finding your footing in quicksand: how leaders can ... · the change roadmap ... adaptive change ....
TRANSCRIPT
1
Finding Your Footing in Quicksand: How Leaders Can Navigate Rapid Change to Maintain Momentum
Bren Manaugh, Principal | Health Management AssociatesArt Jones | Principal, Health Management Associates
December 14, 2018
2
AGENDA
UNDERSTANDING CHANGE AND AVOIDING COMMON PITFALLS
FOCUS ON CHANGES FOR VBP IN INTEGRATION
THE CHANGE ROADMAP
SUSTAINING CHANGE
How has change to support Value Based Payment Readiness in BH integration worked so far? • In advance of this webinar you were asked to
reflect on a significant change you have undertaken within your organization to advance your readiness for value based payment in integrating behavioral health and primary care.
• Consider this change effort as we go through the following slides…
What is the single largest factor in the failure to sustain a significant organizational change?
VBP in Integrated Behavioral Health is a paradigm shift
5
6
UNDERSTANDING CHANGE
✚Value based payment for integrated behavioral health is a paradigm shift
A paradigm shift is…
✚an important change that happens when the usual way of thinking about or doing something is replaced by a new and different way.
7
UNDERSTANDING CHANGE
VBP for Integration Requires Culture Change
Culture is…
✚The 'way of life' of a group of people; “the way we do things around here”. An integrated pattern of human knowledge, belief, and behavior; shared outlook, attitudes, values, morals, and goals.
✚An organization's culture is made up of interlocking goals, roles, processes, values, communications practices, attitudes and assumptions.
8
UNDERSTANDING CHANGE
✚Implementing sustainable BH integration through VBP requires cultural – or ADAPTIVE -transformation in the practice in addition to TECHNICAL transformation
✚Technical change is easily accomplished with expert knowledge and input – adding tools, models, processes, etc.;
✚Adaptive change requires new learning and changes in values and beliefs
The single biggest reason for failed change efforts is leaders treating adaptive challenges like technical problems.
TECHNICAL PROBLEMS ADAPTIVE CHALLENGES
Easy to identify Difficult to identify (easy to deny)
Often lend themselves to quick and easy (cut-and-dried) solutions
Require changes in values, beliefs roles, relationships & approaches to work
Often can be solved by an authority or expert
People with the problem do the work of solving it
Require change in just one or a few places; often contained within organizational boundaries
Require change in numerous places; usually cross organizational boundaries
People are generally receptive to technical solutions
People often resist even acknowledging adaptive challenges.
Solutions can often be implemented quickly—even by edict
“Solutions” require experiments and new discoveries; they can take a long time to implement and cannot be implemented by edict
UNDERSTANDING CHANGE
The Importance of “the Why”
Are we earning $8 per day?Are we running a jackhammer?
Or, are we building a national monument?
11
THE INGREDIENTS OF EFFECTIVE CHANGE
WHAT DOES IT TAKE FOR CHANGE TO BE EFFECTIVE? Quiz: Adaptive or Technical? ✚ A change worth making.
✚ Leadership committed to the change.
✚ Resources sufficient to make the change.
✚ A plan to use those resources well.
✚ Skills and perseverance to carry out the plan.
✚ An ability to learn from doing.
✚ Broad participation and engagement in the full change process.
12
THE JOURNEY TO CHANGE: “Cs” SUCCESS IN DRIVING CHANGE
✚ The “Why” comes first and is always central to planning and communication with staff
✚ Then the what, how, when and where
✚ “Cs” Success:
✚ Committed and Capable leadership
✚ Composition of leadership team
✚ Committed = make time to support the effort
✚ Capable = understand the technical requirements and have emotional intelligence to motivate and support staff
✚ Collaboration – engaging the voice, enthusiasm and strengths/skills (input) of all staff
✚ Communication
13
PAUSE FOR REFLECTION ON YOUR CHANGE EFFORT
How did you do with “ Cs’ing Success”? (Reference Your Worksheet)
✚ Was “the why” clearly understood and messaged?
✚ Was leadership at the top engaged in and driving the effort?
✚ Was a team of champions in place to plan and drive the effort?
✚ How was collaboration and engagement of staff considered and activated?
✚ Was the change effort clearly communicated on an ongoing basis?
INTENTIONAL ORGANIZATIONAL AND CULTURAL CHANGE MANAGEMENT
14
Integration is a Technical Change
If we Hire Them, they Will Team
We Need a Paradigm Shift
but Don’t Change Anything
Management is Sufficient
Clinical Integration is
Enough
Like Kryptonite—Pulled to Silo
The Jump to False Negative
Rushing Through the Starting Gate to Miss the Finish Line
Many organizations miss the importance of set-up
for effective integration and related VBP readiness
8 common organizational
mistakes in taking on integration
From: Integrated Care: A Guide for Effective Implementation. Raney, Lasky and Scott, Eds. 2017.
15
CHANGE TAKES BOTH TECHNICAL AND ADAPTIVE WORK
TECHNICAL CHANGE
ADAPTIVE CHANGE*
Performance Improvement Cycle: 1 2 3 4 5 6 7 *SUSTAIN & IMPROVE
ATTENTIONEFFORT &RESOURCES
TIME
INTENTIONAL ORGANIZATIONAL AND CULTURAL CHANGE MANAGEMENT
16
+ Building the Plane while Flying + Reimbursement-Separate
Payment Systems+ Separate Lines of
Control/Management+Workforce
Readiness/Training+ Logistical and or
Regulatory Barriers
System Level Team Level+ Resistance to Change+ Personal Power Struggles+ Shift from Individual
to Team Philosophy+ Blending Professional
Cultures+ Professional Inequities in
Status (perceived or real)
Common challenges
to integration
Importance of Team
Development and Set-up
Engage in Change
Leadership
LEADERSHIP IS FOUNDATIONAL
TO EFFECTIVE IMPLEMENTATION
Leaders Create the Collective Value Base and Bring “Unity from Diversity”
THE ROLE OF LEADERSHIP
From: Integrated Care: A Guide for Effective Implementation. Raney, Lasky and Scott, Eds. 2017.
INTENTIONAL ORGANIZATIONAL AND CULTURAL CHANGE MANAGEMENT
Articulate & Plan for
Financial Sustainability
Set the Vision for the Model
Commitment to Philosophy
of Care
Solidify Team and Ensure Change in Practice
17
18
WHAT IS RESISTANCE?
IS IS NOT
Inevitable and emotional response Necessarily logical
A natural function of disruption A sign of disloyalty
Manageable Something to overcome or combat
An attempt to protect or defend the individual and protect them from harm
Aimed at you or to be taken personally
A sign that the potential for change exists. An indirect expression of underlying concern
Designed to discredit your competence, despite the words being used
Attempting to control the change process
Indicative of poor performance
A learning process A sign that the change process is out of control
Resistance…
19
Attempting to change the end user’s view with “logical” arguments about why they should change
Dealing with the person; not the issue
Ignoring the end user’s emotions and behaviors concerning the change
Assuming what is “logical” to you is logical to the end user
MOST COMMON MISTAKES IN MANAGING RESISTANCE
Giving up or not repeating the process
20
EFFECTIVE BEHAVIORS IN MANAGING RESISTANCE
✚ Creating rapport. Build strong working relationships
✚ Establishing expectations and providing context
✚ Explaining the change in terms of the stakeholder’s “What is in it for me” baseline
✚ Establishing the source of resistance from the stakeholder’s point of view
✚ Asking open-ended questions—support and invite open expression
✚ Occupy less than 25% of the air time- shut up and listen
✚ Utilize the stakeholder’s energy to help manage the situation
✚ Create WIN-WIN situations
✚ Repeat the resistance management process
Motivational Engagement How many of you use motivational engagement and interviewing to help your patients adopt healthier more adaptivehabits and behaviors? The same applies to organizational change efforts.
• Defining success
• Achieving success
• Translating to organizational change that is sustainable
MOTIVATION FOR CHANGE
22
A CHANGE WORTH MAKING
✚ When thinking about your practice’s journey toward integration – and readiness for value based payment - what are the factors that drive decisions about practice transformation?
✚ A care need in your patient population and a gap in services delivered?
✚ Financial instability?
✚ Data, such as patient or staff satisfaction results?
✚ Strategic opportunity to expand clinical services, access, growth in number of patients?
✚ To make it “a change worth making”, the need has to be greater than the “cost” to do it (money, time, people, other resources)
23
THE JOURNEY TO CHANGE: ORGANIZATIONAL CONSIDERATIONS
✚ Aligned incentives – are there incentives, policy initiatives, strategic goals that support the need for the change? Is the juice worth the squeeze?
✚ Positive climate – finding change agents with positive outlook to lead change
✚ Anticipating the roadblocks and being proactive in addressing them, e.g. staff resistance
✚ Capacity to undertake the change – how much other change is happening at the same time? Are the other changes affecting the same people and resources for this change? Need to prioritize?
24
THE JOURNEY TO CHANGE: HOW DO WE ORGANIZE TO MANAGE (LEAD/ SUPPORT) THIS CHANGE?Key Roles for Change
✚ Sponsor – is there a senior leader who is supporting this change?
✚ Team Leader – who will be the lead that unifies and motivates? PCP champion? BH champion?
✚ Change Agents – who will be on the team that is leading the changes? (e.g., provider, care manager, BH team member, scheduler, rooming nurse, IT and data analytics)
✚ Change Participants – who will be affected by these changes?
25
THE JOURNEY TO CHANGE: HOW DO WE GET FROM HERE TO THERE?
✚ Remember: all change is personal
✚ Levers of change:
✚ Communication – communicate “the why” what is changing, when, and who is leading/who wants to be involved. Hard to “over-communicate.”
✚ Education/Training – training on all new processes and roles helps people feel more confident/comfortable and less resistant to change
✚ Reinforcement (Recognition and Rewards) –Data shows if efforts are working or not working; achievement of goals is highly motivating as is being empowered with a role in supporting progress toward goals
✚ Personal Support – provide to mitigate resistance; inspire!
✚ Plan “there to here,” travel “here to there”
✚ DATA! Using data as a key within these change levers is necessary and powerful
26
THE JOURNEY TO CHANGE: HOW DO WE ALIGN CHANGE STRATEGIES WITH BEHAVIORS?
✚ After planning the work it is now time to work the plan.
✚ Use the structures, roles, and processes you have put in place to manage the change.
✚ On-going alignment questions:
✚ Are we on course? If not, what do we need to do to get back?
✚ What are we learning from our experiences?
✚ Repeat all steps as needed….
27
THE JOURNEY TO CHANGE: ORGANIZATIONAL CONSIDERATIONS
Tell the Story✚ Compelling purpose for the change
– Why do we need to do this?
✚ Translate the “why” into goal(s) for the change
✚ Establish measures – how will you know you are reaching your goals?
✚ Do you have baseline data for your patients with depression? How many are screened? How many screened positive?
✚ Customer focus – patient data, utilization, and care experience surveys
Add yogi berra quote re getting there
Selecting the strategy - What needs to change AND WHY
Defining the change -Describing the destination - the Aim (where your want to get and why) -GOALS
Defining the change -How will you know when you get there?DATA/MEASURES
29
THE JOURNEY TO CHANGE
Integration that drives value depends on practices measuring what they do.
VBP in BH Integration: Driving Quality and Value
30
Integrating behavioral health and physical services for better outcomes through quality.
+ Integrated clinical services for improved access to behavioral and physical health services
+ Care coordination of all patients
+ Care management of high risk patients
+Managing transitions of care
+ Following evidence-based guidelines,
+ Standardized screening, assessment and evaluation tools
+ Performance on quality measures
+ Health IT outcomes measurement capabilities
31
THE JOURNEY TO CHANGE: MEASURING THE CHANGE
High number of patients in our population with diabetes and
depression and outcomes are
below benchmarks
Access to behavioral health needs are > than
30 days out
Readmission rates for our patients
with BH needs are steadily increasing
DATA re where the biggest gaps are in our processes and systems
SELECTING THE STRATEGY | WHAT NEEDS TO CHANGE?
Defining the change - Describing the destination - the Aim (where
you want to get to and why)
Defining the change - How will you know when you get there?
DATA! Need frequent measures over time and after
each action step
An aim/goal is based on the data showing the gap in care.
Set the aim/goal to be a stretch goal but not
unrealistic
32
THE JOURNEY TO CHANGE: EXAMPLE OF AN AIM/GOAL
✚ Goal – To increase the number of patients with depression having a clinical response or remission from 25% to 50% in 12 months
✚ Mid-term process goal – to increase the number of patients screened annually for depression using the PHQ-9 to 95%
✚ Mid-term goal – To increase the number of patients with clinical depression actively engaged in BH care management to 85% within 6 months
✚ Identify the measures and a data plan that will be needed to monitor progress towards these goals, give feedback to reinforce what's working, activate new actions (changes in workflows, technology and tools needed, etc.)
DATA AS A LEVER FOR CHANGE
26
Data is sought by many stakeholders
Tells the story
Reinforces progress and shows gaps in progress
Keeps stakeholders engaged
Combats (false) assumptions
Sharing Data is a Powerful Component of the Change Effort:
34
DATA DRIVING CHANGE
✚ Again, without data/feedback, no one knows the status of a project or initiative
✚ Data reveals the real story, so other stories don’t get made up
✚ Data can help to identify what other levers of change need to be used
35
THE JOURNEY TO CHANGE: NEXT WEBINAR: Data
✚ Our next learning collaborative webinar will focus on data analytics.
✚ What is our aim/goal?
✚ What data should we collect?
✚ How will we collect it?
✚ How do we use it to understand if we are meeting our aims/goals?
✚ How do we use it to drive progress toward our aims/goals?
