US Healthcare Strategies Report, May 2005 a report by |
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The change to electronic health records (EHRs) is an amalgam of daunting challenges that will be facing hospital executives for the foreseeable future. Many hurdles, such as suitably advanced EHR technology, the absence of key data standards, and the costs of EHR initiatives, are being surmounted through the collaborative efforts of public and private organizations and governmental agencies. As the major long-term obstacles to the EHR are removed one by one, the imminent reality of transforming an industry falls to each healthcare provider organization. Their leaders face a dilemma inherent in major paradigm shifts – those most affected by the change are ambivalent and behave as if to say, “We want to, but we don’t want to”. The ambivalence leads to contradictory behaviors that are emotional, i.e. instinctual or automatic reactions like the survival behaviors of the stress response – fight, flight, or freeze. For example, during large-scale change, healthcare executives may observe more conflicts throughout the organization; people resisting or distancing from change activities by resigning, frequent or extended absences, or simply refusing to participate in change activities; or the organization may be overcome by intractable complacency characterized by indecisiveness, pessimism, lack of enthusiasm, concern, or support for change initiatives. It is common to hear conversations like the one below in which a healthcare executive expresses his concerns about the dilemma of change. The Healthcare Executive’s DilemmaA CEO and a healthcare consultant are discussing the organization’s need to move forward with EHRs. The CEO, cognizant of the momentum building in the industry for EHRs tells the consultant, “I have never been interested in being on the ‘bleeding’ edge of technology innovations, but I also do not want to lose competitive advantage by getting started too late. With the government pushing for widespread adoption in physician offices, I have no doubt that the momentum for change is unstoppable. When physicians get accustomed to using electronic practice tools in their offices or other hospitals, it is highly unlikely that they will be satisfied with the old-style paper tools. My physician just told me during a recent visit that he loves how efficient EHRs are because of documentation templates, which mirror his clinical practices. Our organization must move forward now.” The consultant might reply, “I would think you would be thrilled with the prospect of physicians clamoring for EHRs, but you still seem wary. What are you most concerned about in moving forward with this initiative?” The CEO replies, “The patient’s medical record affects every department and employee in the organization. It is integral to every patient care and business process. I am already hearing concerns expressed by my key leaders regarding change and conflicts over process ownership, what systems to purchase, how fast we can and can’t move. The transition from a paper medical record to an EHR is more than an incremental improvement in processes, and more than just another IT project.” The consultant replies, “You are absolutely right, you are talking about transformational change.” The CEO continues, “I am worried about the people issues – the success of our organization is tied directly to our people. Disruptive change is frightening to people, and affects their morale. When morale goes down, quality and productivity suffer, and turnover increases. With the shortages of staff today, we cannot afford to lose good quality people.” The consultant replies, “Transformative change on this scale is a complex undertaking, with many potential pitfalls. However, let me tell you about a framework for leading change that takes into account the complexity and risks, including the human side of change.” Conquering the Dilemma of Transformational Change Healthcare leaders and consultants can readily empathize with the dilemma expressed by the CEO in the conversation above. The vision of an organization using health information technology tools in a way that results in fewer medical errors, higher quality of care, and more efficient use of staff members’ time is very appealing. It is the thought of what it takes to reach the vision that makes leaders nervous. Traditional Change Management Models Are Not Always Successful The deficiency with most traditional change management models is that, though they offer solid strategic and logistical guidance, for the most part they ignore the emotional side of change. When traditional models do touch on behavioral aspects of change, they do so superficially, with the focus only on individual behavior or personalities. Using an individual, ‘otherfocused’ perspective on human behavior can be limited or even self-defeating for change leaders. A broader perspective, one that views the entire organization as a relationship system with patterns of behavior unique to an organization, keeps leaders in tune with their organization. In the midst of transformative change, effective leadership requires more than charisma or charm. Leaders need a solid theory of human behavior, integrated with proven change processes to inform their thinking. Systems-based Leadership and Change Management™ – A Comprehensive Approach to Complex Organizational Change Systems-based Leadership and Change Management™ is an approach that draws on sound theories from the behavioral sciences and the management literature. As a healthcare consultant, the author searched for more than 30 years to find a solution that would make change quick and painless, but no quick fixes were to be found. However, perseverance, study, thoughtful observation and dialogue with hundreds of colleagues and clients who were grappling with change over the years led to creating a framework for leading complex organizational transformation that resonates with people who are in the throes of such a change. The framework draws on four bodies of knowledge to create four key concepts, which, when woven together yield a comprehensive set of processes and tools for leading transformative change.The four concepts are:
Executives who use the first of the four concepts – systems-based leadership – view organizations as a relationship system. They lead with awareness of the automatic nature of relationship behaviors present in all human systems, from families to work systems. To adopt the second of the four concepts – transition management – change leaders are cognizant of the psychological process that individuals go through as they internalize and come to terms with change. They consciously lead people through the transition process with tools and processes that encourage people to openly deal with the losses, a period of uncertainty, and a new reality that is unfolding until the acceptance of that reality is sustainable. The third concept essential for success is an over-riding strategic change process that is comprehensive, iterative, and geared to sustaining the organization’s stamina for coping with the non-stop change demanded of information-age organizations. The fourth concept requires using proven and standardized project management tools and processes throughout the organization for the multiple change projects that comprise a complex organizational transformation. Change leaders who ignore or fail to master any of these four concepts may find that their change initiatives never take off, or they slow down, falter, or fail to stick. Concept One – Systems-based Leadership Leading with Awareness of the Emotionally Driv en Relationship System Systems-Based Leadership™ applies Bowen Family Systems Theory to the workplace. First conceptualized by Dr Murray Bowen in the 1950s,1 Bowen theory presents a perspective on human behavior that has informed the thinking of family therapists and organizational consultants for over half a century. It is a theory of human behavior grounded in observable facts about the human family, and by extension, about the larger social systems of which human families and their members are a part.2 Bowen theory describes organizations and the units within them as relationship systems with predictable patterns of behavior. This is the one area of knowledge and expertise that is too often absent, and the one that, when ignored, creates the most problems during the process of leading change. Systems-based leadership enables leaders to directly address the ‘emotional’ side of change. (The term ‘emotional’ in Bowen theory refers to automatic or instinctual responses to a real or perceived threat.) Leader ship is a Reciprocal ProcessThe fundamental concept of Bowen theory is that whole families or human social groups, like organizations, function as ‘emotional systems’, in which the functioning of each member affects the functioning of every member of the system and vice versa. The key lesson in this concept is that, like a mobile, if one pulls on one piece, all of the pieces automatically move. The emotional system operates outside of our awareness, thus, leaders do not always recognize that they automatically play a role in how the system functions at the emotional level. With increased self-awareness, persons of importance to the system, such as leaders, can focus on changing their own behavior, which in turn changes the patterns of behavior in the whole system. |
Anxiety and Emotional Maturity – Key Variables Bowen theory reveals how the interplay between variations in anxiety and emotional maturity result in emotional behaviors that impact the success or failure in organizations. For example, behaviors such as blaming, stonewalling, angry outbursts, inattentiveness, and careless errors are all symptoms of anxiety. As anxiety increases, the intensity of the symptoms increases. Individuals with a higher level of emotional maturity are less anxious and less vulnerable to the contagious nature of anxiety in systems. During anxious times, leaders who can tolerate anxiety are committed to being ‘present and accounted for’, i.e. by clearly expressing thoughtful positions on issues during the course of the transformation, and by taking responsibility for their own role in the emotional system. Learning to observe anxiety-driven behaviors in oneself and others, and recognizing how they play out in the organization helps change leaders to see their own role in the emotional system. Anxiety is contagious. It spreads from person to person through a system almost instantaneously. But calm is contagious too. Becoming more aware of one’s own anxious behaviors and seeing the impact they have on the functioning of the whole system, provides a different, broader perspective for a leader. It also enables the responsible, motivated leader to see many more options for resolving problems and issues in the organization. Concept Two – The Psychological Process of Transitions William Bridges, PhD, a psychologist, business consultant, and pre-eminent authority on change and managing change observes that change and transition are different. Change is an event or a new situation that happens to people. Transition is the psychological process one goes through to come to terms with the change that has taken place.3 An essential part of a strategic change process is a transition plan that helps those most affected by the change to get through their individual transitions as close to the time of the change as possible. One must recognize, however, that a transition cannot be completed until the change has been implemented. The challenge to the change leader is to know that transition is inevitable. The change leader must start managing the transition process as early as possible, at the individual and the systems level. For example, at the earliest stages of the initiative, the leader should start thinking about the losses that individuals will experience. Bridges describes how the process of transition starts paradoxically with endings, and people need time to come to terms with their losses. Endings are followed by a neutral zone, or period of uncertainty about the future of the new order, and finally end with a new beginning, initially fragile, eventually sustainable. By applying Concept One, an understanding of organizations as emotional systems, change leaders who are thinking systems recognize that individuals vary in their internal processing of change. Then, by weaving in Concept Two, the leader will understand how the transition process is experienced by individuals against the backdrop of their own unique experiences with change, as well as how their family of origin experienced and managed change. An individual’s emotional maturity and the level of anxiety in the emotional system of the organization influence how successfully or how quickly each person goes through the transition. Most importantly, a leader’s capacity for managing his or her anxiety influences the level of organizational anxiety. If leaders are anxious, it’s contagious. Concept Three – An Eight-step Strategic Change Process John Kotter, a Harvard Business School professor and change management expert, describes an eight-step iterative process for the change leader to create a strategy and roadmap for transformational change. From creating urgency through making change stick, Kotter also recognizes the strong emotional component to successful change, introduced in concepts one and two, which is clearly reflected in the eight steps – increase urgency, build a guiding team with people powerful enough to guide a big change, get the vision right and communicate it in a way that gets buy-in, empower action by removing obstacles, create short-term wins to build momentum, stay the course by not letting up, and make change stick by recognizing and resisting the automatic sabotaging behaviors.4
Concept Four – Highly Visible and Universally Used Project Management Tools and Processes No complex change project will be completely successful without careful attention to logistics, implementation timelines, and the coordination of multiple inter-related events. The project management process is well understood and usually well executed in the information technology (IT) world. However, more and more of the work in our 21st century organizations is accomplished through projects. Outside of IT departments, standard project management tools are less universally used. Participants in all types of change will benefit from knowledge of project management processes. Successful change leaders make sure that their organizations use state-of-the-art project management tools and processes to create a readily recognizable model for managing the logistics of all large-scale change projects in the organization. Conclusion – Is the Leader of the Organization Ready for Change? The conversation with the CEO earlier in this article continues: “I am not certain if my organization is ready for a change as far-reaching as the EHR,” says the CEO. “Are you up for the challenge of getting your organization ready?” asks the consultant. The CEO concedes, “Yes I am.What do you think are my next steps in preparing for the EHR?” The consultant replies, “There are four areas that are crucially important to your organization’s success.You will need to determine as objectively as possible how close you are to having those four areas covered. First, the organization needs you and your top leadership to be fully engaged in the EHR initiative throughout the period of transformation and transition to the EHR.You must ask yourself, if you’re willing to make the commitment to lead with emotional awareness, being emotionally ‘present and accounted for’ at all times? Second, your leadership team must understand the three phases of transition and have, or know how to develop, a transition management plan.This plan must identify not only the benefits of EHRs, but what people will lose in the transition.You and your team must have the capacity to calmly and patiently support people as they experience the sense of loss during the endings. You should prepare for the likelihood of having times of uncertainty, and enable leaders at all levels of the organization to calm people, to help them envision new ways of working, and finally help them embrace those new ways. Ask yourself, if you’re willing to advocate for and allocate resources for such a plan? Third, a long-term strategic change framework is essential. It must be comprehensive enough to guide your leadership team in developing a roadmap to get from the current state of health IT to a completely transformed future state. It must include everything from creating urgency across the organization for EHRs, to an organizational infrastructure that can support the transformation process, to a unified vision of the EHR for the organization, all the way through multiple project implementations, to sustaining a healthcare system that integrates health IT into every patient care and business. Fourth, your organization must have a standardized project management process, tools, expertise and experience in planning, budgeting, managing, and coordinating the activities of multiple parties involved in complex organizational change projects.” Like the aging of fine wine or the slow cooking of a special stew, the recipe for successful change leadership using the elements of Systems-based Leadership and Change Management™ takes time. It really isn’t a quick fix. It is more like renewing a lifelong commitment to personal and professional growth for you and your leadership team. The pay-off is enormous for leaders willing to make such an effort. Care Communications is a Chicago-based consulting firm specializing in leading the change to EHRs. To send questions or comments, email lfox@care-communications.com |
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