Chapter 12, "Leadership" The authors compare the terms leadership and management. They also present various leadership theories and the types of leadership. Methods for selecting and creating leaders also are addressed. Additionally, the authors describe circumstances when leadership may not be necessary. Chapter 13, "Power and Politics" This chapter contrasts the terms leadership and power. It explores the bases of power and power tactics, the causes and consequences of political behavior, and the ethics of behaving politically. 16 Personalities. Retrieved from https://www.16personalities.com/free-personality-test This web site gives you the background for the Myers-Briggs Type Indicator and its uses. This page includes a brief description of the characteristics of each of the "types" identified by the Myers-Briggs tool and allows you to identify your own personality type. Reinhold, R., & Poirier, D. (n.d.). Myers-Briggs personality types, your best fit type, and an introduction to the 16 personality types-Part 1. Retrieved from http://www.personalitypathways.com/type_inventory2.html This is where you'll find a more detailed explanation of the various personality types defined by the Myers-Briggs Type Indicator. Michaelis, B., Stegmaier, R., & Sonntag, K. (2009). Affective commitment to change and innovation implementation behavior: The role of charismatic leadership and employees' trust in top management. Journal of Change Management, 9(4), 399. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org /pqdweb?did=1919976501&sid=4&Fmt=2&clientId=70192&RQT=309&VName=PQD This article describes a study demonstrating that charismatic leadership and trust in top management are both positively associated with the willingness of employees to adapt and embrace innovation. Required Media Laureate Education, Inc. (Executive Producer). (2010). Good Samaritan Hospital organizational chart—Week 4: Leadership. Baltimore, MD: Author. This week, several Good Samaritan administrators share their thoughts on what leadership means to them in their current positions. Video Transcripts (zip file) Roberts, R. (Host). (2007, April 11). Exploring the psychology of the boss [Radio broadcast]. Retrieved from http://www.npr.org/templates/story/story.php?storyId=9517852 This National Public Radio program is a freewheeling conversation about the characteristics of effective leaders and of inferior ones. Optional Resources Management Study Guide. (n.d.). Great man theory of leadership. Retrieved from http://managementstudyguide.com/great-man-theory.htm Accel-Team. (n.d.). Human relations contributors: Douglas McGregor: Theory X and Theory Y. Retrieved from http://www.accel-team.com/human_relations/hrels_03_mcgregor.html Learning Resources Required Readings Robbins, S.P., & Judge, T. A. (2017). Essentials of organizational behavior (14th ed.). Upper Saddle River, NJ: Pearson. Chapter 16, "Organizational Culture" The authors compare the functional and dysfunctional effects of organizational culture on employees and the organization. They also explain the factors that create and sustain a positive organizational culture. Chapter 17, "Organizational Change and Stress Management" This chapter describes the forces that can produce important changes in organizations, including technology, economic shocks, competition, and social trends. Tsasis, P., & Bruce-Barrett, C. (2008). Organizational change through lean thinking. Health Services Management Research, 21(3), 192–198. Retrieved from http://ezp.waldenulibrary.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh& AN=2009991312&site=ehost-live&scope=site Lean thinking is becoming pervasive in health care organizations as a means of providing a comprehensive approach toward improving the health care process. This article provides an example illustrating when lean thinking was used to improve efficiency, contain costs, and effect organizational change. Eaton, M. (2010). Making improvements stick: The importance of people over process. Human Resource Management International Digest, 18(5), 30–35. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did= 2082622801&sid=6&Fmt=2&clientId=70192&RQT=309&VName=PQD This article involves how to maintain an organizational change initiative—how to make it stick. It proposes that a top-level champion for change is extremely important, and the champion should encourage comments about the change from the employees. The article also emphasizes that people are more important than process in any organizational change. Scott, T., Mannion, R., Davies, H., & Marshall, M. (2003). Implementing culture change in health care: Theory and practice. International Journal for Quality in Health Care, 15(2), 111–118. Implementing culture change in health care: theory and practice. International Journal for Quality in Health Care, 15, 2 by TIM SCOTT; RUSSELL MANNION; HUW T O DAVIES; MARTIN N MARSHALL. Copyright 2003 by Oxford University Press. Used by permission of Oxford University Press via the Copyright Clearance Center. This literature review analyzes some of the key debates about the nature of organizational culture and culture change in health care organizations. D. (2010, January). Getting the Klingons on your side. Training Journal, 33–37. Retrieved from http://ezp.waldenulibrary.org/login?url=http://proquest.umi.com.ezp.waldenulibrary.org/pqdweb?did= 1941228791&sid=4&Fmt=3&clientId=70192&RQT=309&VName=PQD This article offers useful advice on how to manage corporate "Klingons", i.e. employees who "cling" to outmoded processes and resist changes intended to introduce improvements. U.S. Department of Veterans Affairs, Office of Research and Development. (2000, May). Organizational change primer. Washington, DC: Author. Read pages 1–11. This document presents a concise and useful introduction to organizational change and how it can be successfully implemented and managed. Required Media Laureate Education, Inc. (Executive Producer). (2010). Good Samaritan Hospital organizational chart— Week 5: Organizational change. Baltimore, MD: Author. This week, administrators offer insight into how important changes were successfully managed at Good Samaritan Hospital. Video Transcripts (zip file) Optional Resources PRNewswire. (2010, April 6). Health reform lays ground for new era of individualized care and more patient-focused health system, says PricewaterhouseCoopers in new HealthCast report. Retrieved from http://www.prnewswire.com/news-releases/health-reform-lays-ground-for-new-era-of-individualizedcare-and-more-patient-focused-health-system-says-pricewaterhousecoopers-in-new-healthcast-report89976312.html Accel-Team. (n.d.). Force field analysis. Retrieved from http://www.accelteam.com/techniques/force_field_analysis.html Adventure Associates. (n.d.). Barriers to change. Retrieved from http://www.adventureassoc.com/resources/newsletter/nl-barriers-to-change.html Antariksa, Y. (n.d.). OD intervention success indicators. Retrieved from http://www.explorehr.org/articles/Organization_Analysis/OD_Intervention_Success_Indicators.html International Journal for Quality in Health Care 2003; Volume 15, Number 2: pp. 111–118 10.1093/intqhc/mzg021 Policy Roundtable Presenting the views of experts from around the world on policy-making as it relates to health care quality Implementing culture change in health care: theory and practice TIM SCOTT1,2, RUSSELL MANNION3, HUW T. O. DAVIES4 AND MARTIN N. MARSHALL5 1 Department of Health Sciences and 3Centre for Health Economics, University of York, 4Department of Management, University of St Andrews, 5National Primary Care Research and Development Centre, University of Manchester, UK, 22002–2003 Harkness Fellow and Visiting Scholar, School of Public Health, University of California, Berkeley, CA, USA Abstract Objectives. To review some of the key debates relating to the nature of organizational culture and culture change in health care organizations and systems. Methods. A literature review was conducted that covered both theoretical contributions and published studies of the processes and outcomes of culture change programmes across a range of health and non-health care settings. Results. There is little consensus among scholars over the precise meaning of organizational culture. Competing claims exist concerning whether organizational cultures are capable of being shaped by external manipulation to beneficial effect. A range of culture change models has been developed. A number of underlying factors that commonly attenuate culture change programmes can be identified. Key factors that appear to impede culture change across a range of sectors include: inadequate or inappropriate leadership; constraints imposed by external stakeholders and professional allegiances; perceived lack of ownership; and subcultural diversity within health care organizations and systems. Conclusions. Managing organizational culture is increasingly viewed as an essential part of health system reform. To transform the culture of a whole health system such as the UK National Health Service would be a complex, multi-level, and uncertain process, comprising a range of interlocking strategies and supporting tactics unfolding over a period of years. Keywords: change management, leadership, organizational culture, quality improvement The management of organizational culture is increasingly viewed as a necessary part of health system reform. In the United Kingdom, the latest National Health Service (NHS) reforms are based on the premise that a major cultural transformation of the organization must be secured alongside structural and procedural change to deliver desired improvements in quality and performance [1]. In the United States, in the wake of high profile reports documenting gross medical errors, policy thinking is embracing the notion of culture change as a key element of health system redesign [2], and there is evidence to suggest that many other OECD (Organisation for Economic Cooperation and Development) countries are focusing on cultural renewal as a potential lever for health care improvement [3]. Appeals for culture change in health systems draw upon a belief that culture is related to organizational performance. Some studies have suggested that culture might be an important factor associated with the effectiveness of a wide variety of organizations across a range of sectors [4–6], including health care. For example, health care cultures that emphasize group affiliation, teamwork, and coordination have been associated with greater implementation of continuous quality improvement practices [7] and higher functional health status in coronary artery bypass graft patients [8]. By contrast, organizational cultures that emphasize formal structures, regulations and reporting relationships appear to be negatively associated with quality improvement activity [9]. However, most studies suggesting a link between culture and performance are methodologically weak and their findings should be interpreted with caution [10]. If the nature of the relationship between culture and performance remains to be clarified, is it reasonable to plan Address reprint requests to Dr Russell Mannion, Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK. E-mail: rm15@york.ac.uk International Journal for Quality in Health Care 15(2)  International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved 111 T. Scott et al. interventions to instil those cultural attributes thought to underpin continuous performance improvement? This begs other questions, such as what is organizational culture? Are organizational cultures capable of being shaped by external manipulation? If so, what strategies are available to managers wishing to inculcate an appropriate organizational culture? In this article we aim to shed some light on these issues. We review key theoretical debates on the nature of organizational culture(s) and consider what practical strategies are open to health care organizations to implement culture change. The literature discussed formed part of a larger project, including a systematic review of literature on culture and performance in health care and non-health care settings [10–12,32]. The systematic literature search was conducted using Medline, CINAHL, Helmis, PsychLit, DHdata, and the database of the King’s Fund in London, using the phrase ‘organizational culture’. The information presented in this article is drawn from the systematic review, supplementary reading, and the advice of 30 experts in health services policy and management research in the UK and USA. Organizational culture 1. Origins and development There is little consensus among scholars over the precise meaning of ‘organizational culture’. The term ‘culture’ is derived from the Latin, meaning to tend crops or animals [13]. Early in the last century social anthropologists applied a culture metaphor to describe processes of socialization through family, community, educational, religious, and other institutions [14]. The idea that an organization’s effectiveness can vary as a function of its culture can be traced back at least as far as the Hawthorne studies [15] and related work. Those studies observed how the informal, social dimension of enterprise mediated between organizational structures and performance, and how those dimensions could be manipulated to affect employee effort and commitment. This interest in the organization as a social institution evolved into their study as microsocieties or -cultures [16]. In the postwar period, a number of researchers, including behavioural economists [17], industrial sociologists [18], and organizational psychologists, emphasized the importance of culture in shaping organizational behaviour. However, it was not until the 1980s that the concept entered mainstream management thinking via the influence of a number of best selling management handbooks, which popularized the notion that culture was a critical determinant of organizational performance [19–21]. We focus here on the implications of using culture change as a lever for performance improvement. However, we are aware of the limitations of the managerialist perspective and refer interested readers to a number of excellent scholarly publications that explore in-depth a range of theoretical stances and epistemological positions on the nature of organizational culture and the feasibility of managed culture change [22–24]. 112 2. Conceptual frameworks Organizational culture has been described as perhaps the most difficult of organizational concepts to define [25]. The management literature is replete with overlapping and competing definitions, a situation that has been referred to as ‘an embarrassment of definitional riches’ [22]. Conventionally the culture literature is divided into two broad streams [26]. One stream approaches culture as an ‘attribute’, something an organization ‘has’, along with other attributes such as structure and strategy. Another stream of literature regards culture more globally as defining the whole character and experience of organizational life, i.e. what the organization ‘is’. Here organizations are construed as cultures existing in, and reproduced through, the social interaction of participants. Some scholars view the ‘organization as culture’ approach as but one of a range of paradigms used in organizational analysis. From that relativist perspective, a global definition of organizational culture may be termed as the ‘culture as metaphor’ approach. The distinction between viewing culture as either an attribute, a defining quality, or a metaphor has important policy implications. The view of culture as an attribute has been instrumentally interpreted as an independent variable capable of manipulation to satisfy organizational objectives. From that perspective, culture change is viewed as a means to commercial or other technical ends and comprises a range of activities directed at ‘overhauling’ or ‘re-engineering’ an organization’s value system (Table 1). Much popular management literature adopts this approach. If, by contrast, organizations are approached as cultural systems, culture becomes the defining context by which the meaning of organizational attributes is revealed. Then, change agents are offered fewer levers to influence the formation of desirable cultures. Indeed the whole emphasis shifts from what organizations accomplish to a cultural anthropological understanding of how organizations are socially accomplished and reproduced. These different conceptualizations generate rival claims as to the nature and feasibility of planned culture change. For the purposes of this paper we tread a middle path between the two dominant approaches by treating an organization’s culture is an emergent property, concomitant with its status as a social institution [27]. By this definition, culture is not assumed a priori to be controllable. Instead we assume that its main characteristics can at least be described and assessed in terms of their functional contribution to broader managerial and organizational objectives. 3. Subcultures The management literature on organizational culture has tended to assert a relationship between ‘strong’, unified cultures and commercial success. Yet observation suggests that few large, complex organizations are likely to be characterized by a single dominant culture. Moreover, there is no convincing evidence that a unitary culture yields higher performance than a pluralistic one. Where organizations are differentiated along clear occupational lines, as health care Policy Roundtable Table 1 Key differences between approaches based on culture as an ‘attribute’ and culture as a ‘metaphor’ Culture as an attribute Culture as a metaphor ............................................................................................................................................................................................................................. Epistemological assumptions Positivist Phenomenological Disciplinary base Anthropology/biology Social psychology Theory of cultural cohesion Single, coherent culture Coexisting subcultures Theory of organizational order Provides an adaptive regulating mechanism to maintain status quo Cultural conflicts can engender change Creation and transmission of culture Directed by actions of senior staff to change artefacts and espoused ideology Reproduced by all culture members through their ongoing negotiation of symbols and artefacts Culture change agents Senior management only manipulate culture to meet corporate objectives Managers, as well as other organization members, all seek to influence the cultural direction of the organization organizations have traditionally been, a number of coexisting subcultures are likely to be identified. Subcultures may share a common orientation and similar espoused values, but there may also be disparate subcultures that clash or maintain an uneasy symbiosis [28]. Researchers have adopted two broad frameworks for studying organizational subcultures. The first defines subcultures relative to an organization’s overall cultural patterns, especially its dominant values [28]. From this perspective, subcultures are classified in terms of whether they support, deny, or simply coexist alongside the values of the dominant culture (Figure 1). The second framework acknowledges that subcultures relate to occupational, departmental, ward, speciality, clinical network, and other affiliations. Arguably, these two perspectives need to be synthesized, as elements of both are likely to be found within an organization. For example, the NHS is a distinctly British institution with a recognizable overall identity and certain apparent core values. Within that overall ‘NHS culture’, a number of distinct subcultures can be discerned whose relationship to the overall organizational culture is hard to disentangle. These subcultures can be divided into a number of non-mutually exclusive categories (Figure 2). Managing culture change 1. Reform or transformation Culture change strategies may be targeted at either first order or second order change [29]. During first order change the objective is to ‘do what you do better’. According to Deal and Kennedy [20] many commercial organizations have maintained a competitive advantage by pursuing a policy of ‘cultural continuity’, capitalizing on the lessons, traditions, and working practices that have served the organizational well over a period of time. There the focus is on evolutionary growth or quantitative reproduction and repetition (more of the same). In contrast, second order, qualitative growth (something different) is more appropriate if an existing culture has begun to stagnate and its complete overhaul is required [30]. Second order change is often invoked in response to a growing crisis or deficiency in the existing culture, which cannot be addressed adequately by a change in culture but rather demands a fundamental change of culture. If politicians and management gurus are to be believed, health systems in many countries stand perennially on the threshold of such fundamental change. 2. Developing strategies for cultural change Various models to understand and guide culture change have been developed [22]. Bate highlights the key dimensions to be targeted in a culture change strategy, as follows [30]. The structural dimension. To be successful a culture change programme must take account of the nature of the culture to be changed. Only after an effective diagnosis or cultural audit has revealed how the current order is sustained can effective change management strategies be deployed. As Brooks and Bate maintain, many attempts at changing organizational cultures are strong on prescription but lamentably weak on diagnosis [31]. Such a diagnosis would proceed by first acquiring an appreciation of the currently prevailing culture. A range of quantitative and qualitative assessment tools have been developed to help decipher an organization’s culture. These have been used extensively across different industries and settings, including health care organizations. However, these instruments should be used cautiously as there is wide variance in their established validity and reliability [32]. The process dimension. If cultures develop spontaneously, as an emergent model suggests, how they change is a key question. Bate [30] applies a sailing metaphor based on wave momenta to illustrate spontaneous change. If the latest cultural wave appears to be going in the right direction (a virtuous momentum) then it may be possible to ride the wave using its own energy to deliver the organization to its desired destination. 113 T. Scott et al. Figure 1 Classification of subcultures. If the prevailing wave is not going in the desired direction, at least three alternative strategies are possible. First, to deflect waves using their own momenta (re-framing strategies). Secondly, to wait until the most powerful waves have subsided and then create new ones (new-wave strategies). And thirdly, to wait until a new wave is going in the desired direction and ‘hitch a ride’ (opportunistic strategies). The contextual dimension. It is important to assess the ‘fit’ or alignment between a culture and the wider environment. As the external environment changes so must the internal culture to avoid obsolescence. This adaptive approach involves an assessment of ‘cultural lag’ or ‘strategic drift’ [33] to gauge the gap between the culture in use and the required culture. A number of highly critical reports on quality failings within the NHS have highlighted the need to reduce the dissonance between the prevailing culture of the NHS and broader societal changes occurring since its inception over 50 years ago [34]. 3. Overcoming resistance to planned culture change All strategies of culture change need to be mindful of the possible barriers that serve to block or attenuate purposeful change. Key sources of organizational inertia and resistance include: Lack of ownership. As change often evokes a sense of loss [35], reactions to change by individuals or professional groups can be negative and unpredictable. Even a few disaffected individuals can cause disruption, whilst a disaffected workforce or professional grouping is a recipe for organizational disaster. The implication is that unless a critical mass of 114 employees ‘buy into’ a culture change programme, such initiatives are likely to fail. Complexity. Organization culture is transmitted and embedded via a wide range of media, including established working procedures and practices (e.g. rewards ceremonies, exemplary individuals, written documentation, physical spaces, professional demarcations, shift patterns). It is unrealistic to expect culture change strategies to be effective on all these fronts simultaneously. Successful strategies require realistic time frames to implement the types of complex and multi-level changes required. It would appear that the UK government’s 10-year programme of reform for the NHS is a tacit acknowledgement that cultural transformation cannot be wrought overnight on an organization with such well established practices and values [36]. External influence. The influence of outside interests may cut across and sometimes work against efforts towards internal reform. Culture change strategies need to heed the constraints posed by external stakeholders in determining the values and behaviour of health professionals [37]. In the UK it is accepted that attempts to change the culture of the NHS may also need to target external bodies such as the Royal Medical Colleges, which exert control over training and influence the internalization of professional core values [38]. Similarly, research in Australian hospitals has shown that professionbased attitudes and beliefs have hampered the efforts of health authorities to promote more outcome-focused approaches to health care organization and management [37]. More widely, the Romanow Commission acknowledges the crucial importance for successful health care reform of working with, not against, core public values [39]. Policy Roundtable Figure 2 Varieties of subculture in the UK National Health Service. Lack of appropriate leadership. Leadership plays a central role in any cultural transformation. Inadequate or inappropriate leadership has been identified as a key factor when attempts to change culture fail [40]. Two main styles of leadership are widely recognized: ‘transactional’ leadership, based around securing organizational compliance and control by using material motivational factors like reward systems; and ‘transformational’ leadership processes, which inspire cognitive change by redefining the meaning of information to which organizational members are exposed (but not necessarily sensitized). Integrating these two styles is a necessary and challenging project. For example, it may be possible to 115 T. Scott et al. Figure 3 The meeting of cultures: achieving a cultural fit. Derived and expanded from a classificatory scheme on strategic alliances developed by Child and Faulkner [42] and based on original work by Tung [43]. Figure reproduced with permission. manipulate employment to reward behaviour patterns appropriate to patient-centred care. But such a naive behaviourist (transactional) approach would be insufficient. Leadership is also required to help transform practitioners’ cognitive apprehension of the status and relationships of participants in care-giving situations. In this way practitioners will not only be rewarded for appropriate behaviour, they will view their roles relative both to one another and to patients and their families in a different light. Thus, the patient-centred model of care is not just about modifying familiar behaviour, it is also about radically redefining participants’ interpretations and experiences of health care. This cognitive behavioural or transformational approach to leadership defines cultural as opposed to structural organizational change [41]. Cultural diversity. As we have noted, health care organizations are likely to comprise competing and overlapping 116 professional subgroups. Thus, a key challenge to culture change programmes is to consider carefully the impact of change on specific groups (e.g. doctors, nurses and other health professionals, and managers) and to design appropriate policies to accommodate this. Building on the work of Tung [43], Child and Faulkner [42] have developed a useful typology to assess approaches to managing organizational change in the face of cultural diversity. Their analysis is structured according to two fundamental choices. The first concerns whether one subgroup’s culture should dominate. The second relates to the decision either to integrate different subcultures (in order to derive synergy between them) or to segregate the various subcultures (with the aim of avoiding conflict or efforts devoted to culture management). These strategic choices give rise to four possible bases for accommodating cultural diversity (Figure 3). The first three offer some scope for establishing Policy Roundtable a cultural fit, whilst the fourth may give rise to serious dysfunctional consequences. Dysfunctional consequences. In addition to, or instead of, driving beneficial outcomes, culture change policies may induce a range of unintended and dysfunctional consequences [44]. This is seen, for example, in the range of adverse behaviours generated by the rise of a performance management culture in the UK NHS [45]. For example, qualitative case study research has revealed that in addition to promoting constructive change, the increased emphasis on performance targets has resulted in: a concentration on areas that are measured to the detriment of other important areas, especially qualitative aspects of care that defy quantification (tunnel vision); the deliberate misrepresentation of data, including creative accounting and fraud (misrepresentation); a lack of ambition for quality and performance improvement brought about by a perceived ‘satisfactory’ league table ranking (complacency); and the concentration on short-term issues, to the exclusion of long-term criteria that may only show up in performance measures in many years’ time (myopia). There are also fears that similar problems are emerging because of the culture of public reporting that has grown in the US [46]. Therefore, it is imperative that culture change policies are not monitored only in terms of the extent to which they foster constructive change, but also in terms of the perverse side effects that they inadvertently generate. Contributions R.M. devised the study in conjunction with H.D. and M.M. T.S. conducted the literature review and wrote the first draft of the findings of the review. R.M. wrote the first draft of this paper and all authors contributed to subsequent drafts. Acknowledgements This study was funded by the UK Department of Health through core support for the Centre for Health Economics, University of York, and the National Primary Care Research and Development Centre, University of Manchester. The views expressed in the paper represent those of the authors and not necessarily those of the UK Department of Health. T.S. contributed to the final draft during a Harkness Fellowship funded by the Commonwealth Fund of New York. References 1. Department of Health. Shifting the Balance of Power within the NHS: Securing Delivery. London: Department of Health, 2000. 2. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington DC: National Academy Press, 1999. Concluding remarks There is increasing international interest in managing organizational culture as a lever for health care improvement. Changing the organizational culture along with its structure has become a familiar prescription in health system reform. Nowhere is this more apparent than in the UK, where the centralized administration of the NHS has allowed opportunities for the national government to experiment with a ‘top down’ approach to instilling new values, beliefs, and working relationships. Yet planned culture change is a difficult, uncertain, and risky enterprise. Professional values, affirmed over centuries and woven into the fabric of health care organizations, are resilient enough to frustrate many attempts to ‘engineer’ change from above. 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Accepted for publication 17 December 2002 Organizational Change Primer MANAGEMENT DECISION AND RESEARCH CENTER H E A LTH SERVICES RESEARCH AND DEVELOPMENT SERVICE OFFICE OF RESEARCH AND DEVELOPMENT D E PARTMENT OF VETERANS AFFA I R S Organizational Change Primer MANAGEMENT DECISION AND RESEARCH CENTER H E A LTH SERVICES RESEARCH AND DEVELOPMENT SERVICE OFFICE OF RESEARCH AND DEVELOPMENT D E PARTMENT OF VETERANS AFFA I R S The Health Services Research and Development Service (HSR&D) is a program within the Veterans Health Administration’s Office of Research and Development. HSR&D provides expertise in health services research, a field that examines the effects of organization, financing and management on a wide range of problems in health care delivery—quality of care, access, cost and patient outcomes. Its programs span the continuum of health care research and delivery, from basic research to the dissemination of research results, and ultimately to the application of these findings to clinical, managerial and policy decisions. Organizational Change. Boston, MA: Management Decision and Research Center; Washington, DC: VA Health Services Research and Development Service, Office of Research and Development, Dept. of Veterans Affairs [2000]. p. cm. Includes bibliographical references. Primer. DNLM: 1. Hospitals, Veterans –organization and administration. 2. Organizational Innovation. 3. United States, Department of Veterans Affairs, Management Decision and Research Center. UH 463.068 2000 Organizational Change Purpose of primer series: to help bridge the gap between researchers, policy makers, managers and clinicians in an effort to improve the quality and cost effectiveness of health care for veterans. The primer series is part of a larger set of dissemination initiatives developed by VHA’s Office of Research and Development through the Management Decision and Research Center, a program within the Health Services Research and Development Service. Purpose of the Organizational Change Primer: to provide an introduction or to expand understanding, information, and knowledge about the concepts and application of organizational change processes in general and, specifically, within VA. The primer provides a basic framework for understanding organizational change and how it applies to VHA, a large health care system undergoing change. More in depth readings and other resources are listed in the appendices. Suggested audience: VA professionals, clinicians, managers, front line supervisors, researchers and staff involved in health care delivery in all parts of the Veterans Health Administration. Suggested uses: individual study, orientation for professional staff and health care providers, management training programs in Veterans Integrated Service Networks and within VA facilities, and continuing medical education courses and other medical and health professional training programs. May 2000 i Table of Contents Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii What is Organizational Change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Why is it important to actively manage the change process? . . . . . . . . . . . . . . .2 What is the human side of change and why is it important? . . . . . . . . . . . . . . .2 What are some critical activities for managing change? . . . . . . . . . . . . . . . . . .3 Change Snapshots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 What are some pitfalls in implementing change? . . . . . . . . . . . . . . . . . . . . . .5 What lessons has VA learned to date from its experiences in managing organizational change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 What research has VA done on organizational change? . . . . . . . . . . . . . . . . . .7 Is there a relationship between performance improvement and change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 What resources and references are available to VA managers? . . . . . . . . . . . . .9 Concluding remarks & References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Appendices: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Appendix A: What VA and non-VA resources are available to managers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Appendix B: What reading materials are available to provide more in-depth information on change, the change process, and the impact of change on staff and managers? . . . . . . . . . . . .21 Appendix C: A glossary of organizational change terms . . . . . . . . . . . . . .29 Fax us your comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 ii iii Contributors Contributors: Acknowledgements: The MDRC staff thanks the many managers and researchers who participated in the development of this primer. Mary Darby, editorial consultant, wrote the primer with Gerry McGlynn and with input from a number of researchers and others with expertise in organizational change. Special thanks go to the following individuals for their assistance: Robert A. Petzel, MD, Director, VISN 13, Minneapolis, MN; Fred Malphurs, Director, VISN 2, Albany, NY; Sheila Gelman, MD, Chief Medical Officer, VISN 10, Cincinnati, OH; Brian Mittman, PhD, HSR&D Center of Excellence, Sepulveda, CA; Linda Watson, RN, MSN, Director, Central Alabama Health Care System, Montgomery, AL; Paul Rosenfeld, MD, Chief of Staff, VAMC New Orleans, LA; Laura Miller, Director, VISN 10, Cincinnati, OH; William Weeks, MD, MBA, Director, Patient Safety Center, White River Junction, VT; Stanlie Daniels, RN, Director, Performance Measurement Program, Office of Quality and Performance VAHQ. We also extend our appreciation to colleagues throughout VA for their thoughtful comments in reviewing an earlier draft of this primer: Martin P. Charns, DBA, VA HSR&D MDRC, Boston; Jeannette Chirico-Post, MD, Director, VISN 1, Bedford, MA; Carol Ann Bedford, MD, Quality Management Officer, VISN 2, Albany, NY; Richard McCormick, PhD, Service Line Manager, Psychiatry, Louis Stokes VAMC, Cleveland, OH; Elwood Headley, MD, System Director, VA North Florida/Southern Georgia Health Care System, Gainsville, FL; Stephen Ezeji-Okoye, MD, Primary Care Service Line Manager, VAMC Palo Alto, CA; Bill Feeley, LICSW, Medical Center Director, VAMC Buffalo, NY; Al Perry, FACHE, Director, VA Central California Health Care System, Fresno, CA. Primer development and editing: Geraldine McGlynn, MEd, Elaine Alligood, MLS, Laurel Long, MS, Diane Hanks, MA, and Scott Brigante, all of VA HSR&D Management Decision & Research Center, Boston, MA. iv v Preface The VA health care system is a system in flux – changing its focus, expanding its activities, and restructuring its services. With the reorganization of VA into networks and the change in focus from specialty-based hospital services to outpatientbased primary care, today’s VA looks nothing like yesterday’s. This primer is designed to help VA managers and staff understand, accept, and implement change. Think of it as a survival guide. We believe that by helping managers and staff cope with and survive change, we are assuring VA’s long-term survival and growth as an organization driven by new knowledge and learning. And the fact is that tomorrow’s VA likely will not be the same either. As Benjamin Franklin observed, "When you’re finished changing, you’re finished.” VA’s work is not finished. Our mission is a dynamic one. Our patients’ needs will continue to change, new medical treatments and technologies will continue to emerge, and demands for services will evolve accordingly. Change is a fact of life in today’s health care environment. The spread of managed care, demands for increased accountability, concerns about patient safety, and heightened emphasis on cost-effectiveness and quality improvement contribute to a dynamic that requires all health care providers to be on the alert, flexible, and ready to respond to change. That’s as true for the VA health care system as it is for any other system. The same forces that have rocked the rest of the industry during the past few years have also forced VA to re-examine all facets of its operations to determine how well it is serving America’s veterans and how it might better accomplish that mission. Change can be frightening. And, I’ll be the first to admit, it is extremely difficult. But we can’t afford not to change. In fact, for VA, change is now a continuous process – a means for identifying new and better ways of doing things and, ultimately, for improving the quality and efficiency of veterans’ services. Commitment to quality means commitment to change. VA remains firmly committed to providing the best possible care for America’s veterans – not just today or tomorrow, but for many decades to come. John G. Demakis, M.D. Director, Health Services Research and Development Service vi vii Introduction Every organization must change – not only to survive, but also to retain its relevance in a world of intense competition, constant scientific progress, and rapid communication. But in order for change to bring a benefit and advance an organization to a higher level of service and operation, that change must be driven by knowledge. At VA, this is where the Health Services Research and Development Service ( HSR&D) comes into play. All change efforts are fraught with questions: How do we know when change is needed? How do we know what kind of change is needed? How can we effectively manage change? How do we know that our efforts are producing the desired effects and that the changes we are bringing about are actually desirable? HSR&D is working to supply answers to these and other important questions, as VA continues its journey of improvement through learning and change. In this Primer, we share some of the important lessons we’ve learned to date about organizational change – why it’s important, what we can do to manage it, and some pitfalls to avoid. Our intent is to help managers respond effectively to the great opportunities before us by answering some basic questions about organizational change. A question-and-answer format is used for easier reading and accessibility. Appendices provide VA managers and others involved in implementing change with resources for additional information and references for more in-depth reading. We recognize that implementing change is one of the most challenging and critical responsibilities any manager can face. We also recognize that organizational change can be challenging for all those asked to participate in the change process. We hope that this primer will help make the job a little easier. VA is committed to supporting its managers and staff throughout this continuous process, and to developing new tools and resources for facilitating change that will benefit all veterans. Martin P. Charns, DBA Director, Management Decision and Research Center viii 1 W H AT IS ORGANIZATIONAL CHANGE? Organizational change is any action or set of actions resulting in a shift in direction or process that affects the way an organization works. Change can be deliberate and planned by leaders within the organization (i.e., shift from inpatient hospital focus to outpatient primary care model), or change can originate outside the organization (i.e., budget cut by Congress) and be beyond its control. Change may affect the strategies an organization uses to carry out its mission, the processes for implementing those strategies, the tasks and functions performed by the people in the organization, and the relationships between those people. Naturally, some changes are relatively small, while others are sweeping in scope, amounting to an organizational transformation. Change is a fact of organizational life, just as it is in human life. An organization that does not change cannot survive long – much less thrive – in an unpredictable world. Several factors may make organizational change necessary, including new competition in the marketplace or new demands by customers. These types of external forces may create expectations of improved efficiency, better service, or innovative products. When organizational change is well planned and implemented, it helps assure the organization’s continued survival. It can produce many tangible benefits, including improved competitiveness, better financial performance, and higher levels of customer and employee satisfaction. These benefits may take some time to achieve, however, and the transition period that accompanies major organizational change usually is a time of upheaval and uncertainty. Not every individual in the organization will benefit personally from change; some will be casualties of change, especially if jobs are cut or realigned. But change should make the organization as a whole stronger and better equipped for the future. 2 WHY IS IT IMPORTANT TO ACTIVELY MANAGE THE CHANGE PROCESS? The change process must be managed in order to keep the organization moving toward its new vision and its stated objectives. We’ve all heard examples, in health care and elsewhere, of organizations that launched ambitious change initiatives founded on excellent ideas that were never fully implemented because they weren’t appropriately managed. At best, an unmanaged change process accomplishes nothing, and the work that went into planning the change is wasted effort. But at worst, an unmanaged change initiative can produce unintended, detrimental effects1 such as poor morale, loss of trust in management, workplace jealousy, and lower productivity. Thus, orchestrating the process of change is as important as selecting the content of change. V "Change isn’t always positive; but it can be handled in ways that strengthen rather than diminish the commitment people have to an organization." WILLIAM A. PA S M O R E C R E ATING STRATEGIC CHANGE W H AT IS THE HUMAN SIDE OF CHANGE AND WHY IS IT IMPORTA N T ? Organizational change is about people changing. Organizational change, then, is a highly complex process that must take into account how people respond psychologically when asked to make major changes at work. Their reactions inevitably vary. While some people embrace change, others will resist it – sometimes passively, giving the impression that they support it. A small number of people are energized by change, but many others feel threatened and anxious. This is particularly true if, under the change initiative, people may be transferred to new positions or work sites or even lose their jobs. The human side of change is frequently ignored or handled inadequately despite managers’ best intentions or their intellectual understanding of how difficult change is. Recognizing the pain and insecurity that change can cause in the workplace is not enough; managers must devise ways for responding effectively to these feelings. This may involve engaging employees more actively in change efforts, communicating with them more frequently and comprehensively about new developments, creating a forum for them to vent their frustrations and fears, or simply maintaining an "open door" environment, where employees can approach their managers individually to discuss concerns. For more information see Backer, 1997 and Flarey, 1998 in Appendix B. V "The first rule of change, therefore, is to begin any process of change with concern for its impact on people. The second rule is to prepare people for the change by educating them in what they need to know in order for the change to be successful; the third, to involve them in the change as much as possible; and the fourth, with their involvement, to change what really needs to be changed about the entire system in order for the effort to produce real results." WILLIAM A. PA S M O R E C R E ATING STRATEGIC CHANGE W H AT ARE SOME CRITICAL ACTIVITIES FOR MANAGING CHANGE? There is no one-size-fits-all formula for managing change. Managers may approach change in a number of ways, depending on the organization’s culture, history, and the nature of the change being implemented. At the most basic level, however, managers should try to build flexibility into the organization (into its people, technology, systems and thinking) to create a work environment that is open to change and able to accept it.2 Following are some key points that can help managers achieve this goal. Determine the context for change. This is a period of information gathering and analysis. Some questions for managers include: What is the imperative for change? Who are all the groups that need to be involved in the proposed change – both within and outside the organization? How are they likely to be affected by the change? What support will be needed from them during the change process, and how prepared are they to give it? What are the potential impediments – both internal and external – to change? What resources and system supports does the organization have available to implement the proposed change? What others are needed? 3 Build support for change. Commitment to change usually begins with a small group of "core believers" or champions of the change initiative, who share a common new vision for the organization and are willing to do what it takes to make it a reality. The core believer group is usually comprised of high level, influential managers and staff who bring credibility and personal influence to the change initiative. Their involvement may also be viewed as a demonstration of the organization’s commitment to change. In addition, these leaders frequently control resources and rewards within the organization. Early in the change process, these core believers need to involve a larger group of "initial participators" who don’t necessarily have the same level of commitment to change as do the core believers, but they participate in the initiative out of loyalty to the organization. As the change process takes hold and its successes are publicized, support will spread to others who typically "wait and see" whether they should commit to the initiative. Last to commit to the effort are the "hard-core resisters," some of whom will never support the change process.4 Develop a motivating vision. A clear and concise motivating vision is needed to "inspire" a large number of employees to change. People need to know why change is desirable, why they should make the effort to support it, and what it will achieve. The change can be very painful to some employees whose jobs may require new skills, transfers or even elimination. The motivating vision should be sufficiently concrete so that people can understand what it means and why the change is necessary, but not so rigid that it has no room to evolve. A motivating vision is one that enables people to imagine new possibilities for the organization as a whole and for themselves as members of the organization. Articulate clear, specific and realistic goals and strategies. A vision helps motivate people, but specific goals and strategies are needed to guide them as they undertake the steps necessary to make the vision a reality. In addition, having clear goals helps the organization assess its progress during the change process. One general strategy is to look for natural opportunities to effect change. In other words, search for natural connections among existing programs, events, communication channels, activities and the change program. If natural connections emerge, utilize them to enhance change efforts. For example, development of teams or introduction of case management could be linked with programs to improve quality of care. Such connections may also open up opportunities for creative collaborations and partnerships that might otherwise be overlooked. The key here is to leverage what is already going on and to complement new initiatives being launched. 3 4 Change Snapshots Example 1: Example 2: A chief of medicine at a large teaching hospital was ambivalent about the hospital’s change program for implementing patient-centered care. Although he could articulate numerous problems regarding delivery of care at the hospital, he did not yet see how the change program could solve these problems. Change leaders at the hospital used several methods to communicate the program’s goals throughout the hospital, but the chief and many others viewed this information as meaningless jargon. With many academic and patient care responsibilities, the chief did not make the time to focus on the change program. A hospital chief executive did not realize how much his own communications (or perceived lack of communication) signaled a lack of commitment throughout the organization to a multi-milliondollar, multi-year change initiative. In fact, the executive was very committed to this program. He thought that his few communications through formal channels about the change program conveyed to others his support for it and interest in its success. When the change project manager and consultant realized that staff did not view the chief executive as committed to the change, they took immediate action. They worked with him to develop a set of presentations, both formal and informal, about the change process and his vision for it. They even arranged for him to be featured on a local talk radio show. Surprisingly, after the radio show some staff commented that this was the first that they had heard of the change initiative. This situation changed when the hospital chief executive and the vice president for medical affairs each met with the chief and discussed how the program was designed to improve patient care. They listened to the chief’s problems and asked him to help the change program work to address them. They also made commitments to address problems with hospital systems that were important to the chief. In doing so, they noted that these fixes were part of the change program. Over time, as he saw that the change program was addressing issues of importance to him, the chief became a supporter of change. From this experience, change leaders at the hospital also learned that their communication efforts with staff were ineffective. As a result, they began to use focus groups of staff to critique hospital employee newsletter articles and videotapes about the change program. They found that what seemed perfectly clear to change leaders was not meaningful to many others in the hospital. Accordingly, they set out to develop more effective communication vehicles. Example 3: This story illustrates what can happen when top leadership is not on board with a change initiative. At one hospital, a vice president who expressed support for a change program during senior management meetings behaved differently during his own staff meetings and in fact did little or nothing to promote the change process. Without a clear signal that their VP supported change and their efforts to implement it, staff in that department did not work to implement new methods or systems needed under the change program. Ultimately, the change program failed. Communicate. Clear concise communications about the need for change, the vision, and the change process pave the way for understanding and acceptance. The rule of thumb is to use all available methods of communication to stakeholders and staff including: meetings or retreats, e-mail, department newsletters, bulletins, posters, and, in some instances, one-on-one meetings with staff members, particularly those who are having difficulty accepting the change. Managers need to be aware that communication is a continuous process and that messages related to the change effort require constant reinforcement. The change process should be a regular item on meeting agendas, successes should be publicized, and participants commended for their efforts. Identify barriers to change and develop strategies for overcoming them. There are many types of barriers – internal, external, psychological, cultural, systemic, and logistical – that can block or subvert the change process. Engaging staff and/or stakeholders in structured creative dialogue can identify these. Once identified, address barriers and concerns promptly. Problems that are ignored and allowed to fester, breed resentment, distrust, and uncertainty. Managers who take charge of a problem and try to solve it before it gets out of hand, demonstrate their leadership, honesty, and concern for staff. Look for the early win. By making the most out of small, early successes, managers can establish the credibility of the change initiative, provide a boost for initial participators, and demonstrate to the "wait and see" group that the proposed change can work and is worth their involvement. Recognize participants for their efforts. Change is hard work. Managers can reward participants productively involved in the change process by giving them promotions, bonuses, awards, desirable assignments, praise, attention, and notes of appreciation. They can also use the opportunity to further train/develop participants and encourage them to continue or even increase their efforts in supporting the change process. V “There is nothing permanent except change.” HERACLITUS W H AT ARE SOME PITFALLS IN IMPLEMENTING CHANGE? Every change process has its setbacks and complications. Throughout the change initiative, managers should keep in mind that these setbacks frequently have a positive aspect because they offer opportunities to reassess and improve the implementation process. Mid-course corrections are to be expected—if things are going too smoothly, managers might want to take a closer look and make sure that they are not missing something. Following are some mistakes that managers commonly make when implementing a major change initiative. The manager tries to bring everybody on board. Not everyone in the organization will support the change immediately. Managers should focus their efforts on their core supporters and on swaying the undecideds. In this way, they can achieve a critical mass to move the process forward. Investing too much effort to win over hard-core resisters will merely drain energy and resources needed for other parts of the change process. The manager leaves it to others higher up in the organization to explain "the big picture." Communication is a crucial activity in all change initiatives. The needs of staff for information at every step of the way cannot be underestimated. Managers cannot expect to simply deliver a message once and assume that it has been understood and accepted by everyone in the organization. In addition, they will need to use a variety of media – including staff meetings, newsletters, posters, suggestion boxes, email, and Internet and Intranet sites – because different communication methods are more effective with different people. Finally, managers should keep in mind that communication is an excellent opportunity for them to build trust and credibility with their staff. The manager has to make everyone part of the team. Managers need to accept that a small percentage of hard-core resisters simply will not adapt. These people may drag others down. If this happens, the manager should talk privately with the person, acknowledge his objections, explain why his support is needed, and invite his participation in solving problems. If the person still doesn’t accept the change, he may have to 5 6 leave the organization – both for his own good and for the good of the group.5 This is a difficult situation for managers to deal with especially in a federal personnel system. If, in the end, the manager decides the employee will not fit into the new team and the employee does not leave the organization, the manager may need to work on finding another placement for the employee. The manager confuses stakeholder consultation with change management. Although stakeholder consultation and participation in the change initiative are important, managers should be careful not to allow stakeholders to take over the process. Stakeholders should be viewed as expert resources like any other. Managers need to be aware that stakeholder interaction is essentially a dialogue with individuals who have similar interests but who may or may not share the organization’s perspective. This interaction must be managed effectively, especially with regard to stakeholders’ expectations of how their input from consultations will be used.6 W H AT LESSONS HAS VA LEARNED TO D ATE FROM ITS EXPERIENCES IN MANAGING ORGANIZATIONAL CHANGE? At VA, as in other organizations, each change implementation is unique. Thus, different managers glean different lessons from their experiences with managing change processes. Following are some examples of lessons learned. Different management strategies inevitably entail different tradeoffs. For example, a long roll-out period may allow managers to develop more detailed and precise implementation plans, deploy their financial and human resources more efficiently, and engage stakeholders more effectively. But a prolonged roll-out can also exacerbate staff uncertainty about the future, heighten anxiety, and lower morale. V A useful rule of thumb about vision: “Whenever you cannot describe the vision driving a change initiative in five minutes or less and get a reaction that signifies both understanding and interest, you are in for trouble." Adapted from: Galpin, T.J. The Human Side of Change; Jossey-Bass; 1995. JOHN KOT T E R LEADING CHANGE The human element of managing change cannot be overemphasized. For most people, organizational change creates major anxieties – about job security, whether and how their jobs will change, who their supervisors will be, and whether they’ll have to move to another work site. Staff may become distrustful of the organization’s leaders and change managers. The rumor mill kicks into overdrive. Staff turnover increases. Managers need to try to anticipate staff members’ fears, answer their questions as quickly and completely as possible, dispel false information, and develop a number of communication strategies for keeping people informed of the change process. Set specific goals and objectives before involving staff in strategy development for change implementation. This is particularly important when convening change teams. Left to their own devices, these groups usually have little incentive to initiate major changes. Instead, they are more likely to try to solve problems by "tinkering around the edges." By giving change teams clearly defined expectations regarding quality, cost, and performance, and then allowing them to help develop strategies for meeting those goals, managers are more likely to elicit innovative and effective plans. Communication is critical to the success of any change effort, but it is extremely difficult. As mentioned, organizational change creates a great deal of uncertainty and anxiety for staff. The initial reaction of many people is to deny that the change will actually take place, or that it is permanent and not simply a "passing phase." Managers need to develop solid communication plans that are embedded in the change process and that use a variety of media to reach different audiences with different communication needs and preferences. Some managers find that staff react positively to more interactive approaches, such as town meetings, small focus groups, or one-on-one meetings with supervisors. Managers should also keep in mind that messages about change need to be repeated – sometimes frequently – because they seldom sink in with everyone the first time. Experience with changing organization systems at the facility level is helpful. Much of the groundwork for implementing change involves setting up standard procedures and structures for accounting, information management, workload reporting, and other functions. If facility managers can put these processes and structures into place early, the rest of the change implementation will proceed more smoothly. Change implementation requires persistence. Change rarely works out exactly as planned. Managers may feel overwhelmed at times by their responsibilities and by the stress of change. They may need to ask the organization’s leaders for additional support or training to deal more effectively with certain issues. They may also need to experiment and learn a few lessons the hard way before hitting on the combination of strategies and approaches that will work best for them. W H AT RESEARCH HAS VA DONE ON O R G A N I Z ATIONAL CHANGE? HSR&D, through its Centers of Excellence and the Management Decision and Research Center (MDRC), is examining many of the organizational changes taking place within VA. (See Appendix A for Center descriptions and contact information). For example, the MDRC is working on three major research projects, the Service Line Implementation Study, the Facility Integration Study, and the National VA Quality Improvement Study, which explore the development and implementation of innovations in care delivery and organizational design. Updates on the progress of these three studies are reported quarterly in the MDRC Newsletter, Transition Watch, which is available on the web. (http://www.va.gov/resdev/prt/category.htm#news). Service Line Implementation Study. VA is working to improve health care delivery to veterans by restructuring organization and management practices to increase efficiencies and responsiveness. Service Lines are one aspect of this restructuring. Service Lines are a comprehensive set of services designed to meet the needs of a specific veteran patient group, such as women or elderly veterans. Service Lines are also characterized as an integrated set of services – such as primary care, mental health, geriatrics and extended care – that are distinguished from other services by the technology or specialty employed. In collaboration with the HSR&D Houston Center for Quality of Care and Utilization Studies, the MDRC is conducting a study of service line management implementation among the VA networks, investigating the process of change and the effectiveness of service lines. The study will qualitatively and quantitatively evaluate the various forms of service line management in VA. Facility Integration Study: Hospital or facility integrations are highly complex endeavors, and analyzing the processes and progress of integration can provide unique and valuable information for other systems striving to integrate independent facilities. The MDRC, initially in collaboration with the HSR&D Center for the Study of Healthcare Provider Behavior in Sepulveda, is studying facility integration in VA. The first component of the study looked at the process of integration, including the factors that facilitated or hindered the process, and the structure of 7 8 the resulting integrated systems in fourteen VA systems. The second component of the study monitored the structures and assessed the effects of integration on patient satisfaction, cost, access, and quality enhancement in all VA systems integrated since January 1995. Effects were measured over multiple years so that system changes had time to achieve stability. Among the key findings of the study: • Clear direction from leadership about new struc- ture and guidelines for planning, as well as early involvement of staff and middle management in the planning process, produced higher staff morale and satisfaction. • Systems with a central headquarters – where the top leadership and all or most service chiefs are physically based at one campus – tend to integrate more quickly and extensively than other systems. • While integrated systems significantly improved staffing efficiency after integration, there were only modest effects on other measures of efficiency and performance. The MDRC will continue to track the nature and extent of systems integration in VA and will disseminate results. National VA Quality Improvement Study. This study is a three-year project examining and supporting VA’s transformation through a range of data collection strategies, including employee surveys, interviews with Headquarters staff and network directors, plus site visits to facilities. Surveys obtained information on a variety of indicators related to quality improvement, customer service orientation, and organizational culture. Survey results have been disseminated to provide managers with timely information. By repeating the survey three times, study investigators can assess VA’s progress over time on specific survey indicators. Monitoring these large-scale change efforts will help inform the planning and implementation of future change efforts required by VA’s commitment to continuous learning and improvement. By continuously assessing and disseminating lessons learned, as well as problems encountered and solved, VA advances health care delivery and management. IS THERE A RELATIONSHIP BETWEEN PERFORMANCE IMPROVEMENT AND CHANGE? As noted quality expert Donald Berwick observes, "Not all change is improvement but all improvement is change." 7 Real improvement, he believes, comes from changing systems – not from changes within systems. Thus, improvement requires a model for systemic change. In VA’s Prescription for Change, clinical quality is described as being "critically dependent on organizational systems and structures that minimize the chances for mistakes to occur, improve efficiency, promote accountability, and encourage continuous improvement." VA is committed to measuring, reporting, and comparing performance for multiple patient outcomes at the national, network and facility levels. The idea is that these activities will result in changes that improve the quality and the efficiency of health care services provided by VA. W H AT RESOURCES AND REFERENCES ARE AVAILABLE TO VA MANAGERS? A wide array of resources and references are available to assist VA managers with organizational change. Resources range from local and national groups with expertise in organizational change, to education and training programs, change and improvement consultants, as well as additional web site resources. Appendix A provides an annotated listing of some of these resources both within and outside VA. Appendix B provides an annotated listing of change process books and articles for further reading on the topic. Appendix C provides a glossary of terms used in this Primer and in the change management literature in general. We hope that you will find these useful. 9 10 11 Concluding Remarks & References At VA, change has been rapid and sweeping, as VA transforms itself into an organization of continuous learning and innovation. While many changes have already been implemented, others are still in the works. The reality is that VA is re-examining each of its processes and practices to determine whether they meet the demands for quality, effectiveness, and efficiency in today’s constantly changing environment – and whether they will continue to meet new demands in tomorrow’s world. Thus, change will be a continuous enterprise at VA, a process of continually learning and seeking ways to do things better. In an ever-changing world with constantly emerging challenges, VA cannot afford to merely move from one rigid state to another – albeit better – rigid state. VA is also aware that many others outside VA – including members of Congress and private-sector providers – are watching to see how VA implements its performance improvement and benchmarking activities, and what it achieves from these efforts. Thus, VA can provide leadership for the rest of the health care community in planning, implementing and learning from change. VA might do well to borrow a phrase from noted change author James Lundy as its motto for change: "Lead, follow, or get out of the way!" VA managers are invited to embrace change, learn how they can advance it, and ask for training or other types of support when they need it. 1 Charns MP. Implementing organizational change. FORUM [HSR&D Newsletter] 1994; (December):2-3. 2 Pasmore WA. Creating strategic change: designing the flexible, high-performing organization. New York: John Wiley & Sons; 1994. 3 Wilson P, Sowden A, Watt I. On the evidence. Managing change. Health Services Journal 1999; 109(5643):34-35. 4 Charns, op. cit. 5 Anonymous. Change: overturning myths and blocks. OR Manager 1998; 14(5):31-32. 6 Axler H, Donner GJ, Underwood E, Van de Bogart L. Planning for complex change: insights from the Metro Toronto District Health Council hospital restructuring project. Healthcare Management Forum 1997; 10(2):33-34. 7 Berwick DM. A primer on leading the improvement of systems. British Medical Journal 1996; 312(7031):619-622. 12 13 Appendices: Organizational Change, Resources, Books, Articles, and Definitions These appendices are provided to support change efforts across the VHA organization. As of publication, Spring 2000, the lists are up-to-date and complete. If you have updates or additional resources to add, please contact this office with the specific information. New resources will be added to the electronic Web version of the Primer. Geraldine McGlynn, MEd Manager, Information Dissemination Program Management Decision & Research Center 152-M VA Boston Healthcare System 150 So. Huntington Avenue Boston, MA 02130 Telephone: (617) 278-4433 Fax: (617) 278-4438 geraldine.mcglynn@med.va.gov 14 15 Appendix A: What VA & non-VA resources are available to Managers? There are several different types of resources, references and tools for managers to use in their change planning, implementation or evaluation. First, many people have planned and experienced change within VA. We have asked several of these VA Change Agents if they would be willing and able to share their experiences or serve as resources to other VA managers. A list of their names and contact information follows. Next, there are lists of important VA offices and contacts that can provide information or guidance on change efforts, as well as some non-VA contacts and websites of interest. Resource List of Experienced VA Change Agents The following VA individuals have experienced large-scale change efforts and are willing to share their experiences. NAME Scott Sherman, MD T I T L E / L O C AT I O N TYPE OF CHANGE C O N TACT INFO PACE Development of FIRM System (818) 891-7711 Ext. 9909 ssherman@ucla.edu Sepulveda, CA Terry Washam Chief, Mental Health Services, Cleveland, OH Development of Service Lines (440) 526-3030 Ext. 7949 terry.washam@med.va.gov Mark Peddle Clinical Program Supervisor, Cleveland, OH Implementation of Service Lines (440) 526-3030 Ext. 7977 mark.peddle@med.va.gov John H. Edwards, MD Staff Psychiatrist, Spokane, WA Restructuring traditional services to multi-disciplinary teams (509) 328-4521 john.edwards@med.va.gov Robert Perreault VAMC Director, Atlanta, GA Implementation of Service Lines (404) 728-7601 robert.perreault@med.va.gov David Cornwall AA/Director, West Haven, CT Facility integration (203) 932-5711 Ext. 4734 david.cornwall@med.va.gov Nicheole Amundsen Director, Primary Care, Implementation of "managed care models" for ambulatory care and primary care (202) 273-8558 VAHQ nicheole.amundsen@hq.med.va.gov Scott Murray Network Care Line Director, Behavioral Health, Albany, NY Implementation of Service Lines (518) 462-3311 Ext. 3482 scott.murray@med.va.gov Timothy R. Smith, PhD Program Leader, Behavioral Health, Erie, PA Implementation of Service Lines (814) 860-2061 timothy.smith@med.va.gov Pamela Chester, RN, MSM Practice Manager, Medical VA Care Line, Canandaigua, NY Implementation of Service Lines (716) 393-7133 pamela.chester@med.va.gov 16 Within VA Contact information listed below is current as of April, 2000 Health Services Research and Development Service Within the Office of Research and Development, the Health Services Research and Development Service provides expertise in health services research, a field that examines the effects of health care organization, financing and management on a wide range of delivery issues including quality of care, access, cost and patient outcomes. The following list provides contact information for some of the HSR&D centers and programs related to organizational change. Management Decision and Research Center Martin P. Charns, DBA, Director Boston, MA Telephone: (617) 278-4433 Fax: (617) 278-4438 Email: martin.charns@med.va.gov The Management Decision and Research Center (MDRC) conducts, coordinates and disseminates research to inform policymakers and managers about organizational and managerial practices affecting the quality, cost and accessibility of patient care. MDRC staff have expertise in such areas as organizational development, program evaluation, policy analysis, strategic planning, and information dissemination. MDRC researchers are currently engaged in three major studies of organizational change and innovation discussed elsewhere in this document: the Service Line Implementation Project, the National Quality Improvement Study, and the Facility Integration Study. Center for the Study of Healthcare Provider Behavior Lisa V. Rubenstein, MD, MSPH, Director Sepulveda, CA Telephone: (818) 895-9449 Fax: (818) 895-5838 Email: lisar@rand.org Researchers specifically focus on provider behavior and practice patterns, health care quality and outcomes, quality improvement, clinical practice guideline implementation, and primary care/managed care evaluation. Providing technical assistance and education opportunities are also high priorities. Researchers at the Sepulveda Center are collaborating with researchers at the MDRC on the Facility Integration Study mentioned earlier. Center for Health Care Quality of Care and Utilization Studies Carol Ashton, MD, MPH, Director Houston, TX Telephone: (713) 794-7615 Fax: (713) 794-7103 Email: cashton@bmc.tmc.edu Much of the work at the Houston Center focuses on quality of care assessments and on the study of the levels and determinants of veterans’ utilization of health services. A distinctive feature of the Houston Center is its expertise in using large health care database analysis both within and outside the Department of Veterans Affairs. Researchers at the Houston Center are collaborating with MDRC researchers on the Service Line Implementation Study discussed in the text. Veterans Evidence-Based Research, Dissemination and Implementation Center ( VERDICT) Jacqueline Pugh, MD, Director San Antonio, TX Telephone: (210) 617-5314 Fax: (210) 567-4423 Email: jpugh@verdict.uthscsa.edu Research efforts at this Center aim to link research evidence with clinical practice by summarizing and translating the evidence into useful documents for various consumers, such as providers, patients, managers and policymakers. Employee Education System The Employee Education System (EES) is committed to providing for the learning needs of VA employees. EES provides a wide array of training, education, and other resources to support the development of VA employees. Many EES programs are designed to support organizational change efforts. Two examples of EES activities that support organizational change are listed below: Creating the Future Primer: This online primer is an outcome of the work done by the Primary Managed Care Task Force of the Employee Education System (EES), charged with examining the future of primary care within VHA. The online primer is available on the VHA intranet at http://vaww.sites.lrn.va.gov/futures High Performance Development Model The High Performance Development Model is the Department of Veterans Affairs model for leadership during change. The HPDM helps focus VHA efforts to develop a highly skilled workforce for the 21st century, and to develop a continuous supply of skilled leaders committed to VA’s mission. Additional information is available on the VHA intranet at: http://vaww.va.gov/hpdm or by contacting: Kathryn Young - youngkat@lrn.va.gov Bunny Huller - hullermar@lrn.va.gov EES Cleveland Center, Brecksville OH Telephone: (440) 526-3030 Ext. 6630 Fax: (440) 838-6034 Many of the resources available through EES are listed on the EES intranet web page at http://vaww.ees.lrn.va.gov/. For more information on learning activities, products and services available to VA employees through the Employee Education System contact the Education Service Representative (ESR) assigned to your VISN. A list of ESRs with contact information is provided on the EES web page at http://vaww.ees.lrn.va.gov/Resources/ VALU_STAFF/ESRLIST.vep VHA/Institute for Healthcare Improvement Collaboration Through the Chief Network Director’s Office, VHA is working with the Institute for Health Care Improvement (IHI) on quality improvement and change initiatives. IHI is an independent, nonprofit organization working to accelerate health care improvement in the United States, Canada and Europe. IHI works with health care organizations to develop and implement programs to promote better clinical outcomes, reduced costs that do not compromise quality, an easier-to-use health care system, and improved satisfaction for patients and communities. VHA is working with IHI utilizing their Breakthrough Series methodology of trial and learning to address a number of areas including reducing VA delays and waiting times and reducing adverse drug events. The collaborative is based on the premise that small tests of change in local settings are most effective at promoting internal innovation. If these tests are successful, the results can be used to spread change and improvement to other sites. This approach helps to minimize fear of failure by allowing people to experiment on small-scale projects initially. In addition, it encourages participants to learn from their mistakes as well as from their successes. For more information about IHI, see their web site: http://www.ihi.org 17 18 Office of Quality and Performance The Office of Quality and Performance (OQP) provides staff support and liaison to the Offices of the Under Secretary for Health and Network Directors on matters involving performance and organizational improvement. OQP has several initiatives that support the VHA’s commitment to continuous quality improvement and drive for organizational change including: 1) a Performance Measurement Program that is based on comparing performance in five domains of value -- quality of care, functionality, access to care, satisfaction of care delivery, and cost of care; 2) development and administration of Patient Satisfaction Surveys for different patient populations such as inpatients, outpatients, spinal cord injury patients, and prosthetic and sensory aids recipients; 3) a functional survey that measures quality of life over time; 4) development of data collection and reporting methodologies; and 5) coordination of accreditation from external agencies. OQP ensures the delivery of health care value as defined by price/cost, quality, access, functional status, and customer satisfaction. Contacts in this office include: Jonathan Perlin, MD, PhD, MSHA Chief, Office of Quality and Performance Telephone: (202) 273-8936 Fax: (202) 273-9030 Scott Beck, ME Executive Assistant Telephone: (202) 273-8327 Fax: (202) 273-9030 Stanlie Daniels, RN Director, Performance Measurement Program Telephone: (202) 273-8316 Fax: (202) 263-9030 Debby Walder, RN CPG and EPRP Manager Telephone: (202) 273-8336 Fax: (202) 273-9030 Eileen Ciesco Director, National Customer Feedback Center Telephone: (919) 993-3035 Fax: (919) 993-3053 Patricia O’Bryant Accreditation Manager Telephone: (202) 273-8334 Fax: (202) 273-9030 Other Government Resources A variety of other government agencies provide information or services to support organizational change efforts. The following list provides a starting point for obtaining information about available programs and resources in several federal agencies. NASA Headquarters Library • Organizational Change Resource List http://www.hq.nasa.gov/office/hqlibrary/ppm/ ppm11.htm • Index to Program/Project Management Resources http://www.hq.nasa.gov/office/hqlibrary/ppm/ ppmbib.htm U.S. Army Total Army Quality Program • Leading Change: Links to other information resources http://www.hqda.army.mil/leadingchange/ U.S. Office of Personnel Management • Organizational Change and Performance Improvement Services http://www.opm.gov/employ/html/org_chan.htm Non-government Resources American Productivity and Quality Center • Organizational Change: Managing the Human Side of Change Online Change-related Reference Resources Web Sites http://www.apqc.org/free Change Management Resource Library Picker Institute The Picker Institute is a non-profit institution working to improve the quality of health care "through the patient’s eyes." The Picker Institute offers a variety of products and services for health care providers and organizations looking to develop practical approaches to improving health care through the eyes of the patient. http://www.picker.org http://www.change-management.org/ Managing Change in Organizations http://www.mapnp.org/library/org_chng/chng_mng/ chng_mng.htm 19 20 21 Appendix B: What reading materials are available to provide more in-depth information on change, the change process, and the impact of change on staff and managers? Much is published on all aspects of change for all staff levels. The list below is comprehensive but by no means complete. These books and articles are categorized for easily finding resources for staff and managers. The books below are generally available from http://www.Amazon.com or Barnes & Noble, http://www.bn.com. Many of the listed books as well as the journal articles are also available from the VA Library Service or Learning Resources Service in your VISN. VA Publications Relevant to the Change Process: Transition Watch A quarterly newsletter monitoring three VHA change research projects: facility integrations, quality improvement, and service lines implementation. Volumes 1, 2, 3, 1997 to the present are available in print and online: http://www.va.gov/resdev/prt/category.htm#news A Guidebook for VHA Medical Facility Integration Published in April 1998, this guide was sent to all networks. It contains an overview of the five phases of facility integration with appendices of useful integration documents. Available from the VA Employee Education Service in St. Louis, (314) 894-5742. VHA's Strategic Planning Documents http://vaww.va.gov/vhareorg/ This VA Intranet web-based resource pulls together key VHA change documents and publications: VHA Re-engineering: selected results in brief; Journey of change II, July 1998; VISN strategic submissions 1999-2003; Summary of network strategic planning information 1999-2003; Network strategic plan summary 1998-2002; Journey of change I, April 1997; Maintaining capacity to provide for the specialized treatment & rehabilitative needs of disabled veterans, June 1999; 22 A guide book for VHA medical facility integration, April 1998; Health care, not hospitals: transforming the Veterans Health Administration – Dr. Kenneth Kizer, former Under Secretary for Health; VHA’s prescription for change & appendices; Vision for change – reorganization plan. Looking Ahead: Creating the Future. An introduction to the development of scenarios for use in organizational planning. This online primer grew out of work done by the Primary Managed Care Task Force of the Employee Education System (EES) charged with examining the future of primary care within VHA. The task force learned the importance of scenario building in articulating an organizational vision and strategic planning. This methodology offers a means to identify and refine issues and trends important to health care. http://vaww.sites.lrn.va.gov/futures/ default.asp Books for Everyone Involved in the Change Process: Campbell SM. From chaos to confidence: survival strategies for the new workplace. Phoenix: Fireside; 1996. A practical guide to thriving in the changing workplace of the nineties offers six core "meta-skills" and emphasizes the importance of participating in the change process instead of trying to control it. Fisher R, Sharp A, Richardson J. Getting it done: how to lead when you're not in charge. New York: Harper Business; 1998. Does it seem that good ideas go unnoticed? That meetings are a waste of time? Roger Fisher, author of Getting to yes, and Alan Sharp tackle the inertia that afflicts many groups. The authors describe the idea of lateral leadership as a means of breaking apart the logjams that inhibit effective collaboration in organizations. This is a practical guide to solving common workplace woes, relieving the frustrations many of us experience everyday and at the same time helping us to stand out as leaders. Galpin TJ. The human side of change: a practical guide to organization redesign. Jossey-Bass Business & Management Series. San Francisco: Jossey-Bass Publishers; 1996. Over 1800 books a year are published with the word change in the title. Galpin concentrates on the soft side–the human element. What are the ways to get management to buy into the process? How about the grass roots– frontline employees and their supervisors? How best to act like a coach? What are the parameters for effective goal setting? These questions and others are answered in a series of chapters designed not to focus on the nine-stage change process but on the behaviors needed to effect those changes: forming teams, developing leadership, measuring performance, providing feedback, and so on. Each in turn zeroes in on different guidelines; coaches, for instance, need to adopt a non-critical, positive, and empathic approach. Giovagnoli M. Angels in the workplace: stories and inspirations for creating a new world of work. San Francisco: Jossey-Bass Publishers; 1998. Giovagnoli shows readers that there are practical, powerful things we can all do daily to make a difference in our changing workplaces. A moving book that describes heroes and their stories providing tips for changing work environments by changing attitudes and behaviors in simple ways. Gladwell M. The tipping point: how little things can make a big difference. New York: Little Brown & Company; 2000. This book is about change--about how the smallest things can induce very big changes. "The best way to understand the dramatic of unknown books into bestsellers, or the rise of teenage smoking, or the phenomena of word of mouth or any number of the other mysterious changes that mark everyday life," writes Malcolm Gladwell, "is to think of them as epidemics. Ideas and products and messages and behaviors spread just like viruses do." Although anyone familiar with the theory of memetics will recognize this concept, Gladwell's The tipping point has quite a few interesting twists on the subject. Hall DT. The career is dead - long live the career: a relational approach to careers. Jossey-Bass Business & Management Series. San Francisco: Jossey-Bass Publishers; 1996. The career is dead redefines "career" as a series of lifelong work experiences and personal learnings, making career security the responsibility of the individual. Fourteen essays present views on new organizational forms, career development, secure base relationships at work, growth-enhancing relationships outside work, career issues for single adults without children, the value of diversity, and career development for older workers. Heyman R. Why didn't you say that in the first place? How to be understood at work. San Francisco: Jossey-Bass; 1994. Misunderstanding at work seems to be business as usual, yet nothing is more unproductive, costly, or frustrating. It frays tempers, s...
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