The art of making change happen.

Health care is in a remarkable state of flux as information technology increases the degree of interdependence within the world. More than ever, health care is directly influenced by economic, political, social, and scientific factors--sometimes in that order.

IN THIS ARTICLE ...

Learn the important of choosing projects carefully, doing your homework, starting small and honoring workplace customs as you plan and initiate major changes.

The evolution of medicine from a guild-based, primarily technical profession to a systems-based transorganizational enterprise places new demands on physician executives to effectively lead change.

Everett Rogers, a leading authority in how innovations are disseminated across populations, describes change agents as individuals who influence others to adopt new practices. (1) The mandate to implement change may occur in various contexts depending on the scope of the physician executive's formal and informal position within the organization.

Fiscal concerns may drive efforts to reduce formulary and laboratory costs or the number of denied inpatient days. Clinical concerns may motivate reducing rates of error, complications and mortality. Whatever the goal, physician executives are challenged with the task of influencing highly diverse and complex organizations to adopt new practices that benefit the organization, the community and patient care.

Unfortunately, medical training does not provide the tools necessary to accomplish such change, leaving many new or experienced physician executives particularly vulnerable to failures that can jeopardize their credibility and job security. The ability to facilitate meaningful, sustainable change is based on an understanding of the factors that influence clinical care.

Professional competency

Individual professionalism and science-based clinical expertise are the foundation on which medical practice is based, without competence and integrity, effective and humanistic health care is impossible.

There is little debate that physicians in the 21st century experience unprecedented challenges to incorporate a virtual explosion of new scientific data that is applicable to their daily practice. Since the first randomized controlled trial (RCT) was published in 1952, over 131,000 such articles have been added to the medical literature.

Moreover, the growth rate of this knowledge base is accelerating. Of the 76,000 RCTs published between 1966 and 1995, 49 percent were reported in the most recent five years) Clearly, no individual practitioner can single-handedly master this knowledge base and translate it effectively into patient care.

In response to these challenges, the medical community has undertaken major efforts to provide clinicians with tools to help ensure that their practice patterns are consistent with the most up to date scientific evidence. The Cochrane Collaboration synthesizes periodic systematic reviews of the medical literature on various disorders and interventions, enabling clinicians to see overall trends and the strength of evidence supporting a variety of practices. (3)

Many professional specialty and subspecialty organizations developed clinical practice guidelines (CPGs) or treatment algorithms based on a variable combination of literature reviews and expert consensus. However, despite massive efforts to increase the use of CPGs, adoption has been remarkably limited.

As a result, individual knowledge and the availability of empirically based practice guidelines are not sufficient to influence clinical practice on a large scale. Adoption of guidelines may be impeded by existing resources, practice settings or work processes. (4)

Work processes

The reengineering movement of the late 1980s was inspired by recognition that work processes generally evolve around local, immediate priorities that fail to recognize the complexity of modern organizations. (5)

The basic tenet of this approach is that radical process redesign will eliminate costly, inefficient and counterproductive work processes, enabling increased productivity and quality. The proliferation of inpatient treatment algorithms and critical pathways reflects a growing respect for the importance of workflow design to optimize the utilization of clinical and fiscal resources in an increasingly competitive and regulated industry.

The Institute of Medicine recommends at global and radical redesign of health care delivery in the United States using the design and measurement methods developed in the engineering and manufacturing industries. (6) These redesigned processes would include computer-based decision-support using algorithms and guidelines that are consistent with current scientific knowledge.

Ideally such systems would support and facilitate best practice models, making it "easiest to do the right thing." Additional reinforcement would be obtained through reorganization of health care financing, documentation, communication and care coordination to support such optimal health care.

In particular, electronic medical records (EMRs) were cited as having enormous potential to promote optimal practices by making health information available to all involved clinicians, and through integrated reminders and warnings based on current scientific knowledge.

While these scenarios remain technically within the grasp of the American health care system, the question is how to migrate toward this ideal at the local level, fraught with crises, chaos and distractions. The combination of science-based medical practice and efficient, ergonomic work processes does not appear to be sufficient to effect and sustain large scale change.

The recent decision of Cedars-Sinai Medical Center to suspend use of their computerized physician order entry system suggests that optimizing work processes to incorporate science-based practice is not sufficient reason to adopt change. (7)

This costly and highly publicized reversal of direction was attributed to strong resistance from the hospital's medical staff, suggesting that the social dimensions of change implementation are quite powerful and can undermine even the best-planned efforts of leaders and administrators.

The missing key to change

Organizational culture can be defined as the attitudes, assumptions and values that are often not articulated but influence and determine the behaviors of an organization.

This is based on the findings of social psychologists that any group of people will automatically, over time, develop a social structure that incorporates rules of engagement and behavioral norms to facilitate harmonious co-existence. Organizational culture is often identified as a concern when implementing change and interventions that are not matched to prevailing cultures are generally not adopted. (1)

Superficial, pro forma compliance with change initiatives may occur for a brief period of time, but other crises will soon distract the leadership and the organization to focus on other more pressing matters. This can breed a cynicism in which every change effort is seen as the "flavor of the month."

Some change theorists argue that cultural shifts can only take place after the organization observes tangible results of the change effort that alter their assumptions and expectations. (8) As the organizational culture shifts, change becomes more profound and sustainable as new behavioral norms are established that exert subtle yet pervasive influence on individuals and groups.

This directly contradicts popular belief that cultural change is a means of implementing change rather than a result of successful preliminary implementation. However, this cultural shift has been identified as the "inflection point" that characterizes large-scale adoption of innovations in multiple settings. (1)

In order to bring about change, leaders must address all three of these domains effectively. This is clearly easier said than done. Some basic principles in organizational change and innovation may help improve the success rate.

In recognition of the importance of this area to the transformation of American health care, the Institute of Medicine dedicated an entire day in its 2002 annual meeting specifically to address issues of organizational change and leadership. (9) These principles are inspired by John Kotter, a professor at the Harvard Business School and widely published expert on leadership and organizational change.

Principle 1: Choose your projects carefully

Too often we choose change efforts because they seem relevant and exciting or in response to an emerging crisis. However, it's important to recognize that any change will be met with some measure of resistance for perfectly satisfactory reasons: change disrupts organizational equilibrium and causes anxiety.

It's important to weigh several aspects of the change itself, whether it involves adoption of an electronic medical record, implementation of a clinical algorithm or changing the medical staff privileging process. Research in diffusion of innovations identified several factors that affect the adoption of new practices. (1)

1. Relative advantage--There needs to be a demonstrable advantage to the change. In particular, the change should help stakeholders manage challenges they have identified as problematic or high priorities. This level of urgency is necessary to motivate individuals to alter their routines and endure some level of anxiety or uncertainty.

2. Compatibility with the culture--The change, at least in its initial form, must be compatible with certain core values held by important gatekeepers within the organization.

3. Complexity--The more complex and difficult to describe, the less likely a change is to be adopted. Often it may be necessary to break down a change into component parts to make it doable.

4. Trialability--The change needs to be able to be "tried out" in pieces or in a small pilot project. Organizations and individuals are highly unlikely to sacrifice time, effort and security by completely reengineering practices or processes that have until now been satisfactory--or at least adequate.

5. Observability--The change must be able to produce tangible, observable results.

Principle 2: Do your homework

In order to choose the right project, it's necessary to research the factors mentioned in Principle 1 in order to define a clear problem that can be objectively measured. Assuming this problem and its quantitative measures are sufficient to generate a sense of urgency within a few individuals, additional steps are necessary to ensure success.

1. Create a team with real power--It's important to recognize that each team member will have a sphere of influence that may extend the change effort in ways no individual can accomplish.

This penetration of change into multiple levels of an organization cannot be accomplished through the centralized command and control practices of traditional management. While any major change effort requires a champion at a senior leadership level, local opinion leaders also exert powerful influence, particularly when they have no formal positional authority.

2. Develop a concrete plan--While often self-evident, it is surprising how many "initiatives" have no clear plan or timetable to accomplish objectives--sometimes no clear objectives at all (i.e. "let's practice evidence-based medicine"). The failure to develop clear targets and steps to complete results undermines the initial urgency of the process as other "crises" distract attention from the initial project.

3. Communicate your plan--The chief failure of many change advocates is in under-communicating. Communication is a means of maintaining engagement, reducing anxiety and correcting distortions. It also increases credibility as legitimate concerns are addressed in a transparent manner.

Organizations have remarkably fluid collective memories, so every change agent should assume that no one has received accurate communication about their project.

Principle 3: Start small, then build momentum

Newly hired physician executives may feel pressure to effect large-scale change early on in order to establish credibility. This one-step process deprives them of the opportunity to conduct pilot feasibility studies and to learn from their mistakes.

A very visible, large-scale failure can be damaging to your reputation and even career. Moreover, the time and resources required to implement such extensive processes may exhaust the change team before there are any tangible results. As a result, a change effort may die on the vine for lack of early success.

By contrast, a small, manageable pilot project is more likely to be successful and generate enhanced credibility, particularly to skeptics. The lessons learned from early projects can be used to mode, approaches as the experiment is repeated or expanded to other areas. In the process, more and more individuals can witness the objective viability of change projects that become increasingly large and visible.

The practice of "swinging for the bleachers" should be tempered by the realization that sustainable change requires credibility and reliability that can only be obtained through experience. The more manageable and successful early experiences are, the more they build momentum and win supporters.

Principle 4: Address local custom and culture

Successful change leaders have a talent for reading the fit between their proposed changes and the local organizational culture. When the fit is initially pool, they will often implement only those aspects of change that are compatible with existing norms.

However, as implementation progresses, certain core aspects of the project may directly conflict with traditions and norms. If the change is managed well, this will occur after initial pilot projects demonstrate the validity and credibility of the proposed changes to at least a subset of stakeholders who possess some social influence among their peers.

At this point, the change leader must gamble some emotional capital by challenging the status quo and demonstrating the validity of the new practice. As outcomes support the new practice, staff expectations and assumptions will change and their readiness to accept the new practices will increase.

The result is a gradual shift in organizational culture to support the new changes. These cultural shifts create the social influence to sustain changes long after the "implementation phase" expired. Peer-to-peer influence and unwritten "norms" will reinforce the desired behaviors with a degree of flexibility and persistence that policies, training and oversight can never accomplish.

Attempts to accomplish cultural shifts rapidly or in a single stage are attractive but unrealistic. If we accept the observation that many aspects of organizational culture are based on strongly held yet unarticulated assumptions and expectations, it's amazing that anyone seriously believes that a few lectures, retreats or directives will have even a marginal impact on these sub-textual factors.

In fact, many such efforts may simply reinforce a culture of cynicism and low expectations, i.e. the "flavor of the month" change initiative.

In the history of medicine, change has never been more necessary yet more challenging. This creates unique opportunities for physician executives to promote responsible and attainable clinical excellence on an unprecedented scale.

The ability to effect relevant, effective and sustainable change in complex systems will accelerate the evolution of 21st century health care and ensure the central role of physician executives in this transformation.

References

(1.) Rogers E. Diffusion of Innovations, 4th edition. New York, N.Y., Free Press, i995.

(2) Chassin MR, Galvin RW. "The urgent need to improve health care quality." Institute of Medicine National Roundtable on Health Care Quality. JAMA 1998; 280(11):1000-1005.

(3.) Chalmers I. "The Cochrane Collaboration: preparing, maintaining and disseminating systematic reviews of the effects of health care." Ann NY Acad Sci 1993;703:156-163.

(4.) Grimshaw JM, Shirran L, Thomas T, Graham M, and others. "Changing Provider Behavior. An Overview of Systematic Review of Interventions." Med Care 2001; 39(8) Suppl 2:II2-II45.

(5.) Hammer M, Champy J. "Reengineering the Corporation: A Manifesto for Business Revolution." New York, N.Y., Harper Business Press, 1993.

(6.) Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, D.C., National Academy Press, 2001.

(7.) Stokes J. "Hospital heeds doctors, suspends use of software." Health care Leadership Review, Feb 2003.

(8.) Kotter JP, Cohen DS. The Heart of Change. Cambridge, Mass., Harvard Business School Press, 2002.

(9.) "Organizational Change and Leadership." Institute of Medicine Annual Meeting, October 15, 2002. Meeting website: www.iom.edu

Edward Kim, MD is medical director of adult services at the University of Medicine and Dentistry of New Jersey: University Behavioral HealthCare in Piscataway, N.J. He can be reached by phone at 732-235-3490 or by e-mail at [e-mail].