PowerPoint Presentation

Series 2: Project ManagementUnderstanding and Using 6 Basic Tools9/2013From the CIHS Video Series Ten Minutes at a Time

Welcome to the SAMHSA-HRSA Center for Integrated Health Solutions video series Ten Minutes at a Time. This is Series 2 on Project Management. Modules 1 through 5 in this series can be used as a primer by PBHCI grantees on how to use Project Management Tools to support the success of the PBHCI initiative. It can also be used by any Behavioral Health Provider who is interested in integrated primary and behavioral health care, meeting the standards for Meaningful Use, and/or implementing or upgrading an Electronic Health Record System. 1Module 5: Change Management OverviewDefine and identify basic principles of change management

Two levelsOrganizational readiness for change Project Schedule Activity/Task changes that impact constraints

Example of a Change Management model

Link Change Management to workflow diagramming

This is Module 5: Change Management. In this module we will define what we mean by this term and identify the basic principles that guide its application. We will also describe how Change Management is applied at the macro, or organizational level, and then at the micro, or Project Schedule level, to support project success. We will offer an example of a model that can be used for Change Management and link Change Management to workflow development through the analysis of the As Is and To Be states.2Change ManagementProjects make changes to processes, systems, tools, job roles and even organizational structuresRequire individuals to change how they do their jobs

Change management is the application of the set of tools, processes, skill and principles for managing the people side of change to achieve the required outcomes

Goal is to support individuals through the required changes not impose change

(Prosci, Inc. 1996. Retrieved February 2012 from www.change-management.com)

Change Management is critical to project management because projects are intended to create changes. This means that individuals have to change their daily routines, or the change will not be successful and the project will fail. Change Management efforts can be based on validated and reliable tools and processes that adhere to basic principles while leveraging opportunities to create an environment where the desired change can happen. It helps Project Manager manage risk through stakeholder engagement. 3Change Management in the Project Management PlanGoal is always to keep project on time, on budget and in scope without sacrificing qualityIntegrated throughout Plan:

Communication Plan - includes project sponsor, project manager and project team/stakeholdersRisk Management Plan - based on validated change management tools applied to common and expected project risksProject Schedule requires time and space for implementation, so considered in the project duration

There may be a disconnect between the need for Change Management and the time and money it requires. A good Change Management Plan is not considered separately from the rest of the Project Management plan. It pinpoints how and when effective stakeholder involvement is critical to keeping the Project Schedule on track and it integrates the Change Management intervention with the overall Risk Management and Communication Plans. 4Ten Principles*Address change systematically and proactivelyStart with executive level leadership (via the Project Steering Committee)Involve every layer of the organization Make a formal case why and howLeadership has ownership of the changeCommunicate the change planConsider the organizational culture Address the organizational cultureExpect the unexpected Engage the individual

*Ten Guiding Principles of Change Management (2004). Reggie Van Lee, John Jones, Paul Hyde, Gary Neilson, Andrew Tipping, DeAnne Aguirre, Wolfgang Schirra, Jrg Krings, and Claudia Staub. Booz Allen Hamilton, 2004.

Change Management begins with the Project Charter and Statement of Work. These documents identify the Project Steering Committee and the organizational leadership who gave the go ahead to take on the project. The Project Steering Committee may have a green light for the project, but that does not mean they have embraced the change it will create. Executive-level leadership must own the change that is, they must understand why the change is necessary, even though it may be difficult. They must also have a vision for where the change will take the organization that considers input from those who are charged with implementing the change. This vision must be openly shared because stakeholder buy-in will determine the project success. If the Project Steering Committee is ambivalent, or the vision is not articulated, stakeholder engagement will certainly reflect this. This slide lists ten guiding principles of Change Management that address these and many other concerns. 5Change Management Removes Barriers*Pressure about developing new skills Fear of looking stupid or incompetent in these new skill sets Fear of losing professional status Pressure re: management expectations for improved performance and effectiveness Pressure connected with a perception of more control by management resulting in an expectation of fewer errors Fear of job loss due to the new technology, changing roles

*Hostgaard, A., & Nohr, C. "Dealing with Organizational Change when Implementing EHR Systems." Paper presentation. MEDINFO 2004, San Francisco, CA.

Organizational change can be unwelcome for a number of reasons that might not even occur to leadership, who may be expecting medical professionals and staff to soldier through. Usually a better approach is to seek out the nature of the concerns, then acknowledge and respond to them. This slide identifies some of the most common concerns.

*Hostgaard, A., & Nohr, C. "Dealing with Organizational Change when Implementing EHR Systems." Paper presentation. MEDINFO 2004, San Francisco, CA.

6Force-field Analysis and the Lewin* Change ModelForces for change Forces resisting changeDriving forces Restraining forces

Equilibrium? No change! Driving force MUST exceed restraining force

Kurt Lewin's Contribution and a Summary of Methodology in Analyzing Change (2004). Retrieved 9/2013 from http://www.valuebasedmanagement.net/methods_lewin_force_field_analysis.html .

Lets take a look at a model for Change Management, the Force Field Analysis and Lewin Change Model. This model recognizes the forces that are for change, and that drive it forward. It also considers the forces that resist change, and how they act to keep change from happening. If there is equilibrium between these two forces, change cannot happen. To create an environment for change, the driving force must exceed the restraining force.

Kurt Lewin's Contribution and a Summary of Methodology in Analyzing Change (2004). Retrieved 9/2013 from http://www.valuebasedmanagement.net/methods_lewin_force_field_analysis.html .

7Lewins Model: Unfreeze-Change-RefreezeLewins modelUnfreeze Shake up stage, focus on developing awareness for need for change, nature of change needed, methods planned, needs of those affectedChange Define challenges, identify solutions, create and follow project plan to implement change, troubleshoot to find solutions Refreeze Lock in changes and stabilize, consolidate, evaluate and support, prevent regression to old ways

Lewins model first seeks to unfreeze the status quo, disrupting the equilibrium by shaking things up through a planned intervention that identifies common ground. This is considered the opportunity for undermining restraining forces and strengthening the drivers for change. The change process itself continually focuses on developing awareness for the need for change, it clarifies the nature of change needed, explains the change methods that will be used, and steps through how stakeholders are affected. Once the change has happened, it re-freezes to lock in change - that is, it ensures the change is effectively implemented and there is no sliding back into the old ways of doing things. 8Lewin Force Model With Scoring Pre-AnalysisImplement certified EHR system

Attain Meaningful Use

Demonstrate HIEForces for changeForces against changeGrant $$$Good businessBest practiceScarce ResourcesConfusionNot welcome533544Total = 11Total = 13

It begins with the identification of the exact nature of the change and then identification and analysis of the forces for it and against it. In the case of EHR adoption, there are many forces at work. These arrows illustrate just a few that support change and a few that keep change from happening. Once these are identified, the strength of the forces are evaluated on a scale of 1 to 5, with 1 on the weaker end of the continuum. Then the various force strengths are added together, to see where the bulk of the forces for or against change actually lie. In this case, change is not happening and is even losing some ground because the force field for resistance is stronger than the force field for change. 9Intervene to Unfreeze, Disturb Equilibrium and Reduce Opposing Force

Unfreeze Intervention: Create a shared vision Increase awareness about the new health care paradigmUnderscore role EHR systems have in its implementationLink Meaningful Use to national health reform and role of behavioral health

Unfreeze Intervention: Create individual motivationWhy exchange BH information using NwHIN Direct? What are the underlying best practice principles? How will individual staff person benefit (what are the personal rewards?)

http://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidInfoTechArch/Behavioral-Health-MITA.html

Interventions are planned and executed to disturb this status quo and reduce the strength of the opposing force. One very powerful tool is the process of engaging opposing forces by creating a shared vision. There is an approach for this targeted to Behavioral Health providers that is effective on several levels called the Behavioral Health Medicaid Information Technology Architecture. Despite the name, this is a very process-oriented technique that any Behavioral Health organization can adopt. A link is provided to this resource and the listener should review the Concept of Operations document, in particular, for this guidance. Another effective intervention is based on shared values. Most providers want to do their jobs effectively and efficiently, so the strength of the opposing force is reduced if the change can be linked to this shared value. 10Intervene to Strengthen Forces for ChangeImplement and Freeze (Stabilize) Change Change InterventionsWhat will their job look like when the project is fully implemented? What workflows will be affected? How will the change be monitored and controlled? Where are staff involved in the planning?

Freeze (Stabilize) InterventionReward skill development, active project supportSet a cut-off date for doing things the old way and 100% transition to the new wayImplement training plan (for start up and for new staff orientation; peer-to-peer model for those lacking skill needed for the change)

This is followed by actively implementing the change, but continually intervening to ensure that it is supported. Staff need to participate in making changes to their workflows, for example, and also know that they have a role in the planning and implementation. There must be a vehicle for them to communicate their concerns, and a process for ensuring these are acknowledged and addressed. Otherwise, the stakeholders will soon feel disenfranchised and Change Management will lose effectiveness.

The Change Management Plan must have a strategy for acknowledging the usually extraordinary efforts stakeholders are making to support the realization of the vision, and there must be a widely recognized end point to the change process. This is often signaled by the implementation of the training plan, which no longer accommodates the old ways of doing things. 11Post- Intervention Force Field Analysis ScoringImplement certified EHR system

Attain Meaningful Use

Demonstrate HIEForces for changeForces against changeGrant $$$Good businessBest practiceScarce ResourcesConfusionNot welcome544323Total = 13Total = 8Plan/Do/Study/Act (PDSA) http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx

Interventions are evaluated for effectiveness on an ongoing basis and modified if they are not achieving the desired results. One model for this activity, familiar to most Behavioral Health providers, is Plan/Do/Study/Act or PDSA. A link to more information about this technique is provided. In this slide, it was determined through PDSA that the planned interventions were having the desired effect, and balance of force was shifted to the side for change.

Plan/Do/Study/Act (PDSA) http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx12Change Management and Workflow AnalysisRequires a ProcessIdentify the need for change in As Is state Summarize need and To Be vision in change requestLog the change request (name, date, brief description, any additional follow up for clarification)Project Manager evaluates the change impact on project schedule (time, cost and scope), includes in requestSubmit change request internal change control board (Steering Committee, IT Governance group, GPO)Obtain decisionImplement change (use PDSA) OR document reason for no change in log

Change actually happens in the conduct of the hundreds of tasks that comprise a working day. For this reason, stakeholder input is the most valuable source for information that the Project Manager can tap. There needs to be a process for collecting and mining this input. For example, suppose the receptionists discover existing functionality in the EHR that would make a difference in how efficiently they can do their jobs, but the Project Schedule does not implement it because at the time the utility was not recognized? How can they communicate this within the context of the Change Management process? This slide identifies a path that allows them to make the request in a manner that clearly identifies the benefits of the change while providing consideration of the possible disadvantages within the big picture of project implementation. This can be a feature of the Communication Plan.13SummaryPeople skills, stakeholder consideration are valued during all stages of the projectEmployees and clinicians are informed and engaged (on the project team, included in Communication and Risk Management Plans)Consideration given to what will motivate stakeholders to make the transition Staff involved in workflow analysis and redesign Training (online, classes, one-on-one) offered pre- and post implementation, as needed

Lorenzi, Nancy M., and Riley, Robert T. (200) "Managing Change: An Overview."

In summary, Change Management is central to project success and integral to the Project Plan. The Project Manager adopts a model for Change Management and incorporates it into the Project Schedule, and the Risk and Communication Plans. Stakeholder involvement is highly valued and actively pursued and used. There are many paths for participation in realizing the vision and creating the change, with resources identified for any training or customer service that supports that participation. 14We Have Solutions for Integrating Primary and Behavioral Healthcare

Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs

1701 K Street NW, Ste 400 Washington DC 20006

Web: www.integration.samhsa.govEmail:integration@thenationalcouncil.orgPhone:202-684-7457

Prepared and presented by Colleen ODonnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions

Our thanks go to SAMHSA and to HRSA for providing support to the Center for Integrated Health Solutions (CIHS) for this and many other forms of training and technical assistance related to the integration of primary and behavioral health care. Please visit our web site at www.integration.samhsa.gov, email us at integration@thenationalcouncil.org, or just pick up the phone and give us a call at 202-684-7457.

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