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4 years ago Reflection by Abby
Most of my feelings about this chapter - or, rather, frustrations - are very similar to the previous week's. Namely, that managing change is not a challenge unique to the healthcare space – particularly when it comes to streamlining workflows and/or integrating new technologies to support the workflows and better liaise with clients (in this case patients). I think most readily of the financial sector – although, not necessarily known for security, private finances and private equity make use of cutting edge tech to make better, more accurate predictions as well as protect sensitive client and proprietary information – and the intelligence community, which does largely the same, sometimes on grander scales.
I think the Kotter model is a great example of the ubiquity of this challenge and how easily applicable it is to many other industries in addition to healthcare. Maybe I misread, but it was unclear to me if this model is applied elsewhere outside of the US healthcare system? Regardless, I think tangential industries can learn a great deal from each other especially in their methods and tools for problem solving; the healthcare space is no exception.
pristineliving
1. Introduction: Change Management
Changes in the healthcare space move at a rapid pace. Changes affecting regulation, policy, and technology, in particular, are implemented as quickly as possible – ideally as early as available. Examples of such changes include ICD-10, new models of care, and new workflows to implement Meaningful Use.
The realm of change management is well-developed across many industries. Within healthcare delivery, lead thinkers such as John Kotter plan organizational change at both large and small scales. The Kotter model in particular looks at both the emotional and situational components of change, with a multi-step model of change organized into three step-wise phases. In order for these changes to be successful, however, the underlying systems and processes must also align with the implemented technical changes. These can include communicating the benefits of change, or discussing how the change will help the organization achieve future development goals.
Successful change may address any three organizational factors:
How People Work
Take EHR Meaningful Use or adoption of new models, for example. These are features that fundamentally affects how people in an organization do their work. The key to successfully implementing either of these changes is managing the people dimension of the organization. Changing how people work together altars and a key level the culture of the order of the workplace whether that's an organization or a company – anywhere that this change might take place. In managing how people work in response to change, several factors must first be considered.
Change creates uncertainty. Introduction change into an organizational environment will upset the equilibrium of the established workflow. Second, people are afraid of loss. They're afraid of job loss, social position in their group, and self-esteem as it pertains to their inability to use the technology or care for patients. Team resistance of change is a powerful force and can come from feeling that any tensions or social price as a result of the change are too great. People may also feel that any proposed change is not in the best interest, either of themselves or the practice as a whole, for example. They can believe this change harms their practice and thus resist, especially in cases where negative experiences with other changes or implementations are widely publicized or discussed.
The key to mitigating these barriers to change management at the people level is ensuring that staff at all levels of the organization are involved in the planning, implementation, and evaluation of any and all proposed changes.
Key Processes
Let's continue with the examples of EHR Meaningful Use or changing models of care. In both of these cases facing changes to the fundamental processes and practices, governing rules, or organizational structures is largely unavoidable. Technology is only barely keeping up with the demands of the industry, and as new workflows become available it is imperative that they be implemented as soon as possible.
In order for these implementations to be a smooth as possible all staff must be involved in every level. This includes assessing the policies, procedures, or any work clothes that are proposed. Staff members should form the crux of the implementation process. They should introduce the changes themselves and spearhead any and all assessments. Particularly with changes that permeate all levels of the organization, it's key to remember that these staffs are those experts in the current state and the future development goals of the organization and the field at large. They are in the best position to make recommendations for using novel technologies in ways that will most benefit their practices. Leaders should be in positions that allow them to pioneer changes and adjust them as needed. In order for an organization to not only strive toward but achieve constant innovation, forward-thinking should be rewarded and improvement encouraged.
Technology Implementation
Continuing further with our current examples, it's important to consider possible internal and external forces that will affect success. As they sound, internal forces come from within the organization and affect the organization and its people's desires to achieve their internal goals – e.g. providing better care for patients or improving the efficiency and effectiveness of the organization. External forces are largely those that stand outside what the organization can control. They can include the policy changes, funding changes, or changes in the competitive landscape as it pertains to the particular organization. Successful implementation of technology is generally done do to address on some level the internal and/or external factors affecting the organization.
Generally speaking, the technological changes we're discussing our implemented throughout an organization and have considerable downstream effects for policies, procedures, processes, and the work environment.
2. Kotter’s Model: A Validated Framework for Change Management in Healthcare
Adopting new technologies like electronic health records (EHR), clinical decision support (CDS), and computerized provider order entry (CPOE) systems created the steep need for change management strategies to overcome the technical and organizational barriers in health care organizations (HCOs). We have found several successful implementations for change management under the framework of Kotter’s model. In 2013, Memorial University of Newfoundland implemented the advanced CPOE system for Neonatal Intensive Care at its affiliated hospital to improve patients’ safety and decrease medical errors. In 2008, it was reported that Ohio State University Health System (OSUHS) successfully facilitated the implementation of a CPOE system at its a medical-surgical care facility, a comprehensive cancer center, a neuropsychiatric hospital, and clinics and physicians’ offices (Campbell, 2008). Since then, Kotter’s model has been proved to be a credible and valid tool to use when implementing change in the healthcare setting (Klein, 2013).
Kotter’s model consists of eight steps: creating urgency step, forming a powerful coalition, creating a vision for change, communicating the vision, removing obstacles, create short-term wins, building on the change, and anchoring the changes in corporate culture. The eight steps were further clustered into three phases: creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining the change (Kotter, 2002). The detailed layout is shown as follows.
Figure 1. Kotter's Model in Change Management
Kotter indicated that the traditional change-initiating mindset of “analysis-think-change”, which relied on the rational demonstration of analysis and reports, might not motivate the users to change immediately. It was idealized that people would recognize the benefit and necessity of change in thoughts, thus change their behavior accordingly. However, in the real-world, analysis rarely changes cognition or thinking. Meanwhile, actions are mainly driven by or linked to emotions. Therefore, he changed the mindset of change management to be a “see-feel-change” approach. His insight was that once users see an attention-catching and dramatic situation, they will more likely react to it emotionally, identify it as troublesome or problematic, and feel that change is in acute need. Such a feeling could be a strong driven power to participate in the implementation of change and turn their thoughts into behaviors and promote the process of change primarily.
Figure 2. The guiding team needs to consider who is affected by the new changes
The first cluster of Kotter’s model and its application is to create a climate for change. It is recommended that the manager should call for a sense of urgency among all the individuals, stakeholders, and departments that will be interfered with by the implementation of change. The leading role of the change management should cultivate awareness for change, eliminate complacency, and motivate the members for actions and commitments (Klein, 2013; Kotter, 1996). To achieve such a goal, the healthcare manager could create a short video illustrating the complaints and straightforward consequences (e.g., a death case or steep cost) of the old system’s errors. Meanwhile, the manager could invite the other organizations that had successfully implemented an EHR or CPOE product and used it daily to share their feedback on comparing and contrasting the old and new systems. Such communication could help the colleagues figure out what or why a change needs to happen in the HCO. Once the manager successfully calls for a sense of urgency, a guiding team should form to make the change plan and deploy it throughout the organization. Kotter believed that the members of the guiding team should satisfy several conditions for better serving the need of the HCO. The candidates must have a scope of what changes had happened in the healthcare industry and know the relevant knowledge quite well (to help build a team vision). It is also essential that the candidates are widely accepted by the HCO members with trust and credibility and are capable of smooth communication. Authority of guiding team candidates would help managing, planning, and control of team decisions and actions with leadership and concrete collaboration. Once a guiding team forms, the next step is to build a proper vision for the team. The purpose of this vision is to illuminate the objective for change, as well as provide direction and inspire others to support and participate with the change (Kotter, 1996). For instance, it is worth considering how the health information technology (HIT) artifacts could improve safety, reduce cost and errors, increase the readability of prescription and orders, benefit clinical decision support (CDS), and optimize the healthcare workflow. For instance, a good vision statement could have a series of questions that answer common and essential questions for physicians. On the other hand, the vision statement should cover considerations in dimensions defined by users and all the other interfered groups (e.g., users’ cost and revenue, users’ actions needed, support staff, patients, healthcare practitioners, caregivers, competitors, governments, etc.). An example could be seen in Figure 3. The guiding team regularly gathers to brainstorm on what vision to focus on and how it could be adopted iteratively. Once the vision statement has been created, the guiding team can begin to flesh out the strategy that will be used to achieve the vision, develop plans to implement the strategy, and fund the budget to pay for the plans (Campbell, 2008).
Figure 3. Future pictures of the organization
Later, the team could jump into actions for the second cluster: engaging and enabling the whole organization. Once a feasible vision statement is established, it is recommended to communicate the team’s new visions on implementing the changes. The guiding team should then identify who will be affected by the change plan and forecast how changes would interfere with the workflow, working effort, and commitment for the HCO members. (The communication for group buy-in layered model demonstrates how stepwise communication is achieved, as shown in Figure. 4) The connection starts with “fueling up” the passion of the members by the pathway of awareness->understanding->collaboration->commitment-> and advocacy (Campbell, 2008). Once the call of action is initiated, the guiding team could visualize the vision plan with the rest of the HCO to demonstrate how the change could contribute to the development of HCO. Later, it is critical to communicate with stakeholders to investigate where resistance lies. The team could regularly meet with the HCO members and encourage them to address their concerns and questions. After collecting primary feedback, question-and-answer sessions could help them comprehend how changes would take place and discuss their concerns. With higher acceptance from the HCO members, the team could establish a portal or a channel to provide knowledge HCO members need for daily tasks. The success of OSUHS was based on their strategy of forming a physician consultant group to design functional pathways for their newly implemented CPOE. The physician representatives discussed intensively with their departmental colleagues about the feedback of the prototypes and the importance of the new CPOE system. Their experience with the fast development cycle indicated that it is useful for the HCO members to participate in the design cycles so that they understand the benefit and importance of deploying change plans with more knowledge and a sense of participation. Meanwhile, new obstacles might appear, and the HCO members’ willingness to overcome barriers would support the change plan better. The obstacles include the knowledge to make decisions and the feedback on action taken (Campbell, 2008). For both concerns, the guiding team could seek for help from the HCO for designing training sessions and conducting timely communication regarding the HCO’s departmental and individual performance. They could also provide examples of short-term wins and demonstrate the feasibility of moving forward with everyone’s effort in group work.
Figure 4. The communication for group buy-in layered model
If the two aforementioned clustered are handled smoothly, the HCO could migrate to the third cluster: implementing and sustaining the change. To avoid the difficulty of using the new system, the guiding team should help HCO to solve the technical issues and system problems nonconfrontationally. Later, the HCO and the guiding team could create an environment of safety culture as the final part of the new system’s implementation. It is expected that if the HCO’s culture can be modified to support the implementation of an advanced new system, then this change will be successful (Klein, 2013).
Kotter’s model is non-linear and could iteratively guide the change plan until the implementation achieves long-term benefits, wide acceptance, and stable performance.
3. Key Success Factors (KSFs) and Pitfalls to Avoid (PTAs) in HIT Change Management
Barriers for implementation
Some mistakes are common barriers to HIT change, for example, mismatched IT. This means that the healthcare provider does not have the appropriate environment ready for the new software implementation. One reason may be that the software is not what the healthcare provider is looking for. If a healthcare provider is looking for certain software, there is undoubtedly more than one choice of software. However, they come in a package and are not tailored toward a specific healthcare provider’s needs. One thing the healthcare provider should pay attention to is to be sure to compare the different choices of software so that they can make the right decision to choose the one that fits most closely with their need. Choosing the right software is only a first step, and does not guarantee successful implementation yet. One pitfall is that the healthcare provider does not have the hardware to support its new software implementation. When examining the infrastructure of the healthcare provider, make sure the number of workstations, laptops, and mobile devices is sufficient, the age of the hardware is appropriate, the security of the system is reliable, and different components of the system are well-integrated and are able to integrate with the new software.
Factors that contribute to a successful change
When a change in an organization needs to occur, it will encounter resistance. One key factor to smooth the implementation process is to attend to the mentality and mood of the users. People don’t like change and will go through stages of denial, anger, bargaining, and depression before finally reaching the endpoint of acceptance. To facilitate the process of adapting to new implementation, prepare users, and don’t let the implementation be a surprise. Hold small size meetings and communicate in small groups to prepare users mentally before making the official change. This may be facilitated much easier if the leader of a team is on board with the idea, so having team leaders’ support is crucial. Educational training for users is also essential. Educate users on the new system and help them become comfortable and proficient with it. Make sure it is easy for users to access assistance when difficulty befalls so that their fear and anxiety facing the new system can be reduced. Listen to the users’ opinions and complaints and empathize with their feeling. Allow the bargaining of ideas, but it should be clear what can be changed and what cannot. Even though some opinions are sheer bargaining or anger, some may be actually useful and beneficial. Useful ideas should be picked up and taken into consideration, so users know they can still contribute and not just have no choice but follow the rules. Last but not least, give it time, give users time to adjust and adapt, so they can comfortably shift into the new practice at their own pace.
Different medical teams approach to the new system
When a change in system occurs, different teams are going to be working on different sides of the system and will have different views regarding the same system. The physicians will be focusing on if the new system will improve on their work, such as improving efficiency, not increasing workload, checking for errors and reducing them, and providing decision support. The nursing team will be focusing on the improvement of efficiency and easiness of communicating with other medical teams. The administrative team will be overseeing the integration and transition into the new system, offering educational training and providing individual user support, and test and evaluate the usability of the new system. The IT team will be responsible for the actual software implementation and hardware support, integration of the current system with the new system, and deal with errors and technical issues.
References
Campbell, R. (2008). Change Management in Health Care. The Health Care Manager, 27(1), 23-39. https://doi.org/10.1097/01.hcm.0000285028.79762.a1
HP. (2012). Four EHR change management mistakes and how your medical practice can avoid them [White paper]. http://www.hp.com/sbso/solutions/healthcare/whitepaper_ehr_four_mistakes.pdf
HP. (2011). Successful EHR change management roles and responsibilities [White paper]. http://www.bio-itworld.com/uploadedFiles/Bio-IT_World/Whitepaper_SmartForms/Forms/PDF/HP-Successful-EHR-Change-Management.pdf
Klein L. Implementing an Advanced Computerized Provider Order Entry System to the Neonatal Intensive Care Using Kotter’s Change Management Model. Canadian Journal of Nursing Informatics 2013;8
Kotter, J. (1996). Leading change. Harvard Business Review Press.
Kotter J, Cohen D (2002). The Heart of Change: Real Life Stories of How People Change Their Organization. Boston, MA: Harvard Business School Press. Shoolin, J. S. (2010). Change management–Recommendations for successful electronic medical records implementation. Applied clinical informatics, 1(03), 286-292.