Health care transformation, reform, change—all words for a big, unpredictable mess. While the health care industry has always been complicated, it has never been this tumultuous. From the external pressures of new expectations to the internal pressures of burnout, now is inarguably the most uncertain and challenging time to practice medicine.
WHAT WE KNOW ABOUT CHANGE
Several names dominate any extensive review of the change-management literature. From Lewin’s change model in the 1940s, to Bridges’ transition model in the 1970s, to Kotter’s eight-step process in the 1990s, we have seen approaches to change evolve in response to modernization and globalization.
These researchers and their colleagues provide us with clear direction on managing change personally and leading change within an organizational context. Underlying this guidance are four core assumptions:
- Change is hard—harder than you would expect.
- Change is slow—slower than you would expect.
- Change is tiring—more tiring than you would expect.
- Change is scary—scarier than you would expect.
These four assumptions may seem simple, but they represent precisely what puzzles us about successful change management. The truth is, there is no plan or template in the world that can be cross-applied to the myriad changes the average health care organization is juggling on any given day.
IN REAL LIFE
Accepting these assumptions as truth helps build a more realistic foundation for the kind of support that individuals or teams need in order to weather change. Electronic medical record (EMR) implementations provide a perfect context in which to understand the assumptions of change management.
A traditional EMR implementation will likely define success as “going live” on budget, on time, and without major incident. However, organizations that consider the four assumptions of change can define success more meaningfully, aiming at results like these:
- Diverse participation by respected providers on a Physician Advisory Council
- Medical staff adoption of new rules and regulations governing EMR use
- A training and support plan that makes physicians feel prepared while and right after going live
- High rates of computer physician order management (CPOM)
By thoughtfully creating governance structures and mechanisms for engagement, organizations that incorporate the four assumptions acknowledge that change is a complex emotional, psychological, and political process. In short, spending more time managing the human implications of change will pay off in high levels of engagement, buy-in, and productivity.
CHANGE IS CHANGING
Just as health care is undergoing transformation, the concept of change has in fact changed. Up until recently, the change-management literature centered around models that contain a clear beginning, middle, and end. But the changes facing today’s health care executives, physicians, and workforce are complex, integrated, and often without a neat and tidy conclusion.
Paradigm shifts have rooted change in complexity science. Thousands of pages have been written about complex adaptive change, and this article won’t do them justice—except to highlight that change may be governed by simple rules, but is anything but simple itself. Change should not be viewed through the lens of a single project or program; rather, one must consider that change is as dynamic as any living organism, and is governed by multiple, integrated systems. Sound familiar?
One way to think about change is as something similar to the shift from acute disease intervention to chronic disease management. Change is not a disease, but is instead a condition regarding which one can build a stronger capacity or resilience through a proactive, disciplined approach.
SEVEN STRATEGIES
The seven strategies for managing chronic change in health care will not guarantee success, but they should make change-management programs a whole lot easier for those participating in and leading them. Each strategy detailed below is accompanied by a stakeholder question to ask of those directly affected by the change.
1. Name the change—This doesn’t refer to a clever name, a meaningless acronym, or confusing jargon. As with any baby’s name, think carefully about whether you have to work too hard to explain it, or if people will be able to poke fun at it.
Stakeholder question: What do you think we should name the change?
2. Choose a respected champion—Over time, you will build coalitions of champions and supporters, but it starts with one. If that one person isn’t respected or liked, the change is at risk of being ignored or resented.
Stakeholder question: Would you walk over hot coals for your change champion?
3. Give everyone a clear role—Even the largest change efforts can be avoided, ignored, and critiqued unless stakeholders know exactly how their voices will be valued and how their unique perspectives will be leveraged.
Stakeholder question: What are the tangible and valuable ways in which you can contribute to the success of the change?
4. Tell the whole story, not just the pretty stuff—It is tempting to frame every purposeful change as entirely positive. After all, why else would it be happening? However, even the best changes are filled with discomfort, strife, and loss, so be sure to acknowledge difficulties that you anticipate or that are experienced by people who have already engaged in the change in question.
Stakeholder question: What kind of information will help you fully understand the goals, timeline, and expectations of the change?
5. Create safe spaces to talk, vent, or question—Highly educated, competent people like physicians are not quick to admit their fear of learning something new. Since many changes are logistical, operational, or technical, the human side of change is often glossed over, because it’s viewed as a difficult can of worms that most people feel unqualified to open.
Stakeholder question: What kind of support structures and access to change champions do you need?
6. Identify success metrics that are meaningful and moving—Change is both a process and a product, and the success of both should be regularly monitored, easily measurable, and highly motivating. As with building
any new skill, behavior, or mindset, momentum is built with the accumulation of small, consistent successes.
Stakeholder question: What are all the ways in which you would monitor and define personal, team, and organizational success with this change?
7. Create real mechanisms for re-energizing—With the burnout epidemic topping 50 percent among physicians, the impact of change (exhaustion, confusion, apathy) cannot be overestimated. It is crucial that change champions fully recognize what type of energy—physical, mental, emotional—is required, and respond by reducing or temporarily eliminating other priorities.
Stakeholder question: What should we temporarily stop doing in order to create the time and space to acclimate to this change?
IN CONCLUSION
While no two changes are exactly the same, the seven strategies for managing ongoing, complex, chronic change can improve any scenario in which people are being asked to do their jobs differently from the ways they’re used to doing them. Over the last century, the literature on change has undergone its own transformation from acute care to chronic management. However, what remains constant is that the process of change, no matter what scale, is less about the science of managing a project and much more about the art of leading people.
Lisa Goren is a health care leadership coach and advisor helping physicians and executives lead effectively and resiliently within a transforming industry. She works with individuals and leadership teams to create engaging organizational cultures where individuals feel less exhausted and more excited walking through the door each day. Lisa is a frequent conference presenter, and is on the faculty of several health care Master’s programs. You can find out more at lisagoren.com.