Change Management: An Integral Component of Clinical Transformation
"Change alone is unchanging." — Heraclitus"Change begets change." — Charles Dickens
"The times, they are a' changing."— Bob Dylan
The Greek philosopher Heraclitus believed that perpetual change is the natural law by which the universe operates. He never claimed change would be pleasant, or that we'd be eager to embrace it. In fact, change is inherently stressful, a precarious balance between harmony and discord, between what's comfortable and what's risky. Heraclitus' perspectives on change, formulated 2,500 years ago, uncannily presage the efforts of today's business enterprises to respond to the challenges of changing their business models and relationships. Health care providers are especially aware of the need to implement key changes in the way health care is delivered, to provide safer, more cost effective care to their patients. They have also learned, occasionally through painful experiences, that a purely technical solution — putting laptops in every hospital room, for example — does little to improve the quality and safety of patient care.
Clinical Transformation Defined
The transformation of health care services from manual processes to technology-enabled or automated clinical processes represents a big change in a clinician's daily work activities. Physicians, nurses, and other clinicians will be seeking new ways to improve patient care and their personal productivity while confronting the challenges of learning new processes and technology. They will all need support and encouragement to initiate and sustain these changes.
The true value of an advanced clinical information system (CIS) is to enable transformational change throughout a health care organization. Change in the way information is collected, managed, and shared. Change in the basic clinical processes that support patient care. Change in the way clinicians interact with patients — and with each other. The term for this fundamental change is "clinical transformation." Achieving this transformation will require health care professionals in every category, from physicians and nurses to pharmacists and IS staff, to change the way they think about and do their work. As Heraclitus could have predicted, change is never easy.
Managing the Inevitable
That people resist change should come as no surprise. Change management recognizes that resistance to fundamental change is a natural, understandable, and expected human reaction that needs to be influenced productively. Managing change requires the people affected by change to play a significant role in the process by which decisions are made and the change is implemented. Their involvement translates into better acceptance of transformational changes, and more willing adoption of new processes and practices.
For clinical transformation to achieve the desired benefits, clinical and operational personnel need to understand the rationale behind the transformation, how it will benefit them personally, and what it will cost them in terms of effort and commitment. They must be convinced that the disruption to their lives and the effort to learn new processes and technologies will have a tangible and sufficient reward. Viewing recalcitrant employees or physicians as obstacles to progress is counterproductive. Change management helps channel their expertise and judgment toward the desired future state.
Change Management Is an Integral Part of a Clinical Transformation Initiative
Experience shows that successful transformation initiatives integrate change management techniques throughout the lifecycle of the initiative. Change management is not something that the organization does as an afterthought; it is as important as system testing and training. Change-management activities are directed at identifying and mitigating "people" risks associated with clinical and operational personnel's acceptance of new systems and their ability to use the new processes and technology. In the end when this occurs, clinical transformation is deemed successful.
Change Management Never Ceases
As noted in Figure 1, continuous change requires continuous effort throughout a project's implementation and beyond. Multi-disciplinary work teams are responsible for accomplishing the project's specific initiatives. A communications strategy constantly reminds participants of what they need to accomplish and reports on progress made toward short-term and long-term goals. A training and education strategy provides all participants with the skills they need to design and then use the newly automated processes. It is key to understand that the change-management workstreams shown in Figure 1 do not stand alone as isolated operational task groupings. It is only by leveraging all workstreams together that clinical transformation can achieve its objectives. Let's take a closer look at how change-management principles and approaches are best integrated throughout a system implementation and business transformation.
Figure 1: Change Management Components
Sponsor Alignment
"Perceived lack of sponsorship is the number one fatal flaw for clinical transformation." Interpret this statement to mean that if anyone involved in the change perceives that their leadership is not committed to achieving the transformational results, the initiative will not return the stated benefits. It is imperative that executive sponsorship be established early and sustained throughout the implementation lifecycle.
Before implementation can begin, the initiative requires a steering committee of physicians, nurses, and other operational executives who will act as "sponsors" for specific project objectives. Their work results in a common strategy and emphasis at the top of the organization that provides support for the change and a clear sense of vision and direction. Sponsors must develop a clear consensus regarding the tangible short- and long-term goals and benefits of the initiative. They must commit sufficient time and resources to support the initiative. These clinical and operational leaders must guide the implementation process and hold people accountable for results.
As the implementation gets under way, the process begins to engage physicians, clinicians, and other operational leaders as "owners" of the various process improvement and technology initiatives. Each of these operational leaders must establish realistic expectations of measurable outcomes. Each leader will be held accountable for meeting these expectations.
The involvement of sponsors and the progress of their teams in achieving their milestones should be monitored. If momentum flags, it may be necessary to coach the leaders, change the strategy, or provide motivational messages to re-invigorate the project.
Stakeholder Alignment
A serious risk to successful business transformation is the resistance brought on by clinicians' sense that "someone is doing this to us." Stakeholder alignment involves recruiting "the best and the brightest" people from various disciplines to move the project forward and reduce the likelihood of this risk occurring.
Each project team is comprised of a combination of analysts with Information Services (IS) experience as well as real life clinical and operational experience. These teams are dedicated full time to the project and participate in key design, validation, and go-live readiness events. During the course of the project, the team must work with their sponsors as well as a broad range of clinicians directly involved in patient care to ensure that the system design meets clinical and business needs. It is not uncommon for the project teams to engage hundreds of clinical and operational managers and staff during the design and testing phases. IS professionals play a vital but supporting role in the clinical transformation. This approach results in both the understanding of the business and personal impact of the solution and the transfer of ownership to the discipline by providing a solution that meets their business requirements.
Complacency is often a challenge as a project nears fruition. When individuals are involved in the design of a solution, they are motivated to implement the solution. A lack of commitment may mean that significant issues or business concerns have not been resolved and that there is a need to revisit the transformational objectives.
Communications
Individuals may not understand the need and business drivers of the solution. They may wonder, "How is this going to impact me?" These are common risks that can be avoided. When delivered in an effective and targeted manner, communications facilitate acceptance of the solution's impact.
Communications should establish a common set of expectations around what the future holds for each impacted discipline. A robust communications plan with specific messages for each constituency must be developed. This plan should include: a statement of the case for change and business benefits; the vision for the future; and the implications for the various disciplines. The communication activities must include opportunities for two-way communications and dialogue with the end users. This results in a better understanding by the various stakeholder groups.
To keep the organization current with the progress of the solution, project-related information about issues, challenges, progress, and lessons learned should be communicated in tailored messages to all constituencies.
Training/Education
There is risk to any systems implementation if the end users do not know how to operate the new systems or technology. Education and training help develop effective learning products to support the use of the system and job performance by various disciplines across the organization, during and after implementation.
Project teams need to receive up-front training on basic principles of project management, work-plan management, and specific product knowledge so that they can effectively design, build, and test the system.
As specific changes to processes and technology are clarified, it's time to address end-user training and to develop user-specific curriculum and delivery methods based on roles. Creating and delivering role-based training allows for users to attend learning events tailored to what they do and how they will use the new system, rather than one-size-fits-all training courses. Training and education are only effective if they occur before the system is activated. This sounds rational, but organizations often allow users to skip training. This results in frustrations when it is time to use the system.
It is important to consider the need for ongoing education, as clinicians move to different roles and new associates enter the organization. In order to achieve the desired results, it is necessary to plan for ongoing training support for the new technology.
Training must be customized to meet the specific needs of each user group or constituency. It's a good idea to recruit enthusiastic and capable users from each constituency to act as coaches or mentors to their less experienced colleagues.
Program Management
At the onset of the initiative, the project teams must collaborate on a risk assessment to identify people, process, and technology issues that may affect their organization's ability to change. As the project begins, the project teams develop an issues database and create a process to manage both expected and unexpected challenges on an ongoing basis. One example of an issue that may arise is the need to backfill for the time that nurse managers and operational staff spend participating in system design, implementation, testing, and training.
New objectives need to be decided and agreed upon. Leadership teams need to decide what the desired outcomes for the project should be and how they will be measured. Financial incentives should be built around the new program objectives.
Exceptional contributions should be rewarded. Successes should be celebrated. Doing so consistently throughout the implementation helps to integrate change into an organization's culture.
People Change
Throughout a major transformation, individuals will become stressed and demonstrate either overt or covert resistance. Even beneficial changes aren't necessarily greeted with enthusiasm. A clinical transformation plan that expects great benefits from changing clinical processes and technology needs to be accepted by those affected by the changes. The plan must take into account the behavior of the people who will implement the changes in delivering care to patients. Through an integrated change-management plan, a clear vision of the future is shared throughout the enterprise. Previously unknown plans and processes become familiar. Successes and benefits become common knowledge. Anxieties ease, and the future changes.
