palliative care

The Adoption Of Palliative Care: The Engineering of Organizational Change

Endeavor Management

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The Adoption of Palliative Care: The Engineering of Organizational Change

© 2011 Endeavor Management. All Rights Reserved.

Overview Imagine that you have just been named to the faculty of a distinguished medical institution. Further imagine that you have been asked by the Director of the institution to “help us implement palliative care in our institution.” What would you do? How would you do it? With whom would you work? Whom might you avoid? What missteps would you want to avoid?

Hopefully many of the readers of this case will be asked exactly that question; “Can you help us implement palliative care?” The goal of this white paper is to offer a framework for thinking about such an implementation as well as some practical tools that might be used to make such an implementation possible in a relatively short period of time.

Elements of the Framework While most of us spend our time inside a large organization, we usually don’t spend much time thinking about the organization. What is an organization? What is it made of? What do we mean when we talk about “changing the organization?” When we say that we want to implement palliative care in an organization, what does that mean? The following three subject areas can form a framework for envisioning and then changing an organization and how it operates: 1. The Organization as a Mechanical System. A large organization can be thought of as a mechanical system made up of concrete “moving parts” – parts that can be “engineered” (or altered) to cause the organization to function in a different way, like delivering a new service such as palliative care to the institution’s clients. The mechanical parts of an organization that must be engineered for change are:

• Vision ... the organization’s understanding of its mission and future • Processes ... the steps that allow the organization’s work to be done (including the steps associated with palliative care) • Plant/Tools ... the physical assets (including software) the organization uses in its processes • Performance management system ... the organization’s way of attracting and retaining people to work the organization’s processes, including palliative care



2. The Diffusion of Innovation within a Social Organization. Innovations – ideas that are new to an organization – diffuse through an institution in a patterned way over time, with some organization members far more inclined to adopt an innovation like pallia-‐ tive care than others. Organization members might be described in “thirds:”

• first third ... those clearly eager to try the new and innovative • third third ... those clearly reluctant to try the new and innovative • second third ... those “in the middle” who might follow either the first or third third

3. The Role of Leadership in Creating Change in an Organization. Leaders cause things to happen in an organization. Leaders take direct actions on the moving parts of an or-‐ ganization; they influence organization members to enable the organization to make changes like implementing palliative care on an institutional basis. The following section of this case will provide both understanding as well as action steps that can be used to implement, or “engineer,” an innovation like palliative care into an institution in an effective and efficient way. We want to “pull it all together” to illustrate at a very high level how the actions can be used for the real-‐world implementation of palliative care.

Pulling it all Together… A Palliative Care Success Story Take for example, the introduction of palliative care at M D Anderson Cancer Center in Houston. The Chief Executive made the decision to move toward palliative care and hired a leading physician to come to Anderson and “run the show.” Upon arrival, the newly ap-‐ pointed Palliative Care Department Head encountered stiff resistance and many logistical obstacles that were almost impossible to overcome. At the end of the first 18 months, progress in gaining acceptance of palliative care was very slow, and the third-‐third popula-‐ tion of resisters had made themselves heard. The situation was uncomfortable enough for the Department Head to say “that he felt like he had parachuted in behind enemy lines.” In an effort to move the ball, M D Anderson retained the services of a change consultant to work directly with the Department Head and his palliative care team of department member physicians and administrators. The implementation steps taken included the following:

• Instruction of and consultation with the palliative care team in the change concepts that are described in this paper. The Department Head stated that the consultations and training has “opened a window into the world of organizations” that allowed them to better see and understand the actions that he and his team needed to take.



• Decision of the palliative care team to “ignore the third-‐third detractors” and to find and work with “first-‐third” professionals only (i.e., working only with those who were relatively positive and eager to look at palliative care as a treatment alternative).

• Formation of a Palliative Care Steering Team made up of volunteer senior physicians/faculty

members (all of whom were first third)

• Arranging an early meeting/workshop of the Steering Committee to hear directly from the MDACC Chief Executive. The Chief Executive explained to the steering team his reason for moving the institution toward palliative care, his reasons for selecting the Department Head and his vision of palliative care as a legitimate and important treatment modality for the institution.

• These key, friendly members helped establish a vision, mission, and strategic plan of action

and not only provided extremely useful feedback but by the same process they were sold

• This strategic plan was later moved upwards in the administration to con-‐ vince remaining senior management, and a process of continuous monitoring of the level of adoption of palliative care was established.

• The palliative care team and Steering Team worked directly with administrative officers of the

institution to ensure that processes were in place to handle business and scheduling aspects of palliative care.

• With a palliative vision and strategic in place, the Department was able to launch

communication and public relations programs, clinical education sessions, as well as consultations inside and outside the institution. The focus on these programs was initially on the first-‐third. As a result of positive acceptance by the first-‐third, members of the second third began to sign up ... and before long the first two thirds were chiding members of the third-‐third as “being behind the times.”

• The result of this implementation approach was the large growth in referrals to the palliative

care program that have succeeded in fully establishing it as a viable clinical and financial program. Note the rapid rate of palliative care consultations in the chart below.

(insert chart entitled: “The Impact of Palliative Care Services on overall hospital mortality in a comprehensive cancer care center, ”by Bruera, et al.)

• The palliative care initiative has continued to increase in use and popularity, with



consultations continuing to increase, and the number and cost of deaths in intensive care continuing to decline.

Blending the messages from the three framework elements is essential to effective change. The essential message of this white paper, therefore, is for leaders to: 1. take strong, aggressive, visible action ... 2. with/through the “first-‐third” managers and professionals ... 3. to alter the mechanical attributes of the organization that will enact palliative care. In summary, key to the success of the effective and efficient introduction of palliative care will be the continuing partnership between the committed chief executive and leaders in the management cadre. Dedicated action in the engineering framework described in this chapter ... along with huge doses of “blood, sweat, and tears”... should lead to another palliative care success story.



About Endeavor Endeavor Management, is an international management consulting firm that collaboratively works with their clients to achieve greater value from their transformational business initiatives. Endeavor serves as a catalyst by providing pragmatic methodologies and industry expertise in Transformational Strategies, Operational Excellence, Organizational Effectiveness, and Transformational Leadership. Our clients include those responsible for: • Business Strategy • Marketing and Brand Strategy • Operations • Technology Deployment • Strategic Human Capital • Corporate Finance The firm’s 40 year heritage has produced a substantial portfolio of proven methodologies, deep operational insight and broad industry experience. This experience enables our team to quickly understand the dynamics of client companies and markets. Endeavor’s clients span the globe and are typically leaders in their industry. Gelb Consulting Group, a wholly owned subsidiary, monitors organizational performance and designs winning marketing strategies. Gelb helps organizations focus their marketing initiatives by fully understanding customer needs through proven strategic frameworks to guide marketing strategies, build trusted brands, deliver exceptional experiences and launch new products. Our websites: www.endeavormgmt.com www.gelbconsulting.com www.gulfresearch.com