Change Management

Optimizing Organizational ChangeBy Edgar D. Staren, MD, PhD, MBA, and Chad A. Eckes, MBA, PMP

In this article...

Review how careful attention to change helped lead tothe successful implementation of an EHR.

Anyone in a leadership position is well aware that anytype of change within their organization is never easy butis a normal part of progress; such change is especially com-monplace in the dynamic nature of the current health carelandscape.

Despite that knowledge, how best to manage changeis often unclear and/or ill-defined. This is particularlytroublesome when one considers that a given change mayaffect everyone from one individual to the entire organiza-tion. Moreover, the extent of the impact resulting from thechange will vary depending on its magnitude and duration.

Before embarking on the management components, itis worth noting the critical aspects of the organization thatgenerally should not change. Specifically, we are referringto the organizational vision, mission and values. Exceptionsto this rule may include the process of an organization'stransformational strategic planning process. Otherwise,these entities form the critical foundation for stabilizing anorganization during tumultuous change.

Identifying business issues or opportunities forimprovement is often the initial step toward change.Invariably, a process or technology innovation is needed toremediate the issue. Normally, an innovation leads to longlasting change.

One of the major difficulties with regard to change inhealth care is that the current model is characterized byincreasingly restrictive regulations and bureaucracy. Thismakes the identification and implementation of innovativeprocesses and technologies difficult at best.

However, innovative health care organizations andleaders do not surrender.

Instead, successful organizations flourish by seekingout different paths. They create environments that strive toreinvent their competitive landscape; they create a culturewhere change becomes routine.

Innovative organizations find change is at the core oftheir culture and values. At Cancer Treatment Centers ofAmerica (CTCA), our promise to our patients includes thestatement, "We never stop searching for and providingpowerful and innovative therapies...."

Rosabeth Moss Kanter of Harvard Business School sug-gests that "successful companies develop a culture that justkeeps moving all the time....and provides value to the cus-tomer." In the case of health care organizations this meansthe patient.

Impact of changeWhen a health care leader is anticipating a major

change, it is important to consider the impact that changewill have on the various areas of the organization. Thisimpact may be visualized graphically in what is referred toas a "productivity dip."

Concomitant to predictable decreases in productivity areperiods of responses that can be quite significant dependingon the specifics of the change. Individuals affected by thechange may go through periods of denial and resistance, fol-lowed by possible exploration and finally commitment. At thedepths of the dip, there may be a period of outright anger andeven despair (the so-called "trough of despair").

The goal of optimizing change management is to mini-mize the size and duration of this curve. Moving affectedindividuals as rapidly as possible through the periods of resis-tance, anger and denial, or better yet, avoiding them altogeth-er, requires leaders to understand and be prepared to addressthe reasons why people resist change in the first place.

An astute leader will pay close attention to how thestakeholders affected feel about the change. By understand-ing, appropriate actions can be taken to manage the changefor individual stakeholders.

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An important activity during our EHR go-live was our willingness to acknowledge andreward those individuals willing to take a risk on change. It is essential that leadersidentify ways to motivate their teams.

Graph l

IIoIaCO

Managed Change

Acceptable Levelof Performance

UnmanagedChange

Time

First of all, the good news is thatnot all individuals within an orga-nization will resist change. In fact,some will embrace it. The reasonsfor this are multiple but do provide agroup that can be leveraged to assistin change management.

The other significant minoritywill be those who are overtly againstchange and may actively work againstit.

The majority of individuals with-in an organization will be attentivebut non committal to the proposedchange. That is not to say they do nothave concerns, but they balance thatconcern with faith in their organiza-tion, previous positive experienceswith change, and confidence in theircolleagues proposing such change.

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Resistance to changePeople resist change as a defense

mechanism since change of any typeelicits some level of anxiety. Thisanxiety is understandable becausechange creates the possibility of aloss of status quo or worsening ofposition, impact, compensation andauthority.

Even if the change is unlikely tohave such a direct impact on an indi-vidual, fear of the unknown can lead tosubstantial anxiety. When people havehigh levels of anxiety regarding any-thing, they typically put themselvesinto a "fight-or-flight" state. In thisstate, an attempt to force the changewill result in resistance equal to orgreater than the force being applied.

Change management modelsJohn P. Kotter of Harvard

Business School and author ofLeading Change is a recognizedauthority on change management.He defines change management as"the utilization of basic structure andtools to control any organizationalchange effort."

Kotter notes that more thantwo-thirds of major change effortsin organizations fail. It is not for lackof well-defined models for organiza-tional change. It is likely that thesefailures occur as a result of leadershipnot dealing effectively with the pre-dictable resistant forces.

Doing so necessitates consistentuse of a well-thought-out changemanagement plan. Although manyothers have entered the change-man-agement arena, the eight-step processdelineated by Kotter continues tomake an impact.

Kotter model for changemanagement

Kotter defines step l as "Creatinga climate for change." Within that stepare three components that are imple-mented sequentially.

1. Establishing a sense of urgency.

2. Creating the guiding coalition(i.e. building teams).

3. Developing a change vision.

Step 2 is "Engaging and enablingthe organization." It too has threecomponents:

1. Communicating the vision for

buy-in.

2. Empowering broad-based action.

3. Generating short-term wins.

Finally, step 3 is "Implementingand sustaining the change." It hastwo components:

1. Never let up.

2. Incorporating changes into theculture (i.e., making the changestick).

An idea as changeBefore we delve deeper into

this important and effective changemanagement approach, it is worthnoting that each of the various mod-els approach change managementfrom the standpoint of an isolatedimplementation event.

We would suggest that thismisses the essential idea generationand nurturing component of changemanagement. Moreover, rather thanan isolated event, change manage-ment tends rather to be ongoing andas dynamic a process as the changeitself. If change management is notongoing, behaviors will revert topre-change habits.

Organizational change oftenbegins as a routine component ofcommon incremental activities, e.g.,annual budgets, etc.

Transformational change is gen-erally more major, perhaps even gamechanging, has broader organizational

scope, and is longer in duration. Suchtransformational change starts withconsideration of how any new ideamight provide a value to a customer.In the case of health care, such valueassessment most often applies tothe patient. It requires consideringwhether it is possible to provide theproposed value in light of availableresources such as staff, space,equipment and know-how.

Staff consideration cannot beunderestimated. Support of leader-ship and an influential sponsor, thebaseline attitude of both manage-ment and staff, as well as each oftheir capabilities to address the newidea must be taken into account.Leaders must confirm the consisten-cy of a new idea with the organiza-tion's vision, mission and values.

One might ask at this point, iftransformational strategic planningis routinely associated with suchchange and therefore inherentlyhas the potential for some risk, whyembrace it?

Transformational strategic plan-ning is critical to helping an organi-zation be proactive about its future;specifically, it assists organizationsto anticipate and manage change. Inthe health care arena, clinical and ITexecutives are ideally poised to leadsuch efforts.

Electronic health recordimplementation

In our organization, a national,for-profit, multi-hospital cancer caresystem, such a detailed approach wasused to ensure success in one of themost significant change managementexercises encountered by any healthcare organization—implementation ofan electronic health care record (EHR).

The idea for the EHR originatedabout 36 months before its go-live. Asequential approach composed of avalue assessment, personnel assess-ment and cultural assessment wasused to originate the project.

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Throughout, we held true to apremise that key to the success ofthis major change would be priori-tizing all components based on theimpact to our customers; specifically,our patients.

We deliberately moved into theimplementation phase after one yearof assessment. Although we admit-tedly modified our approach to beconsistent with the unique aspectsand skills of our organization, inthis implementation phase we gener-ally followed much of the standardchange management approach asdescribed in Kotter's model.

The first six months we created aclear sense of urgency. This includeddemonstrating to all levels of theorganization that our current paper-based environment made it difficultfor our stakeholders to optimallydeliver our promise of being "rec-ognized and trusted by people livingwith cancer as the premier center forhealing and hope."

We made regular presentationsat staff, departmental and leadershipmeetings, as well as ad-hoc informa-tion sessions in the form of "roadshows" and town hall meetings.

The information provided waspurposefully compelling, clearlyarticulated and frequently repeatedwhenever and wherever possible. Weensured that the information was con-sistent no matter who was speaking.

Considerable effort focused onportraying a future state that wasunderstandable and was supported byevidence. We used recently publishedreports that demonstrated improvedquality of care resulting from hospi-tals and health care systems havingelectronic records.

This vision also attempted todefine the specifics of how an elec-tronic environment might positivelyimpact the individual stakeholderdirectly; essentially what would bet-ter enable them to do their job.

While we recognized andrespected the audience's resistance.

we also were steadfast on the needfor the change and did not waiver onthat focus.

Most of the discussions werefocused on the positive benefits, butit's worthwhile to recognize thatthe downside of not completing thechange is also compelling to the audi-ences. Many sales people recognizethe power of "fear, uncertainty anddoubt." Part of the assessment (andjustification) process of most healthcare changes necessitates presentationof both the clinical and business case.Although impact on quality of care wasfront and center in our presentations,the importance of a detailed cost-ben-efit analysis was presented as well.

Physician leaders are uniquelyqualified to translate the complexitiesof the clinical and business implica-tions of such major change to healthcare organization governance bodies.

As the change management pro-cess evolves from the initial to inter-mediary phases of implementation,the need to delineate and empowereffective coalitions and teamsbecomes essential. It is particularlycritical to ensure that championshave been identified and engaged inthe process by this point.

Champions are especially usefulif they are diverse. In the case of anEHR implementation, such champi-ons may be expected to address themany and complex components ofclinical and administrative areas ofbuilding an adequately robust EHR tomeet the many needs of even a rela-tively small health care organization.

The second phase of Kotter'smodel encompasses engagement andenabling of the organization. Thisrequires an even clearer delineation ofthe vision for change. Communicatingthe vision in this manner certainlyprovides background information anddescribes the change and its process,but it also reinforces the rationale forthe change.

In the case of an EHR implemen-tation, the need for over-communica-

tion cannot be underestimated. If youbelieve you are over-communicating,you probably are still not communi-cating enough.

Our communications includedwell-publicized kick-off meetings,weekly presentations at each of thehospital sites, a list of frequentlyasked questions, distribution of dailytips during training, and regularlyscheduled management briefings.

Detailed communication contin-ued for a substantial period of timeafter the go-live to ensure and main-tain buy-in. All this communicationwas done with respect to the expect-ed sense of loss felt by the individualsand the organization as a wholeduring the change.

As is often the case, listening ismore important than talking. Manysessions were held for raising issues,identifying risks, Q&A, and communi-cating concerns. We found affinity dia-grams of risks to be especially valuable.

Rewards matterAn important activity during our

EHR go-live was our willingness toacknowledge and reward those indi-viduals willing to take a risk on change.It is essential that leaders identify waysto motivate their teams.

Risks of not adequately deter-mining what motivates the clinicalstaff during major health care changewill result in a less-than-ideal workenvironment and may even put theorganization itself at serious risk.Finding motivators is key.

Although incentive-based moti-vational methods are used, suchmethods may not always involvecash. Opportunities to engage peoplein leadership opportunities, i.e.,participatory management, can beextremely effective.

A number of characteristics ofchange communication can have sig-nificant impact on the communica-tion's effectiveness. The leader mustensure that any change remains true

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to the vision, mission and values.Also, it is worth remembering

that non-verbal communication cansometimes make more of an impactthan verbal. A health care leader isregularly watched by health carestakeholders. He or she needs to beespecially visible during change todemonstrate support as well as toprovide a calming influence. Healthcare leaders should take everyopportunity possible to talk aboutthe change in a manner that is clear,inclusive, confident and frequent.

Health care leaders can ensurethat the change process and theresponsible parties are provided thenecessary resources to succeed. Justas important, they must ensure thatobstacles to success are removedquickly.

A third component of phase twois creating short-term wins. In thecase of our EHR implementation,go-live occurred 18 months after theorganization had been given approvalby its governing body to proceed. Werecognized that with implementationof an EHR that involved 22 modulesand three time zones, short wins wereessential to get us past resistance.

We understood that basic func-tions, such as the ability to quicklysearch for patients, was somethingthat would be embraced by theclinical staff. As a result, increasedtraining and assistance by so-called"super-users" was given to this func-tion. Particularly in the case of anEHR implementation, well-plannedand effective training on the soft-ware and hardware can greatlydecrease resistance.

Particularly for the first fewweeks, our entire implementationteam, including our key health careleaders, dedicated themselves toround-the-clock participation toensure that the change process didnot derail.

As we progressed, we continuedto look for and report widely on thosecircumstances where the EHR was

improving the quality of care pro-vided to our patients. For example, weidentified that implementation of thebar code scanner as a component ofthe EHR, substantially decreased ourincidence of medication errors. Suchinformation was widely reported fromthe level of the front-line stakeholderto the most senior governing body.

Further efforts to ensure thechange included evolving our imple-mentation team (i.e. the EHR com-mittee) into an entity that not onlyhad responsibility for the EHR butfor the quality of care it was designedto support. This group monitoredsafety/quality outcome measures,coordinated system wide qualityimprovement efforts, identified tech-nology needs and clinical staff edu-cation needs, and reviewed practiceguidelines and clinical protocols.

All of these helped ensure thatthe major change brought by the EHRwould stick.

tEdgar D. Staren, MD,PhD, MBA, is presidentand CEO of WesternRegional Medical Center ofCancer Treatment Centersof America in Goodyear, AZ.

Edgar.Staren@ctca-hope.cani

Chad A. Eckes, MBA,PMP, is chief informationofficer for CancerTreatment Centers ofAmerica.

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