Feature
Embedding change in the healthcare sector Mark Eaton has worked in the healthcare sector for the past eight years and led numerous successful transformational programmes. Previously, Mark led the government’s transformation programme for manufacturing and has also worked in the Armed Forces and local government on change programmes. Here, he sets out how healthcare organisations can successfully cope with and embed change within their organisation. THE NEED FOR CHANGE IN THE HEALTHCARE SECTOR In a survey undertaken in 2008, 83%1 of organisations reported that they faced substantial change in the near future; however, fewer than half of the organisations reported that they had successfully introduced, and embedded, major changes in the past. These statistics apply as much in the healthcare sector as they do anywhere else, but the problem for healthcare in 2014 is that everyone is under pressure to make significant change, and therefore, 50% or more may fail to realise the benefits that can arise from successfully embedding organisational change. This article addresses the things that healthcare organisations need to do to increase the probability of success and to deal with the fact that ‘Every day we are faced with a peculiar paradox – that we live in a state of constant flux yet we abhor the process of change’.2
UNDERSTANDING THE CHANGE JOURNEY Implementing substantial organisational change is not easy, although the difficulty is frequently underestimated by those responsible for sponsoring and managing the change process in their organisation. Figure 1 provides a summary of the journey that organisations engaged in substantial change must go through to enable them to realise the long-term benefits. Figure 1 shows that there are three main phases in any change programme:
w Preparation – getting the organisation ready for improvement, setting down the objectives of the improvement programme and putting in place the resources to implement the changes. w Implementation – the physical processes of implementing the changes. w Embedding – the transition phase from having changed structures/
Figure 1 The change journey3
processes and systems to the point where you have changed behaviours.
CRISIS POINTS IN THE CHANGE JOURNEY Within Figure 1 are six key points that could be called ‘Crisis Points’ as each point represents a critical stage in the change process where a crisis may arise that affects the overall success of the programme.
w Crisis Point 1 – Decision to Change: Here there is a realisation that there is a need to improve and that the current way of doing things is no longer acceptable or appropriate. A crisis will occur if those planning the change are split over the need for change.
w Crisis Point 2 – Planning to Change: The crisis here will arise when there are competing priorities for limited time and resources and when there is confusion over such things as the scope and duration of the change programme required.
w Crisis Point 3 – Preparing to Implement: The crisis can occur when those affected by the change start to push back or raise issues and those sponsoring/leading the change lose their nerve and begin to panic or backtrack.
12 Perspectives in Public Health l January 2014 Vol 134 No 1
w Crisis Point 4 – The Noise of Change: This point occurs when the changes are underway. Some things will go well and others will not be as successful. A crisis can arise when individuals use setbacks and issues to undermine all of the proposed changes and to return to the old way of doing things.
w Crisis Point 5 – Adoption of the Changes: When changes have been made, residual behaviours that existed before the change may still exist. You can find people 2–3 years downstream of a merger still referring to ‘them and us’ even though the two independent organisations no longer exist. The crisis occurs when people have the opportunity to revert to doing what they were doing before.
w Crisis Point 6 – The Embedding of the Changes: The crisis can arise when things go wrong or when unexpected situations arise, and people immediately revert to the old way of doing things. The art of managing this phase is to put in place a process that will capture any issues that arise and has time and resources allocated to make adjustments to the way things work.
Feature UNDERSTANDING THE DRIVERS OF THE CRISIS POINTS The reasons why a crisis can occur at one or more of the six points highlighted in the previous section can be summed up by the statement, ‘There are four things that hold back human progress; ignorance, lethargy, committees and inflexibility’.4 More specifically, a crisis can occur because individuals (or even whole teams) are affected by the concept of ‘WIIFM’ (What’s in it for me?) with this leading to such questions as5 ‘Will I/we gain or lose something of value?’; ‘Do I/we understand the nature of the change?’; ‘Do I/we trust those who are initiating the change?’; and ‘Do I/we agree with the change process and what is currently happening?’ It can be that an individual starts off being fully supportive of the proposed changes but then begins to become concerned when they receive mixed messages, or the scope of the change alters or even when one of their leaders challenges the validity or effectiveness of what is occurring. Alternatively, people can begin by being sceptical of the proposed changes but then begin to engage in the process as more information is received and their fears/concerns are addressed. It is important to realise that there will never be universal acceptance of any proposed changes, but the aim of managing and embedding change is to bring the majority of your team along with you.
EFFECTIVELY EMBEDDING CHANGES Referring back to the 2008 survey mentioned in the opening section of this article, the authors of the paper identified the need for nine elements to be in place to ensure the successful embedding of organisational change, and these are listed below with the most important at the top of the list:1
w Sponsorship: having a top level supportive champion of the change. w Engagement and involvement: gaining and maintaining stakeholder
w w
w w
w w w
engagement. This is supported by the quote ‘Without involvement, there is no commitment’.6 Honest and timely communications. Cultural change: focus on changing the behaviour of the organisation to meet the demands of the future. In one study, over 80% of medics and over 60% of nurses reported7 having witnessed colleagues who had done things that concerned them about the safety of patients, yet only 10% had felt able to speak to the colleague about it. Change agents: individuals with the capability to lead. Capability building: a continuing investment in building the skills for change. Performance measures. Effective structure. Incentives.
PRACTICAL ADVICE ON EMBEDDING CHANGE A different view on embedding organisational change gives us five clear pieces of advice that are summarised below:8
1. Understand and spell out the impact of the change on people: Relating to the need for honest and timely communication seen in the earlier ninepoint list, this means that organisations need to be clear about the specific impact the change will have on teams and individuals both in the short term and the longer term. The desire to withhold vital information should be resisted.
2. Build an emotional and rational case for change: Being clear about the need for change will build trust (even if the message is unpleasant), but this stage is concerned with engaging ‘hearts and minds’ in the
process by explaining clearly why the change is needed and why now is the right time for it to happen.
3. Ensure that the entire leadership team is a role model for the change: The importance of this element cannot be overstated. If you have a disjointed senior team who do not support the change process, then you will seriously undermine the ability of your organisation to successfully embed change.
4. Mobilise your people to ‘own’ and accelerate the change: Part of this is about providing your people with the skills and confidence to undertake the changes needed, but another part is empowering them to get on with the change. This means ensuring that they do not feel that they will be blamed if things go wrong and that any (appropriate) risks that they take are going to be supported by the senior team.
5. Embed the change in the fabric of the organisation: Perhaps the most important part of this whole article is about the need not just to implement changes but to ensure they become part of the organisational way of doing things. This means ensuring that there is ongoing senior support for the change process, that issues and ideas that arise are captured and acted upon and having clear and well understood measures that show how performance is improving. There is going to be an ongoing need for significant change in the healthcare sector for the foreseeable future. Successful implementation of organisational change will reduce the costs of the change as well as the risks, but more importantly will allow more money to be available for the delivery of services and initiatives that directly benefit patients, carers and the wider community. Mark Eaton BSc, MSc, MBA, FIET, CEng Email: [email protected]
References 1. IBM. Making change work. 2008. Available online at: public.dhe.ibm.com/common/ssi/ecm/en/ gbe03100usen/GBE03100USEN.PDF (Last accessed 8th November 2013). 2. Quote from Elisabeth Kubler-Ross (1926–2004), the Swiss-American Psychiatrist who developed the ‘Five Stages of Grief’ and was a leading thinker in transition and change management. 3. From the work of Elisabeth Kubler-Ross, with adaptations thereof by Corvus Business Associates.
4. Adapted from Charles JC Lyall’s ‘There are four things that hold back human progress; ignorance, stupidity, committees and accountants’. 5. Price JL, Gardener D, Dunham RB. Management and Organisational Behavior: An Integrated Perspective. Ch. 18. South-Western College Publishing, 2001. 6. Quote by Stephen Covey, author of The Seven Habits of Highly Effective People, 1989. 7. Maryland Patient Safety Center. Implementing a strategic agenda for keeping patients safe. 2009;
Available online at: http://www.marylandpatientsafety.org/html/about_us/index.html (Last accessed 8th November 2013). 8. Harshak A, Aguirre D, Brown A. Making change happen and making it stick. strategy+business 2010; 20 December. Available online at: http:// www.strategy-business.com/ article/00057?gko=39ed2 (Last accessed 8th November 2013).
January 2014 Vol 134 No 1 l Perspectives in Public Health 13
Embedding change in the healthcare sector Mark Eaton has worked in the healthcare sector for the past eight years and led numerous successful transformational programmes. Previously, Mark led the government’s transformation programme for manufacturing and has also worked in the Armed Forces and local government on change programmes. Here, he sets out how healthcare organisations can successfully cope with and embed change within their organisation. THE NEED FOR CHANGE IN THE HEALTHCARE SECTOR In a survey undertaken in 2008, 83%1 of organisations reported that they faced substantial change in the near future; however, fewer than half of the organisations reported that they had successfully introduced, and embedded, major changes in the past. These statistics apply as much in the healthcare sector as they do anywhere else, but the problem for healthcare in 2014 is that everyone is under pressure to make significant change, and therefore, 50% or more may fail to realise the benefits that can arise from successfully embedding organisational change. This article addresses the things that healthcare organisations need to do to increase the probability of success and to deal with the fact that ‘Every day we are faced with a peculiar paradox – that we live in a state of constant flux yet we abhor the process of change’.2
UNDERSTANDING THE CHANGE JOURNEY Implementing substantial organisational change is not easy, although the difficulty is frequently underestimated by those responsible for sponsoring and managing the change process in their organisation. Figure 1 provides a summary of the journey that organisations engaged in substantial change must go through to enable them to realise the long-term benefits. Figure 1 shows that there are three main phases in any change programme:
w Preparation – getting the organisation ready for improvement, setting down the objectives of the improvement programme and putting in place the resources to implement the changes. w Implementation – the physical processes of implementing the changes. w Embedding – the transition phase from having changed structures/
Figure 1 The change journey3
processes and systems to the point where you have changed behaviours.
CRISIS POINTS IN THE CHANGE JOURNEY Within Figure 1 are six key points that could be called ‘Crisis Points’ as each point represents a critical stage in the change process where a crisis may arise that affects the overall success of the programme.
w Crisis Point 1 – Decision to Change: Here there is a realisation that there is a need to improve and that the current way of doing things is no longer acceptable or appropriate. A crisis will occur if those planning the change are split over the need for change.
w Crisis Point 2 – Planning to Change: The crisis here will arise when there are competing priorities for limited time and resources and when there is confusion over such things as the scope and duration of the change programme required.
w Crisis Point 3 – Preparing to Implement: The crisis can occur when those affected by the change start to push back or raise issues and those sponsoring/leading the change lose their nerve and begin to panic or backtrack.
12 Perspectives in Public Health l January 2014 Vol 134 No 1
w Crisis Point 4 – The Noise of Change: This point occurs when the changes are underway. Some things will go well and others will not be as successful. A crisis can arise when individuals use setbacks and issues to undermine all of the proposed changes and to return to the old way of doing things.
w Crisis Point 5 – Adoption of the Changes: When changes have been made, residual behaviours that existed before the change may still exist. You can find people 2–3 years downstream of a merger still referring to ‘them and us’ even though the two independent organisations no longer exist. The crisis occurs when people have the opportunity to revert to doing what they were doing before.
w Crisis Point 6 – The Embedding of the Changes: The crisis can arise when things go wrong or when unexpected situations arise, and people immediately revert to the old way of doing things. The art of managing this phase is to put in place a process that will capture any issues that arise and has time and resources allocated to make adjustments to the way things work.
Feature UNDERSTANDING THE DRIVERS OF THE CRISIS POINTS The reasons why a crisis can occur at one or more of the six points highlighted in the previous section can be summed up by the statement, ‘There are four things that hold back human progress; ignorance, lethargy, committees and inflexibility’.4 More specifically, a crisis can occur because individuals (or even whole teams) are affected by the concept of ‘WIIFM’ (What’s in it for me?) with this leading to such questions as5 ‘Will I/we gain or lose something of value?’; ‘Do I/we understand the nature of the change?’; ‘Do I/we trust those who are initiating the change?’; and ‘Do I/we agree with the change process and what is currently happening?’ It can be that an individual starts off being fully supportive of the proposed changes but then begins to become concerned when they receive mixed messages, or the scope of the change alters or even when one of their leaders challenges the validity or effectiveness of what is occurring. Alternatively, people can begin by being sceptical of the proposed changes but then begin to engage in the process as more information is received and their fears/concerns are addressed. It is important to realise that there will never be universal acceptance of any proposed changes, but the aim of managing and embedding change is to bring the majority of your team along with you.
EFFECTIVELY EMBEDDING CHANGES Referring back to the 2008 survey mentioned in the opening section of this article, the authors of the paper identified the need for nine elements to be in place to ensure the successful embedding of organisational change, and these are listed below with the most important at the top of the list:1
w Sponsorship: having a top level supportive champion of the change. w Engagement and involvement: gaining and maintaining stakeholder
w w
w w
w w w
engagement. This is supported by the quote ‘Without involvement, there is no commitment’.6 Honest and timely communications. Cultural change: focus on changing the behaviour of the organisation to meet the demands of the future. In one study, over 80% of medics and over 60% of nurses reported7 having witnessed colleagues who had done things that concerned them about the safety of patients, yet only 10% had felt able to speak to the colleague about it. Change agents: individuals with the capability to lead. Capability building: a continuing investment in building the skills for change. Performance measures. Effective structure. Incentives.
PRACTICAL ADVICE ON EMBEDDING CHANGE A different view on embedding organisational change gives us five clear pieces of advice that are summarised below:8
1. Understand and spell out the impact of the change on people: Relating to the need for honest and timely communication seen in the earlier ninepoint list, this means that organisations need to be clear about the specific impact the change will have on teams and individuals both in the short term and the longer term. The desire to withhold vital information should be resisted.
2. Build an emotional and rational case for change: Being clear about the need for change will build trust (even if the message is unpleasant), but this stage is concerned with engaging ‘hearts and minds’ in the
process by explaining clearly why the change is needed and why now is the right time for it to happen.
3. Ensure that the entire leadership team is a role model for the change: The importance of this element cannot be overstated. If you have a disjointed senior team who do not support the change process, then you will seriously undermine the ability of your organisation to successfully embed change.
4. Mobilise your people to ‘own’ and accelerate the change: Part of this is about providing your people with the skills and confidence to undertake the changes needed, but another part is empowering them to get on with the change. This means ensuring that they do not feel that they will be blamed if things go wrong and that any (appropriate) risks that they take are going to be supported by the senior team.
5. Embed the change in the fabric of the organisation: Perhaps the most important part of this whole article is about the need not just to implement changes but to ensure they become part of the organisational way of doing things. This means ensuring that there is ongoing senior support for the change process, that issues and ideas that arise are captured and acted upon and having clear and well understood measures that show how performance is improving. There is going to be an ongoing need for significant change in the healthcare sector for the foreseeable future. Successful implementation of organisational change will reduce the costs of the change as well as the risks, but more importantly will allow more money to be available for the delivery of services and initiatives that directly benefit patients, carers and the wider community. Mark Eaton BSc, MSc, MBA, FIET, CEng Email: [email protected]
References 1. IBM. Making change work. 2008. Available online at: public.dhe.ibm.com/common/ssi/ecm/en/ gbe03100usen/GBE03100USEN.PDF (Last accessed 8th November 2013). 2. Quote from Elisabeth Kubler-Ross (1926–2004), the Swiss-American Psychiatrist who developed the ‘Five Stages of Grief’ and was a leading thinker in transition and change management. 3. From the work of Elisabeth Kubler-Ross, with adaptations thereof by Corvus Business Associates.
4. Adapted from Charles JC Lyall’s ‘There are four things that hold back human progress; ignorance, stupidity, committees and accountants’. 5. Price JL, Gardener D, Dunham RB. Management and Organisational Behavior: An Integrated Perspective. Ch. 18. South-Western College Publishing, 2001. 6. Quote by Stephen Covey, author of The Seven Habits of Highly Effective People, 1989. 7. Maryland Patient Safety Center. Implementing a strategic agenda for keeping patients safe. 2009;
Available online at: http://www.marylandpatientsafety.org/html/about_us/index.html (Last accessed 8th November 2013). 8. Harshak A, Aguirre D, Brown A. Making change happen and making it stick. strategy+business 2010; 20 December. Available online at: http:// www.strategy-business.com/ article/00057?gko=39ed2 (Last accessed 8th November 2013).
January 2014 Vol 134 No 1 l Perspectives in Public Health 13
