Organizational Change

Martin P. Charns, DBADirectorCOLMR

Greenhalgh et al.

• Very comprehensive systematic literature review of diffusion & implementation

• Addresses multiple perspectives• Characteristics of innovation• Process of implementation• Context

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

QUERI Focus

• Largely on the innovation (EBP) & process of implementation

• Less detailed focus to date on organizational context, including history

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

The Innovation

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

Adopter

• Needs• Motivation• Values & goals• Skills• Learning Style• Social networks• Adoption Decision: Stages

– Preadoption– Early use– Established users

Communication & Influence

Diffusion (informal, unplanned)Social networksHomophilyPeer opinionMarketingExpert opinionChampionsBoundary SpannersChange agents

Dissemination (formal, planned)

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

Outer Context

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

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

System Readiness for Innovation

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

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

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

Successful Transformation Beyond Projects

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

• Model is more dynamic

The Detailed Model of Healthcare Transformation

Alig

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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

Healthcare Transformation Model - Overview

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top

to b

otto

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Integration across boundaries

Change over time transformation

The

organization/ system

Impetus to transform

Urgency

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)

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

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

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

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

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

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

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

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

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

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

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

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

Conclusions

• Quality improvement activities that are limited in scope are unlikely to be sustained

• Organizational transformation requires addressing all key model elements

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

Questions & Discussion