Change Management 2018: The New Rules

For an industry inundated in change, progress has been hard to find.

This article first appeared in the January/February 2018 issue of HealthLeaders magazine.

The narrative goes something like this: Scathing IOM report comes out in 1999, healthcare industry enthusiastically embraces improvement as a core part of its mission, and the industry gets better.

If only it were that simple.

The IOM report was one among several heavy levers (PPACA, meaningful use, ICD-10) that pushed hospitals into a new age of relentless improvement.

CEOs started to use words such as "Kaizen" and "value stream analysis." Internal and external quality measures multiplied exponentially.

Today's hospitals are an expanding web of concurrent improvement programs, all supposedly mapped to a single big idea to move the organization forward.

Change management has become so big, however, that leaders are beginning to question whether they are leading change, or if it's leading them.

Consider the seminal statistic: mortality. A 2016 study in the BMJ set medical errors as the third-leading cause of death at an estimated 250,000 per year in the U.S., significant growth from the 98,000 estimated in the IOM report almost two decades previous.

The counterargument to those statistics is that healthcare delivery has increased in scope and complexity since then, and that many processes within health systems have indeed chased down certain types of errors significantly (e.g., central line–associated bloodstream infections).

The root cause of this organizational disease is not effort, but skill, specifically change management. Hospitals have ramped up improvement projects on a massive scale that is potentially unfocused and unmanageable.

But healthcare leaders have absorbed the hard-won lessons from two decades of constant improvement.

Change management is now a blend of culture, process, investment, and a lot of pushing. If improvement is a collection of lessons learned, here are a few:

Know the difference between tools and values

An organization that tries to change merely by buying tools may see some results, but then must constantly "retool" when people or priorities change.

"We created a process that works today, but isn't going to work tomorrow, and working tomorrow is the key to sustainability."

—Kurt Barwis, president and CEO, Bristol Hospital

An organization that only approaches change from a soft cultural perspective may lack the process discipline to translate values into outcomes.

Jeff Thompson, MD, executive adviser and chief executive officer emeritus of Gundersen Health System, a regional integrated delivery system based in La Crosse, Wisconsin, says balancing tools and values is going to be different for every organization and its leadership team.

"To get change to move is a combination of the responsibility of senior leaders to set clarity on aspirational goals and activities that will get people excited about leaning into it," Thompson says, "and then giving them the tools to do that that are within their grasp and supported by the organization."

Thompson says as he advises other health systems about managing change, he often encourages them to keep the real purpose of the tools in perspective. A good tool makes change easier, not more complex.

So organizations may deploy Lean, for example, as a way to "actually get some traction in change management, so that the process will be more efficient and feel like a win rather than a burden to bear."

Make sure the measures aren't lying

Hospitals have multiple ways of lying to themselves about the progress they are making, or not making. It's a sneaky little trade secret that leadership teams may choose what to measure by what they are best at already.

And then there are process measures (Did we do what we were supposed to do?) versus outcomes (Did patients get better?).

Gundersen decided to follow advice set out by Jim Collins in Good to Great, which was to "confront the brutal facts."

"You have to measure on multiple levels," Thompson says. That may include measuring the organization's progress not just against past results, but against top performers.

"If you compare this mediocre year with your mediocre last year, and you are 1% better, you're still mediocre. So, you've got to compare with the best you can find. You've got to look at different measures, and with some real discipline, track them over time," he says.

Thompson says sometimes a CEO needs pushback on what a clinical or organizational team wants to measure.

"Sometimes they know what measure is best, but that's not what they're going to track because the really hard things don't always look so good," Thompson says.

One check for such measures is to install dyad teams of clinical and nonclinical leaders to coordinate a balanced set of measures that matter and provide the discipline to track over time, Thompson says.

Create a sense of purpose, not a collection of projects

Give up the idea that you can control every aspect of change. Change is organic. It may fight back. Things will happen.

Gundersen Health drew widespread attention and acclaim in the past decade with its commitment to save energy and reduce the amount of pollution it was generating as a health system.

Gundersen set an ambitious goal in 2008 that the system would reduce carbon emissions by 90%, and be 100% powered by renewable sources of energy, by 2014.

It all seemed to be going well, for a while. Then turbines that were supposed to generate power didn't work as planned.

A plan to use vented gas from a local brewery to power a generator failed when the brewery switched from beer to hard lemonade.

"There will be a project, and they'll hold it up and they'll celebrate too much and make too big a deal of it, and then it falls apart."

—Jeff Thompson, MD, executive adviser and chief executive officer emeritus, Gundersen Health System

So whether it is patient safety or mortality or the environment, leaders must keep the team focused on the end goal and not get too far down or too far up along the way.

"There will be a project, and they'll hold it up and they'll celebrate too much and make too big a deal of it, and then it falls apart," Thompson says.

Gundersen's team was able to "stay on the principles. The principles were that we were causing pollution and we believed we could lower the cost of care, improve the local economy, and address the pollution all at the same time."

By October 2014, they had reached their goals.

"You do short-term and long-term measures and you try and keep people focused on not dropping the short-term ball," Thompson says, "but knowing that we have a long-term goal because there's always going to be ups and downs."

Don't assume that thing you fixed is still fixed

It's a familiar problem that sometimes leaders tend to focus more on the latest initiatives, and that an area that was already thought to be improved—and supposedly "hardwired"—has slipped, and in the process brought the organization's overall progress back down a notch.

"We fall into this trap," says Kurt Barwis, president and CEO of 154-bed Bristol (Connecticut) Hospital. "We set our goal and whatever it takes, we're going to get it done. We put all these resources to it, and if one person leaves, you become short in that area again. We created a process that works today, but isn't going to work tomorrow, and working tomorrow is the key to sustainability."

Barwis says the solution that has worked for Bristol has been to be intentional and robust about continued reporting. Hardwiring may include, for example, asking the right questions in the clinical record so that leaders will be able to see if the process measures put in place are failing.

Celebrate the wins, and then move on quickly

Part of the problem is in the "triage" culture of healers, says Barwis.

"Healthcare culture has pretty much always been that we love a good crisis," Barwis says. "We feel good at the end of the day when we can say, ‘Oh my God, we dealt with this emergency and this crisis.' It has an appeal. It's an instant response thing, but as leaders, our responsibility is to step back and say, ‘Yeah, that feels good that we solved the problem, but how do we stop the problem from happening again and again and again?' "

Two decades of relentless performance improvement has a real human toll: It's simply wearing teams out.

One inspirational tool that's important is to recognize work—celebrate the small victories—because they will motivate people to keep going.

Knowing when to push on is among the hardest nuances CEOs must manage, Thompson says.

"You have to find that balance, because if all we do is drive people, they end up getting pretty tired of being driven," Thompson says. "But if all you do is celebrate every time they turn around, and everybody gets a trophy for participating, you're not going to get to excellence on that."

Thompson reiterates the importance of recognizing wins when they come, but it is up to the leadership team to keep making the transitions to the next step.

His message: "Please take a minute to celebrate and then remember, we're out there to serve our community to the best of our ability, and your abilities are immense. We haven't tapped them all yet. Please help me to keep working on this."

Barwis pushed an aggressive pace of change in his first years as CEO.

"I would just hit the wall with 100 things, and I would just kind of keep people off balance," Barwis says. "I was constantly asking, ‘Do we do this? How do we get this forward?' And I could always look back at the end of the year at what we accomplished. But it left people with a knot in their stomach. If you keep pushing and you never stop, the consequence often is that people feel like they're not good enough and they can't step up."

Barwis says he learned to shift his approach back to the "big measurable, quantifiable things" such as nursing Magnet® status.

Don't accept trade-offs

Cause and effect has been an occasional worry as health systems look to improve everything from quality to patient satisfaction at the same time, with the fear being that improvement is a zero-sum game that might boost one area but cause a dip in another.

Thomas H. Lee, MD, an internist and cardiologist at Brigham and Women's Hospital in Boston and chief medical officer of Press Ganey, says that a core set of goals work together at high-performing health systems.

"To get change to move is a combination of the responsibility of senior leaders to set clarity on aspirational goals and activities that will get people excited about leaning into it, and then giving them the tools to do that that are within their grasp and supported by the organization."

—Jeff Thompson, MD, executive adviser and chief executive officer emeritus, Gundersen Health System

A 2017 Press Ganey report, "Achieving Excellence: The Convergence of Safety, Quality, Experience and Caregiver Engagement," found "cross-domain analyses suggest that these elements are highly interrelated with one another."

"When you look at the data from thousands of institutions, as we've been able to, you don't see tensions," Lee says. "There is no trade-off, for example, between having shorter length of stay and a worse patient experience."

At high-performing organizations, Lee says, you won't see, for example, that nurse engagement is high and physician engagement is low. "The most likely explanation for what really drives an improvement is the culture," he says.

"Basically, our hypothesis is that the organizations that seem to have their act together, are ones that have cultures that seem to be more focused on improvement and on idealistic goals that all the personnel believe in, like zero harm."

Lee recalls that when zero harm first came out as a concept, he saw it as statistically unattainable.

Now he says he embraces the reason why such goals work: because to accept any less would be unacceptable. He's optimistic that so much change is heading to the right point.

"I actually feel like it's a Golden Age of tremendous progress," Lee says. "But Golden Ages never feel that golden to people who went through them."