Introduction Nancy M. Lorenzi

Introduction

Nancy M. Lorenzi

Life in the new millennium continues to be as hectic as, or more so than, in the 1990s.

The rate of change in virtually all organizations is escalating, and healthcare organiza- tions are no exception. The phrase change management has become fairly common, appearing in management articles everywhere. Review the job ads in the Wall Street Journal or the Sunday edition of a major newspaper and notice the positions available for people skilled in change management.

Management in the past decade was associated with many words beginning with “re.”

Some of the most common were renew, reengineer, restructure, revitalize, reenergize, reframe, reinvigorate, and, unfortunately, redundancy. Why were we so fascinated with all these words? Organizational dynamics is one possible answer. Organizational change had escalated to such an intense level that the old paradigms of organizations and of organizational leadership changed. We needed new ways to cope with change—

not only to describe it but also to manage it in positive and proactive ways. All the “re”

words were the organizational equivalent of whistling in the dark or reciting an orga- nizational mantra: “We are not afraid of the future. We understand the future. We are clearly in charge and ready for the future.”

What do all the “re” words really mean? While most executives talk about the impor- tance of people, most do not focus a large amount of their resources and attention on human resources. Many do not know how to effectively deal with people issues. When they identify a new “re” word that offers some concrete steps or suggestions for looking at the complexity of today’s problems and issues in an easy-to-understand style and manner, they grab the “re” word eagerly and then want instant results. When one strips away all the hype from each of the “re” words and their respective advocates, some- where within the core of each “re” word is a set of principles that goes back to basic concepts and theories drawn from a number of associated disciplines such as sociol- ogy, psychology, social psychology, anthropology, organizational development, and management.

Common Principles

Regardless of the particular “re” word followed by an organization and its leaders,

there are seven basic principles shared by all “re” concepts. These principles are linked

to understanding people and the organizational environment in which they function

and to learning—both by the individuals and by the organization as a whole. While

some “re” words have other names, they still share the following seven principles, which

we call “the magnificent seven.”

The Magnificent Seven

1. Respect for People

Treating people with respect through honesty and trust is the cornerstone of all the

“re” words and programs. This should be a basic life principle for everyone. With respect for people as the leading force, all the other principles follow and enrich this basic respect.

2. Involvement

Involving people is another core principle. If you want people to change, they must not be merely informed about the changes that leaders perceive are needed but must also be involved. All “re” programs include the actual involvement of everyone.

3. Empowerment

Once involved, people must be empowered. A major “re” principle is energizing and empowering employees within the organization to move beyond involvement to the next stage of commitment to the organization and accepting responsibility. Empower- ment is often accomplished by a flattening of the organizational structure, effectively eliminating middle-management positions—and in some cases contributing to insecu- rity among employees about what empowerment really means.

4. Teamwork

People working together to make change happen is another core principle underlying the “re” philosophy. In today’s complex organizations, changes affect far more than just one job or one area; therefore, high degrees of teamwork are needed. In many orga- nizations, today’s emphasis on self-directed work teams is an integration of the empow- erment and teamwork principles.

5. Customer First

The customer must come first. Once employees feel comfortable with themselves, it is only natural to refocus the thinking of the organization to determine what their cus- tomers need and what the organization can do to offer support and services to cus- tomers—whether patients, physicians, other employees, etc. This principle places the customer in a central position and requires those on the inside of the organization to shift their perspective and view the organization from the external or customer point of view. Customers must be asked to become involved, either directly or indirectly, with the organization so that the organization learns what its customers need from the total organization.

6. Openness to Change

All the “re” words or programs imply that the system must be open to change, as

opposed to being a closed, highly structured bureaucratic system. In our traditional

systems, stability has been viewed as the norm, with change being a temporary devia-

tion from that norm. In true “re” systems, change is the norm, and stability is the

aberration. A good example is the continuous quality improvement (CQI) concept, with its informal motto: If it ain’t broke, break it!

7. Vision-Oriented

All the “re” philosophies emphasize the importance of a longer-run, vision-oriented approach to the management process in contrast to the more traditional short-run, activity-oriented approach. The word paradigm is used constantly to reflect the need for this future-oriented model.

What Is Change Management?

The healthcare industry, and other businesses as well, are constantly trying to reassess their future direction. Some organizations seemed to go through a series of manage- ment “fads” in a search for some sort of organizational nirvana. Total quality manage- ment (TQM) and CQI are systems that many organizations have adopted today. Most of these implementations are not as successful as organizations had hoped they would be. Rather than truly working to change the organizational culture, many adopters have simply installed a new set of rituals. Rather than leading the effort for change, top man- agement delegates the process to staff and gallops off to deal with crises in the same old way. The danger is that the concept called change management may meet the same fate.

Change management is the process by which an organization reaches its future state—the vision. Traditional planning processes delineate the steps along the journey.

The role of change management is to facilitate this journey. Therefore, creating change starts with creating a vision for change and then empowering individuals to act as change agents to attain this vision. The empowered change management agents need plans that are (1) a total systems approach, (2) realistic, and (3) future-oriented. Change management encompasses the effective strategies and programs that enable its cham- pions to achieve the new vision.

There are critical success factors when managing change, and these include human- human interaction, understanding users’ needs, transcultural management, education and training, and organizational development.

Change Management Strategies

Change management is the process of assisting individuals and organizations in passing from an old way of doing things to a new way of doing things. Based on our research, there is no single change management strategy that can be used in every situation. It is essential for the change management leader to take the time to know the desired state (vision/goal) and the “diagnosis” of the organization’s current (and past) situa- tion and then to develop appropriate strategies and plans to help facilitate attainment of the desired state.

Over the years we have evolved a core model for the major process of change man-

agement. There are many options within this model, but we believe that it is helpful

for leaders to have an overview map in mind as they begin to implement new

information technology systems. The five-stage model that has proven effective for

reducing barriers to technology change begins with an assessment and information- gathering phase.

Assessment

The assessment phase of this model is the foundation for determining the organiza- tional and user knowledge and ownership of the health informatics system under consideration. Ideally this phase of the model begins even before planning for the tech- nological implementation of the new system. The longer the delay, the harder it will be to successfully manage the change and gain ultimate user ownership.

There are two parts to the assessment phase. The first is to inform all potentially affected people, in writing, of the impending change. This written information need not be lengthy or elaborate, but it will alert everyone to the changes in process.

The second part involves collecting information from those involved in the change by using both surveys and interviews. The survey instrument should be sent to ran- domly selected members of the affected group. One person in ten might be appropri- ate if the affected group is large. Five to ten open-ended questions should assess the individuals’ current perceptions of the potential changes, their issues of greatest concern about these changes, and their suggestions for reducing these concerns.

Recording and analyzing the responders’ demographics will allow more in-depth analy- sis of the concerns raised by these potentially affected people.

In personal face-to-face interviews with randomly selected people at all levels throughout the affected portions of the organization, it is important to listen to the stories they tell and to assess their positive and negative feelings about the proposed health informatics system. These interviews should help in ascertaining the current levels of positive and negative feelings, what each person envisions the future will be both with and without the new system, what each interviewee can contribute to making this vision a reality, and how the interviewee can contribute to the future success of the new system. These interviews provide critical insights for the actual implementa- tion plan. Often the people interviewed become advocates—and sometimes even champions—of the new system, thus easing the change process considerably.

An alternative or supplement to one-on-one interviews is focus-group sessions.These allow anywhere from five to seven people from across the organization to share their feelings and ideas about the current system and the new system.

Feedback and Options

The information obtained as described above must then be analyzed, integrated, and packaged for presentation to both top management and to those directly responsible for the technical implementation. This is a key stage in understanding the strengths and weaknesses of the current plans, identifying the major organizational areas of both excitement and resistance (positive and negative forces), identifying the potential stum- bling blocks, understanding the vision the staff holds for the future, and reviewing the options suggested by the staff for making the vision come true. If this stage occurs early enough in the process, data from the assessment stage can be given to the new system developers for review.

When designing a model, this phase is important in order to establish that the orga-

nization learns from the inputs from its staff and begins to act strategically in the deci-

sion and implementation processes.

Strategy Development

The strategy development phase of the model allows those responsible for the change to use the information collected to develop effective change strategies from an orga- nizational perspective. These strategies must focus on a visible, effective process to

“bring on board” the affected people within the organization. This can include newslet- ters, focus groups, discussions, one-on-one training, and confidential “hand holding.”

The latter can be especially important for professionals, such as physicians who may not wish to admit ignorance and/or apprehension about the new system.

Implementation

The implementation phase of the model refers to implementation of the change man- agement strategies determined to be needed for the organization, not to implementa- tion of the new system. Implementation of the change strategies described above must begin before actual implementation of the new system. These behaviorally focused efforts consist of a series of steps including informing and working with the people involved in a systematic and timely manner. This step-by-step progression toward the behavioral change desired and the future goals is important to each individual’s accept- ance of the new system. This is an effective mechanism for tying together the new tech- nology implementation action plan and the behavioral strategies.

Reassessment

Six months after the new system is installed, a behavioral effects data-gathering process should be conducted. This stage resembles the initial assessment stage—involving written surveys and one-on-one and/or focus-group interviews. Data gathered from this stage allows measurement of the acceptance of the new system, providing a basis for fine-tuning. This process also serves as input in evaluation of the implementation process. It ensures all the participants that their inputs and concerns are still valued and sought after even though the particular implementation has already occurred.

Case Introduction

The following four cases represent a variety of change management practices and strategies, successes and failures, and phases. They are meant as learning opportunities for those considering the process of implementing information systems.

Reference

1. Lorenzi NM, Mantel MI, Riley RT. Preparing your organizations for technological change.

Healthcare Informatics 1990;December:33–34.