Organization of Healthcare:
The Art and Science of
Managing Change
IPC3 Learning Session II
Denver, Colorado
April 2011
Roger Chaufournier
Ann Lewis
Objectives
• Participants will understand the human
and social factors of change
• Participants will understand change
models and tools to manage change
• Participants will be able to link the change
and care models used in the Collaborative
as resources to facilitate organizational
change
Overview
•
•
•
•
•
•
•
Individual Change vs. System Change
System Change vs. Diffusion of Innovation
The change process
The diffusion of change
Spread
Using Data to drive change
Coaching for change
“There is Nothing So
Practical as a Good
Theory!”
Kurt Lewin
Deming’s Concept of Profound
Deming’s Concept of Profound Knowledge
Knowledge
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
"One need not be eminent in any part
of profound knowledge in order to
understand it and to apply it. The
various segments of the system of
profound knowledge cannot be
separated. They interact with each
PSYCHOLOGY
other. For example knowledge about
psychology is incomplete without
knowledge of variation."
APPRECIATION
OF A SYSTEM
THEORY OF
KNOWLEDGE
PSYCHOLOGY
UNDERSTANDING
VARIATION
system knowledge
of profound
knowledge
"One need
not be eminent in any part"The
of profound
in order
to
VARIATION
provides
a lens. Itofprovides
a new
understand it and to apply it. The various
segments
the system
of map
profound knowledge cannot be separated.
They interact
with each
other. For and
of theory
by which
to understand
example knowledge about psychology optimize
is incomplete
without knowledge of
our organizations.“
variation."
UNDERSTANDING
"The system of profound knowledge provides a lens. It provides a new map
of theory by which to understand and optimize
organizations.“
Source:ourJerry
Langley, Associates
Process Improvement
Source: Jerry Langley, Associates in Process Improvement
in
The Process of Change
Individuals and Change
•
•
•
•
•
•
•
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Sustain
Source: Prochaska and DiClemente
What is to be Changed?
• Processes
• Behavior
Assessment of Change
• Quantitative Data
– Measures
• Qualitative Observations
– Observed Behavior Changes
– Changed Beliefs, Attitudes, Values
We need them all to claim real change
Is There a General Theory of
Change?
• Yes, if we build on Kurt Lewin’s social
psychological theories of how all
systems are in a state of “Quasistationary Equilibrium” based on
multiple driving and restraining forces.
• What then are the elements and
mechanisms of change?
Process
of Change
TheThe
Process
of Change
Lewin’s Model
Lewin’s Model
Unfreezing
Unfreezing
Disproving
beliefs
Disprovingcurrent
current
beliefs
Creating a tension for change
Creating a tension for change
Need new tools and methods
New Learning
New
Learning
Refreezing
Refreezing
Need new tools and methods
Reinforcement
Reinforcement
Recognition
Recognition
Key Elements of Any
Change
• Disconfirmation
– Survival Anxiety/Guilt (SA)
• Proposed New Direction/Behavior
– Learning Anxiety (LA)
• Difficulty of Unlearning
• Fear of New Learning
• Resistance to Change
Edgar Schein, PhD, Sloan Fellows Professor of Management Emeritus
and Senior Lecturer, Sloan School
Disconfirmation
• Any information that something is not
happening in the way we expect or
want
– Produces motivation to change, usually
felt as Survival Anxiety or Guilt
• What are some examples of ways
leadership can provide
“disconfirmation”?
Proposed new direction
• The recognition of what we might have to
do to solve the problem, to make the
change produces Learning Anxiety
• We realize that the new behavior, attitude,
value etc. wanted of us will be potentially
painful and costly, especially if we have to
unlearn the present behavior that we are
used to.
Resistance to Change
• Is the result of…
– Fear of period of incompetence
– Fear of loss of power/job/role
– Fear of loss of group membership
– Fear of loss of personal identity
– Your thoughts……
The Path to New
Behavior
• Survival Anxiety must be greater than
Learning Anxiety
• Increasing Survival Anxiety increases
resistance
• Therefore, the key is to REDUCE
LEARNING ANXIETY
– By providing Psychological Safety for
Unlearning and New Learning
How to Provide
Psychological Safety
• Provide a compelling positive
vision
–New behavior desired
–Compelling reasons for new
behavior
• This is a Leadership role: paint
the future vision!
Providing Psychological
Safety
• Involve the learner in the learning
process and provide choices on how
to learn
– This becomes a coaching role
How to Provide
Psychological Safety
• Insure that incentive, reward and discipline
processes are congruent with desired new behavior
– Discussion: ideas and examples
• Provide resources for managing the unlearning and
new learning
– Time
– Training/Coaching/Feedback
– Role Models
– Practice fields and opportunities (PDSAs!)
– Support Groups
The Mechanism of
Change
• New Behavior
• New reinforcements and rewards
• Cognitive Redefinition
– New Semantics
– New Adaptation Levels
– New Judgment Criteria (Measurement)
Implications
• All changes undergo some version of
this process if we study them carefully
• Change programs that fail are missing
one or more of the elements described
• How the elements are managed is a
very local phenomenon
• Change is a process that requires
process skills
Spreading Innovation vs.
Change
Everett Rogers
Rogers
Everett
Diffusion
of Innovation
Diffusion
of Innovation
X
Innovators
Innovators
Early
Adopters
2%
13%
Early
Majority
Early
Majority
Late
Majority
Late
Majority
Traditionalists
Laggards
35%
Early Adopters
35%
8
Rogers E. Diffusion of Innovations. New York: The
Free Press, 2004.
15%
Malcolm Gladwell
• The Tipping Point
– Connectors vs.
– Mavens
Leading Change
Tight-Loose-Tight
• Tight on vision and direction
• Loose on how to get there
• Tight on monitoring and feedback
Changing Systems
Different Approaches to System
Change
Use Change Models
Examples of change models:
• PDSA- Continuous improvement methods
• The Care Model
• The Learning Model
Model for
Model
for Improvement
Improvement
What
arewe
wetrying
tryingtoto
What are
accomplish?
accomplish?
How will we know
know that
thataa
Model
change
animprovement?
improvement?
changefor
isisanImprovement
What are we trying to
What
change
can
make
What change
can
wewe
make
thatthat
accomplish?
will
improvement?
will result
result in improvement?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Act
Study
Study
Plan
Plan
Do
Do
Material
is from
The
ImprovementGuide,
Guide,Second
Second Edition,
2009
Material
is from
The
Improvement
Edition,Jossey-Bass,
Jossey-Bass,
2009
Sequential Building
of Knowledge:
Include
a Wide
Repeated
Use of
the
Cycle
Range of Conditions in the Sequence of Tests
A
A PS
Theories,
hunches,
Hunches
& best
practices
Theories
Ideas
A
P
S
D
A
P
S
D
S D
A
P
A P
S
D
S D
Material is from The Improvement Guide, Second Edition, Jossey-Bass, 2009
Changes
That
Breakthrough
in
P Result
Results
Improvement
D
Change Concepts
• The change concept-Rainforest Café
• Lens to view the world
• Lean Thinking examples
Lean
Thinking:
Waste
Lean Thinking: Waste
Overproduction
Overproduction
Waiting
Waiting
Producing more than needed
Producing
needed
Producingfaster
more than
than needed
Producing faster than needed
Time when a worker is idle
Time when a worker is idle
Transportation
Any movement of material or information not
Any movement of material or information not
essential
for the process
essential for the process
Processing
Processing
Operations
donothing
nothing
Operationsthat
thatin
inreality
reality do
Inventory
Inventory
Anythingmore
morethan
than immediate
immediate needs
Anything
needs
Motion
Motion
Motion
manor
ormachine
machine that
Motion
ofofman
thatisisunnecessary
unnecessary
Correction
Correction
Rework and inspection
Rework
and inspection
Transportation
What You Need to Do to
Drive Change
• Prepare the environment-create the
tension for change
• Use the new models to provide your team
with the tools and new methods
• Reinforce by creating a more attractive
future
• Use measurement to reinforce
• Continue the “visioning” process to
connect the dots
Measurement Feedback Is
Critical to the Change Process
Upper Limit
No Lower Limit
Dashboards
Dashboards
KQI_ending-063004.pdf
Informed
decisions through the use of appropriate and timely data
4/22/2011
© 19 99 Arthu r Ande rsen. All rig hts re served .
Source: Richard Davis, Johns Hopkins Business of Medicine Program
Summary
• Understand the human and social
aspects of change
• Use disciplined methods to drive
performance
• Measurement and feedback are critical
to the change process
• Plan for the spread and sustainability
of your work