MANAGEMENT BRIEF

Number 18 Overviews of Health Care Topics for VA Senior Managers December 2000

Change: An Opportunity for Progress

“Change is a fact of life in today’s health care environment. 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’ health care.”

John G. Demakis, MD

Director, Health Services Research and Development Service

What is organizational change?

Organizational change is any action or set of actions that

alters the organizational direction or process, thus affecting

how an organization works. This type of change can be deliberate and planned by leaders within the organization (e.g.,

shift from inpatient hospital focus to outpatient primary care

model), or change can be driven by outside forces (e.g., Congressional budget cuts) and be beyond the organization’s control. Depending on the scope of the change, organizations can

be affected in many ways. For example, the tasks and functions performed by members of an organization and the working relationships between those people may be altered.

Change also may affect the strategies an organization uses

to carry out its mission, and the processes for implementing

those strategies.1

Why is it important to actively manage

the change process?

Excellent ideas can launch ambitious change initiatives

that may or may not succeed depending on whether these

initiatives are adequately and actively managed. An

unmanaged change usually accomplishes nothing, and

can produce unintended, detrimental effects such as poor

morale, loss of trust in management, and lower productivity.

Thus, managing the process of change is as important as

the planning that inspires it.1

What are some critical strategies for managing change?

There are several key strategies that can help managers

make change easier. Depending on an organization’s

culture, history, and the nature of the change being implemented, managers must choose the strategies that fit their

organization’s needs. Strategies to consider include:

determining the context for change (i.e., who’s involved in

the proposed change and how will they be effected); building

support for change (identify “champions” or “core believers”); developing a vision that enables people to imagine new

opportunities; articulating clear, specific and realistic goals;

communicating to all levels of the organization (e.g., meetings, retreats, newsletters, etc.); identifying barriers to change

(internal, external, psychological, cultural, etc.); looking for

the early win (maximize initial, small successes); and recognizing people for their participation in change efforts. Most

important, managers should encourage organizational flexibility in a work environment that is open to change.1

What are possible pitfalls in implementing change?

Challenges and obstacles are an inherent part of organizational change. However, while every setback may provide

an opportunity to reassess and improve the process, there are

some things a manager can do to avoid them. 1) Focus efforts

on core supporters and undecideds. Trying too hard to win

over hard core resisters will drain energy and resources.

2) Don’t underestimate the power of communication throughout the change process. Use a variety of media to get the

word out including email, newsletters, and meetings.

3) Know that some people won’t adapt to the change despite

manager’s efforts to invite their participation. Difficult as it

may be, the employee may need to leave the organization or

the manager may need to find another placement for him/her.

4) Although stakeholder consultation and participation in the

change initiative are important, managers should not allow

stakeholders to “take over” the process. Stakeholders should

be viewed as expert resources and their interaction managed

effectively with a clear understanding of how their input

will be used.1

VA HSR&D Management Brief December 2000 Page 1 of 3
VA HSR&D Management Brief Number 18, December 2000 Page 2 of 3

Restructuring Organization through

Service Line Implementation

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 specific veteran

patient groups, such as those with mental illness or spinal

cord injury (SCI). Service lines are also characterized as an

integrated set of services that are distinguishable from other

services by the technology or specialty employed.

HSR&D's Management Decision and Research Center

(MDRC) recently reported on the development of VISN-level

service lines from 1997 through December 1999. Results of

their study show that all networks have explored the concept

of service lines by forming task forces, and some have gone

further by implementing a more integrative service line structure. Networks can be divided into three groups based on the

degree to which they employ service lines: 1) those using task

forces exclusively (these are not “service line” by VA definition), or those with more integrative structures in highly specialized areas only, such as SCI; 2) those primarily using

teams; and 3) those relying on divisional or matrix structures.

The majority of VISNs are in the first category. One-quarter

of the VISNs are in the last category, are utilizing service

lines as a primary network integration strategy and have provided, or intend to provide, budget authority to their network

service line managers. The study has also found that the

greatest number of network-level service lines is in the

clinical areas of primary care, mental health, and geriatrics/

extended care.

In general, networks have implemented less integrative

forms of service lines than have facilities. This may be due to

differences in the purposes of service lines at the network and

facility levels or to unique issues facing networks, such as the

distance between facilities.

Rising JP, Charns MP. Three paths of implementation:

Network-level service lines, 1997-1999. Transition Watch,

Management Decision and Research Center, VA's Office of

Research and Development, HSR&D, Winter 2000; 3(2):1-6.

Impact of Facility Integration

Hospital or facility integrations are highly complex endeavors. Analyzing the processes and progress of integration

can provide unique and valuable information for other systems striving to integrate independent facilities. In the last six

years, nearly 50 VA medical centers integrated to form new

VA health care systems. These integrations progressed at different rates and have adopted a variety of structures, but they

all share the same objectives – improving the quality,

access and efficiency of health care services for veterans.

In a study conducted by the MDRC, investigators examined the impact of integration on four dimensions that VA

integrated system directors rate as important to achieving

integration objectives: cost savings/system efficiency; redirection of resources from administrative to clinical care;

improved access to care; and quality of care.

Study results suggest that the integration of VA’s health

care systems is, thus far, having modest effects. Integrated

systems improved staffing efficiency significantly more

than comparison groups, but did not show significant improvements in costs or redirecting resources from administration to clinical care. Both integrated and comparison

systems have made significant progress in reducing access

problems for patients. This study also suggests that how

long the system had been integrated did not make a difference in results. Systems that were integrated before

FY1997 did not show more positive results than systems

that had been integrated for a shorter period of time.

The modest effects of facility integration should be

considered in the context of the high costs of integration,

such as change anxiety, disruption and dislocation issues.

System leaders may want to explore alternative strategies

for accomplishing the same efficiencies – service consolidations, single standards of care, and improved access –

without fully merging their facilities.

Lukas CV, Desai K. Effects of facility integration.

Transition Watch, Management Decision and Research

Center, VA’s Office of Research and Development,

HSR&D, Summer 2000; 3(4):4-7.

Health System Integration Scorecard

Many health care organizations are striving to create

integrated delivery systems. The expectation is that integration will enable them to provide higher quality care at

lower costs, while maintaining or improving the health

and satisfaction of their patients. Leaders of the VA Upper

Midwest Health Care Network (VISN 13) worked with

HSR&D investigators to develop a scorecard to help them

monitor their progress toward system integration. The

scorecard has three components: an inventory of service

line structures as implemented in the system, a survey of

staff to measure system integration, and network performance measures. Here, we focus on the results of the

staff survey.

Methodologically, the integration survey demonstrates

that reliable and valid indicators of system integration can

be obtained from staff by means of a self-report questionHSR&D is examining many of the organizational changes taking place within VA.

Below is a brief discussion of some of the studies looking specifically at the development

and implementation of changes in care delivery and organizational design.
MANAGEMENT BRIEF is produced by the Management

Decision and Research Center, a program within VA’s Office

of Research & Development, Health Services Research &

Development Service. The purpose of the MANAGEMENT BRIEF

is to provide VA senior management with a concise and

timely overview of a specific health care topic that includes

topic definition, benefits, VA research activities, and resources for further information.

For more information about this issue of

MANAGEMENT BRIEF please contact:

Geraldine McGlynn, M.Ed., Manager, Information

Dissemination Program, MDRC (152-M), VA Boston Health

Care System, 150 S. Huntington Avenue, Boston, MA 02130.

Phone: 617-278-4433. Fax: 617-278-4438.

To access back issues of MANAGEMENT BRIEF and/or additional MDRC publications and reports, visit the Research and

Development web page at http://www.va.gov/resdev/prt, or

the Intranet site at http://vaww.va.gov/resdev/prt, or call the

MDRC Fax-on-Demand system at (617) 278-4492.

naire. The scales that emerged from the analyses capture

dimensions that Network managers are working on in their

system development. Survey findings report important information in three key areas: 1) Progress of integration: Midrange scores indicate that staff see the characteristics of a

well-integrated system only part of the time, confirming senior leadership’s perception that system integration is in its

early stages. 2) Patterns of integration: For example, staff

across the Network report highest scores on the leadership

scale (i.e., network and facility leaders clearly articulate objectives and staff understand how their work furthers the

objectives), suggesting that this scale is a leading indicator

of integration. In contrast, low scores on service cooperation

(i.e., staff share problem solving and coordinate administrative and support efforts across facilities) indicate that it is an

area that follows later in the integration process. 3) Areas

needing support: For example, managers tend to give higher

scores on the system integration scales than do clinicians or

general staff on all dimensions except clinical coordination.

While this is a common pattern in changing organizations, it

suggests the need for continued efforts to move integration to

front-line clinicians and general staff.

HSR&D researchers are broadening the usefulness of

the integration survey by administering it in the VA Upper

Midwest Health Care Network, and in three other VA health

care networks.

VanDeusen Lukas C, Meterko M, Lowcock S, Donaldson R,

Blakely M, Davies M, Petzel R. Monitoring the progress of

system integration. Corresponding author: C. VanDeusen

Lukas; e-mail: carol.vandeusenlukas@med.va.gov.

National VA Quality Improvement Study:

What the Data Show

The National VA Quality Improvement Study (NVAQIS) is

a three-year project that examines and reports VA’s transformation through a range of data collection strategies, including

employee surveys, interviews with Headquarters staff and

network directors, and site visits to facilities. Supported by

HSR&D and the National Science Foundation, this study obtains information on a variety of indicators related to quality

improvement, customer service orientation, and organizational culture. Study surveys are repeated three times so that

investigators can assess VA’s progress over time on specific

survey indicators. The first two surveys have been completed,

and the third is in progress.

Overall, VA facilities did not exhibit any signs of substantial quality improvement between the first and second rounds

of the survey. However, during the early stages of a transformation effort it is common for the transforming organizations

to experience some decline in performance, due to the disrupVA HSR&D Management Brief Number 18, December 2000 Page 3 of 3

tion surrounding the transformation before improvements in

performance are realized. Continuously monitoring these

large-scale change efforts will ultimately help inform the

planning and implementation of future VA change efforts.

Young GJ, Desai K. National VA Quality Improvement

Study (NVAQIS): Interpreting the data. Transition Watch,

Management Decision and Research Center, VA’s Office of

Research and Development, HSR&D, Spring 1999; 2(3):1-6.

* Updates on the progress of the Service Line

Implementation, Facility Integration, and National VA

Quality Improvement Studies are reported quarterly in

“Transition Watch,” which is available on the web at

http://www.va.gov/resdev/prt/category.htm#news.

References:

1. Organizational Change Primer. May 2000. Boston, MA:

Management Decision and Research Center; Washington,

DC: VA Health Services Research and Development

Service, Office of Research and Development, Department

of Veterans Affairs.

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