Creating a Climate for CHange
In previous modules, we have discussed, at length, the various ways in which the US healthcare system is damaged, and a variety of ways in which digital health systems may be able to help. In these modules, we have frequently discussed the challenges that are associated with the adoption of various electronic systems in various medical settings. Because the challenges associated with change are often a large deterrent from adoption of new policies and procedures, in this module, we will be presenting some of the ways in which clinics and hospitals may overcome these challenges to ease the growing pains associated with major transitions. In our presentation of this information, we will be following Dr. John Kotter's model for change; this model describes three critical phases to facilitating a smooth transition in major changes: (1) creating a climate for change, (2) engaging and enabling the organization, and (3) implementing and sustaining the changes.[1] The three aspects of this model and how they can be applied to changes within the healthcare system will be covered in the sections of this module.
Kotter’s model for change requires the organization to first create an environment for change in which the organization must first establish that the current system is flawed and unsustainable. During this phase, it is essential that the healthcare organization, be it a clinic or a hospital, makes it clear to its employees why they must depart from the current state. In doing this, the healthcare organization must establish a sense of urgency for the change, highlight the organizers and administrators that will be facilitating the change, and build a vision for what the future will look like. In the case of healthcare, this may involve sharing statistics that highlight the inefficiency of paper records and charts and other ways in which the current process is hindering the quality of care that is delivered to patients. A critical component of implementing effective change is also to accomplish this process in tiers. There is plenty of work to show that employees are far more likely to participate in, and be enthusiastic about change when their supervisors are also enthusiastically participating. Thus, rolling out this process in layers in a top-down approach is imperative to creating a positive environment such that the organization as a whole is in support of the change.
It must be noted that during this (and all) steps of the process of change, one must not underestimate the persuasive power of statistics and cold, hard facts. Particularly within the medical community, numbers and facts are highly effective catalysts for change, especially when the current system is truly broken. One consideration that should also be made is whether or not to disclose the potential pitfalls that may come with the change implementation. While it is the most ethical decision to fully inform all affected employees in the ways in which a transition may cause difficulties, it may also pose an additional barrier towards the change itself. There are certainly valid arguments to be made for both sides. On the one hand, full disclosure of potential problems may better prepare employees for what is to come and thus, make the transition smoother. On the other hand, resistance is a normal and very human reaction towards change and thus, it may be in the best interest of the organization to be discreet about the challenges ahead so as to encourage the creation of a climate for change.
There are many considerations to be made when it comes to transitions in the healthcare system and it is clear that these considerations must be made before the decision to make a change has even been finalized. Each healthcare organization is its own culture with its own size and those that wish to make changes within the organization must take these variables into serious thought before an adequate climate for change can be created. Once an appropriate climate has been established to encourage a healthy change, the next phase in Kotter’s model for change is engaging and enabling the organization. In other words, once the attitude for change has been established, it is then time to begin implementing change. How is this done? And how can healthcare organizations accomplish this in a way that minimizes strife among employees while also mitigating any adverse impacts that the change may have on patient quality?
Kotter’s model for change requires the organization to first create an environment for change in which the organization must first establish that the current system is flawed and unsustainable. During this phase, it is essential that the healthcare organization, be it a clinic or a hospital, makes it clear to its employees why they must depart from the current state. In doing this, the healthcare organization must establish a sense of urgency for the change, highlight the organizers and administrators that will be facilitating the change, and build a vision for what the future will look like. In the case of healthcare, this may involve sharing statistics that highlight the inefficiency of paper records and charts and other ways in which the current process is hindering the quality of care that is delivered to patients. A critical component of implementing effective change is also to accomplish this process in tiers. There is plenty of work to show that employees are far more likely to participate in, and be enthusiastic about change when their supervisors are also enthusiastically participating. Thus, rolling out this process in layers in a top-down approach is imperative to creating a positive environment such that the organization as a whole is in support of the change.
It must be noted that during this (and all) steps of the process of change, one must not underestimate the persuasive power of statistics and cold, hard facts. Particularly within the medical community, numbers and facts are highly effective catalysts for change, especially when the current system is truly broken. One consideration that should also be made is whether or not to disclose the potential pitfalls that may come with the change implementation. While it is the most ethical decision to fully inform all affected employees in the ways in which a transition may cause difficulties, it may also pose an additional barrier towards the change itself. There are certainly valid arguments to be made for both sides. On the one hand, full disclosure of potential problems may better prepare employees for what is to come and thus, make the transition smoother. On the other hand, resistance is a normal and very human reaction towards change and thus, it may be in the best interest of the organization to be discreet about the challenges ahead so as to encourage the creation of a climate for change.
There are many considerations to be made when it comes to transitions in the healthcare system and it is clear that these considerations must be made before the decision to make a change has even been finalized. Each healthcare organization is its own culture with its own size and those that wish to make changes within the organization must take these variables into serious thought before an adequate climate for change can be created. Once an appropriate climate has been established to encourage a healthy change, the next phase in Kotter’s model for change is engaging and enabling the organization. In other words, once the attitude for change has been established, it is then time to begin implementing change. How is this done? And how can healthcare organizations accomplish this in a way that minimizes strife among employees while also mitigating any adverse impacts that the change may have on patient quality?
Engaging and enabling the organization
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Change management is “the application of the set of tools, processes, skills and principles for managing the people's side of change to achieve the required outcomes of a change project or initiative.” Changes from standards, care delivery models, and the implementation of new technologies are all sources of change-related stress in the healthcare system. It’s important to consider how the new implementation of technologies and care giving models will affect how people work in terms of their workflow and routine behaviors, as well as the impact it can have on patient health. Research has shown that it is often not that new technologies fail but rather the lack of consideration of human factors while implementing the new technologies that affect the overall outcomes. Fortunately, the study and knowledge of change management is relatively abundant in guiding an organization to navigate the change process. A successful change management strategy will answer the following questions along the changing process.
Another key point in the second phase is training (to ensure all staff understand how to use the new technologies) and the conducting of usability tests to glean the feedback from end-users. As we have discussed in the for EHR and CDSS modules, the negligence of usability and safety tests that consider the human factors in implementing the new technologies could lead to unintended consequences that impair the quality of care. Another article that creates the framework in modeling and guiding the implementation of new HIT (health information and technology) specifically, is a publication from the Journal of the American Medical Informatics Association (see figure, right). The framework presents models of how physical/technical infrastructure and social systems in the organization affect how well end users adopt new technologies; this article also analyzes how the feedback and interaction of these constructs can be used to inform the design and development of new HIT. Whereas Kotter’s three-phase change management framework guides the implementation of change from the beginning to the end from the bigger picture, this article presents an interactive sociotechnical analysis which focuses specifically on the implementation of new technologies and how to use feedback from the interaction to inform the design of technologies that better fit into the workflow of the providers, the overarching social system, and the physical and technical infrastructures already in place.
- What changes in workflow will be necessary?
- What new technologies and skills will be required?
- How will employees learn those new skills and gain knowledge of how the technology fits into their everyday work life?
Another key point in the second phase is training (to ensure all staff understand how to use the new technologies) and the conducting of usability tests to glean the feedback from end-users. As we have discussed in the for EHR and CDSS modules, the negligence of usability and safety tests that consider the human factors in implementing the new technologies could lead to unintended consequences that impair the quality of care. Another article that creates the framework in modeling and guiding the implementation of new HIT (health information and technology) specifically, is a publication from the Journal of the American Medical Informatics Association (see figure, right). The framework presents models of how physical/technical infrastructure and social systems in the organization affect how well end users adopt new technologies; this article also analyzes how the feedback and interaction of these constructs can be used to inform the design and development of new HIT. Whereas Kotter’s three-phase change management framework guides the implementation of change from the beginning to the end from the bigger picture, this article presents an interactive sociotechnical analysis which focuses specifically on the implementation of new technologies and how to use feedback from the interaction to inform the design of technologies that better fit into the workflow of the providers, the overarching social system, and the physical and technical infrastructures already in place.
Implementing and Sustaining Change
The third phase of Kotter’s model for change management is about sustaining the changes that have been made. To accomplish this, healthcare organizations must focus on the need for continued monitoring of new systems and intervention by the guiding team when necessary. It is possible that changes become ineffective once employees begin to lose interest or inspiration in the change management and the previous efforts become feutile [1]. In order to keep the changes and the atmosphere of change effective, it is important for administrators and guides of change to continue to focus on finding problems, promoting solutions, and helping individuals to become innovators in their respective fields. It is also the responsibility of healthcare organizations to spend extra resources in training and retraining the staff they already have so they can be more familiar with the previous implementations and also the future possible changes [1].
After a new system (for example, an EHR system) is implemented, the healthcare organization should actively seek immediate feedback from the staff that use it. If staff have been effectively engaged in all phases of implementation, they will generally be willing and able to provide valuable information about the usability and potential problems of new systems. They are the most active users of the system and are also the best resources we have for improving the system. One way in which changes can be implemented to reduce change-related anxiety is by incremental change. By slowly transitioning in small steps, users and staff experience less change-related stress by giving them a number of new functions but only one at a time. It is during these small changes that it is important to reward and recognize the mental labor that is being done by the employees during the transition.
Patient engagement is difficult when implementing new systems but can provide valuable interactive feedback collection. In other words, finding a way to involve patients themselves in the midst of systematic clinical changes is quite a challenge but can prove to be invaluable if done correctly. When dealing with new HIT, there is always a chance that patients' needs do not turn out to be the same as what was anticipated. Periodic patient check-ins can provide insight as to what components of the system are failing or underperforming and can also help to illuminate pieces of a new system that are having unintended negative consequences on a patient’s care quality. By collecting data on patient-oriented variables such as cosmetic changes to the user portal, communication preferences of reminders, and end-user usability, healthcare administrators are able to optimize the changes that have already been made and preemptively eliminate any concerns about changes that have yet to be made.
To the extent of maintaining and sustaining changes that have already been made, it is always essential to receive employee feedback. It is known that any organization, from large corporations to small non-profits, operate more efficiently and with a higher degree of customer satisfaction when its employees are satisfied. It is important that the input gathered from patients and employees alike is considered by a team with professional from diverse backgrounds to allow for the most pragmatic decisions to be made going forward.
To this end, it is normal for staff to feel that the new system is not as good as the old one. It is only natural for humans to become apathetic (especially when they are still unfamiliar with the new system) and become frustrated. It may be in the best interest of the healthcare organization to inform staff that this may be a natural reaction to have such that when it does occur, issues arising due to these feelings can be mitigated in a way that promotes honest and open communication. In general, when implementing new HIT features within a healthcare system, clinics and hospitals must always be patient and keep in mind that growing pains are just a natural part of life; remember that “normal” is just what you’re used to.
After a new system (for example, an EHR system) is implemented, the healthcare organization should actively seek immediate feedback from the staff that use it. If staff have been effectively engaged in all phases of implementation, they will generally be willing and able to provide valuable information about the usability and potential problems of new systems. They are the most active users of the system and are also the best resources we have for improving the system. One way in which changes can be implemented to reduce change-related anxiety is by incremental change. By slowly transitioning in small steps, users and staff experience less change-related stress by giving them a number of new functions but only one at a time. It is during these small changes that it is important to reward and recognize the mental labor that is being done by the employees during the transition.
Patient engagement is difficult when implementing new systems but can provide valuable interactive feedback collection. In other words, finding a way to involve patients themselves in the midst of systematic clinical changes is quite a challenge but can prove to be invaluable if done correctly. When dealing with new HIT, there is always a chance that patients' needs do not turn out to be the same as what was anticipated. Periodic patient check-ins can provide insight as to what components of the system are failing or underperforming and can also help to illuminate pieces of a new system that are having unintended negative consequences on a patient’s care quality. By collecting data on patient-oriented variables such as cosmetic changes to the user portal, communication preferences of reminders, and end-user usability, healthcare administrators are able to optimize the changes that have already been made and preemptively eliminate any concerns about changes that have yet to be made.
To the extent of maintaining and sustaining changes that have already been made, it is always essential to receive employee feedback. It is known that any organization, from large corporations to small non-profits, operate more efficiently and with a higher degree of customer satisfaction when its employees are satisfied. It is important that the input gathered from patients and employees alike is considered by a team with professional from diverse backgrounds to allow for the most pragmatic decisions to be made going forward.
To this end, it is normal for staff to feel that the new system is not as good as the old one. It is only natural for humans to become apathetic (especially when they are still unfamiliar with the new system) and become frustrated. It may be in the best interest of the healthcare organization to inform staff that this may be a natural reaction to have such that when it does occur, issues arising due to these feelings can be mitigated in a way that promotes honest and open communication. In general, when implementing new HIT features within a healthcare system, clinics and hospitals must always be patient and keep in mind that growing pains are just a natural part of life; remember that “normal” is just what you’re used to.
Want to Learn more?
Here are some resources we used to write this article!
[1] “Change Management in EHR Implementation.” HealthIT.gov, 13 Nov. 2018, www.healthit.gov/resource/change-management-ehr-implementation.
[2] Michael I. Harrison, PhD, Ross Koppel, PhD, Shirly Bar-Lev, PhD, Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis, Journal of the American Medical Informatics Association, Volume 14, Issue 5, September 2007, Pages 542–549, https://doi.org/10.1197/jamia.M2384.
[2] Michael I. Harrison, PhD, Ross Koppel, PhD, Shirly Bar-Lev, PhD, Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis, Journal of the American Medical Informatics Association, Volume 14, Issue 5, September 2007, Pages 542–549, https://doi.org/10.1197/jamia.M2384.
Personal Reflections
Oliver |
As we have learned from the challenges faced by EHR and CDSS, there is a demanding call for qualitative researches that investigate the usability and safety issue for implementing the technologies in healthcare givers’ workflow and routine habits. I think this week’s readings aim to solve this problem but look at it with the bigger picture. If the new technologies or health delivering models are to be adopted, what we can do from the organization point of view to manage this change for our staff in terms of their emotion and new required techniques and skills. When I read the readings, another framework I learned from the article in Dr. Chen’s biomedical information interaction and design class comes to my mind, the sociotechnical analysis framework. However, I think this article focuses more on what interactions between new technologies and social systems, physical and technical infrastructure can affect the real use of technologies by the users and how designers can base on those feedbacks to refine the technologies. I think the main reason I think of this article is because I still have a hard time thinking about what we as an informatician can do for managing the change. Maybe because I think about the whole topic from a researcher’s view but not a chief information manager in the organization. In general, I think these two weeks of readings are interesting because a precise and useful technology in a designer’s eye cannot really reach its potential without thinking about the human factors and what role does organization can play in supporting the implementation and management of change.
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weipeng |
Normally when we talk about the difficulty of implementing an EHR system, it is always the implementation part that intrigues it. The implementation part is important because it involves a lot of dimensions. It requires a calibrated balance between physicians, administrations, and technicians. I always thought this is the hardest stop. However, after I read more, I realized sustaining the changes is also important. There are enormous cases where a hospital implements an EHR system but decides to discard it. They are many reasons for hospital deciding to give up on an EHR system which the hospital has spent so much effort on, but failure to address users' need can always be one. To sustain the change, it is important to collect feedback and continuously make changes to the system because it is never meant to be perfect at first sight.
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Dakota |
I think that the topic of change management in relation to the US healthcare system is a very interesting one. I also think that this is something I would like to learn more about because I suspect that the problems that arise from change implementation are far and wide and perhaps run much deeper than we even know. Humans have always been resistant to change particularly when the current system appears to be "working." An excellent illustration of this is the fact that up until the 2009 HITECH bill, there were very few medical institutions in the US that had adopted EHR/EMR systems despite them being readily available. The rapid adoption of these systems led to many of the problems that we've discussed in previous modules but I believe they may have had another unintended consequence. The litany of problems caused by the rapid adoption of EHR systems led to a plethora of HIT data being recorded and a slew of statistics to be generated. As we have seen, these systems have been to blame for a variety of cost inflations and efficiency concerns and there is plenty of data to now back these facts up. Because (1) the medical community is one that is susceptible to the persuasion of statistics and numbers, and (2) there is nearly endless amounts of data to show that EHR/EMR adoption can have negative and severe consequences for medical institutions, I suspect that this is further driving the skepticism and the resistance towards change in the healthcare industry. In other words, they've seen how poorly the switch to EHR went, and now they're afraid that other changes will be this way.
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