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 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 other. For example knowledge about psychology is incomplete without knowledge of variation." "The system of profound knowledge provides a lens. It provides a new map of theory by which to understand and optimize our organizations.“ Source: Jerry Langley, Associates in Process Improvement

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 “Quasi- stationary Equilibrium” based on multiple driving and restraining forces. What then are the elements and mechanisms of change?

The Process of Change Lewin’s Model Unfreezing New Learning Refreezing Disproving current beliefs Creating a tension for change Need new tools and methods Reinforcement 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

Laggards Innovators Everett Rogers Diffusion of Innovation X Early Adopters EarlyLateMajority

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

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement PlanAct DoStudy

Repeated Use of the Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA Material is from The Improvement Guide, Second Edition, Jossey-Bass, 2009

Change Concepts The change concept-Rainforest Café Lens to view the world Lean Thinking examples

Lean Thinking: Waste

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

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