Managing Change:Managing Change:Tools and TechniquesTools and Techniques

Vijay GanjuVijay GanjuDirector, Center for Mental Health Quality & Director, Center for Mental Health Quality &

AccountabilityAccountabilityNASMHPD Research Institute, Inc.NASMHPD Research Institute, Inc.

703.739.9333 ext. 132703.739.9333 ext. 132vijay.ganju@nri-inc.orgvijay.ganju@nri-inc.org

Lessons from Mental Health Systems Change Lessons from Mental Health Systems Change and Transformation Initiativesand Transformation Initiatives

Presentation at the CMS Conference:

New Freedom Initiative Access to Community Living Transforming Systems: Keys to Success

Baltimore, Maryland April 10-12, 2006

Mental Health SystemMental Health System

Recovery Recovery //

ResiliencResiliencee

Mental Health / HealthMental Health / Health

Consumer / Consumer / Family Family DrivenDriven

EliminatEliminate e DisparitiDisparitieses

Early InterventionEarly Intervention

Evidence-Based Evidence-Based Practices Practices Training / Training / ResearchResearch

Technology Technology & & InformatioInformationn

The Quality PyramidThe Quality Pyramid

Performance MeasurementPerformance Measurement

SYSTEM OUTCOMESSYSTEM OUTCOMES

Evidence-Based Evidence-Based PracticesPractices

Quality Quality ImprovementImprovement

Evidence-Based Practices:Evidence-Based Practices:Some DefinitionsSome Definitions

An evidence-based practice is considered to be any practice that has An evidence-based practice is considered to be any practice that has been established as effective through scientific research according to been established as effective through scientific research according to a set of explicit criteria a set of explicit criteria (Drake et al, 2001)(Drake et al, 2001)..

Evidence-based treatment is the use of treatments for which there is Evidence-based treatment is the use of treatments for which there is sufficiently persuasive evidence to support their effectiveness in sufficiently persuasive evidence to support their effectiveness in attaining desired outcomes attaining desired outcomes (Rosen and Proctor, 2002)(Rosen and Proctor, 2002)..

Evidence-based practice is an approach to healthcare wherein health Evidence-based practice is an approach to healthcare wherein health professionals use the best evidence possible to make clinical professionals use the best evidence possible to make clinical decisions for individual patients (McKibbon, 1998).decisions for individual patients (McKibbon, 1998).

Evidence-based practice is the integration of best research evidence Evidence-based practice is the integration of best research evidence with clinical expertise and patient values with clinical expertise and patient values (Institute of Medicine, 2001)(Institute of Medicine, 2001)..

Number of States Implementing Number of States Implementing EBPs: FY 2003EBPs: FY 2003

5

6

9

12

9

6

1

10

5

11

22

3

6

7

8

12

16

18

25

26

19

6

0 5 10 15 20 25 30

Other Adult EBPs

Medication Algorithm (Bi-Polar)

Other Child EBPs

Therapeutic Foster Care

Medication Algorithm (Schizophrenia)

Self Management

MST for Kids

Family Psychoeducation

Integrated MH/AOD

Assertive Community Treatment

Supported Employment

Implementing Parts of State

Implementing Statewide

N = 47

Implementation of Evidence-Based Implementation of Evidence-Based Practices for Children, 2003Practices for Children, 2003

12

2

7

16

0 2 4 6 8 10 12 14 16 18

Therapeutic FosterCare

MST for Kids

Implementing Parts of State

Implementing Statewide

N = 47

Moving Forward withMoving Forward withEvidence-Based ServicesEvidence-Based Services

Federal InitiativesFederal Initiatives– SAMHSA National EBP Demonstration SAMHSA National EBP Demonstration

ProjectProject– NIMH/SAMHSA Planning GrantsNIMH/SAMHSA Planning Grants– SAMHSA/CMHS EBP Implementation GrantsSAMHSA/CMHS EBP Implementation Grants– SAMHSA National Registry for Effective SAMHSA National Registry for Effective

PracticesPractices– HRSA’s Federal Qualified Health CentersHRSA’s Federal Qualified Health Centers– NRI Center for Mental Health Quality and NRI Center for Mental Health Quality and

AccountabilityAccountability

Preliminary Lessons from Preliminary Lessons from Toolkit ProjectToolkit Project

Organizational development Organizational development component is criticalcomponent is criticalOutcomes must be integrated into Outcomes must be integrated into EBP implementationEBP implementationCultural competence issues need to Cultural competence issues need to be addressedbe addressedOngoing consultation was a great Ongoing consultation was a great facilitatorfacilitator

Lessons Learned from “Toolkit” Lessons Learned from “Toolkit” Trainers, Consultants and EvaluatorsTrainers, Consultants and Evaluators

Desired Consumer Outcomes

Practitioners

Consumer

Family

Agency Implementing

EBP

Steering Committee

State or County Mental Health

Authority

Strategies for Consumer/Family

Strategies for the SMHAStrategies for the

Agencies

Strategies for the Steering Committee

Training/TA Strategies for Practitioners

Factors Affecting State-Wide EBP Factors Affecting State-Wide EBP ImplementationImplementation

System leadershipSystem leadershipOrganized culture/consensusOrganized culture/consensusIT capacity/outcomes measurementIT capacity/outcomes measurementPolicies/proceduresPolicies/proceduresIntegration with performance/quality Integration with performance/quality improvementimprovementHuman resource capacity/trainingHuman resource capacity/trainingFunding methodsFunding methods

Statewide Implementation Statewide Implementation of EBPsof EBPs

Demonstration Demonstration projectsprojects– TrainingTraining– SupportsSupports

Organizational Organizational assessmentassessment

Standards/ Standards/ regulationsregulations

Financing/fiscal Financing/fiscal incentivesincentives

Training and Training and supportsupport

Contractual Contractual requirementsrequirements

Intensive Intensive technical technical assistance / assistance / supportsupport

Early Adopters

(“enthusiasts”)

Late Adopters Non-Adopters

PractitionerPractitioner•KnowledgeKnowledge•Perceived Perceived advantageadvantage•FeedbackFeedback

Consumer/Family Consumer/Family MemberMember•ChoiceChoice•CommitmentCommitment•Perceived advantagePerceived advantage

EBP•CostCost•CompatibilityCompatibility•PayoffsPayoffs•ComplexityComplexity

Provider OrganizationProvider Organization

Public Mental Health AuthorityPublic Mental Health Authority

•LeadershipLeadership•PoliciesPolicies•RegulationRegulation•ResourcesResources

•LeadershipLeadership•Organizational CultureOrganizational Culture•Administrative SupportAdministrative Support•Information TechnologyInformation Technology

Lessons Learned from National EBP Lessons Learned from National EBP Demonstration ProjectDemonstration Project

INFORMATION TECHNOLOGYImplementation Leading to Transformation

System Leadership/ Implementation Plan

Policies and Procedures

Organizational Structures

Funding Methods

Human Resource Capacity

Quality/ Performance Improvement

Causal ConnectionsCausal Connections

RecoveryInfrastructure

Goal:• Interaction with Provider

• Evidence- based and “best” practices

Framework for Technical Assistance Content Needs: Developing Infrastructure for EBPs (9/03)

System Leadership –Implementation PlanLong term goal to transform system & sustainVision/mission/values in alignmentBridge to other agencies & coalition of partnersSelect & empower project leadersPromote consensus building/buy-inPriority settingScan horizon and adapting practice to meet needsMarketing and PRPromote dissemination

Organizational Structures

Interorganizational collaboration Formalize role of advocates/stakeholders in decision-makingTransformation of MHA/local MHASeamless system of care‘Center of Excellence’ modelState readiness – ability to monitorEngage ‘guilds’ in reformEngage local authorityIncorporate EBP initiative in state plan

Policies & Procedures

Review all P&P with an eye to “barrier busting”Regulations must define and support EBPLicense/certification – individual and agencyFamily/consumer involvement in P&P developmentFocus on process/quality of care – not just ‘paper’Align with SAMHSA matrixAuditors to be EBP knowledgeableLMHA and state MHA needs to be in ‘sync’

Funding MethodsIdentify and shift resourcesMust think of all EBPs funded in common wayReliable cost modelingMedicaid cover servicesLobbying: mental health is not optionalFiscal incentivesTie fidelity/outcome to $Define core expectationsExplicit funding for supervisor/trainingBudget models$ to transform systemAcknowledge productivity costs offset for initial training

Performance Improvement

Ongoing fidelity measurement/ refinement-key elements?Who does it-who gets information-for what purpose?Quantitative & qualitative measuresConsumer-based outcomes monitoring in all careOngoing avail. of TAAssess GOI at state level as well as localStakeholder involvement in performance improvement data loop

Human Resource Capacity

Develop internal capacity to train state/local agencyOut source training to state university & community collegesSelect trainers with creditability in modelSupervision: practice- specific emphasizing data/outcomesResources for competency-based managementState sponsored program to train consumers & families to be MH professionals

Information Technology Assess current IT infrastructure/ web access; state/agency/local integration; standards for IT; use IT as a learning tool; assist local agency obtain technology; high-level system champion

Transformation Logic ModelTransformation Logic ModelOutcomes - Impact

TargetSystemsOutputsActivitiesInputsSituation

•Inefficient use of resources•Lack of information•Inade-quate value orientation•Ineffective-ness regarding outcomes

•Stakehold-ers•Staff•Resources

•Leadership commitment•Develop-ment of new structures•Resource development reallocation•Information/ technology development

•New cadre of leaders•Restructur-ing•Availability of new information and technologi-cal capacities

•Internal•External

Short-Term•Leadership development•Training capacity•Information (services, money, competen-cies)•Innovation opportunities•Policy development/changes•Interagency coordination

Intermediate•Multi-stakeholder engagement/consensus•Identifica-tion/flexibility of resources•Increased competenc-ies•New models /protocols•New structural arrange-ments

Long-Term•Consumer outcomes•Population outcomes (e.g. anti-stigma)•Resource efficiencies•Disparity reduction

Data•Leadership capacity•Policy changes•Workforce competencies availability•Use of data•Values orientation•Resources available

Data•Consensus/ engagement assessment•Resource allocation/ development•Contract expectations

Data•NOMs•Recovery/ resilience•Community indicators•Financial indicators

•Technology

•Fragmenta-tion•Stigma•Lack of EBPs•Lack of technology application

•SMHA•CMHAs•Other agencies

NRI Conference on Change NRI Conference on Change Management in Mental Health SystemsManagement in Mental Health Systems

Agenda:Agenda:

June 22-24, 2005, Albuquerque, New MexicoJune 22-24, 2005, Albuquerque, New Mexico

Change Management: The ScienceChange Management: The Science McCracken, AaronsMcCracken, Aarons

Tools for ChangeTools for Change McCrackenMcCracken

FundingFunding Clark, ArmstrongClark, Armstrong

Workforce Development / TrainingWorkforce Development / Training Morris, KanaryMorris, Kanary

Supporting Creativity / InnovationSupporting Creativity / Innovation Mulkern, HillsMulkern, Hills

Implementation Research FindingsImplementation Research Findings Blasé Blasé

Mental Health Change ModelsMental Health Change Models Hudgens, Reynolds, et al.Hudgens, Reynolds, et al.

Leadership Development Leadership Development Power, McCrackenPower, McCracken

Cultural CompetenceCultural Competence Ganju, IsaacsGanju, Isaacs

Use of EvaluationUse of Evaluation Hodges, WotringHodges, Wotring

Definition of a Change ProjectDefinition of a Change Project

Cuts across organizational boundariesCuts across organizational boundaries

Has defined start and completion datesHas defined start and completion dates

Generates observable, measurable resultsGenerates observable, measurable results

Requires significant change in both Requires significant change in both attitudes and the way work is performedattitudes and the way work is performed

Creates both active and passive Creates both active and passive resistanceresistance

Requires a dedicated change teamRequires a dedicated change team

Role of Change ManagementRole of Change Management

TrainingTraining– Explains objectives and provides information on Explains objectives and provides information on

desired activities and outcomes.desired activities and outcomes.

Project ManagementProject Management– Involves tracking, monitoring, measuring, and Involves tracking, monitoring, measuring, and

reporting. Establishes performance standards and reporting. Establishes performance standards and metrics; provides objective measures of progress metrics; provides objective measures of progress against plan; anticipates obstacles and recommends against plan; anticipates obstacles and recommends corrective action.corrective action.

Change Management Change Management – Intensive, field-based exercise in changing behavior. Intensive, field-based exercise in changing behavior.

Focuses on communicating the initiative; creating Focuses on communicating the initiative; creating alignment; identifying and overcoming resistance; alignment; identifying and overcoming resistance; embedding change into the organizational culture.embedding change into the organizational culture.

Organizational Culture of a Mental Organizational Culture of a Mental Health SystemHealth System

Solidarity

Soc

iabi

lity Networked Communal

Fragmented Focused

Change Tools and Techniques Change Tools and Techniques IndexIndex

ToolTool Page NumberPage Number Backwards ImagingBackwards Imaging 1010

Sponsorship AlignmentSponsorship Alignment 1111

Team Competency/InfluenceTeam Competency/Influence 1212

Is/Is NotIs/Is Not 1616

Threat/Opportunity MatrixThreat/Opportunity Matrix 1717

Elevator SpeechElevator Speech 1919

Attitude ChartingAttitude Charting 2222

Stakeholder Analysis/InfluenceStakeholder Analysis/Influence 2323

Payoff MatrixPayoff Matrix 3030

Launching the ProductLaunching the Product

Desired OutcomeDesired Outcome– Well-defined project that is doable, yet Well-defined project that is doable, yet

challengingchallenging– Clear agreement and commitment from Clear agreement and commitment from

sponsorsponsor– A team with competency, influence, and A team with competency, influence, and

representation that has been prepared for the representation that has been prepared for the challengechallenge

Backwards ImagingBackwards Imaging

Imagine a point in the future when your project Imagine a point in the future when your project or initiative is very successfulor initiative is very successfulFind words to describe what you see, hear, feel Find words to describe what you see, hear, feel as you observe the key constituents functioning as you observe the key constituents functioning in the new, changed environmentin the new, changed environmentDiscuss and reach consensus with your team Discuss and reach consensus with your team members on what this new, improved future will members on what this new, improved future will look likelook likeAs a team, develop the obstacles you will likely As a team, develop the obstacles you will likely have encountered and overcome during the have encountered and overcome during the impelmentationimpelmentation

Sponsor Discussion –Sponsor Discussion –Typical QuestionsTypical Questions

Describe the initiative in your own words.Describe the initiative in your own words.Why is this initiative important?Why is this initiative important?What will success look like to you?What will success look like to you?What is outside the scope of this initiative?What is outside the scope of this initiative?What else is on your agenda – where does this project fit?What else is on your agenda – where does this project fit?Who are the key players and how do they view this initiative?Who are the key players and how do they view this initiative?What excites you the most about this initiative?What excites you the most about this initiative?What concerns you the most about this initiative?What concerns you the most about this initiative?What do you think our biggest challenge will be?What do you think our biggest challenge will be?Who should be on the core working team, and how can we get their Who should be on the core working team, and how can we get their commitment?commitment?What role do you see yourself playing?What role do you see yourself playing?How involved do you want to be?How involved do you want to be?What key decisions do you want to make or be involved in?What key decisions do you want to make or be involved in?Do you have any words of advice or suggestions for me in the Do you have any words of advice or suggestions for me in the meantime?meantime?

Tool: Team Competency/InfluenceTool: Team Competency/InfluenceTool: Team Competency – A useful tool to help the team determine if they have the right team members relative to the competencies and influence necessary to execute the initiative

Co

mp

eten

cy/In

flu

ence

Team Member

H = High M=Medium L=Low

Uses: This exercise is particularly useful for two situations: (1) when initially forming the team, it can help the sponsor and/or team leader determine who should be on the team; (2) if the team is already in place and they may be struggling due to lack of ability to do certain facets of the initiative, this tool can be used to determine if adjustments in team members are warranted.

Timing: Before starting the initiative and/or anytime during the initiative when the team seems to be struggling due to lack of competency or influence. This often occurs when a new phase of the initiative begins.

Team Start-Up:Team Start-Up:Levels/Types of DecisionsLevels/Types of Decisions

A.A. I’ve made the decision. Here’s what it is and I’ve made the decision. Here’s what it is and why I had to make it.why I had to make it.

B.B. I’m leaning strongly in this direction. Tell me I’m leaning strongly in this direction. Tell me what the team thinks, then I’ll make the what the team thinks, then I’ll make the decision (your input, my decision).decision (your input, my decision).

C.C. We need more information before the decision We need more information before the decision can be made. Help us see all sides of the can be made. Help us see all sides of the issue, then issue, then we’ll we’ll make the decision based on make the decision based on consensus.consensus.

D.D. I’m willing to go with whatever the team I’m willing to go with whatever the team decides on. Let me know your decision and I’ll decides on. Let me know your decision and I’ll support it.support it.

Team Start-Up: ConsensusTeam Start-Up: Consensus

Consensus is reached when everyone can Consensus is reached when everyone can state:state:– I believe that you understand my point of viewI believe that you understand my point of view– I believe that I understand your point of viewI believe that I understand your point of view– Even though this may not be the way I would Even though this may not be the way I would

decide things by myself, decide things by myself, I will support the I will support the decision 100%decision 100% because it was arrived at in an because it was arrived at in an open and fair manneropen and fair manner

Creating Organizational AlignmentCreating Organizational Alignment

Desired Outcome:Desired Outcome:– A clearly defined project scopeA clearly defined project scope– A sense of urgency and commitment among A sense of urgency and commitment among

key stakeholderskey stakeholders– Clear, consistent, organization-wide Clear, consistent, organization-wide

communication of the projectcommunication of the project

Is / Is NotIs / Is Not

IsIs________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

Is NotIs Not________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

________________________________________________

Helps a team to think through the project by more clearly defining what is inside and outside its scope. Often the “is not” portion of the discussion is more important than the “is” part – that’s where the disagreement usually lies. It can be used during the definition phase as well as later when the team is stuck and needs to be refreshed on the projects boundaries.

Tool: Threat/Opportunity MatrixTool: Threat/Opportunity Matrix

PainPain

GainGain

1 3

2 4

Tool: “Best Practice” organizations know how to frame a change initiative as more than a short-term threat. They work to find ways to frame it as both a threat and an opportunity. By doing so, they are able to create a sense of urgency and commitment among key stakeholders.

Threat OpportunityS

ho

rt T

erm

Lo

ng

Ter

m

Uses and Timing: Building the case for change is one of the most important tasks of the team. This simple tool helps it to redirect the initial focus on short-term threats and generates a clear sense of why the initiative is essential.

Example: Threat/OpportunityExample: Threat/Opportunity

Will create uncertainty and staff anxietyWill create uncertainty and staff anxiety

Physicians will resist any changePhysicians will resist any change

Productivity will dropProductivity will drop

Won’t be able to fund other projectsWon’t be able to fund other projects

Patients are likely to be confusedPatients are likely to be confused

Overhead burden may riseOverhead burden may rise

Control our futureControl our future

Shake up the organizationShake up the organization

Won’t achieve our objectiveWon’t achieve our objective

Will have to work with fewer staffWill have to work with fewer staff

More flexibility/agilityMore flexibility/agility

Improved patient satisfactionImproved patient satisfaction

Able to provide measurably higher Able to provide measurably higher quality carequality care

Increased capacity through improved Increased capacity through improved asset utilizationasset utilization

Able to recruit and retain better Able to recruit and retain better administrative and clinical staffadministrative and clinical staff

Physicians will be more productivePhysicians will be more productive

Threat Opportunity

Sh

ort

Ter

mL

on

g T

erm

Physician Group Initiative

Measuring and Overcoming Measuring and Overcoming ResistanceResistance

Desired Outcome:Desired Outcome:– Identification of sources of both active and Identification of sources of both active and

passive resistancepassive resistance– An effective strategy to influence key An effective strategy to influence key

stakeholdersstakeholders

Resistance to Change:Resistance to Change:What Does it Look Like?What Does it Look Like?

Resistance to change is typically divided Resistance to change is typically divided into two distinct categories:into two distinct categories:– Active resistanceActive resistance– Passive resistancePassive resistance

Attitude ChartingAttitude Charting

Innovators (5%)

Early Adopters (10%)

Early Majority (35%)

Late Majority (35%)

Resistors (15%)

Stakeholder Analysis

Steps: 1. Plot where individuals currently are with regard to desired change. (= current) 2. Plot where individuals need to be (X=desired) in order to successfully accomplish desired change-identify gaps between current and desired 3. Indicate how individuals are linked to each other, draw lines to indicate an influence link using an arrow to indicate who influences whom 4. Plan action steps for closing gaps

Names StronglyAgainst

Moderately Against Neutral

ModeratelySupportive

StronglySupportive

Example #1: Stakeholder Analysis

Chief of Surgery

Dr. Bobbitt

Dr. Clampett

CEO

Chief of Staff

Medical Director

Chief of Medicine

CFO

Asst. Med. Director

Chief Administrator

Dr. Barnes

Chief of Nursing

Sharon Reams, RN

StronglyAgainst

ModeratelyAgainst

Neutral ModeratelySupportive

StronglySupportive

Example #2: Stakeholder Analysis

Chief of Surgery

Dr. Bobbitt

Dr. Clampett

CEO

Chief of Staff

Medical Director

Chief of Medicine

CFO

Asst. Med. Director

Chief Administrator

Dr. Barnes

Chief of Nursing

Sharon Reams, RN

Against Moderately Against Neutral

ModeratelySupportive

StronglySupportive

Example #3: Stakeholder Analysis

Chief of Surgery

Dr. Bobbitt

Dr. Clampett

CEO

Chief of Staff

Medical Director

Chief of Medicine

CFO

Asst. Med. Director

Chief Administrator

Dr. Barnes

Chief of Nursing

Sharon Reams, RN

Against Moderately Against Neutral

ModeratelySupportive

StronglySupportive

Some ExamplesSome Examples

New Mexico Purchasing CollaborativeNew Mexico Purchasing Collaborative

Oklahoma Department of Mental HealthOklahoma Department of Mental Health

Washtenaw Community Health Washtenaw Community Health Organization (Michigan)Organization (Michigan)

Licking and Knox Counties Mental Health Licking and Knox Counties Mental Health Services (Ohio)Services (Ohio)

AustraliaAustralia

“They always say time changes things, but you actually have to change them yourself.”

~Andy Warhol