Organizational Change Martin P. Charns, DBA Director COLMR.
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Transcript of Organizational Change Martin P. Charns, DBA Director COLMR.
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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
Knowledge purveyors
Resource System
Change agency
The Innovation
Dissemination
LINKAGE
Outer context
System readiness
Adoption / assimilation
Implementation
User SystemLINKAGE
Consequences
System antecedents
Diffusion
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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
Knowledge purveyors
Resource System
Change agency
The Innovation
Dissemination
LINKAGE
Outer context
System readiness
Adoption / assimilation
Implementation
User SystemLINKAGE
Consequences
System antecedents
Diffusion
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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
Knowledge purveyors
Resource System
Change agency
The Innovation
Dissemination
LINKAGE
Outer context
System readiness
Adoption / assimilation
Implementation
User SystemLINKAGE
Consequences
System antecedents
Diffusion
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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
Ali
gn
me
nt
fro
m t
op
to
bo
tto
m
Integration across boundaries
Change over time Sustainability, Spread Transformation
The organization/ system
Impetus to transform
Mission, vision, strategy, priorities
Culture Infrastructure
Organizational functions & processes
Tools & structures for integration Quality councils Service lines Integrated patient care delivery
Leadership
Urgency
Tools & structures for alignment Communication Recognition,
rewards & incentives
Accountability & performance evaluation
Resource allocation
Strategic planning
Improvement projects
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Healthcare Transformation Model - Overview
Alig
nmen
t fr
om
top
to b
otto
m
Integration across boundaries
Change over time transformation
The
organization/ system
Impetus to transform
Urgency
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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 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
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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– Don’t 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