Rapid-change events in local, national, and international cultures and economies are challenging traditional expectations in the workplace—and forcing leaders, especially physician leaders, to face the unknown. Countless articles discuss the barrage of disruptions that organizations and people are facing. One of these notes that, in the year studied, one in four organizations undertook a significant change initiative every other month. [ATD/i4cp, “Change Agents: The Role of Organizational Learning in Change Management” (Alexandria, VA: ASTD Press, 2014)] Many have also written (on LinkedIn, Harvard Business Review, FastCo, Forbes, and BizWeek, among others) about the sobering reality that roughly 75 percent of all change efforts fail.
RAPID, DISRUPTIVE CHANGE—NOT THE SAME AS A TECHNICAL CHALLENGE
A Google search for “change management” yields more than 94 million results. Missing from the literature, however, are practical approaches to objectively assessing the types of change organizations face, and the implications for how we respond as leaders. With health care now in a permanent state of disruption, we need ways to understand the nature and types of changes we face, respond to them strategically, and develop tactical solutions accordingly. Physician leaders can help others begin to see change as ongoing, evolutionary, and emergent. This opens the possibility of responding intentionally to change, rather than simply reacting to it.
Thought leaders have identified two distinctly different types of challenges. Originally described by Ronald Heifetz, founding director of the Center for Public Leadership at Harvard University’s John F. Kennedy School of Government, technical challenges are relatively easy to define and understand, and you can organize and manage solutions to them as enterprise initiatives. By contrast, adaptive challenges are ambiguous and hard to define, and sometimes even undetectable to the people facing them.
HOW TO RESPOND: METHOD VS. MINDSET
Traditional change management models respond well to technical challenges. At the enterprise level, John Kotter’s 8 Steps (or variations on that model) can be effectively used to manage, control, and communicate technical change initiatives both large and small. At the individual level, William Bridges’ Transition Model and the Prosci ADKAR Model describe the psychological stages people go through as they face change. These models are important because a frequent cause of failure in change management is a lack of attention to stakeholder reactions or receptivity, as well as misaligned expectations regarding the willingness of people to get on board. Organizations employ these methodologies to manage reactions to change, often using a variety of models in tandem to tackle such technical challenges as an ERP implementation, a re-org, or a facility move.
Many of the changes health care organizations are facing now, however, are adaptive in nature. They require leaders who have developed mindset qualities that do not come naturally, such as introspection and self-governance. Adaptive leadership often requires a change in attitudes and beliefs about what it means to be a leader—deeper work than what is typically involved in a leadership development program focused on knowledge and skill development. Yet it is attitudinal development that enables leaders to navigate increasingly complex operating environments and provide critical system-level leadership.
Moreover, when you change deeply held attitudes, beliefs, and notions of purpose and identity, the experience can be richly rewarding and transformative.
WHAT MAKES A GOOD CHANGE LEADER?
This type of complex cognitive development results in more effective and professional leadership, along with a healthy dose of personal fulfillment. Mindset changes are often challenging, complicated, personally difficult, and time-consuming. They require stepping outside of your comfort zone. For many, the emphasis on traditional leadership competencies and effectiveness can create a false sense of security.
While relatively little has been written about the specific competencies change leaders need, there are a few noteworthy exceptions. My colleague Nancy Winship describes several of them in Meta-Skills for Adaptive/Agile Leadership in a “VUCA” Landscape. Doug Ready at the International Consortium for Executive Development Research similarly describes "4 Things Successful Change Leaders Do Well." Nate Boaz and Erica Ariel Fox at McKinsey & Company make a useful distinction between two types of self-awareness in Change Leader, Change Thyself. One of these is an awareness of one’s competencies, which serves as a strong foundation for adaptive leadership development.
If physician leaders can improve their awareness and understanding of the types of change they face, they can respond better at a personal level while supporting their organizations’ responses to change. The sooner we make distinctions between the types of change we are facing, the sooner we can employ the right tools to address them.
Kevin Osborne is Vice President of Client Services for Waldron, a leading for-benefit consulting firm serving clients in the private and social sectors. Through a unique combination of executive coaching, leadership development, search, and career transition services, Waldron helps organizations and individuals realize their full potential and sharpen their competitive edge.
A LEADER’S ROLE: INSPIRING OTHERS TO EMBRACE TRANSFORMATION (PART 2)
By Debra Wiggs, FACMPE
HOW CAN A LEADER FACILITATE TRANSFORMATION?
In today’s uncertain environment, many health care organizations are looking for solutions to their most pressing issues by implementing large-scale changes in their cultures and launching new processes. Transformation is a series of vision-related changes driving to a much more long-lasting effect. Leading any change is scary for most leaders, and many organizations. While there are several things an individual can do to prepare to lead transformation, in the end, being properly equipped is both a skill and a mindset.
Successful transformation management is reliant upon the attitudes and perspectives of leadership. If leaders see change as an opportunity, not as a burden, and choose to think about it differently, they can lead others in their health care organization by creating a culture of improvement osmosis.
Transformation is rooted in a leader’s intention and, in order to obtain support, that intention needs to be an honorable one, demonstrated first and foremost by leaders themselves. Good leaders will actively immerse themselves in the process of transformation, not just the goal. The gradual pace of implementing substantial changes can be particularly challenging for professionals in health care, where there is a sense of urgency and a tendency for providers and management to focus on the goals, anticipating results rather than being active participants in the process.
As Frances Hesselbein said, “Culture does not change because we desire to change it. Culture changes when the organization is transformed; the culture reflects the realities of people working together every day.”1
WHOM SHOULD A LEADER LOOK TO FOR INPUT?
Leadership is often a lonely place to be, especially when implementing change—resistance and barriers to success surely await. Leaders should engage a trusted team of advisors and stakeholders who will be willing to provide honest feedback or call ideas into question. Wise leaders also seek others who have accomplished the changes they want to achieve, and learn from their experience. Why reinvent the wheel?
Once an intention has been set, a leader can begin to break long-term goals down to a beginning, middle, and end, establishing a path forward. During the initial stages of implementation, engaging others in the strategic planning process will result in a better long-term vision. Without this engagement, managing transformation is very difficult.
Focusing on one or two metrics—related to the value stream—to measure throughout the transformation process, and measuring them the same way every time, is essential. This will help to ensure that the improvement work stays aligned with long-term goals.
HOW CAN LEADERS CREATE BUY-IN?
A leader’s willingness to collaboratively engage others in achieving the desired outcome is also critical. Proactively engaging staff in strategic planning sessions will help to achieve and align the “end in mind,” and help gain buy-in from the organization and staff.
Another way to create buy-in is to create a compelling story. Many people need data to substantiate reasoning, and data is a puzzle that, once completed, can tell a compelling story. When choosing a value stream to focus on, first listen to what the data is saying. Numbers are a great source of truthful information that should drive the scope and magnitude of the changes being implemented. What story are the data telling? Substantiate quantitative data with qualitative data, and be willing to look at things not normally considered. Consider what opportunities present. What is the cost of not changing? Data modeling tools, such as waterfall charts, are helpful here. Be willing to assemble the story one picture at a time, like a puzzle, and reassess when something doesn’t fit.
HOW DO LEADERS GET DETRACTORS AND FENCE-SITTERS ON BOARD?
Engaging skeptics and detractors on the front end of a change can turn them into powerful advocates in the long run. Leaders should focus on educating others about the benefits the change will create, to encourage buy-in. Most importantly, they must show a willingness to listen to concerns. This is also a great way to solicit some creative solutions for the planning process from an alternate perspective. If you include these reluctant participants early on, everything else opens up. Even late adopters can be some of your greatest champions. Your supporters will give you energy and momentum. This bottom-up approach will create a well-prepared team with a shared vision.
HOW CAN LEADERS BEST ENGAGE THEIR TEAMS?
Self-reflection is essential to leadership. It is important to look at where your strengths are and how to grow, both as a leader and as an organization. Ask your staff, “How can we all grow?” One of the core qualities of a strong leader is the willingness to be in a state of continuous learning and constant improvement.
Know your team’s strengths. Tap into their skills as key resources in implementing transformation initiatives. Also, be willing to invest in the tools or resources that will make growth and transformation possible. If it is a new Electronic Health Record platform, be sure to customize this tool so that it will alleviate the burden of work, reduce errors, and allow your staff to perform more high-level tasks.
Listen to your team—the people who will be experiencing the changes. Demonstrating a willingness to listen is one of the most important things a leader can do to prepare their collaborators for transformation. Even further, it’s important to demonstrate a willingness to engage all members of staff in finding and creating solutions. Outside the critical, immutable decisions for which a leader may be solely responsible—such as safety or crisis management—most issues are opportunities to solicit input from the individuals who work every day in the environment in question.
Continue to engage others to find solutions. Your staff are often the people best equipped to identify where the obstacles to improvement are, whether these are people or processes. Most often the obstacles are processes that prevent people from maximizing their strengths, so leading transformation also means leading the change of process elements.
Be realistic about resources when planning transformation initiatives. Short-term change is necessary at times to get things started or propel them forward. Do the next right thing today. Small steps made frequently keep the organization agile and in motion. As for a runner in a marathon, each step is important—and though some steps may not seem significant, as a whole, even these small steps will deliver you further toward the goal. Small adjustments continuously applied provide the opportunity for the leader to be a visible, active participant in change and make changing an iterative process over time. Keep in mind: everything that your organization does now was at one point someone else’s transformation.
Debra Wiggs is a board-certified fellow in the American College of Medical Practice Executives and a past board chair of the national Medical Group Management Association. Deb can be reached through V2V Management Solutions at firstname.lastname@example.org.
1 Frances Hesselbein, “The Key to Cultural Transformation,” Leader to Leader, 1999.
A LEADER’S ROLE: ORGANIZATIONAL IMPLEMENTATION OF CHANGE (PART 3)
By Steve Gordon, MD., and Keely Killpack, Ph.D.
IMPLEMENTING MEANINGFUL CHANGE ACROSS THE ORGANIZATION
The degree of recent change in health care delivery is astounding. How should leaders approach initiating change and improvement in this context? What can be learned from the experiences of others, especially when change efforts go sideways? What does success look like?
Recent examples of transformative change impacting physician practices include electronic health records, HIPAA, ICD-10, pay for performance, practice consolidation, ACOs, and now MACRA, superimposed on an explosion of medical research and new treatment options and modalities. Opinions differ as to whether these changes are beneficial, but increasingly, change fatigue itself is recognized as a cause of professional burnout and a growing leadership challenge.
In our experience, change efforts among physicians and providers falter when leadership stumbles into one or more of nine common pitfalls. We use a tool called Change Curve, a conceptual model commonly employed by change-management methodologies to assess and chart people’s adoption of a change (Killpack, 2017). We have leveraged this standard tool to illustrate challenges that can occur along the way, including:
- Failure to explain the personal impact to physicians, providers and staff, and to specify exactly what each person is being asked to do
- Failure to accurately describe the problem in the first place, including the future impact if the problem goes unaddressed
- Failure to ask for help addressing the problem
- Leaping to solve a problem before determining and verifying its root cause
- Confusing the measure with the aim
- Solution bias and over-confidence in a chosen approach
- Inadequate support over the course of the change
- Failure to thank and celebrate
- Failure to consider and align with other concurrent organizational changes
AVOIDING PITFALLS OF CHANGE: HOW TO GET PHYSICIANS AND PROVIDERS ON BOARD
Envisioning a future state is often easier than working through the necessary steps to get there.
The first step is one’s own recognition that change is required. This may take the form of an extended period of consideration, or simply an instance of awareness. Willingness to change is a personal attribute and is a key change enabler, along with humility, curiosity, perseverance, and focus. Leaders should also assess practice culture, including the history of change in the organization, its enablers or barriers, and whether stakeholders expect to be asked or told what to do.
Additional steps to implementing and embracing change include:
- Identify the specific problem you are trying to solve. Frame it in a way that people understand, and agree on the problem.
- Select which changes to bring to physicians and providers for input or decision-making. Develop instead a tailored approach, focusing on how much and what information to bring forward, and determining the people to whom that information should be tailored.
- Break large solution initiatives into smaller pieces that are most likely to succeed. Don’t present 18 different initiatives, but four or five that are easily understood.
- Don’t go it alone. Align and partner around change with individuals and groups inside and outside your organization, as well as with professional societies and advocacy groups with similar values. Consider investing in expert change management support for larger, complex initiatives and when change fatigue or physician burnout is a risk. Use proven data-informed techniques, such as Lean or 6-Sigma, to guide improvement, and partner with providers interested in being involved and learning more about improvement science. Seek out the individuals within your organization who have the most influence, and ensure your messages are resonating with these team members. Describe any steps being taken to monitor and track performance.
- Market the changes to each group. Explain the problem, process, and action items to each group, along with the specific action items required of that group. Don’t provide information that is not relevant to a specific group, as that will only lead to confusion and an overwhelming feeling.
- Create open dialogue, and show empathy. Don’t just tell physicians and providers what needs to happen— affirm that you understand the myriad challenges they face, and ask for their advice. Celebrate progress and express your appreciation to individuals, not just for the change at hand, but also for providing compassionate, high-quality care every day.
- Shadow people in their daily work, understand their pain points, and offer assistance when you can. Don’t assume that every physician or group can or should be a top performer right away; pushing too hard or too fast may jeopardize long-term success. Focus on the long-term goals, and be sensitive to overlapping demands for change. Look for the signs and symptoms of burnout, and support those at risk. Implement policies aimed at alleviating burnout, such as paid sabbaticals.
- Focus, focus, focus. Competing priorities are distractions. Help alleviate concerns by providing specific action items that address what will be needed, and when. Clarify each person’s role as part of the change. Participants without workflow change can nevertheless be impacted secondarily, so awareness matters. We recommend preparing an inventory of roles and customizing a change plan for each.
- Acknowledge the uncertainty that comes with any change. Especially when dealing with external market forces such as MACRA and other new value-based payment models, emphasize that these programs are likely to change over time, but that they are not going away.
- Above all, always keep your eye on the patient. Virtually all providers and staff can agree on a change when the benefit to patient care is clear.
Change is a predictable component of health care delivery. Developing and refining an effective approach to managing change is an essential leadership skill. Recognizing common pitfalls, planning accordingly, and course-correcting effectively will help to inspire others, ensure success, and minimize adverse impact.
Steve Gordon, MD, is a principal consultant with Point B’s health care practice group.
Keely Killpack, a consultant with Point B, is a founding member of the Association of Change Management Professionals (ACMP), holds a PhD in Organizational Psychology, and has just finished her first book about change-management strategies, ChangeRX for Healthcare.