Part 2 - 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 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.