Organizational Change

1. Organizational Change Martin P. Charns, DBA Director COLMR

2. Greenhalgh et al. • Very comprehensive systematic literature review of diffusion & implementation • Addresses multiple perspectives • Characteristics of innovation • Process of implementation • Context

3. 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

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

5. 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

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

7. Adopter • Needs • Motivation • Values & goals • Skills • Learning Style • Social networks • Adoption Decision: Stages • Preadoption • Early use • Established users

8. Communication & Influence Diffusion (informal, unplanned) Social networks Homophily Peer opinion Marketing Expert opinion Champions Boundary Spanners Change agents Dissemination (formal, planned)

9. 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

10. Outer Context • Sociopolitical climate • Incentives & mandates • Inter-organizational norm-setting & networks • Environmental stability

11. 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

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

13. 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

14. 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

15. Successful Transformation Beyond Projects • Model of transformation utilizes many of the organizational concepts reviewed by Greenhalgh et al. • Model is more dynamic

16. The Detailed Model of Healthcare Transformation

17. Healthcare Transformation Model - Overview

18. 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)

19. 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

20. 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

21. The Impetus To Transform • External sourcesof 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

22. 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

23. Improvement Projects • Builds skills, motivation & culture that will support & sustain quality improvement • Activelyengage 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

24. 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

25. 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

26. Tools & Structures To Support Strategic Alignment • Strategic planning • Strategic plan linked to everyone’s job (SSM & Baldrige) • Management structures • Measurement & Reporting • Dashboards, scorecards • Communication • Transparency • Resource allocation • Accountability & performance evaluation • Recognition, rewards & incentives • P4P, performance awards • Information Technology

27. 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

28. 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

29. 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

30. 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 • Don’t allow continuance of inappropriate behavior • Use of key opportunities & events

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

32. 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

33. Questions & Discussion