Hospital change management: the key to care innovation

Stephanie Kovalick: Hello, and thank you for joining us for our Clinical View podcast series Leading Through Change. During this podcast series, we will discuss the strategies hospital and health system leaders can use to help their clinical and administrative teams adjust and adapt to new projects and initiatives successfully. I'm Stephanie Kovalick, partner and chief strategy officer at Sage Growth Partners, and I'm joined today by Louise Keough Weed. Louise is the principal of KW Facilitation, affiliate faculty member at Harvard Medical Center for Primary Care and instructor at the Harvard T.H. Chan School of Public Health. Today, Louise and I will be discussing the fundamentals of change management for hospital and health system leaders, including why and when change management is so important. So Louise, thanks so much for joining us today. I'd like to get started by having our listeners learn a little bit more about your background and experiences in helping organizations navigate change. How did you get started in this field and why is it so interesting to you?

Louise Weed: Thank you so much for having me. I'm really excited to talk with you about change management. I started as a practitioner doing this work directly in health systems and at health centers. So I have my Master's in Public Health, in Health Policy and Management. When I was in graduate school, I learned about quality improvement and patient safety, and it was the first time I really started to understand why and how change management could really impact our systems and patients lives. So I went on to do that work again, like I said, in a major hospital system, and then more specifically in primary care, where I was getting more into general change management. So any sort of change initiative that was happening at the organization to improve patient care, patient centered, medical home, ACO development, behavioral health integration, you name it, I was a part of it. So I really come to this work as a practitioner, as someone who has done this on the ground and has sort of waded through the mud of what change management really means in the real world. I pivoted quite a few years ago now where I realized that I was sort of agnostic about the change that was happening and I was really interested in all the things that needed to happen under the surface with people, with teams, with systems to actually achieve those changes.

So I shifted to think about leadership and change management for leaders in healthcare systems so that the ripple effect could happen and we could improve the system overall.

Stephanie Kovalick: That's great. Your background is super impressive. I couldn't say that enough. And it's really interesting. Right before we kind of dive into some tips and tricks and advice you might have, one thing is for sure, and I'm sure to agree, healthcare in the United States changes very slowly. So, let's talk a little bit more about change management in general, right? When you hear that phrase change management, what does it mean in that healthcare environment or the hospital and health system environment? How do you define it?

Louise Weed: So for me, I think of change management is about true culture shift. At the end of a change management process, we should ideally be able to say: this is just in the drinking water, this is how we do things here and that is a really hard thing to achieve. I think in the US there's so many different levers and so many different inputs in our healthcare industry. It is really hard to achieve the level of focus and diligence required to achieve that culture shift. So we can think about impact and success in terms of those places, right, in terms of those levers. But things move slowly. But there's also so much happening all the time in healthcare in the US that it's actually really hard to distinguish where we need true change management processes versus smaller operational improvements, versus trade-offs of things we can't focus on right now. So we're moving really slowly, but we also on a day to day basis, our pace is so rapid that it's so hard to achieve that actual genuine culture change where you could walk around a system and folks just say, oh yeah, that's just how we do things here, we can't even remember what it was like before.

So that's the true change management for me. And again, that gets to sort of under the surface all the things that need to happen so that whatever it is you're trying to change or improve is almost a conduit for how systems can generally shift culture, in general.

Stephanie Kovalick: You know, I think we saw change management at its finest, maybe arguably, during the Pandemic, right? US healthcare system had to change, changed really fast, adapted to what patients needed. So what's an example of where change management was successful? Talk a little bit about where it works, where it doesn't work and why there's a difference.

Louise Weed: Yeah, so I think the pandemic is a perfect example of when change management really can work. And it's a terrible example, it's not one we ever want again. And yet, you know, I was working with systems who had been trying to implement telehealth for a decade and then all of a sudden it was up and running in a week, right? And so what we see there, which is I think the hardest thing to achieve, especially in the US healthcare system, is a clear sense of urgency. So one of our biggest barriers in healthcare is everything we do is important, right? Everything impacts patient care. We want every aspect of the healthcare system to improve. And so it's really hard to actually create space for focus on one thing. Right? And we need that sense of urgency, we need that clarity of focus to be successful because we cannot improve 100 things at the same time. We can improve one thing at a time very effectively. And we saw that with COVID, right? There was this incredible mandate get telehealth up and running because we do not have another option. With that sense of urgency and that focus, folks are able to do it.

Folks who work in healthcare are so smart. That's not the problem, right? But, we have a really hard time saying: this is our area of focus and that means we won't focus on these other things right, in service of achieving this in this area. So I think that's one of the hardest things, and the pandemic is such a good example because of that urgency and that focus.

And how do we replicate that without having to live through another pandemic? Because no one wants that. And I think it's been really interesting talking to systems coming out of COVID and almost- I'm not going to say anyone's missing COVID, right? But how do we go back to thinking about change management without that really strong external mandate, right? So I think that that's really important. It's also part of that sense of urgency. Again, that's the hardest thing, I think for leaders to do in healthcare in change management. But it's a way to promote resilience and to reduce burnout, right? Because change management processes that are poorly managed and not seen through contribute to burnout. Change management processes that are done really well and engage folks and are seen through, promote resilience.

So if we think about, again, sort of some of the underlying goals, I think we can see those things really clearly in those spaces. But I think that number one step, creating a sense of urgency, that's actually one of the hardest ones for us to do. And it is a precondition for success, without a doubt.

Stephanie Kovalick: Yeah, we kind of let the macro environment create that sense of urgency for us or the micro environment. So we're seeing it now, we talk to hospital and health system leaders all the time. We're seeing the need for the workforce shortage and the nursing shortage. That staffing crisis has created the sense of urgency to start to do something about it. But let's shift a little bit, right, without that macro force creating the sense of urgency, how do we get there? Let's talk about the fundamentals of change management. Like if you're a hospital or health system leader, you know you want a new initiative, you know change management is a super important part of that. How do you get there?

Louise Weed: Yeah, so I think that first thing is creating a sense of urgency. So if it's not coming externally at the macro level like you're describing, you need to find a way to create that sense of urgency internally, right? So you have a number of different ways to do that. It could be payment based, although clinicians don't love to hear it from that place. It could be patient safety, it could be movement in a system, but you have to create that sense of urgency and that focus. And again, I think that's one of our biggest challenges as leaders in healthcare, because, again, everything we do is important. And I'll tell you, when I teach a group of physicians, and I tell them they have to create a sense of urgency and focus, and with that means trade-offs. And I make them name the trade-offs that they're making so that they can focus on particular areas, 95% of the room fails at that task because it's so counterintuitive to us as leaders in public health and healthcare to have that focus. So the first thing is you have to have your own focus. You need enough external or internal pressure to create that sense of urgency.

You need enough external or internal pressure to create that sense of urgency and then you need leadership buy in across the board that that is where you're going to focus, right? So, we need to be able to create that space. And these are the hardest things in the US healthcare industry. So you need a sense of urgency.

The other thing you need to create, and again, I have slogged through this myself and I know how hard this is. You need to create time and space for folks on the front lines and interdisciplinary teams to work on the solution collectively. The way we are in a fee for service world makes that really difficult to get everyone to the table. But we need to be able to do that. And as leaders, that's an investment we can make, knowing that we will improve patient care, we will implement something new, we will shift our culture. Right? Then when we're getting everyone to the table, we need to make sure we're facilitating to that. Something that's really unique to healthcare and is really interesting is the power dynamics that are coming to the table, right?

So we have MDs who have trained in their area for what, at least seven years minimum, right? And then we have medical assistants who are just as much part of our change process but don't come with the same degree. You also may have different types of power at play that are informal. So a nurse manager who may have formal authority may be coming to the table but have less informal authority than the MD at the table. So one of the things we need to do, which is really counterintuitive to healthcare, is actually name all those things and facilitate to them rather than pretending they don't exist. We need to work with folks who aren't used to being in meetings, right, because they're frontline clinicians. We need to bring IT to the same table as our end users. So all of these things from a leadership perspective are challenging to create. But if you have that sense of urgency and you have that focus, you have buy in and you make the space, those are two of the biggest things you can impact as a leader that will result in the success for your team, for your system.

The last thing I'll say, and I have done this a ton, is we pilot, we're great at piloting things, we get things going, we have our short term wins, which is really excellent. We have momentum, but we want to move on to the next thing, right? And we don't take the time to see something through and to really get to that full culture shift. So those are three areas that leaders can really focus on and invest in to allow for change to grow beyond them, right? And have the teams be the ones putting it forward, putting out where it is that we're going and then that results in your culture change.

Stephanie Kovalick: Yeah, that's great. Really great tips of advice. I think I've heard you talk in the past about the three dimensions of success and Lewin's stage theory of change and how these concepts play pretty big role in effective change management. Can you talk a little bit more about these and why they're so important?

Louise Weed: Yeah, I would love to. And what I like about them is, layered together they're really effective, but individually they don't answer all of our questions. So, Lewin Stages of Change is a very distilled, simplified version of what it takes to do change management, right? You unfreeze what it is that you're doing, you change, you implement and you refreeze, right? You do that over and over and over again. And what I like about that is it makes it really approachable, it's accessible to folks that we can see that that needs to be done. But I think that we miss, again, especially in healthcare, we miss the depth of work that needs to happen in each of those areas to be successful. And the depth of that work relies on soft skills, which is not something we are naturally drawn to in healthcare. Some folks are, but often we aren't, right? And so to unfreeze a culture, to change it and to refreeze it is all about humans and people management and understanding. So if we layer the dimensions of success on top of that, which comes out of the Interaction Institute for Social Change, which posits that it's my favorite thing I talk about, I talk about it all the time, I frame everything around this.

But it posits that process, results and relationship need to be equally weighted in equal measure in our leadership strategies in order to create sustained change over time. So let's think about that, right? If we have process and folks understand the process that we are engaging in, it allows for a level of trust and buy in, that folks are going to have input, that we're going to make decisions at this point, right? And folks can buy into the process. If we don't have relationship with each other or if we have negative relationships with each other, it's really hard to come to the table and work together. And if we don't have results, people are going to stop coming to the table. Whereas if we only focus on results without process and relationship, people are going to burn out and leave, right? So what we see is that if we can keep those in equal balance in equal measure, it allows for teams to then create a sustainable success framework over time. And if we're thinking as leaders, oh, we've really invested a lot in relationship, but we need to invest more in process or whatever it is, then that allows us to move the levers that we have access to, to shift a group.

So if we think about Lewin's Stages of Change or Model for Change and we layer that on top and we're saying in each of those, we're iterating on the three process relationship result, process relationship result and that is how we get to those unfreezing changing and refreezing. It allows us to think with a little more nuance about what needs to happen because we aren't a free bubble framework. We are humans doing really important work and we need to meet people at that place. So it allows us to think in a more sophisticated way about somewhat rigid approaches that aren't wrong but don't tell the whole story.

Stephanie Kovalick: Louise, thanks so much for sharing your observations and your insights today. It's been super helpful and fantastic to hear you think through all of that and talk through it with us today and your recommendations I'm sure our listeners found very helpful as they consider and think about how their organizations approach change management. And thank you to our listeners for joining us today and we look forward to sharing more insights with you during our next podcast in our Leading Through Change series.

Stephanie Kovalick: Hello, and thank you for joining us for our Clinical View podcast series Leading Through Change. During this podcast series, we will discuss the strategies hospital and health system leaders can use to help their clinical and administrative teams adjust and adapt to new projects and initiatives successfully. I'm Stephanie Kovalick, partner and Chief Strategy Officer at Sage Growth Partners, and I'm joined today by Louise Keough Weed. Louise is the principal of KW Facilitation, affiliate faculty member at Harvard Medical Center for Primary Care, and instructor at the Harvard T.H. Chan School of Public Health. . Today, Louise and I will be discussing the fundamentals of change management for hospital and health system leaders, including how to succeed with change management and how to avoid some of the most common issues and challenges. So, Louise, thanks so much for joining us today. 

During our last discussion, we spoke a lot about change management best practices generally, but you also touched on how important it is to have physicians and nurses involved on a day to day basis. I'd like to talk about that a little bit more to start off today. Any advice for hospital and health system leaders when they think about bringing clinicians on board fully with a change management initiative?

Louise Weed: Yeah, I mean, I think the first thing is you need to engage them from the start, and if your clinicians aren't on board with at least the concept of where you're going, you aren't going to get very far, right? So bringing clinicians in to think about what and how can we implement so that we can knowing it's a big shift in your lives so that we can build it together in a way that works. So I think that's the first thing, we got to bring folks in from the start, but that also means we might need to spend time honestly training and educating our clinicians on how to think about change management, like in this conversation, because you're coming out of clinical training, you don't necessarily know this other side of it. So I've had so many conversations with clinicians where they say, sounds great, let's start it tomorrow, and I'm like about 75 steps before we can actually pilot it, right? So I need to take a step back and help folks understand that side of it so that we can be working on the same team. We can ask them the specific questions, but we're working on the same team and moving in the same direction and each playing our own roles.

Another thing we don't think about enough is the sense of loss that folks experience even when we are improving a system. Like you said, clinicians are very special people, they care a lot about their work and they want autonomy over their work appropriately. They want their work to make sense to them. And so even if we're improving a system, even if we're implementing something that will help them, help their teams, help their patients, they have to go through understanding the losses that will come with that. Shifts in workflows, shifts in how you do your work comes with loss, comes with emotion that we aren't necessarily prepared to deal with, right? So I think that if we spend more time in that area, we are going to see bigger improvements. I'll give you an example of a time I messed this up. I was working with a group of primary care clinicians and we were implementing behavioral health integration. And I'm sitting there going, we're adding therapists essentially to your care team. That's amazing. How could that be seen as anything but improvement to your lives? PCPs. And we did all this work with the therapists on their loss and their shift of how they were practicing and what that meant.

And we completely missed the part where PCPs didn´t, even though they wanted the help, there was loss for them in giving up that part of their relationship with the patient and giving up that scope of care. And that turned out to be a huge block for us in implementing it because we totally missed that. By asking them to shift their routines, to shift their pathways, to shift their approaches with patients, even though it was ultimately better for everyone, everyone agreed on that, there was enough loss and enough loss of control over their relationship with the patient, that it made it really hard to actually move forward without dealing with that. And that was something that I had to learn, that loss is everywhere, even if we perceive things as only adding.

Stephanie Kovalick: Yeah, that's fascinating. That's a really great story. So a lot of the change that we're seeing involves changing and workflows and processes and how you interact with patients or with your peers and your clinicians. So much of it, the influx of technology in healthcare is almost ridiculous, right? A lot of clinicians are begging for the new technologies. A lot of them don't want to. But as a hospital and health system leader, you kind of have to filter the technology, kind of make your way through the maze. But some of it just makes sense and some of it is difficult. Is there any difference in managing change with technology versus workflow?

Louise Weed: Yeah, I think it's a really good question and I think it varies by type of technology that we're talking about and the level of impact that is going to have on our patients. Again, I really think it boils down to where are we focusing and what's our return on investment, right? Because introduction of new technologies can make a lot of people's lives a lot simpler. Like you said, some folks are strong resistors to new technology because they're really rooted in the way that they are practicing. So I think with new technologies, it's again really important to decide where to focus. And then it's even more important to have your early adopters, because you're going to have your folks who want all the new technologies, who will pilot it for you, who will help you work out what works about it and what doesn't, and then they're going to bring the care teams along with them. So even more than just sort of general workflow management, having those early adopters who are bought in, who will lead the charge in whatever area you're in, and then you are surrounding them with those additional techniques for how to move the change forward, I think that's one of the areas where we see the biggest impact.

Stephanie Kovalick: Yeah, great. So we recently conducted a survey of over more than 200 hospital and health system leaders and two thirds of them said that their clinicians and staff members are regularly involved in change management initiatives. What do you think of that statistic?

Louise Weed: I don't buy it. I probably shouldn't say that, but I don't buy it. It all depends on your definition. So of course, because we're changing things in the system, anyone who touches that part of the system is theoretically involved in change management. But when we think about truly inviting people to the table, coaching folks through how to think about change, how to approach it, facilitating two interdisciplinary teams and then allowing that team to build it and move it forward, I know for a fact that I have never seen a system that has so many folks involved. Right. Because it's a huge investment and it's a really hard thing to pull off. So we all touch the system and we all might be a part of implementing small changes, but in terms of that commitment to bringing folks to the table, allowing that sense of clarity, creating prepared minds so that people can design and push it forward, I would honestly have a hard time believing that statistic at that level.

Stephanie Kovalick: Yeah, interesting. Hopefully we'll start to see that change a little bit more, right? Because it's so important.

Louise Weed: And I think if we want to get there, we need to think about the system as a whole. It's not hospitals in isolation, it's not their fault, right? But if you think about the levers in the US healthcare system, you have to think about the payers, you have to think about regulation. You have to think about all of these things which leaders can use to their advantage and say, oh, the payment model is moving in this direction, so we have to change or they're starting to reimburse for this thing. So we can start to think about this new technology, but if we can't pretend that those things aren't happening and we can't pretend we don't work in a hugely expensive system so I guess you don't want to shut down a unit for a day to go through a change management process. But if we can start to think about how to build those things slowly. And iteratively over time I think we'll have much bigger yeah, yeah, great.

Stephanie Kovalick: So Louise, you've shared some great advice on how to successfully lead change management initiatives. You've also shared your own story about where you might I think I'm quoting you when I say messed up with the PCP and behavioral health integration. So that was a good example, right? By not recognizing all stakeholders in the process, you might be leaving something out and making a big impact. Are there other common pitfalls that folks should consider or think about or be aware of?

Louise Weed: Yeah, so I think they go back to some of the things we've already discussed. So I think common pitfalls are not creating enough of an area of focus and then not investing around that area of focus. I think we also pitfall is not bringing all the stakeholders to the table and then facilitating to success within that stakeholder group. And then lastly, I really think it's about seeing it through. Again, we're so smart in healthcare, we're great at the next new initiative and we want to get to that next new initiative. But if we don't take time to allow the change to become part of the drinking water and really how we do things here, it might end up being perceived as a sunk cost. And again, if you aren't seeing them through, there's a chance you're contributing to burnout instead of contributing to resilience, which is a really big deal in healthcare right now. So for me, those are the biggest ones and if we need to come at it from the human aspect and like we've talked about engaging equally in process, relationship and result and not overemphasizing just one.

Stephanie Kovalick: Louise, you said something interesting. You talked about measuring the impact of change. Talk a little bit more about that. How do you do that?

Louise Weed: Yeah, so I think it's really important because how do we know that we've actually improved something? How do we know that we're getting anywhere? This is something that is especially important for clinicians to know that we're moving in the right direction. So figuring out the correct measurement tools from the beginning and being able to measure those over time is going to be really important for all of our team. I like for folks to think about both process and outcome measures because you're not going to see those outcome measures right away. But if our theory of change is that by shifting this piece, the outcome will be impacted, then what we can do is focus on those process measures, right? So we're going to use this screening tool x number of times. We're going to think about how we screen folks for whether they can access this new technology, right? And that allows us to understand if we're impacting that. And then ultimately down the line, you can see those outcome measures.

Some folks also think about those in terms of leading and lagging indicators. But really what it's giving us is 

1. are we implementing what we think our theory of change is and 
2. then is it actually impacting the thing that we want to impact.

And this is another area that's a little tricky because you may not see those outcomes as quickly as you want because again, we're dealing with human beings and there's lots of different factors and often we can't impact people's lives. Unless we're implementing something that's so dramatically focused, right? We might not see those things right away. So we have to hold on to our theory of change and make sure that our process measures are working and that over time we will be able to see those results.

Stephanie Kovalick: All right, so that's the really hard question. If you could share one piece of advice, just one piece of advice. What is that most important thing hospital and health system leaders should think about when thinking through change?

Louise Weed:  Sense of urgency. Just because it's the hardest one for us in healthcare. We have to create a sense of urgency and a sense of focus. And I am with you, that is the hardest thing for us to do because it means trade-offs and we don't want to make trade-offs when it comes to improving our system. But that is where I think we need to currently, in our current system, in our current way of thinking, make the biggest investment.

Stephanie Kovalick: Thank you very much, Louise, for sharing your observations and your insights today. It's been really fantastic to hear you talk through everything and I'm sure our viewers found your recommendations very helpful as they consider and think about how their organizations can and should approach change management.

Louise Weed:  Thank you for having me.