Organizational Change

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Organizational Change

• Martin P. Charns, DBA
• Director
• COLMR

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Greenhalgh et al.

• Very comprehensive systematic literature review
  of diffusion implementation
• Addresses multiple perspectives
• Characteristics of innovation
• Process of implementation
• Context

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Greenhalgh et al. Model for Diffusion,
Dissemination, Implementation
LINKAGE
User System
Resource System
System antecedents
The Innovation
Knowledge purveyors
System readiness
Diffusion
Adoption / assimilation
Dissemination
Change agency
Implementation
LINKAGE
Consequences
Outer context
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QUERI Focus

• Largely on the innovation (EBP) process of
  implementation
• Less detailed focus to date on organizational
  context, including history

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Greenhalgh et al. Model for Diffusion,
Dissemination, Implementation- Showing Emphasis
on Innovation
LINKAGE
User System
Resource System
System antecedents
The Innovation
Knowledge purveyors
System readiness
Diffusion
Adoption / assimilation
Dissemination
Change agency
Implementation
LINKAGE
Consequences
Outer context
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The Innovation

• Relative advantage
• Compatibility
• Low complexity
• Trialability
• Observability
• Potential for reinvention
• Fuzzy boundaries
• Risk
• Task Issues
• Nature of knowledge required
• Technical support

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Adopter

• Needs
• Motivation
• Values goals
• Skills
• Learning Style
• Social networks
• Adoption Decision Stages
• Preadoption
• Early use
• Established users

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Communication Influence

• Diffusion (informal, unplanned)
• Social networks
• Homophily
• Peer opinion
• Marketing
• Expert opinion
• Champions
• Boundary Spanners
• Change agents
• Dissemination (formal, planned)

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Greenhalgh et al. Model for Diffusion,
Dissemination, Implementation- Showing Emphasis
on Organizational Factors
LINKAGE
User System
Resource System
System antecedents
The Innovation
Knowledge purveyors
System readiness
Diffusion
Adoption / assimilation
Dissemination
Change agency
Implementation
LINKAGE
Consequences
Outer context
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Outer Context

• Sociopolitical climate
• Incentives mandates
• Inter-organizational norm-setting networks
• Environmental stability

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System Antecedents for Innovation

• Structure
• Greenhalgh et al. note that structural features
  account for 13 of variation among organizations
  in their innovativeness
• Absorptive capacity for new knowledge
• knowledge must be enacted and made social
• Receptive context for change
• Leadership, culture

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System Readiness for Innovation

• Tension for change
• Innovation-system fit
• Power balances (supporters v. opponents)
• Assessment of implications
• Dedicated time/resources
• Monitoring feedback

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Implementation Process

• Decision making devolved to frontline teams
• Hands-on approach by leaders managers
• Human resource issues, esp. training
• Dedicated resources
• Internal communication
• External collaboration
• Reinvention/development
• Feedback on progress

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Successful Transformation Beyond Projects

• Most organizations can manage individual projects
  even many individual projects
• Making specific projects a priority
• Getting people to work extra hard
• Often achieves project change
• Is not sustainable
• By focusing on individual projects it is easy to
  forget
• that many others things are happening in the
  organization
• that other things outside of the project need to
  be addressed to achieve project success

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Successful Transformation Beyond Projects

• Model of transformation utilizes many of the
  organizational concepts reviewed by Greenhalgh et
  al.
• Model is more dynamic

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The Detailed Model of Healthcare Transformation
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Healthcare Transformation Model - Overview
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Model Overview

• Transformation begins with a sense of urgency
• Permanent, organization-wide change builds
  iteratively
• To maximize effectiveness, organizations align
  integrate efforts
• Organizations develop infrastructure to support
  the new way of functioning
• Improvement becomes part of organizational fabric
  the way we work
• Success motivates staff to continuously strive
  for higher goals (e.g., patient satisfaction
  high reliability)

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Change Is Iterative

• Fundamental organization change takes longer than
  2-3 years
• Organizations learn from prior experiences
• Failures are instructive
• Redesigning care implementation involve
  multiple, iterative cycles the more we
  improve, the more there is to do
• Testing new models
• Training
• Facilitation
• Resolving barriers
• Changing culture

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Impetus to Transform

• Creates sense of urgency to overcome inertia
  fear of change
• Examples
• Critical incident
• Financial crisis
• Financial stability
• Growth
• Mission (patient-centered)
• Combination of two or more

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The Impetus To Transform

• External sources of urgency (Crossing the Quality
  Chasm, JCAHO, VA Mandate, etc.)
• Sentinel events benchmarking data make staff
  realize that care quality not as good as they
  should be
• Maintain sense of urgency

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Improvement Projects

• Vehicle for process/outcome improvement
• Vehicle to engage multi-disciplinary front-line
  staff in meaningful problem solving
• Concrete (vs abstract vision statement)
• Clinical important focus to engage clinicians

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Improvement Projects

• Builds skills, motivation culture that will
  support sustain quality improvement
• Actively engage staff around priority clinical
  issue
• Collaborative, interdisciplinary work, including
  MDs
• System re-design to build evidence-based
  practices into daily work
• Goals measures (monitor progress whether
  improvement is sustained)
• Project support (training, tools, measures,
  facilitation)
• Shared learning spread

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Infrastructure

• Hard Infrastructure
• Information systems
• Clinical support systems
• Soft Infrastructure
• Workforce skills, values, expectations
  (engagement)
• Organizational culture
• Key role of infrastructure in transformation
• AMI example

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Alignment

• Managing the vertical consistent
  organizational vision, values behavior from top
  to bottom
• Both strategic operational
• Improving quality is top priority support,
  resources rewards are aligned accordingly
• Align improvement projects with strategy
  organizational goals throughout the organization

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Tools Structures To Support Strategic Alignment

• Strategic planning
• Strategic plan linked to everyones job (SSM
  Baldrige)
• Management structures
• Measurement Reporting
• Dashboards, scorecards
• Communication
• Transparency
• Resource allocation
• Accountability performance evaluation
• Recognition, rewards incentives
• P4P, performance awards
• Information Technology

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Integration

• Managing the horizontal consistency across
  the organization(s)
• Breaking down silos across
• departments workgroups
• organizational units
• Integrating across improvement initiatives
• Improving coordination of patient care

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Examples of Integrating Mechanisms Processes

• Service Lines
• Cross-organizational teams, workgroups
• Quality management oversight structures
• Steering committees (e.g., integration across
  organizational/community boundaries)
• Project teams with overlapping membership
• Clinical effectiveness departments moving
  innovations from one team to others
• Clinical Systems Integration unit
• Collaboratives
• Integrating quality into operations
• Information systems

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Leadership Drives Facilitates Alignment
Integration

• Leadership team leaders at all organizational
  levels
• Board, administrative, clinical leaders
• Commitment to passion for quality improvement
  walks the talk
• Constancy of purpose unrelenting pursuit of
  goals
• Translates commitment into action
• Investment of own time in quality activities
• Fosters learning
• Holds staff teams accountable
• Provides resources infrastructure for improving
  quality
• Integrate activities across organizational
  boundaries (facilities, workgroups, functions)
• Communicates builds relationships
• Gets the right people on off the bus
• Facilitates a well organized well run effort

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Leadership Drives Facilitates Alignment
Integration

• Establish structures to link improvement efforts
  to senior management
• Create accountability through measures, reporting
  and monitoring progress
• Actively support the projects and resolve
  problems
• Identify senior (e.g., quadrad) champion
• Recognize reward success
• Dont allow continuance of inappropriate behavior
• Use of key opportunities events

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Conclusions

• Quality improvement activities that are limited
  in scope are unlikely to be sustained
• Organizational transformation requires addressing
  all key model elements

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ConclusionsBuilding Change Over Time

• QI projects cornerstones of organizational change
  
• Demonstrate that change is possible
• Build involvement
• Engage clinicians
• Bring about spread
• Infrastructure development (e.g., information
  technology)
• Building culture skills (e.g., workforce
  development)
• Frontline/microsystem efforts
• Patient involvement in redesign efforts
• Success builds knowledge stimulates momentum

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Questions Discussion