1. Organizational Change Martin P. Charns, DBA Director COLMR

2. Greenhalgh et al. Very comprehensive systematic literature review of diffusion & implementation Addresses multiple perspectives Characteristics of innovation Process of implementation Context

3. Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation Knowledge purveyors Resource System Change agency The Innovation Dissemination LINKAGE Outer context System readiness Adoption / assimilation Implementation User System LINKAGE Consequences System antecedents Diffusion

4. QUERI Focus Largely on the innovation (EBP) & process of implementation Less detailed focus to date on organizational context, including history

5. Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Innovation Knowledge purveyors Resource System Change agency The Innovation Dissemination LINKAGE Outer context System readiness Adoption / assimilation Implementation User System LINKAGE Consequences System antecedents Diffusion

6. The Innovation Relative advantage Compatibility Low complexity Trialability Observability Potential for reinvention Fuzzy boundaries Risk Task Issues Nature of knowledge required Technical support

7. Adopter Needs Motivation Values & goals Skills Learning Style Social networks Adoption Decision: Stages –Preadoption –Early use –Established users

8. Communication & Influence Diffusion (informal, unplanned) Social networks Homophily Peer opinion Marketing Expert opinion Champions Boundary Spanners Change agents Dissemination (formal, planned)

9. Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Organizational Factors Knowledge purveyors Resource System Change agency The Innovation Dissemination LINKAGE Outer context System readiness Adoption / assimilation Implementation User System LINKAGE Consequences System antecedents Diffusion

10. Outer Context Sociopolitical climate Incentives & mandates Inter-organizational norm-setting & networks Environmental stability

11. System Antecedents for Innovation Structure –Greenhalgh et al. note that structural features account for 13% of variation among organizations in their innovativeness Absorptive capacity for new knowledge –“…knowledge must be enacted and made social” Receptive context for change –Leadership, culture

12. System Readiness for Innovation Tension for change Innovation-system fit Power balances (supporters v. opponents) Assessment of implications Dedicated time/resources Monitoring & feedback

13. Implementation Process Decision making devolved to frontline teams Hands-on approach by leaders & managers Human resource issues, esp. training Dedicated resources Internal communication External collaboration Reinvention/development Feedback on progress

14. Successful Transformation Beyond Projects Most organizations can manage individual projects – even many individual projects Making specific projects a priority Getting people to work extra hard Often achieves project change Is not sustainable By focusing on individual projects it is easy to forget: –that many others things are happening in the organization –that other things outside of the project need to be addressed to achieve project success

15. Successful Transformation Beyond Projects Model of transformation utilizes many of the organizational concepts reviewed by Greenhalgh et al. Model is more dynamic

16. The Detailed Model of Healthcare Transformation

17. Healthcare Transformation Model - Overview

18. Model Overview Transformation begins with a sense of urgency Permanent, organization-wide change builds iteratively To maximize effectiveness, organizations align & integrate efforts Organizations develop infrastructure to support the new way of functioning Improvement becomes part of organizational fabric – “the way we work” Success motivates staff to continuously strive for higher goals (e.g., patient satisfaction & high reliability)

19. Change Is Iterative Fundamental organization change takes longer than 2-3 years Organizations learn from prior experiences –Failures are instructive Redesigning care & implementation involve multiple, iterative cycles – “the more we improve, the more there is to do…” Testing new models Training Facilitation Resolving barriers Changing culture

20. Impetus to Transform Creates sense of urgency to overcome inertia & fear of change Examples –Critical incident –Financial crisis –Financial stability –Growth –Mission (patient-centered) –Combination of two or more

21. The Impetus To Transform External sources of urgency (Crossing the Quality Chasm, JCAHO, VA Mandate, etc.) Sentinel events & benchmarking data make staff realize that care & quality not as good as they should be Maintain sense of urgency

22. Improvement Projects Vehicle for process/outcome improvement Vehicle to engage multi-disciplinary front-line staff in meaningful problem solving –Concrete (vs abstract vision statement) –Clinical & important focus to engage clinicians

23. Improvement Projects Builds skills, motivation & culture that will support & sustain quality improvement –Actively engage staff around priority clinical issue –Collaborative, interdisciplinary work, including MDs –System re-design to build evidence-based practices into daily work –Goals & measures (monitor progress & whether improvement is sustained) –Project support (training, tools, measures, facilitation) –Shared learning & spread

24. Infrastructure “Hard” Infrastructure –Information systems –Clinical support systems “Soft” Infrastructure –Workforce skills, values, expectations (engagement) –Organizational culture Key role of infrastructure in transformation: –AMI example

25. Alignment Managing the “vertical” = consistent organizational vision, values & behavior from top to bottom Both strategic & operational Improving quality is top priority; support, resources & rewards are aligned accordingly Align improvement projects with strategy & organizational goals throughout the organization

26. Tools & Structures To Support Strategic Alignment Strategic planning –Strategic plan linked to everyone’s job (SSM & Baldrige) Management structures Measurement & Reporting –Dashboards, scorecards Communication –Transparency Resource allocation Accountability & performance evaluation Recognition, rewards & incentives –P4P, performance awards Information Technology

27. Integration Managing the “horizontal” = consistency across the organization(s) Breaking down silos across: –departments & workgroups –organizational units Integrating across improvement initiatives Improving coordination of patient care

28. Examples of Integrating Mechanisms & Processes Service Lines Cross-organizational teams, workgroups Quality management oversight structures Steering committees (e.g., integration across organizational/community boundaries) Project teams with overlapping membership Clinical effectiveness departments moving innovations from one team to others “Clinical Systems Integration” unit Collaboratives Integrating quality into operations Information systems

29. Leadership Drives & Facilitates Alignment & Integration Leadership team & leaders at all organizational levels Board, administrative, clinical leaders Commitment to & passion for quality improvement – “walks the talk” Constancy of purpose; unrelenting pursuit of goals Translates commitment into action Investment of own time in quality activities Fosters learning Holds staff & teams accountable Provides resources & infrastructure for improving quality Integrate activities across organizational boundaries (facilities, workgroups, functions) Communicates & builds relationships Gets the right people “on & off the bus” Facilitates a well organized & well run effort

30. Leadership Drives & Facilitates Alignment & Integration Establish structures to link improvement efforts to senior management: –Create accountability through measures, reporting and monitoring progress –Actively support the projects and resolve problems –Identify senior (e.g., quadrad) champion –Recognize & reward success –Don’t allow continuance of inappropriate behavior –Use of key opportunities & events

31. Conclusions Quality improvement activities that are limited in scope are unlikely to be sustained Organizational transformation requires addressing all key model elements

32. Conclusions Building Change Over Time QI projects cornerstones of organizational change Demonstrate that change is possible Build involvement Engage clinicians Bring about spread Infrastructure development (e.g., information technology) Building culture & skills (e.g., workforce development) Frontline/microsystem efforts Patient involvement in redesign efforts Success builds knowledge & stimulates momentum

33. Questions & Discussion