, the study would look at financial implications of measurement, by evaluating the cost/benefit ratios of the implementation of metrics in healthcare. Interviews with stakeholders would further identify what is working and what is not in healthcare metrics implementation. Garry Salisbury raised, “Hunter and Gatherers: Barriers and facilitators of information provision in healthcare measurement and evaluation,” a study which would identify factors that encourage and discourage gatherers in terms of providing honest and accurate information. Building a series of case studies at both the individual and organizational levels would elucidate the emerging culture of measurement and evaluation, drawing on planned behaviour theory and supporting research on organizational learning as well as power and influence. Last, the group discussed the role of transparency in effective quality measurement, in particular the impact of leadership in setting and articulating expectations for measurement and evaluation. Such a project could develop retroactive case studies on measurement implementation initiatives and utilize surveys to capture effectiveness outcomes. Stakeholder+engagement+and+governance+ Two studies were proposed to address issues related to stakeholder engagement and governance. First, “Do Boards Matter?” would draw on organizational theory to connect how board organization relates to the ability of boards to support organizational innovation and performance. It would

identify existing healthcare organization board models, characteristics of board members, and keys to board success using both organization surveys and a systematic review of existing best practices. The second study would use economic theory to assess the effect of employee incentives (financial and otherwise) on patient experience. It would identify the types of incentives used in healthcare systems, the impact of each incentive structure on stakeholders (e.g., nurses, physicians, patients, management), and the characteristics of effective health organizations and the kinds of incentives they utilize.