Managing Change: Tools and Techniques

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Managing ChangeTools and Techniques
Lessons from Mental Health Systems Change and
Transformation Initiatives

• Vijay Ganju
• Director, Center for Mental Health Quality
  Accountability
• NASMHPD Research Institute, Inc.
• 703.739.9333 ext. 132
• vijay.ganju_at_nri-inc.org

Presentation at the CMS Conference New Freedom
Initiative Access to Community Living
Transforming Systems Keys to
Success
Baltimore, Maryland ? April 10-12, 2006
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Mental Health System
Transformation
Mental Health / Health
Technology Information
Consumer / Family Driven
Recovery / Resilience
Evidence-Based Practices Training / Research
Eliminate Disparities
Early Intervention
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The Quality Pyramid
SYSTEM OUTCOMES
Evidence-Based Practices
Quality Improvement
Performance Measurement
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Evidence-Based PracticesSome Definitions

• An evidence-based practice is considered to be
  any practice that has been established as
  effective through scientific research according
  to a set of explicit criteria (Drake et al,
  2001).
• Evidence-based treatment is the use of treatments
  for which there is sufficiently persuasive
  evidence to support their effectiveness in
  attaining desired outcomes (Rosen and Proctor,
  2002).
• Evidence-based practice is an approach to
  healthcare wherein health professionals use the
  best evidence possible to make clinical decisions
  for individual patients (McKibbon, 1998).
• Evidence-based practice is the integration of
  best research evidence with clinical expertise
  and patient values (Institute of Medicine, 2001).

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Number of States Implementing EBPs FY 2003
N 47
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Implementation of Evidence-Based Practices for
Children, 2003
N 47
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Moving Forward withEvidence-Based Services

• Federal Initiatives
• SAMHSA National EBP Demonstration Project
• NIMH/SAMHSA Planning Grants
• SAMHSA/CMHS EBP Implementation Grants
• SAMHSA National Registry for Effective Practices
• HRSAs Federal Qualified Health Centers
• NRI Center for Mental Health Quality and
  Accountability

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Preliminary Lessons from Toolkit Project

• Organizational development component is critical
• Outcomes must be integrated into EBP
  implementation
• Cultural competence issues need to be addressed
• Ongoing consultation was a great facilitator

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Lessons Learned from Toolkit Trainers,
Consultants and Evaluators
Desired Consumer Outcomes
Consumer
Training/TA Strategies for Practitioners
Practitioners
Family
Strategies for Consumer/Family
Agency Implementing EBP
State or County Mental Health Authority
Steering Committee
Strategies for the Steering Committee
Strategies for the SMHA
Strategies for the Agencies
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Factors Affecting State-Wide EBP Implementation

• System leadership
• Organized culture/consensus
• IT capacity/outcomes measurement
• Policies/procedures
• Integration with performance/quality improvement
• Human resource capacity/training
• Funding methods

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Statewide Implementation of EBPs

• Demonstration projects
• Training
• Supports

• Organizational assessment
• Standards/ regulations
• Financing/fiscal incentives
• Training and support

• Contractual requirements
• Intensive technical assistance / support

Early Adopters (enthusiasts)
Late Adopters
Non-Adopters
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Public Mental Health Authority
Provider Organization

• Leadership
• Policies
• Regulation
• Resources

• Leadership
• Organizational Culture
• Administrative Support
• Information Technology

• Practitioner
• Knowledge
• Perceived advantage
• Feedback

• Consumer/Family Member
• Choice
• Commitment
• Perceived advantage

• EBP
• Cost
• Compatibility
• Payoffs
• Complexity

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Lessons Learned from National EBP Demonstration
Project
System Leadership/ Implementation Plan
Funding Methods
Human Resource Capacity
INFORMATION TECHNOLOGY
Implementation Leading to Transformation
Policies and Procedures
Organizational Structures
Quality/ Performance Improvement
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Causal Connections
Goal

• Interaction with
• Provider
• Evidence-
• based and
• best practices

Infrastructure
Recovery
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Transformation Logic Model
Target Systems
Outcomes - Impact
Outputs
Activities
Inputs
Situation

• Inefficient use of resources
• Lack of information
• Inade-quate value orientation
• Ineffective-ness regarding outcomes

• Stakehold-ers
• Staff
• Resources

• Leadership commitment
• Develop-ment of new structures
• Resource development reallocation
• Information/ technology development

• New cadre of leaders
• Restructur-ing
• Availability of new information and
  technologi-cal capacities

• Internal
• External

• Short-Term
• Leadership development
• Training capacity
• Information (services, money, competen-cies)
• Innovation opportunities
• Policy development/changes
• Interagency coordination

• Intermediate
• Multi-stakeholder engagement/consensus
• Identifica-tion/flexibility of resources
• Increased competenc-ies
• New models /protocols
• New structural arrange-ments

• Long-Term
• Consumer outcomes
• Population outcomes (e.g. anti-stigma)
• Resource efficiencies
• Disparity reduction

• SMHA
• CMHAs
• Other agencies

• Technology

• Fragmenta-tion
• Stigma
• Lack of EBPs
• Lack of technology application

• Data
• Leadership capacity
• Policy changes
• Workforce competencies availability
• Use of data
• Values orientation
• Resources available

• Data
• Consensus/ engagement assessment
• Resource allocation/ development
• Contract expectations

• Data
• NOMs
• Recovery/ resilience
• Community indicators
• Financial indicators

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NRI Conference on Change Management in Mental
Health Systems
June 22-24, 2005, Albuquerque, New Mexico

• Agenda

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Definition of a Change Project

• Cuts across organizational boundaries
• Has defined start and completion dates
• Generates observable, measurable results
• Requires significant change in both attitudes and
  the way work is performed
• Creates both active and passive resistance
• Requires a dedicated change team

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Role of Change Management

• Training
• Explains objectives and provides information on
  desired activities and outcomes.
• Project Management
• Involves tracking, monitoring, measuring, and
  reporting. Establishes performance standards and
  metrics provides objective measures of progress
  against plan anticipates obstacles and
  recommends corrective action.
• Change Management
• Intensive, field-based exercise in changing
  behavior. Focuses on communicating the
  initiative creating alignment identifying and
  overcoming resistance embedding change into the
  organizational culture.

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Organizational Culture of a Mental Health System
Networked
Communal
Sociability
Fragmented
Focused
Solidarity
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Change Tools and Techniques Index
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Launching the Product

• Desired Outcome
• Well-defined project that is doable, yet
  challenging
• Clear agreement and commitment from sponsor
• A team with competency, influence, and
  representation that has been prepared for the
  challenge

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Backwards Imaging

• Imagine a point in the future when your project
  or initiative is very successful
• Find words to describe what you see, hear, feel
  as you observe the key constituents functioning
  in the new, changed environment
• Discuss and reach consensus with your team
  members on what this new, improved future will
  look like
• As a team, develop the obstacles you will likely
  have encountered and overcome during the
  impelmentation

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Sponsor Discussion Typical Questions

• Describe the initiative in your own words.
• Why is this initiative important?
• What will success look like to you?
• What is outside the scope of this initiative?
• What else is on your agenda where does this
  project fit?
• Who are the key players and how do they view this
  initiative?
• What excites you the most about this initiative?
• What concerns you the most about this initiative?
• What do you think our biggest challenge will be?
• Who should be on the core working team, and how
  can we get their commitment?
• What role do you see yourself playing?
• How involved do you want to be?
• What key decisions do you want to make or be
  involved in?
• Do you have any words of advice or suggestions
  for me in the meantime?

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Tool Team Competency/Influence
Tool Team Competency A useful tool to help the
team determine if they have the right team
members relative to the competencies and
influence necessary to execute the initiative
Team Member
Competency/Influence
H High
MMedium
LLow
Uses This exercise is particularly useful for
two situations (1) when initially forming the
team, it can help the sponsor and/or team leader
determine who should be on the team (2) if the
team is already in place and they may be
struggling due to lack of ability to do certain
facets of the initiative, this tool can be used
to determine if adjustments in team members are
warranted. Timing Before starting the
initiative and/or anytime during the initiative
when the team seems to be struggling due to lack
of competency or influence. This often occurs
when a new phase of the initiative begins.
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Team Start-UpLevels/Types of Decisions

• Ive made the decision. Heres what it is and
  why I had to make it.
• Im leaning strongly in this direction. Tell me
  what the team thinks, then Ill make the decision
  (your input, my decision).
• We need more information before the decision can
  be made. Help us see all sides of the issue,
  then well make the decision based on consensus.
• Im willing to go with whatever the team decides
  on. Let me know your decision and Ill support
  it.

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Team Start-Up Consensus

• Consensus is reached when everyone can state
• I believe that you understand my point of view
• I believe that I understand your point of view
• Even though this may not be the way I would
  decide things by myself, I will support the
  decision 100 because it was arrived at in an
  open and fair manner

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Creating Organizational Alignment

• Desired Outcome
• A clearly defined project scope
• A sense of urgency and commitment among key
  stakeholders
• Clear, consistent, organization-wide
  communication of the project

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Is / Is Not
Helps a team to think through the project by more
clearly defining what is inside and outside its
scope. Often the is not portion of the
discussion is more important than the is part
thats where the disagreement usually lies. It
can be used during the definition phase as well
as later when the team is stuck and needs to be
refreshed on the projects boundaries.

• Is
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________

• Is Not
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________
• ________________________

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Tool Threat/Opportunity Matrix
Tool Best Practice organizations know how to
frame a change initiative as more than a
short-term threat. They work to find ways to
frame it as both a threat and an opportunity. By
doing so, they are able to create a sense of
urgency and commitment among key stakeholders.
Threat
Opportunity
Short Term
1
3
2
4
Long Term
Uses and Timing Building the case for change is
one of the most important tasks of the team.
This simple tool helps it to redirect the initial
focus on short-term threats and generates a clear
sense of why the initiative is essential.
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Example Threat/Opportunity
Physician Group Initiative
Threat
Opportunity
Short Term
Long Term
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Measuring and Overcoming Resistance

• Desired Outcome
• Identification of sources of both active and
  passive resistance
• An effective strategy to influence key
  stakeholders

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Resistance to ChangeWhat Does it Look Like?

• Resistance to change is typically divided into
  two distinct categories
• Active resistance
• Passive resistance

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Attitude Charting
Late Majority (35)
Early Adopters (10)
Innovators (5)
Resistors (15)
Early Majority (35)
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Stakeholder Analysis
Strongly Against
Moderately Against
Moderately Supportive
Strongly Supportive
Names
Neutral
Steps 1. Plot where individuals currently are
with regard to desired change. (4 current)
2. Plot where individuals need to be (Xdesired)
in order to successfully accomplish desired
change-identify gaps between current and
desired 3. Indicate how individuals are linked
to each other, draw lines to indicate an
influence link using an arrow to indicate who
influences whom 4. Plan action steps for
closing gaps
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Example 1 Stakeholder Analysis
Strongly Against
Strongly Supportive
Moderately Against
Neutral
Moderately Supportive
Chief of Surgery Dr. Bobbitt Dr.
Clampett CEO Chief of Staff Medical
Director Chief of Medicine CFO Asst. Med.
Director Chief Administrator Dr. Barnes Chief of
Nursing Sharon Reams, RN
l
l
l
l
l
l
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Example 2 Stakeholder Analysis
Strongly Supportive
Moderately Against
Moderately Supportive
Against
Neutral
Chief of Surgery Dr. Bobbitt Dr.
Clampett CEO Chief of Staff Medical
Director Chief of Medicine CFO Asst. Med.
Director Chief Administrator Dr. Barnes Chief of
Nursing Sharon Reams, RN
l
l
l
l
l
l
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Example 3 Stakeholder Analysis
Strongly Supportive
Moderately Against
Moderately Supportive
Against
Neutral
Chief of Surgery Dr. Bobbitt Dr.
Clampett CEO Chief of Staff Medical
Director Chief of Medicine CFO Asst. Med.
Director Chief Administrator Dr. Barnes Chief of
Nursing Sharon Reams, RN
l
l
l
l
l
l
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Some Examples

• New Mexico Purchasing Collaborative
• Oklahoma Department of Mental Health
• Washtenaw Community Health Organization
  (Michigan)
• Licking and Knox Counties Mental Health Services
  (Ohio)
• Australia

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They always say time changes things, but you
actually have to change them yourself. Andy
Warhol