# Presentation: 184186

## Organizational Change

- Martin P. Charns, DBA
- Director
- COLMR

## Greenhalgh et al.

- Very comprehensive systematic literature review of diffusion & implementation
- Addresses multiple perspectives
- Characteristics of innovation
- Process of implementation
- Context

## Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation

**Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation**

***Knowledge ***
***purveyors***

***Resource System***

***Change agency***

**The Innovation**

**Dissemination**

**LINKAGE**

***Outer context***

**System readiness**

**Adoption**** ****/**** ****assimilation**

**Implementation**

***User System***

**LINKAGE**

**Consequences**

**System antecedents**

**Diffusion**

## QUERI Focus

- Largely on the innovation (EBP) & process of implementation
- Less detailed focus to date on organizational context, including history

## Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Innovation

**Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Innovation**

***Knowledge ***
***purveyors***

***Resource System***

***Change agency***

**The Innovation**

**Dissemination**

**LINKAGE**

***Outer context***

**System readiness**

**Adoption**** ****/**** ****assimilation**

**Implementation**

***User System***

**LINKAGE**

**Consequences**

**System antecedents**

**Diffusion**

## The Innovation

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

## Adopter

- Needs
- Motivation
- Values & goals
- Skills
- Learning Style
- Social networks
- Adoption Decision: Stages
- Preadoption
- Early use
- Established users

## Communication & Influence

- Diffusion (informal, unplanned)
- Social networks
- Homophily
- Peer opinion
- Marketing
- Expert opinion
- Champions
- Boundary Spanners
- Change agents
- Dissemination (formal, planned)

## Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Organizational Factors

**Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Organizational Factors**

***Knowledge ***
***purveyors***

***Resource System***

***Change agency***

**The Innovation**

**Dissemination**

**LINKAGE**

***Outer context***

**System readiness**

**Adoption**** ****/**** ****assimilation**

**Implementation**

***User System***

**LINKAGE**

**Consequences**

**System antecedents**

**Diffusion**

## Outer Context

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

## System Antecedents for Innovation

- Structure
- Greenhalgh et al. note that structural features account for 13% of variation among organizations in their innovativeness
- Absorptive capacity for new knowledge
- “...knowledge must be enacted and made social”
- Receptive context for change
- Leadership, culture

## System Readiness for Innovation

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

## Implementation Process

- Decision making devolved to frontline teams
- Hands-on approach by leaders & managers
- Human resource issues, esp. training
- Dedicated resources
- Internal communication
- External collaboration
- Reinvention/development
- Feedback on progress

## Successful Transformation Beyond Projects

- Most organizations can manage individual projects – even many individual projects
- Making specific projects a priority
- Getting people to work extra hard
- Often achieves project change
- Is not sustainable
- By focusing on individual projects it is easy to forget:
- that many others things are happening in the organization
- that other things outside of the project need to be addressed to achieve project success

## Successful Transformation Beyond Projects

- Model of transformation utilizes many of the organizational concepts reviewed by Greenhalgh et al.
- Model is more dynamic

## The Detailed Model of Healthcare Transformation

## Healthcare Transformation Model - Overview

## Model Overview

- Transformation begins with a sense of _urgency_
- Permanent, organization-wide change builds _iteratively_
- To maximize effectiveness, organizations _align_ & _integrate_ efforts
- Organizations develop infrastructure to support the new way of functioning
- Improvement becomes part of organizational fabric – “the way we work”
- Success motivates staff to continuously strive for higher goals (e.g., patient satisfaction & high reliability)

**Notes:**
Survey: Having organizational direction (a clear sense of direction and a clear action plan) is correlated at .48 (range .33 - .53) with staff perceptions of patient care today.

## Change Is Iterative

- Fundamental organization change takes longer than 2-3 years
- Organizations learn from prior experiences
- Failures are instructive
- Redesigning care & implementation involve multiple, iterative cycles – “the more we improve, the more there is to do...”
- Testing new models
- Training
- Facilitation
- Resolving barriers
- Changing culture

**Notes:**
Site’s use of new models: The Clinical System Improvement group identifies process owners for each project so the right people are at the table from the start and so that the changes that result are tested and adopted.
Site’s Use of new Models: In earlier phases they used implementation coaches but shifted to assigning managers and staff responsible for affected work processes to teams.
Other models: Service lines are responsible for implementation. Multidisciplinary rounds are individual performance units that build and maintain uniformity and contribute to implementation.
Evaluators’ comment: In spring 2004, we asked each site how far along the continuum towards perfect care they thought they were. They described how as they have done the work of the last three years they realized just how far it is they have to go. They saw themselves as between 11 – 30 percent of the way there. If we had asked the question a few years ago, they would have given a higher number.  The end point moves...

## Impetus to Transform

- Creates sense of urgency to overcome inertia & fear of change
- Examples
- Critical incident
- Financial crisis
- Financial stability
- Growth
- Mission (patient-centered)
- Combination of two or more

## The Impetus To Transform

- External sources* *of urgency* (Crossing the Quality Chasm*,* *JCAHO, VA Mandate, etc.)
- Sentinel events & benchmarking data make staff realize that care & quality not as good as they should be
- Maintain sense of urgency

**Notes:**
Site’s perspective on urgency: “The Six Aims are a major part of what our organization strives toward.” Starting with a senior management retreat, the organization  acknowledged quality gaps and were transparent about the need to improve. Staff are now expected to be familiar with the Six Aims; orientation to the Six Aims is part of new employee orientation. 
Site’s perspective on P2 visibility: Because P2 was a high visibility grant, people were paying attention to what they were doing and were anxious to hear what was happening. It did not feel like a typical challenge.
Site’s perspective on creating urgency: One challenge was getting physicians aligned with the goal of being a world-class organization. Using JCAHO and CMS measures, we showed physicians that they were not as good as they thought they were. Physicians were taken aback when they saw the numbers.
Other site examples of ways to maintain urgency: theatrical presentations, videotapes of staff who were patients as they recount episodes reflecting poor quality or safety, training
Survey: The perspective that the organization is committed to delivering perfect care was correlated with patient care today (.44 with range of .34 - .60) and being comfortable leaving a relative alone (mother question) (.40 with range of .28 - .54) 

## Improvement Projects

- Vehicle for process/outcome improvement
- Vehicle to engage multi-disciplinary front-line staff in meaningful problem solving
- Concrete (vs abstract vision statement)
- Clinical & important focus to engage clinicians

## Improvement Projects

- Builds skills, motivation & culture that will support & sustain quality improvement
- Actively engage staff around priority clinical issue
- Collaborative, interdisciplinary work, including MDs
- System re-design to build evidence-based practices into daily work
- Goals & measures (monitor progress & whether improvement is sustained)
- Project support (training, tools, measures, facilitation)
- Shared learning & spread

## Infrastructure

- “Hard” Infrastructure
- Information systems
- Clinical support systems
- “Soft” Infrastructure
- Workforce skills, values, expectations (engagement)
- Organizational culture
- Key role of infrastructure in transformation:
- AMI example

## Alignment

- Managing the “vertical” = consistent organizational vision, values & behavior from top to bottom
- Both strategic & operational
- Improving quality is top priority; support, resources & rewards are aligned accordingly
- Align improvement projects with strategy & organizational goals throughout the organization

**Notes:**
Site: realized that all of their separate QI projects were not getting the organizational change they were looking for; they moved to specifying improvement projects that were based on their strategic goals.

## Tools & Structures To Support Strategic Alignment

- Strategic planning
- Strategic plan linked to everyone’s job (SSM & Baldrige)
- Management structures
- Measurement & Reporting
- Dashboards, scorecards
- Communication
- Transparency
- Resource allocation
- Accountability & performance evaluation
- Recognition, rewards & incentives
- P4P, performance awards
- Information Technology

**Notes:**
Managing the vertical: Examples: #1: CEO Council uses the Baldrige framework to set organizational goals, objectives and progress measures. Departmental goals and measures are specifically linked to organizational objectives with the plan to link individual performance objectives. #2: The strategic plan emphasizes service excellence and employee satisfaction and is built around core values. All organizational initiatives are mapped to service lines for accountability. #3: Uses 6 month planning cycles to refresh strategic framework. All business plans and QI initiatives are aligned with 6 key priorities or are taken off the plate. 
Improvement as a top priority: Examples: CEO attends weekly organizational quality meetings, CEO spends significant time talking with staff about transformation, senior leadership rounds with patients and staff weekly and sometimes daily, email forum and open door policy to encourage dialogue, CEO minimizes external commitments to help maintain focus on priorities
Survey: From the workgroup perspective, daily activities demonstrating quality’s importance was correlated with patient care today (.44 with range .34 - .54) and with the “mother question” (38 with range 31 - .47).
Survey: Having an organizational priority to have leadership involved in QI was correlated with patient care today (.34 with range .24 - .53) and with the “mother question” (.34 with range .20 - .53) 
Baldrige: One organization required each site to apply for the state award and continue to work towards continued national acknowledgement. Other sites  submitted Baldrige applications and are using the feedback to improve; other sites are using the framework to strengthen alignment, and some are planning to apply.

## Integration

- Managing the “horizontal” = consistency across the organization(s)
- Breaking down silos across:
- departments & workgroups
- organizational units
- Integrating across improvement initiatives
- Improving coordination of patient care

**Notes:**
Need to get example of integrating across improvement efforts to facilitate spread.
Example: “You don’t go and redesign the cath lab; you work toward patient outcomes. In the process, the cath lab is redesigned. From project to project, methodology and results are applied to other issues – this is spread. This is how you get to all – to transformation.”
Example: to engage physicians in private offices, identified a problem common to all physicians which revolved around inpatient admission and discharge processes. 
Survey: having difficulty fixing problems with other workgroups was correlated with the perception of patient care today (.35 with range .24 - .43) and with the mother question (.36 with range .24 - .48) 
Survey: Relational coordination (Across workgroups, people communicate accurately and timely, respect each other’s work and share goals) was correlated with patient care today (.43 with range .33 – 55) and the mother question (.41 with range .29 - .55)

## Examples of Integrating Mechanisms & Processes

- Service Lines
- Cross-organizational teams, workgroups
- Quality management oversight structures
- Steering committees (e.g., integration across organizational/community boundaries)
- Project teams with overlapping membership
- Clinical effectiveness departments moving innovations from one team to others
- “Clinical Systems Integration” unit
- Collaboratives
- Integrating quality into operations
- Information systems

## Leadership Drives & Facilitates Alignment & Integration

- Leadership team & leaders at all organizational levels
- Board, administrative, clinical leaders
- Commitment to & passion for quality improvement – “walks the talk”
- Constancy of purpose; unrelenting pursuit of goals
- Translates commitment into action
- Investment of own time in quality activities
- Fosters learning
- Holds staff & teams accountable
- Provides resources & infrastructure for improving quality
- Integrate activities across organizational boundaries (facilities, workgroups, functions)
- Communicates & builds relationships
- Gets the right people “on & off the bus”
- Facilitates a well organized & well run effort

**Notes:**
Need to identify examples of leadership that are not the obvious ones....
Passion: The CEO represents passion and is described as a critical component. “It is not lip service; it’s sweat equity.”
Constancy of purpose: CEO’s emphasis on transformation is intended to change the culture and maintain a sense of urgency. The CEO will be disappointed if the organization does not develop an “impatient, edgy culture and that there is no excuse for not doing things exceptionally well.”
Learning: book club for physicians, the expectation of those in the top 1/3 of the organizations within a larger structure on performance measures going outside the organization to learn something new and those in lower 2/3 go to another site within the organization to learn
Right people: LM uses physician compacts to set and align expectations: some physicians have left and new hiring has been affected. 
Survey: perception that the organization has a priority for leadership to be involved in QI efforts was correlated with patient care today (.34 with range .24 - .53) and the mother question (.34 with range .20  - .53)
Survey: perception that organization provides training supportive of quality was correlated with patient care today (.38 with range .24 - .49) and with the mother question (.35 with range .20 - .47)
Survey: the provision of resources and support at the workgroup level was correlated with patient care today (.41 with range .32 - .53) and mother question (.43 with range .33 - .54)
Survey: communicating about the reasons for change and QI progress was correlated with patient care today (.45 with range .33 - .48) and with the mother question (.39 with range .26 - .48)
Survey: the perception that the organization employs people with the passion and influence to make change happen was correlated with patient care today (.37 with range .26 - .43) and with the mother question (.35 with range .26 - .42)
Survey: perceiving that within the workgroup there is a well organized process of change was correlated with patient care today (.43 with range .31 - .57) and mother question (.41 with range .32 - .56)
Survey: receiving adequate notice of change was correlated with patient care (.38 with range .26 - .51) and with mother care (.38 with range .29 - .50) 

## Leadership Drives & Facilitates Alignment & Integration

- Establish structures to link improvement efforts to senior management:
- Create accountability through measures, reporting and monitoring  progress
- Actively support the projects and resolve problems
- Identify senior (e.g., quadrad) champion
- Recognize & reward success
- Don’t allow continuance of inappropriate behavior
- Use of key opportunities & events

## Conclusions

- Quality improvement activities that are limited in scope are unlikely to be sustained
- Organizational transformation requires addressing all key model elements

## ConclusionsBuilding Change Over Time

- QI projects cornerstones of organizational change
- Demonstrate that change is possible
- Build involvement
- Engage clinicians
- Bring about spread
- Infrastructure development (e.g., information technology)
- Building culture & skills (e.g., workforce development)
- Frontline/microsystem efforts
- Patient involvement in redesign efforts
- Success builds knowledge & stimulates momentum

## Questions & Discussion