Getting from here to there in health care.

"There is nothing more difficult to take in hand, more perilous to
conduct, or more uncertain in its success than to take the lead in the
introduction of a new order of things"--Niccolo Machiavelli, The
Prince (1)

Machiavelli's words describe your job as a health care leader in today's rapidly changing environment. Pressure for change is great and failure rates are high. We must change and yet many people lack enthusiasm for both the required outcomes and the process of getting from here to there.

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Avoiding change is not a long-term option

Large powerful forces are driving change into our health care organizations. These forces include patients, businesses, competitors, government regulations, technologies, and demographic trends.

Demands to improve quality, enhance patient safety, strengthen physician/administrator relations and implement new technologies require fundamental shifts in the way we do things in our health care organizations. As organizations attempt to make the transitions required to respond effectively to these new pressures, the requirements often multiply in chain reactions that lead to the need for yet further changes.

For example, implementing new technologies often results in the need for workflow redesigns, which in turn require changes in compensation systems. Like falling dominoes, each change event triggers numerous other adjustments in a chain of reactions. In the face of such pressures, organizations must rely on their people to make required shifts in their attitudes and behaviors. Often these do not occur.

Reactions to change

How do your people react when faced with today's demands for ongoing change? Answers often include stressed, worried, fearful, overwhelmed, angry, and resistant.

While a few people respond with excitement, many drag their feet regarding leadership objectives as well as the behavior changes required to reach the outcomes. (2)

How do you respond when your organization announces a new and demanding change initiative? That probably depends on your past experience with change, as well as your confidence in current leadership.

For many people who have been through unsuccessful change initiatives, reactions are often similar to that of a rat looking down a maze, seeing food at the end, but realizing that there is a good chance of electric shock before reaching the food.

No wonder people are often less than enthusiastic when leaders announce the latest change initiative.

Failure rates are high

Change is difficult and failure rates for change initiatives such as new technologies, customer-oriented cultural transformations, mergers and acquisitions, process improvements and restructurings are high.

For example, average failure rates for business expansion efforts and cultural changes may be 80 percent or higher, while failure rates for mergers and alliances as well as reengineering and process design initiatives are estimated to be as high as 65 percent to 75 percent. (3)

Beyond failing to achieve intended outcomes on time and within budget, it is not uncommon for such efforts to create problems serious enough to threaten the survival of the organizations involved. Nevertheless, leaders continue to invest in these initiatives.

While some types of change are more likely to achieve success than others (such as strategy deployment versus cultural change), a review of results achieved across a diverse range of changes suggests high failure rates are not uncommon. (3)

Health care is no exception. Implementing transitions in health care organizations is particularly challenging given the conflicting interests of many stakeholders, the frequent lack of clear, accepted, overarching objectives, and highly conservative regulatory structures and organizational cultures.

As a result, bringing about change is difficult in most organizations, and is "especially so in professional bureaucracies such as hospitals and universities in which highly trained and autonomous professionals, rather than administrators, largely control the core processes." (4)

The costs of failing to successfully implement change initiatives are diverse and often severe. Not only do stress, worry and fear often increase, but confidence in leadership typically decreases. As that confidence in leadership decreases, opposition, obstacles and obstructions often increase, resulting in lost time, money, and morale. (2)

When objectives are missed on a regular basis, leadership is, in effect, communicating that these objectives are unimportant or management does not know what it is doing. Organizational members who participate in and experience the consequences of repeated failures increasingly internalize both the apparent unimportance of the objectives (i.e., we failed and yet we still have our jobs) and the lack of credibility of the leadership. The possibility of future successes is decreased over time due to a growing sense of the futility of it all and a lack of faith that the future will be better than the past.

That begins a self-reinforcing chain of failures.

Environmental pressures demand that health care organizations change at an ever-increasing rate. These changes take many forms, failure rates are high and the costs associated with these failures continue to mount. Organizations must change and yet many individuals lack enthusiasm for both the final destination and for the trip itself.

Turnover under these conditions is often high, putting even more pressure on the downward spiral of both attitudes and performance in organizations that have failed to successfully implement change.

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What an opportunity

If the average change implementation success rate is 35 percent, how good do you have to be to achieve exceptional performance? Hopefully this question is no more difficult than asking, "What color was Washington's white horse?"

When average success rates are this low, a valuable opportunity exists for many leaders to exceed low expectations by implementing proven change management practices within their organizations. Beneficial results include increased confidence, enthusiasm, faith, satisfaction and commitment along with reduced opposition, obstructions, resistance and turnover as objectives are achieved, opportunities realized, and resources replenished.

Achieving 100 percent perfection may not be realistic when implementing change. But approximately half of our organizations do exceed average performance and many are highly successful over time in implementing major changes. Many of us have much to learn from the systematic pattern of leadership strategies evident in these success stories.

In future editions of this column, we will summarize what separates the winners from the losers. In addition, we will provide concrete leadership tools necessary to move people into and through transitions, examples of these tools in use, and questions to assess the application of these tools in your organizational setting.

References:

1. Machiavelli, N. 1532. The Prince. Edited by Quentin Skinner. New York: Cambridge University Press, 1988.

2. O'Connor, E. J. & Fiol, C. M. (1997). Creating a roadmap for leading change: In J. Lowery (Ed.), Culture Shift: A Leader's Guide to Managing Change In Health Care. Chicago: American Hospital Publishing, Inc., 39-60.

3. Smith, M. 2002. Success rates for different types of organizational change. Performance Improvement, 41, 1, 26-33.; Cameron, K. 1997. Techniques for making organizations effective. In D. Druckman, J. Singer, & H. Van Cott (eds.) Enhancing Organizational Performance. Washington D.C.; National Academy Press, 39-64.

4. Zell, D. 2003. Organizational change as a process of death, dying, and rebirth. Journal of Applied Behavioral Science, 39, 1, 73-96.

By Edward J. O'Connor, PhD and C. Marlena Fiol, PhD

Edward J. O'Connor, PhD, is a principal with the Implementation Institute, a professor of management at the University of Colorado at Denver and a member of the faculties of the American College of Physician Executives and the Kaiser Consulting Network. He can be reached by calling [phone] or by e-mail at [e-mail].

C. Marlene Fiol, PhD, is an associate professor at the University of Colorado-Denver. She can be reached by phone at [phone] or by e-mail at [e-mail].