WEEK 7 DISC

3 4 3

L e a r n i n g O b j e c t i v e s

C H A P T E R 1 4

M A N A G I N G C H A N G E

People’s readiness for change depends on creating a felt need for change.

Thomas G. Cummings and Christopher G. Worley,

management scholars and authors

Studying this chapter will help you to

➤ describe change in healthcare organizations,

➤ explain a three-step approach to implementing small-scale change,

➤ explain an eight-step approach to implementing large-scale change,

➤ understand why people resist change and how managers can overcome

resistance,

➤ explain how to use concepts and methods from prior chapters to implement

change, and

➤ describe how organization learning and organization development can facilitate

change.

C o p y r i g h t 2 0 1 9 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s3 4 4

Here’s WHat HaPPeneD The Partners HealthCare system was engaged in extensive change to adapt to its changing external environment, satisfy its stakeholders, and fulfill its mission. Part- ners changed some of its strategic goals, patient care delivery models, management systems, organization structure, clinical processes, communication policies, work technologies, staff positions, and performance measurements. Some changes were radical, such as a major redesign of patient care delivery, while others were incre- mental, with only minor adjustments to procedures. To successfully make these changes, managers used change management methods. For instance, senior managers demonstrated support for the changes by committing funds and resources to them. Employee “champions” were identified who understood the changes and could rally others to accept and support them. Managers provided specialized staff to imple- ment new technologies and processes. The managers gave employees enough time to adapt to the changes in their work. New patient care systems were pilot tested with more than a hundred patients before expanding to more than a thousand. Managers evaluated many aspects of the changes and reported positive outcomes to overcome staff resistance. Although the changes affected many employees, managers success- fully implemented the changes so that Partners could improve population health in its community.

A s we learned in the opening Here’s What Happened, healthcare organizations (HCOs) often change. In fact, they continually change. Some employees think that living with change is a survival skill for working in HCOs. While that might

be true, merely surviving change is not enough for managers. Because of their roles and responsibilities, all managers must lead and manage change for their HCO, not just change themselves. By doing so, managers make important contributions to their HCOs. The ability to manage change is essential for managers’ job success and career growth. This chapter will help you develop this skill.

Managers deal with change when they perform the five management functions: plan- ning, organizing, staffing, leading, and controlling. We first learned about these functions in chapter 2. Planning, by nature, causes change as new goals and strategies are developed for the future. Organizing work, tasks, jobs, teams, and departments involves changing author- ity, responsibility, and supervisory relationships to fit new developments such as artificial intelligence. Staffing involves change as new tasks are added to jobs, people retire and are replaced, and compensation changes. Leading and motivating also require change because HCO workforces comprise four to five generations of employees with different motivators. Controlling is changing to embrace big data and analytics that continually compare precise performance measures with targets. Two of Mintzberg’s ten managerial roles (discussed in chapter 2) clearly involve change: entrepreneur and disturbance handler. Although change

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 4 5

management is not a distinct management function, it is part of performing the five basic management functions and the roles of managers.

Think about the changes mentioned in the opening Here’s What Happened, changes described throughout this book, changes reported in the local news, and changes in your daily life. Many of these involve health, healthcare, and HCOs. When changes in HCOs succeed, they can help people lead healthier lives. Managers who help plan and imple- ment the changes feel positive emotions afterward—satisfaction, accomplishment, joy, and sometimes relief. Yet, “despite the huge investment that companies have made in tools, training, and thousands of books . . . most studies still show a 60%–70% failure rate for organizational change projects—a statistic that has stayed constant from the 1970’s to the present” (Ashkenas 2013). As bad as that failure rate is, it may be worsening as change becomes more complex, uncertain, and difficult.

This chapter will help you succeed with change. It begins by examining change in HCOs. We next learn a three-step process to implement small changes. Then we study an eight-step approach to implement large-scale organization change. Next, the chapter explains why people resist change and how managers can overcome resistance. The chapter then explores how managers use concepts, methods, and tools from prior chapters to imple- ment change in HCOs. The final section presents organization learning and organization development to further enable successful change in HCOs. The chapter provides important tools to manage change, which managers use at all levels of an HCO.

cH a n g e I n He a Lt H c a r e or g a n I z at I o n s Can you think of some changes in HCOs? Why do you suppose those changes occurred? Recall from chapters 1 and 3 that changes in the external environment often drive changes in HCOs. Chapter 1 lists trends and developments in the environment—such as workforce demographics, payment based on value, mobile health technology, and retail medicine—that are forcing change in HCOs. A medical practice in Minneapolis might move to a different facility, tighten the supply chain system, or implement telehealth. While much change in HCOs results from external factors, sometimes it is driven by internal factors. The volunteer services coordinator retires. The heating system keeps malfunctioning. Cheryl discovers a daily pattern of narcotics missing from the pharmacy. Some of these factors are predictable, and some are surprises.

Another reason for so much change is that one change leads to other changes. Most HCOs are complex and have many interacting parts. When the storeroom changes its schedule for delivering supplies to the clinics, the clinics then change their procedures for using and ordering supplies. A business that sells customer service training modules to HCOs sees complaints on social media about its high prices. In response, Kelly, the sales manager, decentralizes authority so that sales staff can adjust prices for customers. This sales department change causes Roberto in the accounting department to change corporate

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control mechanisms that monitor sales, prices, and revenues. Change in one department causes changes in other departments.

In HCOs, managers face two types of change. Radical change is big and revolu- tionary. Incremental change is smaller and evolutionary (Daft 2016). During the 1990s,

change shifted (changed) toward radical change as consultants told managers to get rid of their old business models and create entirely new ones. Consultants said the external environment had changed so much and so fast that minor adjust- ments to the existing way would not be enough. Instead, major changes were required. But a few years later, leaders realized the downsides of radi- cal, wholesale change (Abrahamson 2000). What do you think had happened? Rapid, extensive change had left too little time for organizations and people to recover and restabilize. There was too much turmoil and instability for everyone to function normally. Employees were fearful and overstressed. Managers were so busy with change that they did not perform other necessary work.

Leaders realized that too much change implemented too quickly ruined an organization’s core competencies without successfully developing new competencies. Managers learned to carefully manage the amount and pace of change.

ma n a g I n g or g a n I z at I o n cH a n g e Literature and research on managing organization change offer useful lessons and models. Taken together, these models emphasize the importance of not only a shared, big-picture vision but also a carefully developed implementation plan with flexibility to adapt (Kash et al. 2014). We next examine two models for change that are often used in organiza- tions—including HCOs.

s m a L L -s c a L e c H a n g e

Kurt Lewin developed a systematic three-step process for change in the mid-twentieth century that is still popular and effective today. He viewed change as a movement from an old way to a new way of doing something. The three steps are (1) unfreeze, (2) move, and (3) refreeze (see exhibit 14.1). They are explained in this section based on the work of Cummings and Worley (2015) and Griffin, Phillips, and Gully (2017). An example at an HCO’s business office for fundraising was created to illustrate the three steps.

unfreeze

Create dissatisfaction

with the current way

and motivate people to

want change.

refreeze

Lock in the new way

and make it the

correct way of doing

something.

CHECK IT OUT ONLINE

How comfortable are you with change? Tests can help people

judge their readiness for change and how well they accept

change. Managers can use these tests when leading change in

HCOs because readiness is needed for successful change. Some

online tests take only a few minutes to complete. For example,

try the Change-Readiness Assessment at www.ecfvp.org/files/

uploads/2_-change_readiness_assessment_0426111.pdf (from

a website for a leadership class taught by T. J. Jenney at Purdue

University). Check it out online and see what you discover.

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 4 7

Step 1: Unfreeze the way something is done.

◆ Clear out old ideas to make room for new ideas.

◆ Explain why change is needed; weaken the forces that maintain the status quo.

◆ Describe clearly what will change, what will not change, and how jobs will be affected.

◆ Motivate people to want to change; make them feel dissatisfied with the current way.

◆ Alter how people think about the situation; help people see how the future could be better.

◆ Lead people to feel change is possible and can succeed.

◆ Begin to overcome resistance.

If this first step is done well, people will be committed to make the change succeed. Better yet, they will persist if difficulty arises.

Throughout healthcare, many nonprofit health associations, charities, foundations, and interest groups raise funds to help people with their health. You have probably heard of some, such as the American Cancer Society, American Lung Association, and Children’s

exHIbIt 14.1 The Three-Step Change Process

Unfreeze the current situation

Move/change the current situation to something new

Refreeze the situation with the change in place

Source: Data from Cummings and Worley (2015); Griffin, Phillips, and Gully (2017).

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Hunger Fund. Some are national, with state and local offices. Others are regional or local. To obtain donations, the organizations must work well with clients, donors, and other stakeholders. Let’s imagine a business office at such an HCO near Alexandria.

The business office manager, Mr. Remson, held a staff meeting. He reviewed social media feedback (used to monitor performance as part of the control process) that indicated some people who called the business office were unhappy about staff performance. More specifically, the social media comments revealed that the staff members were not helpful or polite when taking phone calls from clients and families. One caller even followed up with a letter complaining about the staff. Mr. Remson shared the feedback and letter with the nine business office employees. He explained that an impolite, uncaring way of handling phone calls (as perceived by the callers) harmed the reputation of the business office and the entire HCO. Mr. Remson added that a bad image would lead to fewer clients, fewer donations, and perhaps job losses. He suggested that employees try the “mother” test: “Ask yourself, ‘Is this how I would want someone to talk to my mother?’” Mr. Remson next read telephone guidelines from a business etiquette website. He asked for feedback, opinions, and input from each employee, and discussion followed. One employee noted that HCOs are supposed to provide an excellent customer experience in every interaction. Mr. Remson agreed and told the staff they should do that. Then he expressed confidence in them.

Step 2: Move to the new way of doing it.

◆ Move to the new methods, processes, techniques, structures, culture, behaviors, policies, procedures, training, tools, work settings, and people.

◆ Reorganize work, jobs, and tasks and the way they are performed.

◆ Use the new way.

◆ Exert energy and effort to overcome inertia (i.e., the existing way).

◆ Set control mechanisms to measure new performance.

This step applies management principles learned earlier in this book to change the way work is performed. For example, work standardization is applied.

At the business office, each employee was given a list of telephone etiquette standards to follow (e.g., answer a call by the third ring, introduce yourself, control the tone of your voice). Job descriptions were changed to specifically state that telephone etiquette was an important part of the job. Employees took turns calling each other pretending to be a client, and staff practiced the new standard way of handling phone calls. During practice calls, employees sometimes backed up for a redo as they learned the new way. There were a few funny moments. Mr. Remson continued to emphasize that excellent customer service is a core value and that the new telephone guidelines show the correct way to handle phone

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 4 9

calls to ensure excellent service. He added that calls would be electronically monitored for quality control purposes.

Step 3: Refreeze the way it is done.

◆ Reward and reinforce the new way.

◆ Prevent employees who favor the old way from punishing (e.g., rejecting, scorning) employees who use the new way.

◆ Make the change the new normal and part of the daily routine.

◆ Stabilize the new way with repetition to strongly establish it.

◆ Link the new way to the rest of the organization (e.g., the organization culture, reward systems).

If this third step is not done well, people may drift back to the old way, especially if the new way becomes too hard.

Back at the business office, Mr. Remson continually emphasized the new telephone standards and commended staff when he heard them following the guidelines. He individu- ally asked employees about their experiences with and feelings about the changes. These conversations enabled him to identify a “change champion,” who then helped promote the new way with the office staff. After the first week, the change was going well. The staff celebrated their progress with a cake, and one employee felt safe joking with Mr. Remson about a call she handled. Resistance gradually faded, and employees accepted the new way. It then became automatic.

All three steps must be done well for the change to take root and succeed. At the front end, inadequate unfreezing and lack of readiness to change are frequent causes of failure. If you are managing change, invest the time needed to prepare people and unfreeze. At the back end, sometimes too little effort is made to refreeze after change has begun. If you are managing change, invest the time needed to refreeze. That will help the change “stick.”

e I g H t -s t e P a P P r o a c H t o L a r g e -s c a L e c H a n g e

In the 1990s, John P. Kotter developed a useful eight-step approach to create and sustain large-scale change in organizations. The steps are described in this section based on Cum- mings and Worley (2015) and Dunn (2016). This approach builds on the three steps for small-scale change. Steps 1 through 4 unfreeze the old way, steps 5 and 6 move to a new way, and steps 7 and 8 refreeze the situation with the new way in place. After studying these steps, you will realize that managers must provide plenty of time and not try to rush a large change. For example, the first step may take weeks to allow people time to hear about a

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proposed change, think about it, talk with others about it, think more about it, ask questions about it, and gradually understand how it could affect them individually and collectively.

Managers can use principles and methods from previous chapters of this book when they perform these eight steps. For example, the chapters on leadership and organizing teams have useful ideas. Think about how you could use the concepts, tools, and methods you have already learned to execute these eight steps.

Step 1: Establish urgency.

◆ Show a real need that cannot wait any longer; explain why the change is essential.

◆ Describe a real or potential crisis.

◆ Create dissatisfaction with the way things are now.

◆ Describe a great opportunity or vision that must be pursued.

◆ Realize that merely identifying a problem does not create urgency.

Step 2: Create a guiding coalition.

◆ Line up influential supporters at all levels of the organization.

◆ Enlist the support of people whose input and commitment are needed to make change happen.

◆ Create a project team to implement the change.

Step 3: Develop a change vision.

◆ Create a clear, simple, and easily understood statement of what the future will be.

◆ Tell how the future can be better than the current situation.

◆ Provide a sense of direction that motivates people.

◆ Ensure the vision statement makes sense to people at all levels of the organization.

Step 4: Communicate the change vision.

◆ Enable the guiding coalition to clearly communicate the change and its benefits.

◆ Communicate the change repeatedly in multiple ways, both formally and informally.

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 5 1

◆ Ask people what they know about the proposed change.

◆ Seek feedback and input from others about the change.

◆ Constantly repeat and reinforce the change vision message.

Step 5: Empower broad-based action.

◆ Give others permission to try the change.

◆ Revise policies, procedures, rules, and structures to enable the change.

◆ Provide training, practice, and support for the change.

◆ Let people take risks and learn from mistakes when trying the change.

◆ Support and reward the early adopters of the change.

◆ Continually work to overcome resistance.

Step 6: Create short-term wins.

◆ Arrange some quick, easy successes with the change.

◆ Publicize and celebrate the early wins and their benefits.

Step 7: Consolidate gains.

◆ Reward success to keep the change momentum going.

◆ Build on early successes to expand the change.

◆ Train more people to use the change.

◆ Show how success with the change benefits workers and other stakeholders.

◆ Redesign organization structure and processes to “lock in” early successes with the change.

Step 8: Anchor new approaches in the culture.

◆ Make the change part of what is valued and considered correct in the organization.

◆ Reward and reinforce the change to make it “the way we do things here.”

◆ Hire and promote people who support the change.

◆ Ingrain the change in the culture to make it permanent.

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Note that the second step—creating a guiding coalition—includes creating a project team to implement the change. So let’s briefly return to project management, which we studied in chapter 3. Recall that project managers work to ensure assigned projects are completed within established constraints of time, budget, risk, scope, quality, and avail- able resources (Project Management Institute 2017; Schwalbe and Furlong 2013). This work helps an HCO implement change. To ensure projects are completed, a project man- ager forms a project team based on the specific requirements of the project. This requires careful thought and choices (explained in chapter 6 on teams). The project manager and team then use management tools and project management tools to implement the project (change). When managers implement a project—such as a population health project, a clinical integration project, or a mobile health project—they should think of their project also as a change project and use appropriate change methods.

The Here’s What Happened at the beginning of this chapter described Partners HealthCare managing change. The entire Partners HealthCare case study is in an appendix at the end of this book. Read the full case for more detail about what Partners did to suc- cessfully implement large-scale change.

re s I s ta n c e t o cH a n g e Forces outside and inside an HCO push for change. Yet, simultaneously, other forces push back against change. The resistance comes from an essential part of every HCO: people who work there! Not everyone resists change, but there will be some who resist, push back, and perhaps try to block the change. “Employees often go through the stages of anticipation, denial, anger, bargaining, depression, and, finally, acceptance” (McConnell 2018, 401). Some will ignore the change, some will cynically scorn it, some will quietly worry about it, some will accept it, and some will resist it. Let’s consider a public health department in New York City. For a single proposed change, such as a different work schedule, employees may range from highly supportive to highly resistant. The manager communicates the same information to all employees. But employees have unique personalities, past experiences, biases, current life stressors, and other factors that might lead them to resist.

Employees at all levels, including managers, may resist change. This is why the two models for implementing change (small-scale and large-scale) include actions to overcome resistance. When managers plan and lead change, they should expect resistance, noncom- pliance, and perhaps outright defiance. In the Here’s What Happened at the beginning of this chapter, some staff resisted change at Partners HealthCare. Resistance is a natural part of the change management process. Be ready for it. This topic is explored further by studying people, organizations, and the nature of healthcare.

W H y P e o P L e r e s I s t c H a n g e

Pop quiz: Name the five human needs in Maslow’s hierarchy of needs. (This is an open-book quiz, so feel free to check chapter 10.) After recalling these five needs, imagine a change

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 5 3

that might interfere with your fulfilling one of these needs. You are not exactly sure about the proposed change, yet you worry it might interfere with fulfilling one of these basic human needs. Do you feel like resisting the change? Thinking about Maslow’s needs gives us a framework for understanding reasons people resist change (see exhibit 14.2). People often resist changes at work because they fear the changes might reduce satisfaction of their needs. They fear a possible loss of something they value. Even though people do not know for certain that they will experience loss, they worry that they might lose something. Uncertainty and the unknown create fears and worry, which cause resistance.

Another reason people resist change is that they do not understand how it might benefit them. Exhibit 14.2 could be redone to show that a change might increase fulfillment of Maslow’s needs. A change might lead to more job pay, security, friendships, esteem, and growth. Sometimes people do not perceive the possible benefits of change, which leaves them worried about loss instead.

Why else do people in organizations resist change? They may not see the reason for the change and may not understand why it is needed. They may ask, “Why do we have to go through all this change?” or “What’s the purpose?”

Next, let’s assume employees understand the purpose of a change and feel that over- all it will benefit them. Yet, they still might resist. Why? Because they think the change is unrealistic or even impossible. There is not enough time, expertise, or resources, or there are too many obstacles and restraints to accomplish the change.

Changes at Work Effect on Needs

Job might become too routine and less fulfilling; job might not use my abilities; job might provide less chance for growth and professional development

Less self-fulfillment; less self-actualization

Job might become lower status and less important; job might be less respected by others; job might lose power and resources; job change is bad for my professional image

Less esteem; less respect from others

Job might not let me work with my favorite coworkers; job might break up my work group; job might not conform to peer group norms, so peers reject me

Less affiliation, friend- ship, love, and belonging

Job might become unsafe; job and resources might become less secure; new boss creates insecurity; less control of my work schedule; fear of failure in new job

Less security; less safety

Job (and paycheck) might be eliminated; work hours (and pay) might be reduced

Less certainty about meeting basic needs (e.g., food, shelter)

exHIbIt 14.2 Changes at Work and Effects on Maslow’s Needs

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Finally, some people resist change to spite or get revenge on a manager or organization. Workers who feel mistreated and have a grudge can resist or even sabotage change out of revenge. These workers may feel their actions are justified and resist change openly or secretly.

o r g a n I z at I o n c H a r a c t e r I s t I c s t H at m ay I m P e D e c H a n g e

Like people, organizations have personalities, past experiences, biases, current life stressors, and other factors that may impede change (Griffin, Phillips, and Gully 2017). Recall from chapter 4 that organizations range from very mechanistic to very organic. Do you recall which type has rigid, specialized tasks and strict hierarchy, control, rules, and authority? Right—the mechanistic type. Organizations that are too mechanistic may have structural inertia that deters change. In contrast, organizations with an organic structure have flexible, shared tasks and loose hierarchy, control, rules, and authority. An organic structure supports new ways and change.

Organizations often create structures and systems to control work and create stability (Griffin, Phillips, and Gully 2017). These include job descriptions, policies, procedures, training, rewards, punishments, performance appraisals, and other mechanisms designed to control performance. They create structural inertia—resistance to change due to structures and systems. That is good for stability and predictability, but it inhibits change. Extra effort and energy is required to overcome structural inertia to work in a new way. Rather than make the extra effort, people may resist the new way. They keep doing things the usual way. They might even say, “I like doing it the usual way because I can be on autopilot.”

Other organization characteristics can also impede change. Recall from chapter 11 what comprises organization culture: values, norms, guiding beliefs, and understanding shared by members as the correct way to think, feel, and behave. Some organizations have a culture in which employees believe they are not allowed to question their managers, dare not make mistakes, and should respect tradition. Although that type of culture has some advantages, it also has the disadvantage of blocking change. Other cultures value innova- tion, asking questions, learning by trial and error, and trying new and creative ideas. That type of culture supports change.

Several other characteristics of organizations can deter change (Griffin, Phillips, and Gully 2017; Longenecker and Longenecker 2014). Organizations that have limited resources and tight budgets are less able to try new ideas and spend money on change that might fail. Some organizations lack the leadership, teamwork, and cooperation needed for change. Organizations in stable environments feel less pressure to change than do organizations in frequently changing environments. Finally, some organizations have commitments such as contracts with labor unions, supply chain partners, banks, physicians, and others. Some have legal commitments with accountable care organizations, joint ventures, strategic alli- ances, innovation partnerships, and other interorganization structures. These organization commitments—some of which may last for years—may restrict how an organization is allowed to change. (On the other hand, some commitments may require certain changes.)

structural inertia

Resistance to change

created by organization

structures and

systems.

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 5 5

H e a Lt H c a r e c H a r a c t e r I s t I c s t H at m ay I m P e D e c H a n g e

We next consider several characteristics of healthcare that can impede change in HCOs. In general, the pace of successful change in healthcare and HCOs has been slow. We learned in chapter 12 that HCOs have lagged behind other industries in controlling and improving their performance (McLaughlin and Olson 2017). The healthcare characteristics listed in exhibit 14.3 help to explain why. These statements are general and do not apply to every worker and HCO. For example, when managers use transformational leadership and teams, their HCOs are less affected by these factors. Still, managers in HCOs should be mindful of these healthcare characteristics when they attempt to manage change.

H o W P e o P L e r e s I s t c H a n g e

People may resist change aggressively or passively, directly or indirectly, openly or secretly (McConnell 2018). At one extreme, workers may openly, aggressively resist change. Nurses have marched in the streets with protest signs about proposed changes. An individual worker may refuse to comply with a change, such as when an employee feels the change is unsafe. Direct, aggressive resistance is easy to detect, so it is less common. Workers are more likely to resist indirectly. They usually want to be viewed as team players rather than troublemakers, so they may resist a change without directly refusing to comply. Instead, they take more sick time, arrive late, “forget” to do something, violate minor rules, or cooperate less. Their resistance may be seen in sloppy work, less work, and barely acceptable work. Workers may also resist a change in their current job by moving to a different job in the same organization or a different one.

Characteristic of Healthcare How It Impedes Change

Healthcare involves risk to patients amid uncertainty and with big consequences.

Staff is averse to experimentation needed for successful change.

Staff interactions are often based on pro- fessional hierarchy, identities, and status.

Staff does not naturally collaborate, which is needed for organization changes.

Identity and self-image of many workers are strongly linked to one’s profession and only weakly to one’s organization.

Staff interest in organization change may be weak.

Relationships between healthcare staff and managers are based on transactions, self-interests, and conflicting goals.

Healthcare staff and managers may struggle to pursue shared organization change.

Source: Data from Nembhard et al. (2009).

exHIbIt 14.3 Healthcare Characteristics That Impede Change

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People exhibit different degrees of sincerity in their resistance. Some people may speak up to stop a change that they sincerely believe (rightly or wrongly) will harm people or the HCO. Recall from chapter 8 that employees have a right to protection from harm, and they have some rights (within boundaries) to express their views about work. On the other hand, as mentioned, some people resist change as a form of revenge. Their opposi- tion to change is not sincere.

In the long run, employees are usually better off accepting a reasonable change in their job or organization. Continued resistance can make a worker obsolete and unable to function in the new work world. Employees, especially managers who lead others, should accept that change is inevitable and will soon be coming to a workplace near them. Lower-level managers and supervisors who adjust to change—and help their staff adjust to change—are respected by high-level executives and are more likely to advance in their careers.

People in HCOs resist change for many reasons. Some of these reasons are illustrated in the adjacent Using Chapter 14 in the Real World, which is about change in primary care medical practices. Think about this the next time you visit a primary care office.

f o r c e f I e L D a n a Ly s I s

Besides developing the three-step process for change explained earlier in this chapter, Kurt Lewin created force field analysis. This graphical technique shows and evaluates the strength of various forces that are for and against a change (McLaughlin and Olson 2017). Managers use the tool to judge if a proposed change can be implemented and to plan how to implement a change that has been approved. Managers can assess and then lessen resistance to the change.

For any change, there are forces that will drive (enable) the change and other forces that will restrain (block) the change. What forces can you think of? Which ones were described earlier in this chapter? Common forces may include resource availability, history and tradition, laws, powerful stakeholders, organization structures, organization values, social expectations, entrenched interests, costs, and people’s attitudes, needs, and values. Each of these forces might be for or against a particular change. The forces will vary in their strength. A force field analysis of a specific change lists each driving force—and its strength—that would enable the change. The analysis does the same for each restraining force that would block the change. An example of this analysis is shown in exhibit 14.4. The change would create a new way for nursing staff from one shift to hand over patients to incoming staff on the next shift.

A manager can add up the strength of forces for and against a change. In exhibit 14.4, the restraining forces total 21 and are stronger than the driving forces, which total 19. Thus, currently the change is likely to fail. The manager can see that he must strengthen

force field analysis

Graphical technique

that shows and

evaluates the strength

of various forces that

are for and against a

change.

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 5 7

driving forces, reduce restraining forces, or both. How can he do that? He might redesign the change. For example, he could revise the way confi dential information is shared dur- ing shift change handovers to ensure no disclosure occurs. Th at would weaken or remove a strong restraining force and make the change more likely to succeed. Th e manager could also use the three-step change model to unfreeze the ritualism and tradition that restrain the proposed new way of doing end-of-shift handovers. Th at would further increase the likelihood of successful change. Many other ideas for overcoming restraining forces and resistance—based on prior chapters—are described next.

USING CHAPTER 14 IN THE REAL WORLD

A large, multidisciplinary health system implemented change in its primary care clinics

to increase effi ciency, reduce costs, improve customer experience, and better utilize pri-

mary care physicians (Gray, Harrison, and Hung 2016). Medical assistants (MAs), whose

training includes an associate degree or less, had been performing various lower-level

clerical, administrative, and clinical tasks. The change redesigned patient care processes

and shifted more tasks to MAs and away from physicians. An MA was assigned to each

physician to act as a “fl ow manager.” The MA would manage the fl ow of that physician’s

patients through their appointments and the clinics. In this role, each MA guided her

physician during the day, monitored and handled some of the physician’s e-mail, deter-

mined the schedule, and handled other tasks previously done by the physician. MAs had

to be more proactive and directive to instruct their physician what to do.

Some MAs and physicians resisted this change for several reasons. One major rea-

son was that their two jobs differed greatly in prestige, power, education, and work

traits. Some physicians were reluctant to yield so much control to an MA. Some said

they did not see any benefi t from it. Some felt unsafe and insecure in letting go of certain

tasks. Some were not used to being directed. Perceived status was affected. One physi-

cian implied the change was not realistic, saying the clinic was asking too much of MAs.

Meanwhile, some MAs felt awkward about having their work scrutinized by physicians

and about directing physicians. Some felt their working relationships had become more

diffi cult. MAs had to learn and use new skills that made some MAs uncomfortable. Some

MAs viewed the change as just extra work piled on them. However, other MAs “found the

change rewarding and satisfying” (Gray, Harrison, and Hung 2016, 188). Some MAs and

physicians adjusted to the change fi ne and benefi ted from it. Others did not.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s3 5 8

o v e r c o m I n g r e s I s ta n c e t o c H a n g e

Although managers must try to minimize resistance to change, they do not have to eliminate it. Managers should keep this in mind especially when undertaking large-scale change that will affect many people throughout an HCO. Dealing with possible or actual resistance might be frustrating to eager managers who want to implement the change. Yet, if man- agers don’t do enough at the beginning to minimize resistance, it will block change and frustrate them later.

So what should managers do? Here are suggestions from this book and other sources (Daft 2016; Dunn 2016; Griffin, Phillips, and Gully 2017; Longenecker and Longenecker 2014; McConnell 2018). These ideas add depth and detail to the two change models studied earlier. Ideas are grouped into four broad, interrelated categories:

1. Involve relevant people in planning, deciding, and implementing the change.

2. Explain the change multiple times and in varied ways to employees and other stakeholders.

secroF gniniartseRsecroF gnivirD

Plan: Change to

bedside shift handover

Critical incidents on the increase

Staff knowledgeable in change management

Increase in discharge against medical advice

Complaints from patients and doctors increasing

Care given is predominantly biomedical in orientation

Ritualism and tradition

Fear that this may lead to more work

Fear of increased accountability

Problems associated with late arrivals

Possible disclosure of confidential information

4

5

3

3

4

Total: 19

4

4

3

5

5

Total: 21

exHIbIt 14.4 Force Field

Analysis

Source: McLaughlin and Olson (2017, 163).

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 5 9

3. Apply leadership principles and methods.

4. Realize that people change at different times and speeds.

These ideas work best when managers have trusting relationships with others and have the organization structure, culture, and resources to enable change. If these factors are missing, managers will struggle to overcome resistance because people will not believe them or not feel safe trying new ideas. The organization and employees first should be ready for change.

Involve relevant people in planning, deciding, and implementing the change. This activity begins in the planning stage of management when decisions are being made for plans and how to implement them. Managers should involve the right people in making plans and decisions so that they “buy in” to the decision and will support it. For example, when planning an implementation schedule (see chapter 3), a manager should think about who will be affected by the change and who is needed to help it succeed. If the compliance staff must all move to a new location, involve them in planning the move. Their involve- ment will strengthen their commitment to the change and help create a realistic plan and schedule. The timing for involving people will vary depending on the change, the people, the timing, and other factors. A manager needs good judgment (which can be developed through experience) to determine when to involve which people. If in doubt, involving people sooner is usually better than doing so later.

Explain the change multiple times and in varied ways to employees and other stakeholders. This recommendation is related to the first one. As implementation proceeds, a manager must explain the change to a wider group of people who need to know about it. The timing for this explanation will vary depending on how particular people will be involved. It will also depend on the extent to which they were involved in the decision to make a change or to implement it.

As patiently and openly as possible, explain the who, what, why, where, when, and how of the change. Emphasize the purpose of the change and make a compel- ling case for it. Suggest how it might affect specific groups of people, such as second- shift workers, former cancer patients, and visitors younger than age 18. Try to reduce uncertainty by addressing pros and cons. Be prepared for questions and answer them sincerely. Empathy and honesty will help; superficial buzzwords and vague promises will not. Depending on the nature of the change, anticipate and do not overreact to criticism, frustration, denial, and anger from others. Allow people to express feelings, and then sincerely acknowledge and respond to their feelings. Tap in to the social media grapevine and informal networks to discover and correct inaccurate gossip and rumors. These steps can reduce resistance.

Provide sufficient time for people to get information, think about it, and follow up later with questions. People who resist are unlikely to change overnight, so allow them time to gradually accept the change. Repetition and multiple methods of communication

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s3 6 0

may be required depending on the change, the number of people involved, and other fac- tors. Chapter 15 on professionalism and communication offers more advice on this topic.

Managers should be willing to “change the change” when necessary to resolve people’s valid concerns. For example, a medical office decided to change to open-access schedul- ing, which was expected to improve patients’ access to appointments. The staff began implementing the change, but turmoil arose. The leader assessed the situation and had to decide whether to push ahead or back off. He decided to back off the change rather than force it. Open-access scheduling was still a good idea, but he acknowledged the staff did not understand it well enough to implement it. So he and the staff stepped back, revised the change plan and schedule, learned more about open scheduling, and tried again. Then they achieved the desired change (Reinertsen 2014).

Apply leadership principles and methods. Think back to earlier chapters on leader- ship, conflict resolution, motivation, power, and culture. Use knowledge and tools from those chapters to implement change and overcome resistance. For example, establish clear, compelling goals. Identify and clarify tasks, roles, responsibilities, and accountabilities for the change. Apply conflict resolution methods appropriately. Strive for win–win collaboration and be flexible when possible. Compromise and negotiation can help overcome resistance.

Don’t be quick to use managerial authority to force change. Although that approach might sometimes be necessary (e.g., to comply with a court decision), it will likely irritate employees and cause indirect resistance, such as rule infractions and absence from work. Softer forms of power, such as persuasion and appeal to the greater good, may suffice to influence resisters. Apply principles of motivation. For example, a change might create opportunity for job growth or job autonomy that could motivate some workers. Be a role model for change and help create a culture of change that values experimenting, trying new ideas, learning from mistakes, and taking reasonable risks. In this culture, workers will feel more secure about trying a change, not succeeding at first, and practicing until they get it right.

Realize that people change at different times and speeds. A manager should judge people’s readiness for a proposed change. (Change readiness can be assessed using a survey such as the one mentioned in this chapter’s Check It Out Online.) Think about which groups in general and which key individuals in particular must help the change succeed. When judging the readiness of workers on a scale of 1 to 10, some will be 1, some 10, and most will be in between. Some people thrive on change and become bored without it; they might be ready for change before the managers are. Others wait to follow the crowd; they will be ready after a majority has tried the change and has told coworkers it is not too bad. Some people delay and avoid change for reasons given earlier. Manage the pace of change, but do not try to move everyone at the same pace. Support people as they proceed through the change process. Enlist early adopters of change as change champions to lead others.

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 6 1

When you are a manager, realize that overcoming resistance to change is not the same as creating commitment to change. For example, Alice does not resist changing to a new method of setting individual goals—but that does not mean she really supports it. Alice might not exert herself much to accomplish the change and might not help sell it to others. If the change falters, she won’t do much to strengthen it. Remember that lack of resistance is not commitment. “I don’t have a problem with it” does not mean “I am committed to making it succeed.”

or g a n I z at I o n Le a r n I n g a n D or g a n I z at I o n De v e L o P m e n t To help their HCOs continually and successfully change, managers can use two approaches that focus on the organization as a whole rather than on a particular person, project, or change.

“Organization learning (OL) enhances an organization’s capability to acquire and develop new knowledge” (Cummings and Worley 2015, 582). It goes beyond individual learning by individual employees. Instead, OL enables the entire organization to discover, produce, store, and reuse knowledge to benefit the organization. In rapidly changing external environments, OL is essential and can be a valuable competitive advantage.

Managers may design their organization’s structures and processes to enable OL. For example, teams are better for OL than vertical hierarchies are. Employee empowerment and participation in decision processes enables OL. For OL to flourish, the culture must value learning, discovery, openness, teamwork, and sharing. People are not blamed for failure; instead, the culture encourages them to learn from failure. An organization’s performance appraisal and reward systems promote individual learning and help the organization learn.

organization learning

A process that

enhances an

organization’s

capability to acquire

and develop new

knowledge.

TRY IT, APPLY IT

Think about a big change you’ve seen in an organization. It might be an organization

where you did an internship, held a part-time job, or now go to college. Use what you

have learned in this chapter to analyze how the change was managed. What was the

change and its purpose? Who led and managed the change? Do you recall if any steps

from the three-step change model were used? Were any steps from the eight-step

change model applied? What was done to deal with resistance? Discuss your ideas with

classmates.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s3 6 2

Knowledge management (see chapter 13) further enables OL. Employees gather knowl- edge and share it throughout the organization via wikis, blogs, networks (electronic and personal), searchable databases, conversations, and other ways of sharing both tacit and documented knowledge (Griffin, Phillips, and Gully 2017). Furthermore, managers encour- age employees to review and reflect on experiences, projects, successes, and failures. People who were involved in a project confer quickly, openly, and honestly to discuss what was supposed to happen, what did happen, why there were differences, and what they learned (Griffin, Phillips, and Gully 2017, 581). In addition to learning, reflection develops trust among participants. Managers can design other structures and processes to support OL to improve their HCO’s ability to change.

Organization development (OD) also helps HCOs to continually and success- fully change. As defined in chapter 2, OD is “a process that applies . . . behavioral science knowledge and practices to help organizations build their capability to change and to achieve greater effectiveness” (Cummings and Worley 2015, 1). This approach establishes an organization’s social systems and culture that facilitate changing human behavior in the organization. Going beyond training, OD uses team building, interdepartmental activities, employee participation, conflict resolution, organization redesign, process redesign, culture change, group dynamics, respect, trust, autonomy, fairness, and employee empowerment (Cummings and Worley 2015; Daft 2016; Johnson and Rossow 2019). When these are blended together in an organization, change becomes more possible.

Managers at all levels of an HCO must successfully manage change. Change is constant, so this ability is important for managers’ job success and career growth. Although change man- agement is not a distinct management function, it is used when performing the five basic management functions: planning, organizing, staffing, leading, and controlling. Managers make changes in an HCO because of external factors, internal factors, and previous changes in the HCO. Some changes are radical and others are incremental; both types are needed.

Small-scale change can be implemented using Lewin’s three steps: unfreeze, move, and refreeze. Large-scale change can be managed with Kotter’s eight-step approach, which builds on the three steps for small-scale change; managers should establish urgency, cre- ate a guiding coalition, develop a change vision, communicate the change vision, empower broad-based action, create short-term wins, consolidate gains, and anchor new approaches

o n e m o r e t I m e

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 6 3

in the organization culture. They can also apply project management techniques to keep change within budget and on schedule.

People often resist change. Common reasons include fear of not being able to fulfill wants and needs, fear of losing something they value, not understanding the reasons for change, not understanding the benefits of change, feeling change is not possible, and in- ertia. Resistance may be evident or hidden. Managers use force field analysis to judge the forces for and against change and to reduce resistance to a proposed change. To reduce resistance, managers should involve people who will be affected by the change in plan- ning and implementing that change, explain the change multiple times in multiple ways to stakeholders, apply leadership principles and methods, and realize that people change at different times and speeds. Organization learning and organization development can help HCOs become more capable of accomplishing change.

1. Consider in detail Lewin’s three-step process for change. Which of the three steps do you think would be hardest? How could you develop your ability to apply this change process?

2. Describe with specific examples how at least five management theories, principles, methods, or tools studied in other chapters could be used in Kotter’s eight-step process for large-scale organization change.

FOR YOUR TOOLBOX

• Lewin’s three-step approach to

change

• Kotter’s eight-step approach to

large-scale change

• Force field analysis

• Organization learning

• Organization development

f o r D I s c u s s I o n

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3. Think about a change that you resisted at your college or workplace. Why did you resist the change? Why do people in general resist change?

4. How can managers overcome resistance to change?

These questions refer to the Integrative Case Studies at the back of this book.

1. Disparities in Care at Southern Regional Health System case: At the end of the case study, what change does Mr. Hank want to make? Using information in the case study, plus any inferences you want to make, conduct a force field analysis for his desired change. Explain how Mr. Hank could apply Kotter’s eight-step process to achieve his change.

2. Hospice Goes Hollywood case: Using information from this chapter, explain why you think the hospice’s clinical staff resist the change proposed by Ms. Thurmond. Describe how she could use Lewin’s three-step process to implement her change.

3. “I Can’t Do It All!” case: What change does Mr. Brice want to make? Describe how Mr. Brice could use Lewin’s three-step process to implement his change.

4. Increasing the Focus on Patient Safety at First Medical Center case: What change does Dr. Frame want to implement? Using information in the case study, plus any inferences you want to make, conduct a force field analysis for the proposed change.

5. The Rocky Road to Patient Satisfaction at Leonard-Griggs case: Using information from this chapter, explain why you think the office staff resist the change for implementing patient surveys. Describe how Ms. Ratcliff could use Lewin’s three-step process to implement her change.

c a s e s t u D y Q u e s t I o n s

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C h a p t e r 1 4 : M a n a g i n g C h a n g e 3 6 5

RIVERBEND ORTHOPEDICS MINI CASE STUDY

Riverbend Orthopedics is a busy group practice with expanded services for orthopedic

care. It has seven physicians and a podiatrist, plus about 70 other employees. At its big,

new clinic building, Riverbend provides extensive orthopedic care. Several technicians

provide diagnostic medical imaging, from basic X-rays to magnetic resonance images.

The physicians perform surgery in their own outpatient surgery center with Riverbend’s

own operating nurses and technicians. Therapy is provided by three physical thera-

pists and one part-time contracted occupational therapist. In addition to staff provid-

ing actual patient care, the clinic has staff for fi nancial management, medical records,

human resources, information systems/technology, building maintenance, and other

administrative matters. Occasional marketing work is done by an advertising company.

Legal work is outsourced to a law fi rm. Riverbend is managed by a new president, Ms.

Garcia. She and Riverbend have set a goal of achieving “Excellent” ratings for patient

experience from at least 90 percent of Riverbend’s patients this year.

To achieve the goal, Ms. Garcia wonders if employees should be using standardized

scripts for interactions with patients. (For an example, review Using Chapter 4 in the

Real World.) This would be a change; some employees would consider it a big change.

mInI case stuDy QuestIons

1. To help Ms. Garcia think about the proposed change for scripted interactions with

patients, prepare a force fi eld analysis for the change. You may make reasonable

assumptions and inferences.

2. Using information from this chapter, prepare a list of steps for Ms. Garcia to take to

implement the change to standardized scripts.

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M a n a g e m e n t o f H e a l t h c a r e O r g a n i z a t i o n s3 6 6

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L e a r n i n g O b j e c t i v e s

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