Lesson 4 Discussion

1212 unread replies.1212 replies.

You often hear people say “nobody likes change”. As a manager, you cannot have this mentality as healthcare is constantly changing and managers lead organizational change.

How would you address employees who are reluctant to change?

Your response must be at least one complete paragraph.

HQ_vol10_UHN_A_revised.indd magine you are a member of a hospital’s execu- tive team, having just left a meeting in which you and other members discussed the possible intro- duction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital’s commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a “big bang.” While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions – CPOE would be implemented and you would be the executive responsible for the system’s design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto’s University Health Network to illustrate the change model, the model is intended to speak to change leaders imple- menting various types of complex changes in all healthcare organizations. Introduction: Leading Transformative Change However much healthcare organizations may resemble – at least on the surface – other large, complex organizations, thoughtful analysis reveals that healthcare organizations are considerably more than mere businesses. Peter Drucker (1993) tells us that healthcare organizations are the most complex form of human organization we have ever attempted to manage. This complexity derives from, among other things, the confluence of profes- sions (e.g., physicians, nurses, pharmacists and administrators) and other stakeholders (e.g., patients and government) often with seemingly incompatible interests, perspectives and time horizons. Exacerbating the challenges for healthcare leaders is the well-known need to satisfy what appears to be the insatiable demand for healthcare – without unlimited financial support. With these challenges in mind, this article attempts to lay out a research-based model of how to lead change in health- care organizations. It uses the implementation of a CPOE system – specifically, Medication Order Entry/Medication Administration Record (MOE/MAR) at Toronto’s University Health Network (UHN) – as an ongoing case. In addition to the UHN case, which was largely successful but not without some bumps along the road, additional evidence is drawn from the vast literature on change management.1 Though this article will use the change at UHN for illustrative purposes, its intended audience includes all healthcare managers, from the most junior to the most senior, in search of a systematic approach to creating order during complex change. I Transforming Healthcare Organizations Brian Golden 10 | HE A L T H C A R E QU A R T E R L Y VO L.10 SP E C I A L I S S U E • 2006 HE A L T H C A R E QU A R T E R L Y VO L. 10 SP E C I A L I S S U E • 2006 | 11 Four Stages of Change As in all industries, change management is complex (i.e., there are many interdependent processes and variables); it is difficult to fully lay out a comprehensive change program in advance; the organization must be prepared for unanticipated events; employees are likely to be unnerved; and rarely does there seem to be sufficient time and resources to bring about the needed change. In my view, this description of organizational change in “generic organizations” understates the difficulty of managing change in healthcare organizations. Healthcare managers frequently face additional challenges because (1) they face disparate stakeholder groups, (2) healthcare organiza- tions have multiple missions (e.g., provide healthcare to their communities, remain fiscally solvent and – frequently – be a primary employer in the community), (3) professionals such as physicians and nurses value professional autonomy, and their decisions influence a major portion of healthcare expenditures and (4) the information necessary to manage the change process is often sorely lacking in healthcare organizations. Recognizing important similarities and differences between healthcare organizations and other organizations, I began the development of this four-stage healthcare change framework with a study of change in other industries (cf., Kotter 1996; Tushman and O’Reilly 1997). The goal was to build upon previous observations about managing change – but only to the extent that these observations were appropriate for the healthcare setting. In many cases, fine-tuning, customization and elabora- tion of these models was necessary so that this paper’s four-stage process would be of the greatest value to healthcare managers. This process is described in great detail as a “how-to” manual for change leaders, and is brought to life with illustrations from UHN’s implementation of MOE/MAR – one of the most ambitious change initiatives at UHN in years (see sidebar for MOE/MAR description). Stage One: Determine Desired End State I take as a given in this article that a leader’s initial thoughts about change derive from his or her recogni- tion of a performance gap – the difference between how well the organization is performing and how well the leader wishes it to perform; in short, a perfor- mance gap represents the space between current reality and future aspirations. In many cases this gap exists not due to mismanagement, but rather, because strategic or technical opportunities have emerged that allow the organization to do better. Such was the case with MOE/ MAR, offering the real opportunity to substantially decrease medication errors and increase patient safety. This oppor- tunity was recog- nized by UHN’s well-regarded Chief Information Officer. Importantly – so that MOE/MAR would be viewed as a safety impera- tive rather than merely as an inter- esting Information Technology (IT) project – the opportunity to implement MOE/MAR was also supported by UHN’s systems-thinking CEO and by the Board Chair. Both had for years publicly expressed their frustration with the health sector’s failure to employ IT to improve performance. Getting to a new desired end state is often appropriately described as a journey, but in large, complex healthcare organ- izations, the kind of journey during which the weather may change unexpectedly, pot-holes line the route and detours or the occasional road-blocks are confronted. The experienced change leader prepares for this and recognizes that while departures from plan may be necessary, the desired end state is always kept in sight and is clear to all. Many writers refer to this as a vision or “where will we be when we get there,” and beginning with the end in mind is critical. However, “vision” can be a nebulous concept without sufficient specificity to be actionable. In the case of UHN’s vision for a fully implemented MOE/ MAR initiative, it was necessary to specify measurable goals that would allow it to chart progress and determine success or failure. In my experience, the discipline of developing and monitoring performance measures is critical to focusing the attention of change leaders and those who will be asked (or required) to change. The initial supporters of MOE/MAR, as discussed in “The Benefits of the MOE/MAR Implementation: A Quantitative Approach” (see p. 77 in this issue), had very clear and measurable goals in mind from the start (e.g., reduction in both transcription errors and cycle time from medication order to administration). Also part of their visioning process Medication Order Entry/Medication Administration Record MOE/MAR is UHN’s major patient safety initiative, enabled by computerized medication order entry and medication administration. By supporting clinical decision-making that is consistent with hospital policy and evidence-based practice, MOE/MAR is intended to decrease adverse events related to medication error. In addition, MOE/MAR provides a rich data set to monitor and improve operational performance. MOE/MAR was designed to operate at multiple UHN hospitals, across diverse inpatient services, including General Internal Medicine, General Surgery, Emergency and Cardiology. Initial planning for MOE/MAR began in 2001, went live across divisions from 2004 to 2006 and has cost UHN approximately $5 million. Gale (2005) reports that only 2% of North American hospitals have greater than 50% computerized medication order entry utilization rates. As of July 2006, UHN’s utilization rate was over 85%. … healthcare organizations are the most complex form of human organization … Brian Golden Transforming Healthcare Organizations 12 | HE A L T H C A R E QU A R T E R L Y VO L. 10 SP E C I A L I S S U E • 2006 were initial thoughts about the systems and activities required to measure these outcomes (e.g., chart audits, time and motion studies, electronic reporting from the data warehouse). In addition to specifying measurable goals, other neces- sary sub-components of vision had to be considered from the onset. For example, what new behaviours, such as navigating a computerized patient record, would clinicians have to perform? What changes to organizational structure and systems would be necessary to support the implementation of MOE/MAR? Answers to these questions about vision can act as touchstones as change leaders confront the numerous decision points that will invariably emerge in the change process. While the specifics of changing behaviours, capabilities, organizational structure and systems are discussed in a later section, for now it is suffi- cient to emphasize that the outcomes of the visioning process are the building blocks of effective change. Stage Two: Assessing Readiness for Change Once supporters of a change have come to a reasonably clear understanding of their objectives, it is time to assess the organization’s readiness for change. This begins with a broad situational analysis, which includes determining whether • the need for change is recognized by those whose work will be affected • other change programs are vying for executive attention and resources • the organization will have to develop new capabilities to close the performance gap • there is something in the organization’s history (e.g., a prior failed IT initiative) that either predisposes staff for or against the change or, more generally, from which the change leaders must learn At UHN the executive team decided that MOE/MAR would be a priority and that they would support all