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Advisory Note

Publication Date: 14/10/2013 ID Number:

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Change Management Planning Should be Integral to Any Healthcare System

Zafar Chaudry, M.D. and Monique Koehler

This paper reviews the impact of change management on healthcare system planning from an international best practice approach and makes recommendations on how healthcare delivery organisations should tackle it.

Key Findings

A prerequisite for any successful IT project is the acknowledgement that new technology should be built around the best practices of clinicians, not the other way around.

IT projects involve not only technology, which in itself can be intimidating to some people, but also includes elements of business process, workflow, control, and the exposure of information.

Negative responses to IT implementation is defined by seven stages that include immobilisation, denial, anger, bargaining, depression, testing and acceptance.

As long as technology and processes integrate people, there will always be some levels of resistance to change due to feelings of loss of control, technical inadequacy, uncertainty, surprise, resentment, job loss/replacement, competition, and more work.

Change management examines the current environment with respect to organisation culture, communication, organisation design, job design, infrastructure, personnel, skills and knowledge, people/machine interfaces, and incentive systems.

Resistance is a natural response to change that is introduced by somebody else. Seventy-five percent of an organisation’s management needs to "buy into" the change for success.

Success is typically achieved by:

Having a defined communication strategy;

Consistency about sharing information;

Using a variety of media to reach people;

Involving stakeholders in the planning process;

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Supporting staff with training and opportunities to practise;

Listening and acting on questions, feedback and concerns;

Celebrating ideas, achievements and success;

Having a clear reason for implementing change;

Having a shared vision about what the change will achieve;

Being aware of the different rate of uptake of change;

Providing feedback on progress to stakeholders.

Recommendations

Engage well-defined processes and tactics for controlling and influencing the pace and acceptance of organisational change through effective communication, education and implementation of new organisational strategies in an approach that allows people to identify with the need for change and internalise new processes.

Embed organisational change activities into the programme plan, highlighting the risks associated with not fully engaging or enabling change in the organisation.

When developing strategies, consider the barriers to implementing change and cater for them within the strategy development.

Identify the change champions, the innovators; these are the people who will be prepared to introduce change.

An effective change management programme must focus on the following key elements:

Redesign/design of the new business processes to the desired business and IT functionality;

Assessment of the impact of implementing the new processes on the relevant aspects of the organisation;

Implementation of an awareness programme across the entire organisation to communicate the new changes and create a sense of ownership;

Conducting performance based training to allow users to implement the new workforce and change requirements;

Engagement in continuous analysis of the impact of the change programmes, whilst taking corrective measures.

Build a change management plan which establishes motivations for change, identifies impediments to change, and organises defined objectives for the change management strategy which include planned communications, a formalised implementation plan with ownership allocations, risk management tactics, and reinforcement activities to ensure that changes are internalised throughout the organisation and lingering resistance is eliminated.



Consider Kotter’s 8 step approach:

Step 1: Create urgency;

Step 2: Form a powerful coalition;

Step 3: Create a vision for change;

Step 4: Communicate the vision;

Step 5: Remove obstacles;

Step 6: Create short-term wins;

Step 7: Build on the change;

Step 8: Anchor the changes in corporate culture.

Consider the following key steps to achieving a successful health IT implementation:

Identify the stakeholders;

Get real about workflows;

During a system transition, expect worries about patient safety;

Communication should drive change management for IT.

Consider adopting the 8 components of the NHS Change Model:

Shared purpose: patients and their experience of their healthcare should be at the heart of what drives change;

Engagement to mobilise: are the right people mobilised and engaged?;

System drivers: align processes, incentives and systems to enable change;

Transparent measures: measure the outcome of the change continuously and transparently;

Rigorous delivery: devise an effective approach for delivery of change and monitoring of progress towards planned objectives;

Improvement methodology: use an evidence-based improvement methodology;

Spread of innovation: build in the active spread of innovation from the start.



TABLE OF CONTENTS

Key Findings ......................................................................................................................... 1 Recommendations ................................................................................................................ 2

Strategic Planning Assumptions ........................................................................................................ 5 Issues Related to Technology ................................................................................. 5

Analysis ............................................................................................................................................. 9 Stages of Change .................................................................................................... 9 Clinical Transformation ............................................................................................ 9 Change Strategies ................................................................................................. 10 Agents of Change .................................................................................................. 11 Recognising and Responding to Resistance to Change ....................................... 13 Reading People ..................................................................................................... 14 Kotter’s 8 Step Approach....................................................................................... 14 HIMSS Approach ................................................................................................... 17 IT Projects: Steps For Success ............................................................................. 18 Transforming Healthcare ....................................................................................... 18 Components of Successful Healthcare Change Management ............................. 19 Challenges in IT Adoption in Healthcare ............................................................... 20 The NHS Change Model ....................................................................................... 21 The Relevance of Communication in Change and Adoption ................................ 22 Psychology and Change ........................................................................................ 23 Final Thoughts ....................................................................................................... 24

Recommended Reading .................................................................................................................. 24



Strategic Planning Assumptions

This paper is written to discuss the concept of organisational change management, define those issues that specifically face the information technology (IT) environment, and proposes a solution to mitigate organisational change management issues. The implementation of IT systems almost always involves change within the user community and can have a dramatic effect on the organisational processes of a business. Therefore, the way that individuals interpret change to their daily business functions is as important as the actual change to the technology or business process itself. IT can change how people work and people can interpret the use of IT in ways that designers never anticipated. These issues must be addressed in a change management plan. Consequently, an organisation’s approach to change management can have a greater impact on the success or failure of an IT project than the ability of the technology to meet the business objectives for which it was designed. In fact, change management policies will often determine a project’s ultimate success as end-user acceptance is critical to any IT initiative.

By definition, change management is a structured approach to transitioning individuals, teams, and organisations from a current state to a desired future state. The current definition of change management includes both organisational change management processes and individual change management models, which together are used to manage the people side of change

1. The term

change management is more commonly, and increasingly, associated with a systematic process of taking into account the global conditions affecting an organisation, as well as specific conditions in the organisation. Change management methodology examines the current environment with respect to organisation culture, communication, organisation design, job design, infrastructure, personnel, skills and knowledge, people/machine interfaces, and incentive systems.

There are many reasons why people in an organisation resist change. Every organisation has its own culture that is defined by processes, methods, habits, procedures and perceptions that are ingrained in the fabric of the business and its people. These traits are not easily altered as they are developed over the course of time and become the precedence and standard for the correct way things are done within an organisation; consequently, expectations and belief systems are established which identify with the social and economic factors within a company’s working environment. Because of these factors, organisational culture is a significant force in resisting change. Consequently, change management is focused on understanding the complexities of these relationships and motivating people to change in order to support new organisational paradigms in the context of business transformation and process re-engineering efforts. Overcoming resistance (to change) is about neutralising negativity. Motivation is about lighting a fire. When people are burning with enthusiasm, they’ll take risks, go the extra mile, and fully commit themselves to change. Therefore, change management engages well-defined processes and tactics for controlling and influencing the pace and acceptance of organisational change through effective communication, education and implementation of new organisational strategies in an approach that allows people to identify with the need for change and internalise the new processes.

Issues Related to Technology

Changes in technology pose significant challenges for organisational change management due to the complexities and dynamics involved with various components of information technology projects. IT projects involve not only technology, which in itself can be intimidating to some

1 Source: Change Management for A New Clinical Future, Healthcare-informatics, 2008

http://www.healthcare-informatics.com/blogs/albert/change-management-new-clinical-future



people, but also includes elements of business process, workflow, control, and the exposure of information. This makes organisational changes that involve IT to be potentially threatening to an organisation’s culture and counter intuitive since they are often initially seen as intrusive, redundant, and not relevant to an individual’s specific job function. The rollout of information systems threatens people in organisations on many levels. It introduces new procedures that interfere with the organisational norms, new technologies which can create fear of the unknown, and new power relationships that upset the hierarchy.

When technology changes occur within an organisation, the typical response can often be negative due to the fact that personnel, process and procedural changes will likely coincide with changes in technology such as hardware, software and systems. This negative response and its contributing factors is a process which is defined by seven stages that include immobilisation, denial, anger, bargaining, depression, testing and acceptance. During immobilisation, an emotional response is generated which shocks the system and prompts defense mechanisms to be engaged in response to the new technology threats. Then, denial takes hold as constituents formulate an approach of waiting out the technology movement as they believe it will fade over time, like so many other corporate initiatives. This response is followed by anger, when employees see the technology being implemented around them, and they feel helpless to control the process or movement. Now that the implementation has become real to them, the constituents start to engage in bargaining as their feedback is now being solicited as to the changes in technology, and they feel that they need to contribute to the process to mitigate its potential impact on their status quo. If not addressed properly, feelings of depression can follow this stage if employees feel helpless in the process and unable to influence or accept the new changes in a positive manner. Eventually, people will start to adjust to the new system as they test their ability to adapt to the changes and exert positive influences on the process. Finally, after the processes of denial, confrontation, anger and negotiation have run their course, people will begin to accept the change as they begin to personally see the benefits associated with the change at a personal level, and they embrace the new technology and processes going forward now that they have accepted the premise that the change is permanent. The purpose of change management is to compress this cycle whilst exerting positive influence. As long as technology and processes integrate people, there will always be some level of resistance to change due to feelings of loss of control, technical inadequacy, uncertainty, surprise, resentment, job loss/replacement, competition, and more work. These challenges can pose serious risks and roadblocks to an organisation’s ability to successfully implement technology change, especially if not managed correctly with a well-designed and methodical approach.

The keys to a successful change management approach is not a war won in a single battle; moreover, it is a sales campaign involving constant and consistent education and communications that begin with the realisation that change is required and doesn’t finish until well after the redesigned processes have been put into place. As such, a well-designed change management approach needs to incorporate strong principles of education, training and communications at the heart of its overall strategy and methodology. A good model for managing change through IT provides a framework for building a change management plan which establishes motivations for change, identifies impediments to change, and organises defined objectives for the change management strategy. This includes planned communications, a formalised implementation plan with ownership allocations, risk management tactics, and reinforcement activities to ensure that changes are internalised throughout the organisation and lingering resistance is eliminated. An effective change management programme must be established and will focus on the following key elements:

Redesign/design of the new business processes to the desired business and IT functionality;



Assessment of the impact of implementing the new processes on the relevant aspects of the organisation;

Implementation of an awareness programme across the entire organisation to communicate the new changes and create a sense of ownership;

Conducting performance based training to allow users to implement the new workforce and change requirements;

Engagement in continuous analysis of the impact of the change programmes whilst taking corrective measures.

The goal of this change management approach is to ensure the successful transition from the current systems and processes to the new system and associated processes.

Any change is disruptive to an organisation. Implementing a change management programme is a major initiative that will result in some disruption to the organisation's performance. In order to be successful, a change management programme must adhere to the following critical success factors:

Minimise fears;

Create sponsorship and ownership;

Enhance communication;

Provide education;

Maximise performance and rollout of the initiative with sufficient resources and planning.

By getting representation from all areas within the organisation into the change management process, user acceptance levels are increased as departments and business units feel represented and their concerns are being considered in the implementation and change management strategy. This enables each business unit to buy in to the process and help to facilitate the integration of people with the technology and process changes. Furthermore, in addition to various business units, different constituencies within the organisation should also be represented to provide group leadership and ensure that all end user communities are actively involved since they are more likely to understand how the current processes are actually being performed, which can vary from how they are supposed to be completed according to defined company policies and procedures. This can prove to be a very insightful exercise within the change management process as this often leads to awareness of the need for change as inconsistencies, waste and process redundancies are uncovered. By incorporating the right resources into the implementation of the change management strategy, end user acceptance will increase and project benefits will be realised through the establishment of solid project leaders and role models for the organisation, greater adherence to project schedule and budget due to lower levels of change resistance, enhanced organisational benefits from the impact of new innovations derived from the collective input of user community, and a mutual respect and sense of purpose to achieve the accepted common goal. These factors, along with team building techniques and events, can enable an organisation to achieve their change management strategy provided that enough resources are secured and dedicated upfront in the project’s lifecycle and they remain committed to its success throughout implementation and rollout. Lastly, organisational change management requires the incorporation of a consistent and effective communications strategy to achieve success which creates awareness, builds a consensus for change and manages employee’s expectations throughout the process. Effective change management communications provide an understanding of the need for change and the new vision so that all stakeholders understand the reason for the new processes and IT systems.



In addition, a consistent policy helps to promote acceptance and enthusiasm for the changes necessary to move the organisation forward and allows opportunity for selective input to the change process. This input will enable the change management team to identify the most effective communication vehicles and channels for establishing two-way communications with stakeholders and gives them a sense of inclusion into the process, thereby ensuring the project’s success and effectively mitigates change management risk.



Analysis

The sheer size and scope of the literature on change management can make it hard for managers and practitioners to access the literature and find their way around it. What is needed are obvious points of entry and clear signposts through the forest. Listing models by chronology or school of origin does little to provide a coherent pathway; alternatively, trying to link concepts to stages in a change process may prove misleading or repetitive, since the majority of models can be used for several different purposes. Change is one of the most difficult behaviors to affect. While few people are willing to articulate why change is so difficult for them on a personal level; change is frequently viewed as shifting the balance of power—and no one likes giving up what they perceive as power. An impending change often results in fear, resistance, and even sabotage.

Stages of Change

Unfortunately, no magic wand is available to affect change without effort. Some studies suggest that change requires progression through stages, such as the five stages of the grieving process in death (denial, anger, bargaining, depression, and acceptance). Several studies support that change requires pre-contemplation, contemplation, preparation, action, and maintenance, often over a fairly significant amount of time, or at least more time than is often devoted to IT acclimation. Other change management experts describe a process that entails unfreezing old habits by pointing out deficiencies and the value of new approaches; making the change through engagement, education, and training; and then refreezing the change into new habits through continual reminders and reinforcement, as well as commitment to enforcing, supporting, and celebrating the results of the change. All of these suggest one commonality—that change is complex and people progress through multiple stages before real change occurs.

Clinical Transformation

Clinical transformation is a concept that describes the scope of change brought about by new IT in general and EHR systems in particular. Regulations, staffing, reimbursement, cost, malpractice, report cards, and other issues have catapulted organisations to seek a significant revamping of their workflows and processes to meet requirements, recruit and retain good staff, optimise reimbursement, reduce waste, reduce errors, and address public concerns. Clinical quality is now at the forefront of all healthcare organisations’ concerns. Clinical transformation suggests some hallmarks that are different from previous approaches to change in healthcare organisations:

Clinically-focused. IT and EMR in particular have largely been on the periphery of the core business of healthcare. Financial, administrative, and operational systems have been widely implemented; clinical systems are the next frontier. Clinical information systems focus directly on the core business of healthcare—taking care of patients. The resulting clinical transformation programmes have focused on the effectiveness and efficiency of patient care delivery.

Integrated. Where many of the financial, administrative, and operational/departmental systems were largely standalone and potentially interfaced to share limited demographic data, most such systems have not been truly integrated. Moving from one application to another is not seamless. To transform clinical processes, all current and new systems must serve as source systems linking directly to one another or through a data repository.

Comprehensive. Clinical transformation relies on having access to all data for processing into the right presentations of information and into clinical decision making. Although nursing homes will go through a period of time in which they operate with a hybrid record system (some parts on



paper and some parts electronic), the goal is ultimately to electronically capture data from all sources for use in care delivery, management, and operations.

Knowledge-based. Clinicians are knowledge workers and demand that systems intended to support them be as knowledge based as possible. Financial, administrative, and even operational/departmental systems have primarily addressed clerical and operational tasks. While clinicians would be hard-pressed to function in an environment that did not have such systems, they are not touched as directly by them as they are with clinical systems. But if the clinical systems do not provide information based on solid evidence, they have minimal value to the clinician. Further, knowledge is continually evolving and changing. Organisations must recognise that HIT is dynamic and must be continually assessed for accuracy and appropriately supported.

Outcome-oriented. Clinical transformation is about achieving better outcomes. If there were a way to achieve better outcomes without major investments in information technology, these would be readily adopted. HIT systems are recognised as significant contributors to improving patient safety and quality outcomes.

Change Strategies

Change management for IT is not only about recognising the stages required to accept change and the clinical transformation that is about to take place, but is also about applying strategies to support change. One element of developing a change management strategy is to understand the organisation’s innate change management style. Every organisation has some way of introducing and requiring even moderate amounts of change. Most effective change managers recognise the corporate culture of the organisation and either work within that culture or attempt to move the organisation to a more positive culture. One or more of the following types of change management strategies is typically found in every organisation. Although each can be effective, given the characteristics of the organisation, the general school of thought is that the most-effective and longest-lasting change is achieved through a behavioral norm-based strategy, with effectiveness decreasing with incentive-based, sanction-based, and adoption-based strategies.

Behavioral norm-based strategy is when behavioral norms or expectations are changed by organisational leadership and/or external factors. An example is the promotion of bar code medication administration recently promoted for hospitals by The Joint Commission and recognised by healthcare leadership as an important means to achieving patient safety. Nursing homes are only now starting to be the target of more such expectations, although with mixed signals. CMS is strongly supportive of IT, while some states are suffering significant change management issues themselves in acclimating to IT.

Incentive-based strategy is one in which conformance is rewarded. This is becoming more popular as payers have announced pay-for-performance incentives for IT adoption. An example is computerised provider order entry systems for which hospitals have been given favorable contracting incentives. Physicians have been incentivised by Medicare to adopt e-prescribing and primary care systems in the U.K. Some experts fear, however, that once the incentive is removed, organisations will slip back into old ways.

Sanction-based strategy may be viewed as the opposite of the incentive-based strategy, where nonconformance is penalised. In this case, payers may introduce disincentives, such as Medicare, adding time to pay on claims if not filed using the HIPAA-required electronic transactions, withholding a percentage of payment from hospitals that do not participate in voluntary quality reporting, or reducing the fee schedule for physicians who do not use e-prescribing.



Adoption-based strategy is one in which people are transferred from the old way to the new way over time, such as giving providers the option of whether they will adopt CPOE or not. This strategy may be useful in some instances, but with today’s focus on clinical transformation, most organisations find they do not have the time or resources to accommodate such a strategy. The strategy essentially requires running dual processes—paper records and electronic records— until everyone decides to adopt the new technology. Such a strategy is costly and results in a hybrid record environment that not only is confusing but potentially a patient safety issue.

Agents of Change

Another key strategy in managing change is to recognise that the project manager, administrator, director of nursing, physician champion, or IT staff is not the sole change agent. In fact, everyone involved in the process of HIT adoption needs to be a change agent—discussing the skills needed with the members of the HIT steering committee and all supervisors can be well worth the time. Each person involved in the HIT project may need to reflect upon the following skill requirements and take steps to hone them for the good of the organisation:

People skills are essential to understand the diversity among all individuals, skill sets, and positions that are impacted by HIT. Effective change managers are able to listen, restate, reflect, clarify without interrogating, draw out the quiet, quiet the verbose, channel discussion, plant ideas, and develop trust and confidence in users.

Political skills are needed to understand the various viewpoints and counter viewpoints that may arise during discussion about HIT.

System skills help organise and manage the technology while translating this into language that users will understand and respect.

Analytical skills ensure that workflow and processes are not only understood and appropriately improved upon, but also used to assess and manage the financial impact of the change.

Business skills are needed to understand the underlying way the healthcare organisation works and the underlying clinical processes. Change agents need be able to “talk the talk” and “walk the walk” related to their roles.

Most healthcare delivery organisations assign a ‘Change Manager’ or ‘Change Agent’ on any given project or major programme of work; however the role and responsibility of this agent is generally only active for a part of the project, i.e. once the programme is ‘successfully implemented’, the change agent role is dissolved – meaning that ongoing concerns, issues and challenges that may occur – end up not being resolved. This is where usability and adoption falls by the wayside. The role of a Change Manager and the allocated funding against these tasks are usually the first to be cut when healthcare delivery organisations are faced with budget pressures and funding constraints. Enterprises that are investing heavily in change initiatives fail 70% of the time because they "tell" people to change, rather than engaging them in the change.

Many HDO’s that do assign a Change Agent and implement a programme in place to support a new programme of work, do not have the rigour or process around the roles and responsibilities that should be given. There is generally a lack of accountability and supporting step by step process to provide the accountability and commitment required from various stakeholders; clinical and business; in order to improve adoption and usability. Some organisations in Australia have, however, made positive steps to reinforce the importance of change and adoption in healthcare delivery programmes.

An example of a Change and Adoption Process used in healthcare is below:



Step 1: Stakeholder participation:

Reviewing stakeholder(s’) needs;

Establishing reference groups;

Identifying and engaging key managers, early adopters, change champions, opinion leaders, subject experts;

Reviewing workflow and business processes;

Clearly defining user requirements;

Developing user requirements;

Engaging users in the design process;

Prototyping with the users.

Step 2: Understanding your current business:

Patient journey:

Define patient journey;

Understanding the touch-on effects of the project;

Uncovering the value and benefit for the patient;

Analysing who will use/gain access to the solution;

Understanding what is important for the users.

Business Analysis:

Process mapping;

What are the gaps/areas of opportunity for change?;

What are the efficiencies that could be made from this programme?

Step 3: Training:

Regular engagement across multiple stakeholders;

Utilisation of various media sources to engage with a variety of mediums (web, bulletins, events, emails);

Training options: Group, individual, web based, classroom style, train the trainer, etc.

Step 4: Rollout:

Socialise the stages and steps of project delivery;

Keep personnel well informed on progress and quick wins.



Step 5: Ongoing Management:

Monitor performance and be prepared to change and adapt to new requirements;

Be prepared for failures and act;

Maintain communication with stakeholders;

Regularly report back the benefits (clinical and business) to relevant personnel.

Recognising and Responding to Resistance to Change

Reading people and preparing to respond to their concerns about change is an important task for change agents. In addition to the pace at which individuals adopt change, people react to change in different ways, from threatening to leave to actively supporting the change. Reading reactions and responding appropriately is very important. This is especially true for those known to be “informal leaders” or “opinion leaders” who you will want on the side of change. Common reactions to change and how to respond include:

Leaving. Some clinicians indicate that they would retire before adopting an EMR or other IT. Some may be convinced to stay and can serve the organisation well if their active resistance can be channeled into representing a resister’s viewpoint for the good of the project. However, if this is not possible, simply acknowledge the person’s accomplishments and let them make their own decision. Threats by physicians to take their business elsewhere are generally no longer very effective, as most nursing homes are either adopting IT and EMR or have them on a future agenda. Many nursing homes find that young physicians who are interested in geriatrics or using nursing home business to supplement their revenues early in their practice are very interested in

EMR from their training experiences. Replacing nurses may not be as easy, so putting effort into

education and engagement will be essential for the bulk of your user community.

Active resistance. In active resistance, the organisation has an advantage because the individuals are clear about how they feel. Such individuals can be a benefit to an HIT project if, as described above, the active resistance can be channelled into representing a resister’s viewpoint for the good of the project. Once active resisters are turned around, they can be equally active in

their support. Active resisters often do not threaten to leave either because they are not old

enough to retire or know of other facilities adopting HIT as well. As a result, they are easier to turn around than those threatening to leave. Active resisters must be turned around because their resistance can be infectious.

Opposition. A person who opposes HIT but is not an active resister can be the most difficult to identify and turn around. Often this is a person who is negative about everything and potentially depressed. Offering life/career counseling to such individuals is often necessary. If this is done, however, the benefits can be great not only for the HIT project but for the individual.

Acquiescence. An individual who grudgingly accepts HIT is someone who needs to be monitored closely. This individual could swing to either opposition or acceptance. Involving this individual with specific tasks and recognition for work well done will help ensure acceptance.

Acceptance/modification. An individual who reacts by always claiming to accept the project but continuously offers modifications to the system can put a project at risk for delaying or going over budget. Often a person with such a reaction is actually one who opposes the project and is trying to avoid using the system, or avoids any change it may be designed to impose. This exuberance for modifying the new system back to old ways needs to be managed.



Acceptance. A person who quietly accepts the change is certainly one to be appreciated. However, such persons could contribute more to the process of turning others around if they were more actively supportive of the project, and they should be encouraged, if not called upon, to describe their interest.

Active support. Some people will genuinely be active supporters and should be greatly appreciated. Their energy and enthusiasm should be channeled into constructive help.

Reading People

A final consideration is to learn how to read the various responses people may have to an IT project. Supervisors and managers should try to understand the thoughts of staff who react with silent opposition or acceptance. One way of both reading people and to start the change management process is to use a force field analysis that helps everyone put driving forces and restraining forces for the IT project on the table. If done in a way that is not personal, but instructive to the organisation, the force field analysis process can be revealing and help to educate all.

Kotter’s 8 Step Approach

As rapid change is taking place in the healthcare sector with adoption of new technologies, consider Kotter’s dynamic, nonlinear 8-step approach

2:

Step 1: Create urgency. For change to happen, it helps if the whole organisation really wants it. Develop a sense of urgency around the need for change. This may help spark the initial motivation to get things moving. If many people start talking about the change you propose, the urgency can build and feed on itself.

What organisations should do:

Identify potential threats, and develop scenarios showing what could happen in the future.

Examine opportunities that should be, or could be, exploited.

Start honest discussions, and give dynamic and convincing reasons to get people talking and thinking.

Request support from internal and external stakeholders to strengthen your argument.

Step 2: Form a powerful coalition. Convince people that change is necessary. This often takes strong leadership and visible support from key people within the organisation. Managing change isn't enough – you have to lead it. You can find effective change leaders throughout your organisation – they don't necessarily follow the traditional organisational hierarchy. To lead change, you need to bring together a coalition, or team, of influential people whose power comes from a variety of sources, including job title, status, expertise, and political importance. Once formed, your "change coalition" needs to work as a team, continuing to build urgency and momentum around the need for change.


Identify the true leaders in your organisation.

2 Source: Change Management in Health Care, Robert James Campbell, 2008

http://academy.clevelandclinic.org/LinkClick.aspx?fileticket=tCy9kstz6FU%3D&tabid=1846



Ask for an emotional commitment from these key people.

Work on team building within your change coalition.

Check your team for weak areas, and ensure that you have a good mix of people from different departments and different levels within the organisation.

Step 3: Create a vision for change. When you first start thinking about change, there will probably be many great ideas and solutions floating around. Link these concepts to an overall vision that people can grasp easily and remember. A clear vision can help everyone understand why you're asking them to do something. When people see for themselves what you're trying to achieve, then the directives they're given tend to make more sense.


Determine the values that are central to the change.

Develop a short summary (one or two sentences) that captures what you "see" as the future of your organisation.

Create a strategy to execute that vision.

Ensure that your change coalition can describe the vision in five minutes or less.

Practice your "vision speech" often.

Step 4: Communicate the vision. What you do with your vision after you create it will determine your success. Your message will probably have strong competition from other day-to-day communications within the company, so you need to communicate it frequently and powerfully, and embed it within everything that you do. Don't just call special meetings to communicate your vision. Instead, talk about it every chance you get. Use the vision daily to make decisions and solve problems. When you keep it fresh on everyone's minds, they'll remember it and respond to it. It's also important to "walk the talk." What you do is far more important – and believable – than what you say. Demonstrate the kind of behaviour that you want from others.


Talk often about your change vision.

Openly and honestly address peoples' concerns and anxieties.

Apply your vision to all aspects of operations – from training to performance reviews. Tie everything back to the vision.

Lead by example.

Step 5: Remove obstacles. If you follow these steps and reach this point in the change process, you've been talking about your vision and building buy-in from all levels of the organisation. Hopefully, your staff wants to get busy and achieve the benefits that you've been promoting. But is anyone resisting the change? And are there processes or structures that are getting in its way? Put in place the structure for change, and continually check for barriers to it. Removing obstacles can empower the people you need to execute your vision, and it can help the change move forward.




Identify or hire change leaders whose main roles are to deliver the change.

Look at your organisational structure, job descriptions, performance and compensation systems to ensure they're in line with your vision.

Recognise and reward people for making change happen.

Identify people who are resisting the change, and help them see what's needed.

Take action to quickly remove barriers (human or otherwise).

Step 6: Create short-term wins. Nothing motivates more than success. Give your organisation a taste of victory early in the change process. Within a short time frame (this could be a month or a year, depending on the type of change), you'll want to have results that your staff can see. Without this, critics and negative thinkers might hurt your progress. Create short-term targets – not just one long-term goal. You want each smaller target to be achievable, with little room for failure. Your change team may have to work very hard to come up with these targets, but each "win" that you produce can further motivate the entire staff.


Look for sure-fire projects that you can implement without help from any strong critics of the change.

Don't choose early targets that are expensive. You want to be able to justify the investment in each project.

Thoroughly analyse the potential pros and cons of your targets. If you don't succeed with an early goal, it can hurt your entire change initiative.

Reward the people who help you meet the targets.

Step 7: Build on the change. Many change projects fail because victory is declared too early. Real change runs deep. Quick wins are only the beginning of what needs to be done to achieve long-term change. Each success provides an opportunity to build on what went right and identify what you can improve.


After every win, analyse what went right and what needs improving.

Set goals to continue building on the momentum you've achieved.

Learn about kaizen, the idea of continuous improvement.

Keep ideas fresh by bringing in new change agents and leaders for your change coalition.

Step 8: Anchor the changes in corporate culture. Finally, to make any change stick, it should become part of the core of your organisation. Your corporate culture often determines what gets done, so the values behind your vision must show in day-to-day work. Make continuous efforts to ensure that the change is seen in every aspect of your organisation. This will help give that change a solid place in your organisation's culture. It's also important that your company's



leaders continue to support the change. This includes existing staff and new leaders who are brought in. If you lose the support of these people, you might end up back where you started.


Talk about progress every chance you get. Tell success stories about the change process, and repeat other stories that you hear.

Include the change ideals and values when hiring and training new staff.

Publicly recognise key members of your original change coalition, and make sure the rest of the staff – new and old – remembers their contributions.

Create plans to replace key leaders of change as they move on. This will help ensure that their legacy is not lost or forgotten.

HIMSS Approach

HIMSS has also built a change management model that must have an application specific focus, e.g., CPOE, ERP, ICD-10 coding, business intelligence, etc., and be designed to assist the healthcare organisation in making the most effective use of their human resources, processes and technology to maximise the healthcare organisation’s investment in the application. HIMSS defines a four-phased approach designed to successfully accept and adopt the new application/technology, functionality, and associated new ways of doing business. These phases include:

Phase 1: Change readiness evaluation. Understand the organisation’s culture in terms of readiness and capability for change. Leverage surveys, focus groups and interviews to gain an immediate understanding of how the communication of previous change has been regarded by stakeholders. The change readiness evaluation will reveal perceptions about the capability of the healthcare organisation to incorporate and sustain change.

Phase 2: Change management strategy. Define the change and communication activities required to move the healthcare organisation from project start-up through to implementation.



Phase 3: Change management plan. Develop a change management plan to provide tasks, actions, and details of the required materials to be developed to meet communications needs, as well as the schedule/logistics for communications.

Phase 4: Change management delivery and re-evaluation. Develop communication materials, events, provide guidance and counsel regarding the delivery of change management.

IT Projects: Steps For Success

A prerequisite for any successful IT project is the acknowledgement that new technology should be built around the best practices of clinicians, not the other way around. Human factors are the very challenges that can prevent the technical objectives from being achieved. The following key steps have been found to be important to achieve a successful health IT implementation:

Identify the stakeholders: managers must determine who the stakeholders are, and bring them on board at the beginning of the project.

A group effort to map the future: executives should also try to anticipate key organisational consequences of technological change.

Get real about workflows: when it comes to assessing existing workflows and designing revamped procedures that will mesh with a new IT system, many reality checks are needed.

During a system transition, expect worries about patient safety: one approach to maintaining patient safety is to implement a new IT system in small steps. It’s very important to take your time, to introduce things incrementally.

Communication should drive change management for IT: one of the most important methods to overcome resistance to change is to communicate about it beforehand.

Transforming Healthcare

A four stage model (shown below) has been used to learn how to lead change in healthcare organisations. It was used at Toronto’s University Health Network for the implementation of a CPOE system. Five critical elements were identified for change process (vision, skill, incentive, resources and action plan) and have been addressed in this four stage model.



Source: Transforming Healthcare Organisations, Brian Golden, 2006

Components of Successful Healthcare Change Management

As the healthcare sector reshapes business and care delivery models to create a collaborative environment and empower patients to get and stay healthy, organisations must work to transition from traditional paper-based and fee-for-service workflows to new technology-backed, patient-centric processes

3:

Healthcare organisations that show the most success with clinical IT adoption have

thoughtfully developed strategies and tactics to support clinician users throughout the

technology transition process.

High quality change management plans help provider organisations realise the

extraordinary possibilities of healthcare IT.

Successful change management programmes focus on assisting clinicians to move

through several stages of ongoing change and engagement.

Change and engagement can be classified into stages: Awareness, Understanding,

Collaboration, Commitment and Advocacy.

To ensure that the change management process is successful, workflows are

streamlined and provider-patient relationships are strengthened; healthcare leaders must

3 Source: Three Components for Successful Change Management, Orion, 26 Jun 2013

http://fhs.mcmaster.ca/cbs/documents/ChangeTransformingHealthcareOrganizationsarticle.pdf

http://www.orionhealth.com/easyblog/changemanagement



assess their specific organisational needs, agree upon clear goals and actively

communicate with all members throughout.

Please refer to the link for full article - Three Components for Successful Change Management, Orion, 26 Jun 2013

Challenges in IT Adoption in Healthcare4

Based on the following conceptual framework, there are three aspects that pertain to the issue of IT adoption in healthcare: (1) organisations, (2) human, and (3) technology. IT impacts not only the IT department but every area or department in the organisation, since IT is responsible for the integration of information across the entire organisation.

4 Source: Managing ICT in healthcare organisation, University of Wollongong Dubai, 2010



http://ro.uow.edu.au/cgi/viewcontent.cgi?article=1241&context=dubaipapers



The NHS Change Model

The NHS Change Model was created to support the NHS to adopt a shared approach to leading change and transformation. It was designed to understand what needs to change and why to make the NHS the best quality service for the best value, and be sustainable over time. The NHS Change Model brings together collective improvement knowledge and experience from across the NHS. It has been developed with hundreds of senior leaders, clinicians, commissioners, providers and improvement activists who want to get involved in building the energy for change across the NHS by adopting a systematic and sustainable approach to improving quality of care. It was developed by:

Looking at best practice from across the world;

Learning from what’s gone before to create a common approach;

Consulting with people in the service – using their ideas, experiences and words;

Building on all we’ve learned about large scale change;

Sharing progress – descriptors and design;

Making sense at every level.



The 8 components are shown above with the relevant questions the NHS is asking.

The Relevance of Communication in Change and Adoption

There have been many studies conducted that highlight the importance of communication when undertaking or delivering a major change initiative. When organisations do not first assess the impact of change on stakeholders, or engage them to uncover political landmines, poor results will follow. It is important to identify stakeholders who will need to embrace change so that your project can deliver the business and clinical outcomes you have set out to achieve. Understanding your audience enables you to plan for the organisational change activities and, more importantly, gain often forgotten input from them. Communications can be tailored to ensure that those impacted are fully informed and not surprised, because you have anticipated their potential reactions, solicited their input and addressed their concerns. Informed and engaged stakeholders are more likely to positively contribute to the project, resulting in more successful business outcomes and adoption. Communication is critical and must start at the time of project inception, continuing post implementation to ensure that new behaviors and ways to work are ingrained.



Organisations are usually very good at top-down, directive communications. While this "telling" style creates an imperative for change, it fails to provide sufficient motivation for others who are needed to achieve true organisational change, and poses a challenge for programme managers. Telling is only part of the equation, and if you stop here, your programme will likely end up being one of the 70% of transformation efforts that fail. Organisations must have, as a key element, a 360-degree mechanism that enables and encourages feedback to flow from the organisation upward. Programme managers must determine if the "do-it people" understand the strategic message and have the necessary context to deliver results. The suggested post-implementation communication is suggested for approximately 3 to 6 months, depending on the magnitude of the change and the number of stakeholders involved.

The Communications Cascade

Psychology and Change

Analyst: Elise Olding

Change is all about psychology. You can’t manage change or make employees change. You can arm them with the information they need to help themselves to make the changes and guide the journey. People are not resistant to change, they fear the unknown and not having a choice in the change. An effective organisational change plan with good communication can go a long way to reduce threats, stress and squelch rumors which will grow in the absence of effective communication. It will also invite engagement and participation so employees feel they have a choice – a key component of enabling one to change. Success stories are also vital as part of the change strategy. They will highlight successes of others who may be further along on the change journey – enabling the slower adopters to see that change is possible, helping them to “prime” their brains for change (and able to create new neural pathways which are new behaviors and habits).



Final Thoughts

Organisations are complex entities that require constant nurturing and development in order to sustain growth and achieve maturity. Effective communication and organisation change management practices and policies are essential to ensuring that organisations continue their development and are able to build and deliver on their strategies for growth. In order to establish a vision and direction in which to lead an organisation, leaders need to be able to influence a company’s strategy as well as make sound decisions. The research outlined in this paper will help to further a leader’s understanding of the decision making process and create awareness as to the cognitive functions, processes, models and styles associated with building influence and strategy to affect change within an organisation. By increasing their understanding of the functions of the change management process, leaders will enhance their own level of awareness with respect to the decision making process, end user acceptance, and the impact of change to the organisation’s stakeholder community. This awareness will help them to better identify opportunities for growth and recognise the potential impacts to the organisation and its communities during an evaluation process so that appropriate IT strategies can be identified and deployed. This increased understanding of the change management process will provide leaders with the aptitude to approach the process with enlightened meaning, and it will guide them in implementing the most appropriate decision model and risk mitigation plan for a particular situation. By selecting the most appropriate decision model, leaders will be able to maximise their ability to influence change in an organisation’s strategy development and implementation process. Thoroughly understanding the methods and mechanics of each model will be indispensable to leaders in helping them to position their ideas and alternatives, and it will positively impact their ability to address organisational IT decisions with a strategic approach that is characterised by a heightened level of consciousness and adoption.

Recommended Reading

Some documents may not be available as part of your current Gartner subscription.

"Using a Communications Cascade to Align Programme Execution With Strategy" G00233955

"Healthcare Delivery Organization CIOs Need Strong Change Management Skills to Succeed" G00250436

"Know the Top Five Reasons Why New Change Management Implementations Fail and How to Avoid Failure" G00250015

"Leadership Development Module 5, Chapter 8: Tools and Techniques for Organizational Change Management" G00169919

"Leadership Development Module 5, Chapter 2: The Art and Science of Organizational Change Management" G00169137

Acronym Key and Glossary Terms

HDO Healthcare delivery organisation

Evidence

In preparing this document, Gartner used a combination of secondary research, industry research and academic publications to create a map of major business and technology trends in healthcare IT.



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