Steps In Developing Transformation Model

1
An Organizational Model of Transformational
Change in Health Care P2 Evaluation Team Martin
P. Charns, DBA1,4 Alan B. Cohen, ScD3,4 Irene E.
Cramer, PhD, MSSA1,4 Sally K. Holmes, MBA1,4 Mark
Meterko, PhD1,4 Joseph Restuccia, DrPH2,4 Michael
Shwartz, PhD2,4 Carol VanDeusen Lukas,
EdD1,4 1Boston University School of Public
Health 2Boston University School of
Management 3Boston University Health Policy
Institute 4VA Center for Organization, Leadership
Management Research
2
The RWJF Pursuing Perfection Program (P2)

• IOM Reports (To Err is Human Crossing the
  Quality Chasm) created urgency to address patient
  quality safety issues.
• In response, the Robert Wood Johnson Foundation
  funded 7 organizations to transform patient care
  through quality improvement pursue perfect
  care
• Institute for Healthcare Improvement (IHI) was
  the national program office for P2
• A Boston University/VA research team was selected
  to evaluate grantees progress.

3
Hybrid Evaluation Design

• Qualitative methods
• Site visits began in 2002 and were completed in
  2005.
• Included all 7 funded sites and 5 comparison
  sites
• Respondents ranged from C-suite to frontline
  clinical staff
• Visits were every 3-6 months
• N gt750 one-hour interview sessions

• Quantitative methods
• Staff survey conducted in 2004 and 2006.
• Eight of 12 study sites participated
• Survey instrument explored perceptions about
  organizational priorities, values, behaviors
  outcomes
• Survey measures changes over time at respondent
  level
• N gt4000

4
P2 Strategy for Change

• Utilize process improvement
• PDSA Cycles
• Measurement
• Start with 2 projects
• Spread to 5 more
• Spread to rest of organization
• Spread to other institutions

5
Early in P2 we learned that

• 2 to 5 to all strategy didnt work
• An organization can do 100 improvement projects
  successfully not achieve organizational
  transformation
• Challenge is to spread sustain the innovations,
  new values, skills, expectations
• Perfect care requires major organizational
  investment in culture, infrastructure, new
  management structures processes to succeed

6
Organizational TransformationModel
7
Five critical elements drive change

• Transformation begins with a sense of urgency
• Leadership drives and facilitates change
• Improvement initiatives engage multi-disciplinary
  front-line staff in meaningful problem solving
• To maximize effectiveness, organizations align
  integrate efforts

8
through the organization

• Mission, vision strategies that set its
  direction and priorities
• Culture that reflects its values and norms
• Organizational functions and processes that
  embody the work that is done in patient care
• Infrastructure (e.g., IT, HR, fiscal, facilities
  management) support the delivery of patient care

9
Transformation begins with a sense of urgency

• Impetus creating and maintaining a sense of
  urgency to overcome inertia fear of change
• External pressures bring urgency
• Crossing the Quality Chasm, CMS, AHRQ, Joint
  Commission)
• P2 grantee status visibility
• Internal events changes can create urgency
• Sentinel events benchmarking data highlight
  quality problems
• New leadership

10
Leadership drives facilitates change

• Leadership Board, C-suite, administrative
  clinical, formal informal leaders but starts
  at the top
• Commitment to passion for quality improvement
• Constancy of purpose unrelenting pursuit of
  goals
• Walks the talk
• Invests own time in quality activities
• Translate commitment into action
• Gets the right people on off the bus
• Communicates builds relationships
• Holds staff teams accountable
• Provides resources infrastructure for improving
  quality
• Fosters learning
• Facilitates a well organized well run effort

11
Improvement initiatives engage multi-disciplinary
staff in meaningful problem solving

• Impact desired performance
• System re-design to build evidence-based
  practices into daily work
• Micro-level effectively address frontline
  quality safety issues (surgical infection
  prevention)
• Macro-level fundamentally change how care is
  delivered (flow projects, chronic care models,
  EMR implementation)
• Build skills, motivation and culture to support
  and sustain quality improvement
• Actively engage staff around priority clinical
  issue
• Collaborative, interdisciplinary work, including
  MDs
• Build staff knowledge confidence in making
  improvement
• Create momentum for spread

12
Alignment achieves consistency of goals with
actions resource allocation across the
organization

• Managing the vertical consistent
  organizational vision, values behavior from top
  to bottom
• Alignment is strategic operational
• Improving quality is top priority support,
  resources rewards are aligned accordingly
• Improvement projects aligned with strategy
  organizational goals throughout the organization
• E.g., Mechanisms
• Cabinet champion for improvement initiatives
• Cascaded improvement priorities
• Accountability performance evaluation down to
  individual
• Resource allocation, rewards, recognition

13
Integration bridges traditional
intra-organizational boundaries between
individual components

• Managing the horizontal consistency and
  coordination across the organization(s)
• Improving coordination of patient care
• Integrating across improvement initiatives
• Breaking down silos across departments
  workgroups organizational units (i.e., physician
  offices, other organizations)
• Building system-level performance
• E.g., Mechanisms
• Collaboratives
• Steering committees or quality management
  oversight structures committees
• Matrixed organizational structures (e.g., service
  lines)
• Cross-function management

14
Dynamic interaction among elements and the
organization builds to transformation

• QI initiatives are cornerstones of organizational
  change if they are aligned with organizational
  priorities
• Improvement becomes part of organizational fabric
  the way we work
• QI initiatives drive change in IT and HR which in
  turn support spread and further change
• Organizations develop infrastructure to support
  the new way of functioning
• Infrastructure is the glue that cements the
  changes

15
Organizational TransformationModel
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Conclusions Building Change Over Time

• Organizational transformation requires addressing
  all key model elements
• Fundamental organization change takes more than 5
  years
• Permanent, organization-wide change builds
  iteratively
• Redesigning care implementation involve
  multiple, iterative cycles
• Change is non-linear two steps forward one
  back
• Failures are instructive
• The goalpost keeps movingthe more we improve,
  the more there is to do

17
Lukas, C.V., Holmes, S.K., Cohen, A.B.,
Restuccia, J., Cramer, I.E, Shwartz, M., Charns
M.P. (2007). An organizational model of
transformational change in healthcare systems.
Health Care Management Review, 32(4) 309-320.