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Organization of Healthcare: Organization of Healthcare: The Art and Science of The Art and Science of
Managing ChangeManaging ChangeIPC3 Learning Session IIIPC3 Learning Session II
Denver, ColoradoDenver, ColoradoApril 2011April 2011
Roger ChaufournierRoger ChaufournierAnn LewisAnn Lewis
Objectives
• Participants will understand the human and social factors of change
• Participants will understand change models and tools to manage change
• Participants will be able to link the change and care models used in the Collaborative as resources to facilitate organizational change
Overview
• Individual Change vs. System Change• System Change vs. Diffusion of Innovation• The change process• The diffusion of change• Spread• Using Data to drive change• Coaching for change
““There is Nothing So There is Nothing So Practical as a Good Practical as a Good
Theory!”Theory!”Kurt LewinKurt Lewin
Deming’s Concept of Profound Knowledge
"One need not be eminent in any part of profound knowledge in order to
understand it and to apply it. The various segments of the system of profound knowledge cannot be separated. They interact with each other. For example knowledge about psychology is incomplete without knowledge of variation."
"The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.“
Source: Jerry Langley, Associates in Process Improvement
APPRECIATION OF A SYSTEM
PSYCHOLOGY
UNDERSTANDINGVARIATION
THEORY OFKNOWLEDGE
Deming’s Concept of Profound Knowledge
"One need not be eminent in any partof profound knowledge in order tounderstand it and to apply it. Thevarious segments of the system ofprofound knowledge cannot beseparated. They interact with eachother. For example knowledge aboutpsychology is incomplete withoutknowledge of variation."
"The system of profound knowledgeprovides a lens. It provides a new mapof theory by which to understand andoptimize our organizations.“
Source: Jerry Langley, Associates inProcess Improvement
APPRECIATION OF A SYSTEM
PSYCHOLOGY
UNDERSTANDINGVARIATION
THEORY OFKNOWLEDGE
The Process of ChangeThe Process of Change
Individuals and Change
• Pre-Contemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
• SustainSource: Prochaska and DiClemente
What is to be Changed?
• Processes
• Behavior
Assessment of Change
• Quantitative Data– Measures
• Qualitative Observations– Observed Behavior Changes– Changed Beliefs, Attitudes, Values
We need them all to claim real change
Is There a General Theory of Change?
• Yes, if we build on Kurt Lewin’s social psychological theories of how all systems are in a state of “Quasi-stationary Equilibrium” based on multiple driving and restraining forces.
• What then are the elements and mechanisms of change?
The Process of ChangeLewin’s Model
Unfreezing
New Learning
Refreezing
Disproving current beliefsCreating a tension for change
Need new tools and methods
ReinforcementRecognition
The Process of ChangeLewin’s Model
Unfreezing
New Learning
Refreezing
Disproving current beliefsCreating a tension for change
Need new tools and methods
ReinforcementRecognition
Key Elements of Any Change
• Disconfirmation– Survival Anxiety/Guilt (SA)
• Proposed New Direction/Behavior– Learning Anxiety (LA)
• Difficulty of Unlearning • Fear of New Learning
• Resistance to Change
Edgar Schein, PhD, Sloan Fellows Professor of Management Emeritus and Senior Lecturer, Sloan School
Disconfirmation
• Any information that something is not happening in the way we expect or want– Produces motivation to change, usually felt
as Survival Anxiety or Guilt
• What are some examples of ways leadership can provide “disconfirmation”?
Proposed new direction
• The recognition of what we might have to do to solve the problem, to make the change produces Learning Anxiety
• We realize that the new behavior, attitude, value etc. wanted of us will be potentially painful and costly, especially if we have to unlearn the present behavior that we are used to.
Resistance to Change
• Is the result of…– Fear of period of incompetence
– Fear of loss of power/job/role
– Fear of loss of group membership
– Fear of loss of personal identity
– Your thoughts……
The Path to New Behavior
• Survival Anxiety must be greater than Learning Anxiety
• Increasing Survival Anxiety increases resistance
• Therefore, the key is to REDUCE LEARNING ANXIETY– By providing Psychological Safety for
Unlearning and New Learning
How to Provide Psychological Safety
• Provide a compelling positive vision–New behavior desired–Compelling reasons for new
behavior
• This is a Leadership role: paint the future vision!
Providing Psychological Safety
• Involve the learner in the learning process and provide choices on how to learn– This becomes a coaching role
How to Provide Psychological Safety
• Insure that incentive, reward and discipline processes are congruent with desired new behavior– Discussion: ideas and examples
• Provide resources for managing the unlearning and new learning– Time– Training/Coaching/Feedback– Role Models– Practice fields and opportunities (PDSAs!)– Support Groups
The Mechanism of Change
• New Behavior
• New reinforcements and rewards
• Cognitive Redefinition– New Semantics– New Adaptation Levels– New Judgment Criteria (Measurement)
Implications
• All changes undergo some version of this process if we study them carefully
• Change programs that fail are missing one or more of the elements described
• How the elements are managed is a very local phenomenon
• Change is a process that requires process skills
Spreading Innovation vs. Spreading Innovation vs. ChangeChange
Laggards
Innovators
Everett Rogers Diffusion of Innovation
X
Early Adopters
Early LateMajority Majority
8
Late Majority
Early Majority
Early Adopters
Innovators
Everett RogersDiffusion of Innovation
2% 13% 35% 35% 15%
Traditionalists
Rogers E. Diffusion of Innovations. New York: The Free Press, 2004.
Malcolm Gladwell
• The Tipping Point
– Connectors vs.
– Mavens
Leading ChangeLeading Change
Tight-Loose-Tight
• Tight on vision and direction
• Loose on how to get there
• Tight on monitoring and feedback
Changing SystemsChanging Systems
Different Approaches to System Different Approaches to System ChangeChange
Use Change Models
Examples of change models:
• PDSA- Continuous improvement methods
• The Care Model
• The Learning Model
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
PlanAct
DoStudy
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Material is from The Improvement Guide, Second Edition, Jossey-Bass, 2009
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Material is from The Improvement Guide, Second Edition, Jossey-Bass, 2009
Repeated Use of the Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S DD S
P ADATA
BreakthroughResults
Theories, hunches,
& best practices
A P
S D
A P
S D
A P
S D
A P
S D
Sequential Building of Knowledge: Include a Wide Range of Conditions in the Sequence of Tests
Material is from The Improvement Guide, Second Edition, Jossey-Bass, 2009
Change Concepts
• The change concept-Rainforest Café
• Lens to view the world
• Lean Thinking examples
Lean Thinking: Waste
Overproduction Producing more than neededProducing faster than needed
Waiting Time when a worker is idle
Transportation Any movement of material or information notessential for the process
Processing Operations that in reality do nothing
Inventory Anything more than immediate needs
Motion Motion of man or machine that is unnecessary
Correction Rework and inspection
Lean Thinking: Waste
Overproduction Producing more than neededProducing faster than needed
Waiting Time when a worker is idle
Transportation Any movement of material or information notessential for the process
Processing Operations that in reality do nothing
Inventory Anything more than immediate needs
Motion Motion of man or machine that is unnecessary
Correction Rework and inspection
What You Need to Do to Drive Change
• Prepare the environment-create the tension for change
• Use the new models to provide your team with the tools and new methods
• Reinforce by creating a more attractive future
• Use measurement to reinforce
• Continue the “visioning” process to connect the dots
Measurement Feedback Is Critical to the Change Process
Unreconciled Meds
0
10
20
30
40
50
60
70
Per
cent Upper Limit
No Lower Limit
Dashboards
KQI_ending-063004.pdf
4/22/2011
Dashboards
© 19 99 Arthu r Ande rsen. All rig hts re served . Informed decisions through the use of appropriate and timely data
KQI_ending-063004.pdf
Source: Richard Davis, Johns Hopkins Business of Medicine Program
Summary
• Understand the human and social aspects of change
• Use disciplined methods to drive performance
• Measurement and feedback are critical to the change process
• Plan for the spread and sustainability of your work
