Pioneers in Palliative Care

Feature Editor: Vyjeyanthi S. Periyakoil

Change Management: The Secret Sauce of SuccessfulProgram Building

Vyjeyanthi S. Periyakoil, M.D.

The field of palliative care is somewhat ‘‘countercul-ture’’ to mainstream biomedicine. In conventional bio-

medicine, symptoms are used merely as a means to an end,i.e., symptoms are used as clues to diagnose the underlyingculprit, the disease. Once identified, all energy is devoted toannihilating the culprit. In contrast, in the field of palliativecare, the symptom (pain, dyspnea, nausea, etc.) itself is thefocus and much effort is directed at alleviating the symptom.Understandably, this premise of palliative care sets it apartfrom the rest of mainstream biomedicine. Additionally, hos-pice and palliative medicine being the ‘‘newest kid on theblock’’ of medical subspecialties fundamentally representschange. Therefore, effecting and sustaining change is a key sur-vival skill for all palliative care professionals.

Effecting change is a process (not an event) and requiresboth strategic thinking and ongoing hard work. The Centerfor Advancement of Palliative Care (CAPC) founded by thepioneering efforts of Dr. Diane Meier offers a framework,requisite tools, and support for clinicians who want tochange their local health care systems for the better bybuilding new and expanding existing palliative care pro-grams.1 Additionally, clinicians have to become skilled inthe process of change management in order to harness thefull power of the CAPC tools to create successful palliativecare programs.

Kotter’s Eight-Step Model for Change Management

Change management is a stepwise approach for ensuringthat programmatic changes are implemented smoothly andsystematically and that the lasting benefits of change areachieved. One of the most effective and widely used changemanagement models was developed by John Kotter at theHarvard Business School.2 The Kotter model outlined belowserves as a successful roadmap and can be used to oper-ationalize any of your palliative care initiatives.

Set the Stage

� Step 1: Establish a sense of urgency: It is not that peopleare incapable of seeing the solution. Often people are in-capable of seeing the problem. Once convinced that theproblem does exist, most people are willing to adopt rea-sonable solutions. Local institutional data (for example:

poor observed-to-expected mortality ratios for hospitalizedpatients) and compelling patient case studies are two ef-fective tools that will typically galvanize stakeholders intosupporting your palliative care initiative.

� Step 2: Create a coalition for change: Identify the trueleaders=champions in your organization. Champions arepeople whose power and influence may come from a va-riety of sources, including job title, status, expertise, po-litical importance, community connections, and specialskills. Securing commitment=endorsement from andscheduling regular brief meetings with these championswill build collegiality and a common purpose that can beharnessed to create buy-in for the project.

Decide What to Do

� Step 3: Develop a vision and strategy: A vision can bedefined as a desired realistic and credible future state thatan organization hopes to achieve. An effective vision is acompelling dream that energizes the project team andprovides both the emotional and intellectual energy for theseries of actions that will ultimately result in the actual-ization of the vision. The team should write a brief visionstatement and also identify the concrete tasks to be done toget closer to the vision.

Make it Happen

� Step 4: Communicate the change vision to others: Theproject team should assiduously look for and articulate thevision speech at every available formal and informal op-portunity in order to secure stakeholder buy-in. The morethe vision is publicized over time, the more effective itbecomes.

� Step 5: Identify and overcome resistance: Any changeinitiative will always run into human resistance. Diag-nosing and overcoming resistance is the backbone ofchange management. Overcoming resistance will serve toempower the people you need to execute the vision.Education, negotiation, and persuasion are the most effec-tive tools in overcoming resistance to change. The pallia-tive care communication skills that we use so successfullyon patients and families are just as effective when used oncolleagues and coworkers.

Stanford University School of Medicine, Stanford, California.

JOURNAL OF PALLIATIVE MEDICINEVolume 12, Number 4, 2009ª Mary Ann Liebert, Inc.DOI: 10.1089=jpm.2009.9645

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� Step 6: Generate short term successes: Nothing succeedslike success. The project team needs a taste of victory quiteearly in the change process. It is therefore critical to iden-tify ‘‘low-hanging fruit’’ (simple and surefire milestoneswith little room for failure) and achieve them as a dem-onstration of the credibility and validity of the proposedinitiative. Small and early successes will feed on them-selves to create sufficient momentum and morale to over-come the perils and pitfalls related to the project.

� Step 7: Consolidate gains and produce more change:Kotter states that many change projects fail because smallwins are confused for enduring victory. Enduring changeneeds to overcome organizational cultural resistance andthis process takes time and effort. With every projectmilestone achieved (or failed), it is important to analyzeand learn from the outcomes. It is also important to pre-serve and augment the momentum by recruiting new stakeholders and celebrating successful project milestones.

Make it Stick

� Step 8: Anchor the changes in the institutional culture:Finally, the change has to be hardwired into the core ofyour organization. The healthcare environment is everchanging, with staff turnover, influx of new initiatives andshifting organizational priorities. Incorporating the initia-tive into local protocols and procedures and adopting areminder system are two effective strategies to weave thechange into the organizational fabric. Finally, anythingworth doing is also worth measuring. Brief surveys (col-leagues and stakeholders as well as patients and families)that can be tailored to focus on specific features that aremost relevant to the new initiative are the most commonlyused metrics. Sharing project data with stakeholders fur-

ther serves to bring in new streams of energy and re-sources.

� Our lives are not the only ones that are affected by what ishappening to us and what we are doing at work. Everyonein our work lives (friends, co-workers, subordinates, su-pervisors) are touched in some way by what we do. Mostimportantly, the more we incorporate palliative care intoour organizations and effect change, the more we enableand empower those around us to change for the better. LaoTzu the ancient Chinese philosopher eloquently summa-rizes this process as:

Learn from the peoplePlan with the peopleBegin with what they haveBuild on what they know

Of the best leadersWhen the task is accomplishedThe people all remarkWe have done it ourselves.

References

1. Meier D: Finding my place. J. Palliat. Med 2009;12:331–335.2. Kotter JP: Leading change. Harvard Bus Rev 2007;85:96–103.

Address reprint requests to:Vyjeyanthi S. Periyakoil, M.D.

Stanford University School of Medicine3801 Miranda Avenue

100-4APalo Alto, CA 94304

E-mail: periyakoil@stanford.edu

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