transformational change management design and leadership ... · david lloyd, founder 1...

Presented By: David Lloyd, Founder 1

Transformational Change Management Design and

Leadership Implementation Support for CCBHCs

Presented by:

David Lloyd, Founder M.T.M. Services, LLCP. O. Box 1027, Holly Springs, NC 27540Phone: 919-434-3709 Fax: 919-773-8141E-mail: [email protected] Site: mtmservices.org

mailto:[email protected]

Faculty Presenter:


• David Lloyd, Founder of MTM Services is the author of three books o How to Maximize Service Capacity, o How to Deliver Accountable Careo Leadership Skills to Support High Functioning Teams and o Co-author of Operationalizing Healthcare Reform

• Provided training and consultation to over 800 CBHCs nationally since 1993

• Mr. Lloyd has developed service delivery process models, principles and solutions on how CBHCs can deliver “Value-Based” accountable care.

Use of Leadership Skills to Support High Functioning Teams

All Change Management Leadership Tools referenced in the workshop are available for download on the following URL: http://www.thenationalcouncil.org/mtm-services/leadership-essentials-download-area/and all change techniques are further supported in David Lloyd’s book, Leadership Skills to Support High Functioning Teams, published by the National Council for Behavioral Health

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David Lloyd, Founder

http://www.thenationalcouncil.org/mtm-services/leadership-essentials-download-area/


Transformational Change Challenges and Current Status for Texas Council Member Centers

1. Move entire system to CCBHC model of care for all 39-member centers by September 2020 – 22 months from now Seven centers and one FQHC are currently certified and a part of

the pilot Five centers received SAMHSA CCBHC Grants (Four were already

certified and one that is up and coming received expansion funding).

Four additional centers are in the process of being certified within the next couple of months.

Texas Council will be asking 4 or 5 additional centers to begin the certification process soon.

2. 23 additional centers will need to be certified with a target date of September 2020 – 22 work months from now.


Transformational Change Challenges and Current Status for Texas Council Member Centers

3. APM payment model is being developed within the next nine months.

4. Senate Bill 58 provided moving selected services into managed care. Consider the time and ongoing efforts necessary to prepare for and successfully bill Medicaid MCOs. CCBHC transformation has to be completed and operational in one (1) year and 10 work months from now.

5. “Need to slow down” - “can’t do all of these changes at the same time”- “Boards and outside entities do not understand why there are multiple changes at one time”. Strategic Business Planning with Management and Board members will be required.

The “Values” that CCBHC Group Practices Now Need… Certified Community Behavioral Health Clinics (CCBHCs) have an

excellent opportunity to be helpful partners in the new integrated healthcare system if they can display the following specific values:

1. Be Accessible (Provide fast access to all needed services).2. Be Efficient (Provide high quality services at lowest possible

cost).3. Be Connected (Have the ability to share core clinical

information electronically).4. Be Accountable (Produce measurement information about

the clinical outcomes achieved).5. Be Resilient (Have ability or willingness to use alternative

payment arrangements).


Current Practice Management Challenges BHOs and IPAs are Facing…

1. Accommodating reduced and shared-risk funding2. Operating as a “loosely-held federation of private

units/departments” instead of a systems learning friendly group practice model

3. Clinically trained managers tend to have a “therapeutic relationship” with their staff

4. Ability to have timely and accurate data to measure process costs and support management decision-making

5. Lack of an ability to present an objective “business case” to support collaborations/partnering with other healthcare providers


Biggest Challenge Facing Behavioral Health in CCBHC Reform Era

“Willingness for BH leaders to continually step across the Threshold of Risk to make bold and creative decisions about service delivery processes/methods!”

Need to make timely CQI based “tough” decisions in an era of transformational change and stick with the decisions in the face of challenge..

What tools are needed to support minimizing the leadership decision-making “risks”?


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Historical Leadership Challenges…

1. Recruitment and HR issues related to staff performance, behaviors, aptitude and attitude HR issues

2. Staff training requirements3. Timely and accurate documentation submission4. Internal customer service challenges within the

organization5. Need to renew the state or county contracts6. Need to send timely reports to Medicaid/County/

State

Presented By: David Lloyd, Founder


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Historical Leadership Challenges Produced:

“System Noise” that required leadership to focus energy on the internal challenges over and over again… This historical focus on the internal system needs was more workable when the external healthcare environment was not changing at a rapid pace…

However, NOW…

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David Lloyd, Founder11

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New Healthcare Reform Leadership Focus Areas…

1. Developing a new Strategic Business Plan that will respond to the requirement to shift from fee-for-service to an encounter based funding model.

2. CCBHC Population Management Models instead of one client at a time model including levels of care criteria

3. Shifting from “volume of services” revenue model to VALUE of Services Revenue model

4. Operating in a Shared Risk/Saving Funding Model based on a bundled payments for a episode of care cycle

5. Identification of client centered outcomes in an integrated CCBHC healthcare model instead of fidelity to process measurement outcomes

6. Making the business case for your agency to MCOs/ACOsPresented By:


David Lloyd, Founder12

Historical Strategic Change Challenges…

1. Sequential Change” – Complete one goal and then address next goal, etc.

2. Quality Improvement Process Focus (QI) – Typically Supports Process/Lack of Forward Movement/ Attainment

Vs.

3. “Transformational Change” – Continuous change management model using Rapid Cycle Change Model (PDSA)

4. Continuous Quality Improvement Solution Focus (CQI) –Implies Movement Forward/Action Has Happened to Provide Continuous Improvement


Rapid Cycle Improvement - Plan Do Study Act (PDSA) Cycles

The Deming Cycle,Deming's wheel, or thePDSA cycle is a long timeutilized continuous qualityimprovement changephilosophy created as partof W. Edwards Deming'sTotal Quality Managementprocess (TQM) in the1950's. Deming's workwas based off of the Plan,Do and See cycle createdby Mr. Walter A. Shewartin the 1920's, and hascreated successful changeinitiatives across multipleindustries.

•Evaluate the effectiveness of the change.

•React to the results of the evaluation.

•Implement the planned changes.

•Establish the Parameters for the change.

1. Plan 2. Do

3. Study4. Act

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CQI Implementation Process Reality

CQI implementation process seems MESSY…

CQI implementation process means creating additional solutions to challenges on the fly…

CQI implementation process creates more risk for managers..

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Consensus Processing Model = Staff and Organization Level Disempowerment Consensus building focus is a good clinical skill that social

workers are taught to use when working their clients/families However, the informal consensus model of decision-

making produces disempowerment for the project team members and the organization due to elongated planning/discussion phase (PDSA rapid cycle change management) which seldom produces timely implementation

Consensus decision-making creates staff change fatigue due to staff feeling like the organization will never actually change, but they keep meeting to discuss the need for change

“What did I accomplish in the past two-hour meeting?”


“Committee of the Whole” Vs. Delegated Authority Change Management

“Committee of the Whole” Change Model:

1. Sequential Change Model (one change goal at a time)

2. QI – Discussion focused on “What ifs” not implementation action

3. “Galvanized Team Members” extend the planning phase because decisions are made by “consensus of all gathered”

4. Collective Authority does not support Individual Responsibility Levels

Delegated Authority Change Model:

1. Transformational Change Model (multiple change goals at the same time)

2. CQI – Action based implementation to identify additional change needs

3. 70% Majority Decision-Making addresses “Galvanized Team Members” challenge

4. Individual Authority is given to match the level of Individual Responsibility


Sea Level is…Where The Organization Changes

“Sea Level” is the objective level where staff, managers, and leaders NEED to reside to support objective decision-making, compliance, etc. and this is where solution design and implementation of change will occur…

10,000 to 20,000 feet above sea level is where consensus decision-making resides which primarily focuses on subjective philosophical concepts, personal opinions, anecdotal information where many a large number of staff members gather to process the challenges of the need to change. When change initiatives are focused on consensus process the subjective “what ifs” become too weighty to implement…



Performance Measurement Needed to Support Effective Coaching for Change Implementation

A. Performance Standards for ALL StaffB. Objective Job Descriptions that support key

performance standards (KPI)C. Objective Performance Evaluations that provide

an honest/effective system learning environment related to attainment of the KPIs per staff

D. Formal Supervision Plan with Supervision Types and Supervision Session Guidelines

E. Performance Measurement with Full DisclosureF. Accountability with Positive and Negative

Consequences

Use Data to Measure Effectiveness of Current Change Model



Processing Crisis Vs. Managing Change Model

1. Supervisor: Reactive and Retrospective Problem Solver Role, therefore, he/she Processes Crisis

2. Manager: Dynamic Awareness of Current Issues that Provides Proactive Solution-Focused Decision-Making, therefore she/he Manages Complexities

3. Leader/Coach/Mentor: Possess Dynamic Awareness and Uses this information to envision possibilities for the organization, therefore he/she Manages/Sustains Change


Stages of the Acceptance of the Need to Change and Leadership “Blinking”

1. Denial2. Negotiation (This approach by supervisors “pushes”

staff to change)

3. Anxiety/Anger – Blaming – Outside then Inside

4. Drop Out – “It’s Awful!”5. Acceptance of the Need to Change6. Excited about the taking advantage of the

opportunities (This approach by managers “pulls” staff through the process of acceptance)


Implementation of Change Goals is Focused on Leadership/Coaching

Is About Coaching Staff… Buy-In by manager and staff Proactive Solution Focused Attitude “We can do

this...” Creativity in determining “How we can do this…” Overcoming Resistance to Change with coaching staff Developing Self Leadership Taking a step back to see the horizon and the past Celebrate every possible victory (change)… Reinforce

appropriate behavior/performance


Managing/Mentoring Staff Conflict Behaviors

Addressing inappropriate behaviors at the time of the behavior is key to change

Intervene in triangular dynamics between staff Developing Self Leadership will empower staff Identify the behaviors that you would like to see and

discuss them in staff meetings, in individual supervision sessions, etc.

Model the behaviors you would like for your staff to have

Celebrate every possible victory (change)… Reinforce appropriate behavior/performance

Reasons for Managers and Staff Resistance to Change

Belief that the change initiative is temporary based on organizational history

Belief that fellow employees or managers are incompetent Loss of authority or control Loss of status with in the organization Fearful that they lack the ability to learn new skills Change overload (too much too soon) Lack of trust in or dislike of managers Loss of job security Loss of family or personal time Feeling that the organization is not entitled to the extra effort


Spectrum of Disruptive Manager and/or Staff Behaviors that Create Barriers to Change Implementation

1. Aggressive Behaviors:• Inappropriate anger/threats• Yelling publicly, disrespecting team members• Intimidating fellow staff

2. Passive Aggressive Behaviors:• Hostile Notes and e-mails• Derogatory comments about center, management team, board• Complaining, blaming

3. Passive Behaviors: • Chronically late• Failure to return calls or answer emails timely• Avoiding meetings or individuals• Non-Participation• Ill prepared, not prepared• Chronic excuses


Transformational Change Implementation Project Management Support Outline

1. Develop strategic transformation Goals and identify the type of strategic plan format you will use – two dimensional or three-dimensional with GANTT chart

2. Establish timeline for completion of each Goal based on the prioritized needs within your CCBHC

3. Identify the Transformational Project Organizational Structure that you will use to support solution development, training, implementation and evaluation of outcomes achieved

4. Identify the Project Teams Decision-Making Process, standardized meeting minutes format and Project Team Recommendation Form that each team will use



5. “Galvanized” Managers and staff members Challenge must be identified before selection of staff to participate in the initiative

6. Delegation Model is essential to support CQI based transformational plans with multiple goals being addressed at the same time. Very different than the historical “committee of the whole” decision-making model that supported sequential change

7. Select Project Manager for each strategic Goal in the plan. Each project manager will be provided written authority from the CEO/Executive Director to match the responsibility being given to her/him as the project manager

8. Select Project Team members for each Goal based on their knowledge of the subject matter of the Goal and their involvement in the current processes that will provide a baseline of current operations/clinical process data that will support solution development



9. Ask each project manager who chairs their respective project team to use the “MTM Services Implementation Planning Form” to identify the barriers to implementing the Goal and to identify the action objectives/strategies that the Project Team will need to address to overcome or minimize the barriers identified. These action objectives/strategies will become the scope of work for the Project Team to support solution development and implementation of each action objective/strategy which will support implementation of the strategic Goal.

10. When the action objectives/strategies have been identified then the Project Team will develop a work plan for each action objective/strategy that includes addressing all of the documentation, skills assessment/training, resources, communication needs, etc. that the team must address to support an implementable solution.

11. Develop an evaluation process to support CQI process to confirm if the outcomes desired from each action objective/strategy has been achieved.


Focus of Strategic Business Plan Development

1. External Efforts: Assisting state and local healthcare systems to leverage the opportunities under healthcare reform and ensure that persons with mental health and substance use disorders and the organizations that serve them are included in the emerging healthcare ecosystem being envisioned under the integrated care model (i.e., Section 1115 Medicaid waiver and/or CCBHC Certification). This focus will also assess the ability of CBHCs to effectively partner in the management, board representation, and/or service delivery capacity for the new integrated healthcare entities.

2. Internal Efforts: Assessing and redesigning internal operations to better align with healthcare reform and be able to demonstrate to clients, healthcare providers and state policy-makers that your CBHC has a distinct competency as high-performing, quality-focused, and efficient provider of mental health and substance use services and are essential partners in helping healthcare reform as envision by your state succeed.

35Presented By: David Lloyd, Founder

Strategic Business Plan Development Core Elements

1. “How will we earn the revenue to support the strategic initiatives?” – Focused on cost based financial realities

2. “Who, what and when are important implementation elements!”3. Addresses the organizational structure/management cultural

changes that will be required4. Must be supported by a more “risk-based” and timely decision

focused leadership/ management at all levels of the organizational structure

5. Requires assessment of operational processes and costs6. Includes market share/branding/customer service awareness/

needs7. Essential element is ability for outcome data measurement,

reporting and management’s use of the data capacity

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Core Elements of Strategic Business Plan Development

First Step is the need to identify and adopt a “Business Model”- focused on either: How to earn additional revenues to support expenses

in a changing shared risk funding environment; and/or How to reduce costs through process re-

engineering/increased staff performance; and/or Willingness to participate in partnerships and

mergers to grow your market base; and/or Ability to diversify your services to attract a large

share of the current market base with new service types.

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Core Elements of a SBP

Elements of a Strategic Business Plan:1. Business Vision and Mission2. Primary focus of Business Model that will be used

(i.e., diversification, mergers and partnerships, reduce costs, enhance revenues, etc.)

3. Market Research: Market Segmentation and Targeting (i.e., benefits,

demographics, geographic, etc.) Confirmation of needs of the customers/clients Competitive Environment – Strengths, Weaknesses,

Opportunities and Threats (SWOT) on Primary and Secondary Competitors

4. Description of service(s) needed based on research



Elements of a Strategic Business Plan (Cont’d):5. Strengths, Weaknesses, Opportunities and Threats (SWOT)

analysis for current organization to deliver identified services including what are the “Unique Factors” your organization can bring to your business case (i.e., Same day access, Just in Time Medical Appointments, outcomes achieved, etc.)

6. Assessment of current organizational structure to determine if the current structure needs to be changed

7. Branding and Marketing Plan to develop an awareness of your new business model

8. Implementation Plan including Timeline, Strategic Action Plan development and confirmation of benchmarks that need to be achieved to demonstrate the plan is working



Elements of a Business Plan (Cont’d):9. Rapid Cycle transformation change plan that supports

empowered top down and bottom up decision making strategies One Year Action Plan Goals 45 Day Action Plan Goals and Accountability to design and

implement10. Financial analysis of the business plan including

investment required short term and long term, return on investment targets and timeframe benchmarks for determining when the plan is not working for the organization

11. Evaluation of the outcomes achieved on an ongoing basis


Core Elements of Strategic Business Development (SBD)

1. Any business model needs to be designed so that it can be continuously assessed in light of current market conditions (i.e., integrated healthcare reform changes) and needs to include flexibility to remake/modify the model every 1 to 2 years OR MORE OFTEN IF NEEDED

2. Internal management decision making will need to support matching the responsibility of each manager with the authority to make timely and risk-based decisions – empowering decision making at all levels of management – not just at the top which is key to flexibility

3. Shift from a historical Non-Profit CBHC model to a Business Development model

4. Shift from a committee of the whole or top down decision-making model which has been a barrier in many cases to timely and effective decision-making. It take the WHOLE team to make this work…

5. Ability to measure current processes and costs to support SBD

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Establish UPFRONT Design, Implementation and Evaluation Timeframes and Supports

BEFORE you start the project, establish a start and complete date for each strategic change goal

Identify a pre-announced evaluation process to ensure all feedback regarding change initiatives is given consideration

Invite team members who have the ability to see the “Horizon of where CCBHC is going” to join in implementation team efforts

S

Develop Strategic Transformation Goals and Identify the type of Strategic Action Plan Format



Establish timeline for completion of each Goal based on the prioritized needs within your CCBHC

Identify the Transformational Project Organizational Structure that you will use to support solution development,

training, implementation and evaluation of outcomes achieved


Identify Roles and Responsibilities


Identify the Project Teams Decision-Making Process, standardized meeting minutes format and Project Team Recommendation Form that each team will use

NOTE: Please download and review the MTM Services’ Meeting Guidelines


Identify the Project Teams Decision-Making Process, standardized meeting minutes format and Project Team Recommendation Form that each team will use



Planning and Decision-Making Side of Change is About Management/LeadershipIs About… Processes of Change – Project Teams, etc. Measurement of Current Service

Delivery Performance Developing Performance Standards Organizational and Management Structure

Re-Alignment Developing Standardized Protocols Data to show objective issues/not

subjective

“Galvanized” Managers and staff members Challenge must be identified before selection of staff to participate in the initiative

Selection of team members to serve as members of the QMC/Senior Leadership Team, Compliance Review, and Project Teams must not have displayed that she/he is “galvanized”

Team members supporting the transformational project must be willing to think outside the box and envision possibilities

Select Project Team members for each Goal based on their knowledge of the subject matter of the Goal and their involvement in the current processes that will provide a baseline of current operations/clinical process data that will support solution development


Delegation Model is Essential to Support Transformational Change

Delegation Model is essential to support CQI based transformational plans with multiple goals being addressed at the same time. Very different than the historical “committee of the whole” decision-making model that supported sequential change

Select Project Manager for each strategic Goal in the plan. Each project manager will be provided written authority from the CEO/Executive Director to match the responsibility being given to her/him as the project manager


Identifying Strategies/Objectives Needed to Support Goal Implementation

Ask each project manager who chairs their respective project team to use the “MTM Services Implementation Planning Form” to identify the barriers to implementing the Goal and to identify the action objectives/strategies that the Project Team will need to address to overcome or minimize the barriers identified. These action objectives/strategies will become the scope of work for the Project Team to support solution development and implementation of each action objective/strategy which will support implementation of the strategic Goal.


Moving from a Good Idea to an Implementable Solution

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Tion


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Sample Rapid Cycle Change Plan


Approval of Final Transformational Change Plan Goals and Strategies

To support the Delegation Model, the Project Manager and project team for each Goal have identified their strategies/action objectives to support design and implementation

Also, the project team identifies the design, training, implementation and evaluation timelines for each strategy/action objective

The final transformational plan for each goal with timelines will be approved by the QMC before solution design work begins.


After Approval of the Final Transformational Plan

When the action objectives/strategies have been approved by the QMC/Senior Leadership Team the Project Team will develop a work plan for each action objective/strategy that includes addressing all of the documentation, skills assessment/training, resources, communication needs, etc. that the team must address to support an implementable solution.


Work Plan to Operationalize the Solution Recommendation

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Before Solution Design Begins.. The Project Teams Need DATA…

As a key part of the work plan, it is critically important for each Project Team to measure current processes, service delivery practices, etc. in order to base the solution designs for each strategy/action objective on “sea level” objective measurement data, not anecdotal or subjective information



Problem Focused Project Team Change Versus Solution Focused Decision-Making

Is the discussion at the meeting focused more on “Why we can’t change!” than on “How we can change!”?

What percent of the meeting is spent focused on attainment versus how unfair the situation is?

Is the focus of the discussion inside the organization’s control zone or outside the organization’s control zone?


Stages of the Acceptance of the Need to Change and Leadership “Blinking”

1. Denial2. Negotiation (This approach by supervisors “pushes”

staff to change)

3. Anxiety/Anger – Blaming – Outside then Inside

4. Drop Out – “It’s Awful!”5. Acceptance of the Need to Change6. Excited about the taking advantage of the

opportunities (This approach by managers “pulls” staff through the process of acceptance)


Change Management Meetings -Problem Focused Vs. Solution Focused Decision-Making

Project Team Meetings are to present Challenges/Issues not problems

To add a Challenge/Issue to the meeting agenda, there must be a summary of issues, objective measurement of the scope and one solution plan of how to resolve the issue presented to team members 36 to 24-hours before the meeting.

Team members come to meeting prepared to discuss solutions based on knowledge of issue, its scope and solution model recommended, not problems

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Essential to Implementation of CQI Change Management Process…

Develop an evaluation process to support CQI process to confirm if the outcomes desired from each action objective/strategy has been achieved.


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“Scramble Team Model” to Respond in Real Time to Evaluation Information

The Scramble Team is composed of 2 or 3 senior managers that have been given the responsibility and authority to review the evaluation of outcomes being achieved from the implemented solutions from each of the project teams and “ON THE FLY” (CQI) make decisions to adjust the processes to respond identified challenges with the solutions being implemented

At the next regularly scheduled QMC the Scramble Team will report out their revised solution designs and the further outcome evaluation data from the revisions.


Presented By: David Lloyd, Founder 70D

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Sample Rapid Cycle Change Plan


Be Agile and Adaptable…KEY…

Break down the larger goals into 45-90 day attainment cycles

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David Lloyd,

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Sample 45 day Planning Cycle

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Our Challenge in Implementation of Change…

How to appropriate blend the hard and soft sides of change…

How to stay focused and supportive as a management team…

How to continue to stay objectively focused on the implementation plan when all about you are emoting…

D


Change Initiative Reality…

Some staff even with our best efforts to Coach them will not be able to accept the change initiatives for various reasons

Organizations that have not historically experienced significant levels of change have an “Elastic Culture” that must be addressed

Leaders of change initiative must “stake out” this elastic culture to ensure lasting implementation

Recommended Reading For Transformational Leadership Model

1. All In, by Adrian Gostick and Chester Elton (Free Press)2. “Evidence-Based Management” by Jeffrey Pfeffer and Robert I. Sutton, Harvard Business

Journal, January 2006 (URL: http://hbr.org/2006/01/evidence-based-management/ar/1 )

3. Leadership Skills to Support High Functioning Teams, by David Lloyd (National Council for Behavioral Health)

4. How to Deliver Accountable Care – Chapters 3 and 4, by David Lloyd (National Council for Behavioral Health)

5. Operationalizing Health Reform – Chapters 1, 11 and 14, by David Lloyd, et. al. (National Council for Behavioral Health)

6. How Will You Measure Your Life?, by Clayton M. Christensen, James Allworth and Karen Dillon (Harper Collins)

7. Moneyball, By Michael Lewis (W.W. Norton and Company)8. The Checklist Manifesto – How to Get Things Right, by Atul Gawande, MD

(Metropolitan Books)9. Winning, by Jack Welch (HarperBusiness)

• Specific focus on Chapter 5 – Leadership; Chapter 6 – Hiring; Chapter 7 – People Management; Chapter 8 –Parting Ways; and Chapter 9 – Change.

10. Emotional Intelligence 2.0, by Travis Bradberry and Jean Greaves (Talent Smart_

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http://hbr.org/2006/01/evidence-based-management/ar/1

Questions?


transformational change management design and leadership ... · david lloyd, founder 1...

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