Making Change

There is nothing simple about the composition of health care organizations.  This complexity comes from, among other things, a concourse of medical professions and other stakeholders (e.g., patients and government) usually with incompatible interests, perspectives and time frames.  Exacerbating the challenges for health care leaders is the well-known need to satisfy the insatiable demand for health care - with limited financial assistance.  

Health care executives frequently face additional challenges because:

• they have disparate stakeholder groups
• health care organizations have multiple missions (e.g., provide health care to their communities, remain fiscally sound, and be a primary employer in the community)
• professionals such as physicians and nurses value professional autonomy, and their decisions have a huge influence on health care expenditures, and
• the information necessary to manage the change process is usually sparse and always insufficient.

A 4-Phase Approach

Since there are so many interdependent processes and variables in health care settings, it is not practical to fully lay out a comprehensive change program in advance.  The fact is, the organization must be prepared for unanticipated events, employees are likely to be unsettled to say the least, and there generally is insufficient time and resources to bring about the needed change. 

One: The End State

Let’s start with the difference between how well the organization is performing and how well the leader wishes it to perform.  In many cases this gap exists not due to mismanagement, but rather, because opportunities have emerged that allow the organization to do better. 

Getting to a new desired end state is often appropriately described as a journey, but in large, complex health care organizations, it’s usually a bumpy ride.  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.  Keeping this in sight and modulating the journey depends on meaningful performance measures (e.g., chart audits, time and motion studies, and electronic data reporting).  The performance measures developed during the visioning exercise, if structured and marketed appropriately, keep the various stakeholders in the game.  In effect, the outcomes of the visioning process are the building blocks of effective change.

Two: Assessing Readiness for Change

Once supporters of a change have arrived at an understanding of their objectives, it is time to assess the organization's readiness for change.  This starts with a broad situational study that determines:

• if the need for change is recognized by those whose work will be affected
• how other change programs are vying for executive attention and resources
• how the organization will have to develop new capabilities to close the performance gap
• if there is something in the organization's history that either biased staff for or against the change or, more generally, from which the change leaders must learn.

How the above change-readiness questions are answered is critical to the next set of Stage 2 activities - enlisting the most appropriate change leaders.  These change leaders are often not, and should not be, the organization's most senior executives.  While senior leadership must endorse large change programs, they rarely have the time or intimate knowledge of the change to be the actual change leaders.  Instead, the change leaders should be influential, connected and skilled.  They should also be motivated, think broadly and have a lot of self confidence.  While past research suggests how important these qualities are, it does not suggest that there must be a single change leader. 

Three: Broaden Support and Organizational Redesign

Up to this point, much of the change work has been behind the scenes, both enlisting the support of important allies and sizing up the challenge.  It is now time for the change to affect others in the organization, and this will occur on two fronts simultaneously - broadening support and organizational redesign.

• Broadening Support -- the communication process is central to broadening support. First, the change leaders, supported by the CEO, must articulate a consistent message about the change objectives and means.  Second, the message is often best communicated using multiple media (e.g., formal presentations, casual conversation, technology demonstrations, e-mail, newsletters) since there are multiple shifts and diverse educational levels in play.  Change leaders must also ensure that the message is tailored to its particular audience and delivered by a credible source.  Part of building credibility and buy in is to stay away from presenting an idea as a fait accompli.  Rather, communications works better when taking the form of posing questions and joint diagnosis, in which broad objectives are stated by leadership, but plans to operationalize these are left open for discussion. 
• Redesigning the Organization – Here we ensure that the organization is sufficiently aligned to support the change.  Part of any such alignment is the elimination of resistance.  Resistance to change occurs because individuals do not see the benefit of changing.  This is where organizational redesign comes in, reworking goals, human resources, structure, etc.  For example, the structural change from program-based to disease-based management may create the need to change information and decision support systems so that performance can be properly evaluated and rewarded.  Structural changes can include the creation of temporary or more permanent teams, new departments or integrating mechanisms.  As experienced managers well know, in any change effort there is a very real risk that intended change recipients will become change resistors.  Thus, once staff are confident that they will be able to implement the change (e.g., they receive appropriate training, sufficient resources and necessary information), they must also be motivated to change.  This requires change leaders to promote the benefits to various stakeholders, not just the features.  Experienced managers know they can ask their staff to accept personal sacrifices for the good of the organization, but for only so long.  At the end of the day, what is good for the organization must also have either a neutral or a positive effect on those who must change.  It would be foolish to think otherwise.  Yet, this does not present an impossible-to-solve problem.  In one sense, health care leaders are more fortunate than leaders in commercial enterprises since the core mission of non-profit health care organizations is universally regarded as worthy.  Thus, leaders must design a transparent change plan so that the targeted staff will understand that they will be better off (or at least not worse off) if they support the change.  Alternatively, the staff must realize that they will be penalized somehow if they oppose it.  Critical here is providing support for staff to learn themselves about the benefits of the change, which gets back to a multi-media communications effort, if they wish, rather than simply accepting the word of the change leaders.

Four: Reinforce/Sustain Change

This stage is no less rigorous than the preceding three.  It involves monitoring performance, showcasing any successes, rewarding those who have supported the program, recognizing and offsetting any losses caused by the change, reconsidering goals and continuing to make any necessary operational, management, administrative and cultural changes.

Ongoing performance monitoring allows the organization to make technical adjustments and also to identify where some additional organizational realignment may be necessary (e.g., additional training).  Stage 4 is also the time to reflect on both the change process and the change itself.  This opportunity to reflect should not be wasted, despite how eager staff may be to regain some ‘normalcy’ in their work. 

The ultimate reward is to watch an organization come to consider change as normal.