An Organizational Model of Transformational Change in Health Care P2 Evaluation Team Martin P. Charns, DBA 1,4 Alan B. Cohen, ScD 3,4 Irene E. Cramer, PhD, MSSA 1,4 Sally K. Holmes, MBA 1,4 Mark Meterko, PhD 1,4 Joseph Restuccia, DrPH 2,4 Michael Shwartz, PhD 2,4 Carol VanDeusen Lukas, EdD 1,4 1 Boston University School of Public Health 2 Boston University School of Management 3 Boston University Health Policy Institute 4 VA Center for Organization, Leadership & Management Research

The RWJF Pursuing Perfection Program (P2) IOM Reports (To Err is Human & Crossing the Quality Chasm) created urgency to address patient quality & safety issues. In response, the Robert Wood Johnson Foundation funded 7 organizations to transform patient care through quality improvement – pursue “perfect care”… Institute for Healthcare Improvement (IHI) was the national program office for P2 A Boston University/VA research team was selected to evaluate grantees’ progress.

Hybrid Evaluation Design Qualitative methods Site visits began in 2002 and were completed in Included all 7 funded sites and 5 “comparison sites” Respondents ranged from C- suite to frontline clinical staff Visits were every 3-6 months N = >750 one-hour interview sessions Quantitative methods Staff survey conducted in 2004 and Eight of 12 study sites participated Survey instrument explored perceptions about organizational priorities, values, behaviors & outcomes Survey measures changes over time at respondent level N = >4000

P2 Strategy for Change Utilize process improvement PDSA Cycles Measurement Start with 2 projects Spread to 5 more Spread to rest of organization Spread to other institutions

Early in P2 we learned that: “2 to 5 to all” strategy didn’t work An organization can do 100 improvement projects successfully & not achieve organizational transformation Challenge is to spread & sustain the innovations, new values, skills, expectations Perfect care requires major organizational investment in culture, infrastructure, new management structures & processes to succeed

Organizational Transformation Model

Five critical elements drive change… Transformation begins with a sense of urgency Leadership drives and facilitates change Improvement initiatives engage multi-disciplinary front-line staff in meaningful problem solving To maximize effectiveness, organizations align & integrate efforts

… through the organization Mission, vision & strategies that set its direction and priorities Culture that reflects its values and norms Organizational functions and processes that embody the work that is done in patient care Infrastructure (e.g., IT, HR, fiscal, facilities management) support the delivery of patient care

Transformation begins with a sense of urgency Impetus = creating and maintaining a sense of urgency to overcome inertia & fear of change External pressures bring urgency Crossing the Quality Chasm, CMS, AHRQ, Joint Commission) P2 grantee status & visibility Internal events & changes can create urgency Sentinel events & benchmarking data highlight quality problems New leadership

Leadership drives & facilitates change Leadership = Board, C-suite, administrative & clinical, formal & informal leaders – but starts at the top Commitment to & passion for quality improvement Constancy of purpose; unrelenting pursuit of goals “Walks the talk” Invests own time in quality activities Translate commitment into action Gets the right people “on & off the bus” Communicates & builds relationships Holds staff & teams accountable Provides resources & infrastructure for improving quality Fosters learning Facilitates a well organized & well run effort

Improvement initiatives engage multi- disciplinary staff in meaningful problem solving Impact desired performance System re-design to build evidence-based practices into daily work Micro-level: effectively address frontline quality & safety issues (surgical infection prevention) Macro-level: fundamentally change how care is delivered (flow projects, chronic care models, EMR implementation) Build skills, motivation and culture to support and sustain quality improvement Actively engage staff around priority clinical issue Collaborative, interdisciplinary work, including MDs Build staff knowledge & confidence in making improvement Create momentum for spread

Alignment achieves consistency of goals with actions & resource allocation across the organization Managing the “vertical” = consistent organizational vision, values & behavior from top to bottom Alignment is strategic & operational Improving quality is top priority; support, resources & rewards are aligned accordingly Improvement projects aligned with strategy & organizational goals throughout the organization E.g., Mechanisms Cabinet champion for improvement initiatives Cascaded improvement priorities Accountability & performance evaluation down to individual Resource allocation, rewards, recognition

Integration bridges traditional intra- organizational boundaries between individual components Managing the “horizontal” = consistency and coordination across the organization(s) Improving coordination of patient care Integrating across improvement initiatives Breaking down silos across departments & workgroups; organizational units (i.e., physician offices, other organizations) Building system-level performance E.g., Mechanisms Collaboratives Steering committees or quality management oversight structures committees Matrixed organizational structures (e.g., service lines) Cross-function management

Dynamic interaction among elements and the organization builds to transformation QI initiatives are cornerstones of organizational change – if they are aligned with organizational priorities Improvement becomes part of organizational fabric – “the way we work” QI initiatives drive change in IT and HR which in turn support spread and further change Organizations develop infrastructure to support the new way of functioning Infrastructure is the glue that cements the changes

Organizational Transformation Model

Conclusions: Building Change Over Time Organizational transformation requires addressing all key model elements Fundamental organization change takes more than 5 years Permanent, organization-wide change builds iteratively Redesigning care & implementation involve multiple, iterative cycles Change is non-linear – “two steps forward & one back “ Failures are instructive “The goalpost keeps moving…the more we improve, the more there is to do…”

Lukas, C.V., Holmes, S.K., Cohen, A.B., Restuccia, J., Cramer, I.E, Shwartz, M., Charns M.P. (2007). An organizational model of transformational change in healthcare systems. Health Care Management Review, 32(4):