the keys to successfully managing “big change”€¦ · of empath consulting, an assis-tant...

42 GROUP PRACTICE JOURNAL A P R I L 2 0 0 9

The Keys to Successfully Managing “Big Change”BY BRENT A. FISHER, M.B.A., FACHE, FACMPE

integrated delivery systems and hospitals are among the most

complex organizations in the world. Eff ecting meaningful and sustainable change of any kind within these types of organizations is a challenge, to say the least. Th e fact that you are reading this article indicates that you have probably experienced that challenge fi rsthand and know of its intensity. To lead large-scale, enterprise-wide change is even more daunting. In fact, one world-renowned leader of “Big Change,” Michael Hammer, Ph.D., estimates no more than 10 percent of large enterprises have made a serious and successful eff ort at it.1 Studies show that two out of three such initiatives fail.2

“Big Change” is driven

by a desire to go well

beyond industry standards

of measurement-based

performance.

Beyond Process ImprovementTh e management of “Big Change”

requires something more than is off ered by traditional process improvement tools (such as Lean, Six Sigma, clinical micro systems, etc.). Such tools are excellent within their limitations: incremental change to or operational excellence of clearly

defi ned, narrow, existing processes. Th ese tools are not designed for, nor capable of, eff ecting transformational change.3 More and more organiza-tions that have used traditional process improvement tools and techniques are frustrated with the relatively small improvements and the length of time needed to achieve them.

“Big Change” is driven by a desire to go well beyond industry standards of measurement-based performance. Stretch performance goals are the expectation. Without such specifi c targets, “Big Change” will drift into incremental improvement. Only targets clearly unattainable through traditional means will stimulate the radical thinking and create the willingness necessary to overturn the conventional mindset of how to do work.

“Big Change” is a departure from familiar protocols. It requires a major advance in how a department con-ducts its work and how it interacts with other departments. It is deep change that aff ects the very essence of how work is done. Th e ability to manage this kind of super project requires a methodology to match its complexity.

ImplementationLarge-scale, enterprise-wide

projects must move quickly with close adherence to a tight schedule and with resources allocated accord-ingly. Traditional implementation typically takes too long to show value, increasing the likelihood of failure. Lengthy projects with no immediate evidence of value aff ord staff the opportunity to campaign

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CommitmentPhase

AcceptancePhase

IntroductionPhase

VII. Institutionalization

VI. Adoption

V. Installation

IV. Positive Perception

III. Understand the Change

CommitmentThreshold

Unawareness Confusion Negative Perception Decision Not to Change Aborted Change Aborted Try/Support after Initial after Extensive Installation Utilization Utilization

VII. Internalization

Degr

ee o

f Sup

port

for t

he C

hang

e

Time

2% 13% 35% 35% 15%

Resisters(Traditionalists)

Innovators

PAT/RCTMentors

Early Adopters

Early Majority

Late Majority

against them. Th is often results in a loss of enthusiasm, resources, and support, causing the project to fall prey to organizational inertia. Consequently, it is eff ective to implement an initiative such as hospital-wide operational redesign in multiple projects focusing on such areas as perioperative services, inpatient acute care, emergency services, radiology, etc.

Certain key elements are critical to achieving success in large-scale change management. Th ese ele-ments were identifi ed in a study of 225 major company projects by the Boston Consulting Group in 1994.4 Th ey include project duration, performance integrity, commitment, and eff ort. Although there are many elements that impact the success or failure of a project, these four factors are consistently correlated to a project’s success.

Duration Conventional wisdom holds that

the longer it takes to complete a project, the less likely it is to succeed. However, studies show, and my expe-rience demonstrates, that the true critical factor is the length of time between project reviews, suggesting less time between reviews equates with a more successful completion.

Reviewing a project at multiple levels on a regular basis keeps leadership involved and actively participating. It allows the reviewing groups to rapidly respond to any obstacle. Such action demonstrates to frontline staff and managers that their executives are seriously engaged, supportive, and actively monitoring progress, therefore increasing the adoption of new processes and technology. It also helps staff feel that the eff ort to make a signifi cant change in their daily work life will not be in vain, because executives are there to make it stick. (See Figure 1.)

Th e ideal frequency of reviews is based on their type: for example, weekly updates with the clinical area executive sponsor (i.e., CNO for

inpatient acute units, VP-Ancillary Services for radiology, Chief Surgeon for surgery, etc.); bi-weekly clinical area steering committee meetings; and monthly executive steering committee meetings.

Integrity Performance integrity refers to the

ability of the “Big Change” imple-mentation team to deliver the goods. “Big Change” requires freeing up the best staff to participate and lead the initiative. Success demands it.

“Best staff ” does not mean those who are most liked. Eff ective manag-ers of the status quo don’t necessarily make good change leaders. A job

description should be developed and skill set identifi ed so all can-didates being considered for any role can be evaluated against these benchmarks. Usually, good team leaders have problem-solving skills, are results-oriented, are methodi-cal but can work with ambiguity, are organizationally savvy, accept responsibility for their decisions, and are highly motivated but don’t seek the limelight.

Members of the team need to handle a wide variety of activities, resources, pressures, and unforeseen obstacles. Team members should be interviewed and their roles clari-fi ed, commitments articulated, and

FIGURE 1

Adopter Categories

FIGURE 2

Change Progression and Institutionalization



Considerations:1. Who must receive the message?2. What do people need to know?3. What is the desired and likely responses?4. How should the message be delivered? How often?5. Who should deliver the message?6. How will communication effectiveness be measured?

Contact:- Memo- Video- Meeting- Newsletter

Awareness of Change:- Presentation- Education- Focus Groups

Understand:- Training- Simulation- One-on-One

Installation- Rapid Cycle Test- Pilot Projects

Adoption:- Objectives Being Met- Performance Improved

Institutionalization:- Policy Manuals- Training Program- Performance Evaluation

Internalization:- Culture Statements- Vision- Belief

Positive/NegativePerception:- Manage Response

Degr

ee o

f Sup

port

for t

he C

hang

e

Time

Denial

Resistance

ApparentChaos

Dysfunction

Excitement

Today “Valley of Despair”

Higher Level of Performance

Perfo

rman

ce

Desig

n

Impl

emen

t

Tim

e

accountability defi ned. Executives need to determine whether all or only a portion of the employees’ time will be committed. But a clearly defi ned and protected time require-ment is a must.

Commitment Commitment must come from

two diff erent levels within the organization—executive and front-

line management— to create initial adoption and sustainability.

My experience, both good and bad, teaches that it is not worth man-aging a major change project without complete support from the executive team—not just one executive sponsor but the entire group , especially the most infl uential executives. Th at commitment must be articulated in presentations, newsletters, e-mails,

and meetings, as well as by the allocation of people and money. Support must be repeated, repeated, repeated continuously in every communication venue, throughout the entire length of the project, and consistently by each and every execu-tive. (See Figures 2 and 3.)

It is not uncommon for some

executives to be reluctant to

be so visible in their support

for a large-scale, challenging

project.

It is not uncommon for some executives to be reluctant to be so visible in their support for a large-scale, challenging project. When “Big Change” is implemented, someone’s comfortable world will be impacted. Executives will hear complaints. However, if executives don’t overtly communicate the need for the change and its value to patients, physicians, and employees, they jeopardize the project. Late, slow, or incomplete communication alienates managers and staff and creates distrust.

Although executive commitment is the most important and is double weighted in its impact on a project, mid-level managers must also be committed in order for rapid adop-tion to occur and for the project to be sustainable. My experience is that a frontline manager who is commit-ted to the change will increase staff adoption three to four times as fast as a manager who is not.

It is important that managers be able to articulate the value of “Big Change” and help their staff through the transition of new operational workfl ow. As staff transition from old to new processes and technology, they will pass through a “valley of despair.” Frontline managers need to encourage their staff and help them through this valley— the transition between giving up their comfortable,

FIGURE 3

Communication Strategies

FIGURE 4

Change Opportunities and Challenges


A P R I L 2 0 0 9 GROUP PRACTICE JOURNAL 47

second-nature knowledge of how to do things and becoming competent in the new process. (See Figure 4.)

EffortA major eff ort to transform an

organization can require much more staff time than a leader realizes. Studies indicate that if a person’s normal workload is increased more than 10 percent during the project, the implementation is headed for trouble.5 Based on my experience with transformational projects, I have found this to be absolutely true.

Th erefore, a project plan must be developed with very specifi c manpower and time requirements by job role. Th e plan should outline needs for dedicated FTEs, part-time participants, and those requiring intermittent participation. “Big Change” projects also require the reassignment of job duties and the

hiring of new or temporary people. But such actions have always proven an investment easily and quickly paid for by the dramatic improvements that result from a relatively rapid implementation.

ConclusionAn understanding of the

critical factors that lead to successful implementation of “Big Change” is important. It creates a framework for project discussions. Managers will also know forums where concerns can be aired. With an understanding of the principles, concepts, and struc-ture above, managers throughout the organization can eff ectively provide input that will shape the success of a project. Establishing and then monitoring continued adherence to these critical factors will result in successful “Big Change.”

References1. M. Hammer. 2004. Deep Change: How

Operational Innovation Can Transform Your Company. Harvard Business Review, April 2004.

2. H.L. Sirkin, P. Keenan, and A. Jackson. 2005. Th e Hard Side of Change Manage-ment. Harvard Business Review, October 2005: 110.

3. M. Hammer and J. Goding. 2001. Putting Six Sigma in Perspective. Quality, Octo-ber 2001.

4. H.L. Sirkin, P. Keenan, and A. Jackson. 2005. Op cit.

5. Ibid. Page 113.

Brent A. Fisher, M.B.A., FACHE,

FACMPE, is chief operations offi cer

of EMPATH Consulting, an assis-

tant clinical professor at Loma Linda

University, and a former member of the

AMGA Board of Directors.


the keys to successfully managing “big change”€¦ · of empath consulting, an assis-tant...

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