Shifting Cultures: A Change Management Guide for Hospital Leaders

The healthcare industry is currently undergoing mass-scale changes that have not been seriously discussed at the federal level since the 1990s, when then-President Bill Clinton tried to implement a healthcare reform package that would have expanded healthcare coverage to more Americans, among other outcomes. Now, President Barack Obama's healthcare reform law, the Patient Protection and Affordable Care Act, is undergoing determinative scrutiny from the Supreme Court over the coming months on its constitutionality.

However, hospitals and health systems are still coming to a fork in the road, regardless of what happens with the PPACA. They can either enact system-wide changes to cope with the rising costs of healthcare and disparity in healthcare access, or they can fall by the wayside. Forward-thinking hospital leaders willing to make the changes now face the task of getting buy-in from their organization and are perhaps asking themselves, "How do I carry out this change management?"

Bringing any organization, hospital or otherwise, into a desired state of change involves several steps to take and challenges to overcome, and becoming a change management vanguard for an institution is a multipronged approach.

Enacting change management: The four R's and more
The purpose of change is to stimulate people to adopt new ways of doing things. Joseph Fortuna, MD, chair of the American Society for Quality's Healthcare Division, says it's never easy but is always necessary. "Culture change is harder than trying to go in and fix something," Dr. Fortuna says. "But culture change is important because otherwise you don't have sustainability."

Tim Durkin, a leadership and change management consultant and owner of Seneca Leadership Programs, has worked with several hospital administrators throughout country. He says before hospital leaders can outright change an entire culture, they must realize what the biggest hurdle in change management is — confused people do not move.

In order for hospital executives to enlighten their staffs and lead in change initiatives — such as electronic health records, accountable care organizations, readmission reduction programs, patient-centered medical homes, system labor restructuring and others — Mr. Durkin recommends they start at the four R's:

•    Reason. Healthcare employees asking "why" things are changing is the second-most important question, Mr. Durkin says. If hospital leaders explain why the organization is making a change — i.e., the switch to EHRs will allow clinicians to access the right patient information at the right place at the right time — a clearer and more coherent rationale becomes visible. As Friedrich Nietzsche said, "He who has a why…can bear almost any how."

•    Result. Hospital leaders must be able to paint a vivid picture for employees as to what future changes will look like. Showing that cost-cutting measures or readmission rates will save "X" amount of time, effort and money can give other managers and employees a more tangible concept to grasp.

•    Route. Any effective change management guide must lay out how the changes will move throughout the health system. For example, EHR implementation will begin with radiology and will then be rolled out to the business office before reaching other departments. "Tell people the path that the change will take place," Mr. Durkin says.

•    Role. The fourth R — role — answers the number one question, Mr. Durkin says. Employees want to know how the change will impact them personally and what, exactly, is in it for them. "You tell people what their role is if you know it," he adds. "If you can't share it or don't know it [at the time], then you say, 'My expectation of you is to be flexible and positive to help us along through this change.' If you paint the picture well enough, you can do that."

Michael D'Agnes, president and CEO of Raritan Bay Medical Center in Perth Amboy, N.J., emphasizes that explaining the "role" to everyone throughout the hospital as new initiatives take place is inherently important. "[That understanding] starts with the administrators, but it needs to cascade through the organization," Mr. D'Agnes says. "They need to make sure department head supervisors and frontline employees — nurses, technicians, pharmacists, aides — understand what the goal is."

The four R's are dependent on several characteristics of the hospital leadership, though. Jon Elion, MD, is an associate professor of medicine at Brown University and a part-time cardiologist at The Miriam Hospital in Providence, R.I. He says change management cannot grow in an environment that breeds defensiveness or condescending overtones. Instead, hospital leaders must be willing to create an atmosphere of trust, especially with physicians, and cannot be afraid to expose their own weaknesses or admit their own mistakes during the change transition period. "Hospitals need to foster an environment of trust with their own people," Dr. Elion says. "It's most difficult for hospital administrators to foster trust between physicians and the administration, but that environment is needed at the hospital. Talk about the adverse outcome, and have people jump on 'what' and not 'who.'"

To make sure that people jump on the "what" and not the "who," hospital leaders must also surround themselves with the right people. Mr. D'Agnes says finding and recruiting new physicians, managers and frontline staff is the beginning of a new effective change management plan. This is not to say a hospital needs to rehire its entire facility, but as open positions are getting filled or new physicians are being brought in, a hospital leader must make sure the new employees are onboard with the fast-moving and ever-changing environment. "When you hire intelligent people who show initiative, getting the buy-in is not hard because you have a common goal: financial strength and the delivery of the product, which is patient care," Mr. D'Agnes says. "If everybody is aligned with the goals, it becomes much easier to get someone to buy in."

"New school" hospital leadership
Just like the shifting healthcare environment, hospital leaders of the present and future will also have to keep pace. Dr. Elion, who also founded clinical documentation improvement company ChartWise Medical Systems, says there are three sides of today's hospital leadership triangle: medical, technical and business. He has met several hospital CEOs, CFOs, CMOs and other C-suite executives who excel in one side of the triangle, but that's not sufficient in today's era.

For example, a CMO might excel in his or her medical duties and now is in charge of leading a program to reduce the hospital's readmissions. The CMO might be getting basic data on the percentage of patients being readmitted within 30 days, but there is a wealth of other information that can be extracted — and the CMO could dive into it if he or she knew how to procure more actionable data from the hospital's technical systems. Dr. Elion says IT staffs have the ability to give several types of reports to the administration, but the communication is not always there.

A hospital leader who has fused all three sides of the hospital leadership triangle, though, is on a more solid foundation to enact the desired change. Dr. Fortuna sums up the new age of hospital leadership in this way: "Not every doctor knows how to do an MRI, but every doctor knows what an MRI is and what to do with it." Hospital leaders do not have to know every nook and cranny of every healthcare detail, but they certainly should become a jack-of-all-trades.

Speed bumps to overcome
Drastic changes in routines, programs and goals usually do not come without challenges. For those involved on the medical side of patient care, Dr. Elion says it might be commonplace to see staff flustered or confused about new technologies or the implementation of new programs. The key is to remind everyone that effective change management is rooted in effective medicine. "If you have a resident who is panicking, sit them down, and tell them, 'You know how to do this,'" Dr. Elion says. "[Healthcare reform] deals with all the overwhelming and complex issues that have to be dealt with, but in the meantime, take care of the 'little' things. People are so focused on reimbursement, but they have to look at the practice of medicine. There's a way to practice it more efficiently."

One of the biggest barriers to effective change management is when hospitals employees resort to what Mr. Durkin calls "MSU," or "making stuff up." If hospital leaders want to curtail any sort of grapevine chatter, he says they must be willing to communicate frequently. Personal communication not only clears the air from the beginning, but it also shows willingness on the part of the leader that he or she wants the entire hospital community to be on the same page. "You can't stop the grapevine, but you can control it," Mr. Durkin says. "There is no such thing as over-communication."

Related Articles on Change Management:

Healthcare Reform and Opportunities for Performance Improvement: How to Use Data to Incent Physicians, Change Behavior

An Integrated Approach to Deploying Performance Improvement

Is Your EHR Implementation in Trouble? 10 Things to Check

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