Make it or Break it

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Make it or Break it!
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You Want Me to Change?

• Diseases always attack men when they are exposed
  to change.
• - Herodotus, Greek Historian (Fifth Century ,
  B.C.)

3
Overview

• The problem
• Change for an individual is difficult
• Change for a system of individuals is complex
• The solution
• Create a positive environment for personal change
• Leverage the systems of changing individuals to
  produce the expected outcomes

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Self-Serving Reactionaries?

• Self-defeating to try to surmount peoples
  resistance to change
• MUST tackle the threat the change poses to their
  world

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The Context of Change

• Changing behavior is an individual experience
• WIIFM
• Motivate change myth
• Change saturation too many no change
• Abrupt change most difficult
• System change is a leader experience

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Why Kill Yourself?

• Technology transforming how business done
• Change is the name of the game
• Organizations that cannot change quickly

7
Great Read

• Managing Transitions
• Making the Most of Change
• By William Bridges

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Three Phases of Transition

• Ending, Losing, Letting Go
• Help people deal with their losses

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Three Phases of Transition

• The Neutral Zone
• Old not gone
• New not operational

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Three Phases of Transition

• The New Beginning
• New identity
• New energy
• New sense of purpose

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Its not the progress I mind, its the change I
dont like.

• Mark Twain

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Core Theories of System Change

• Change is felt by individuals that comprise the
  system
• Watzalawick et al. 1974
• Second order change Paper to EMR
• Lewin 1965 positive, negative, or both
• Rituals of transition exist employ them
• Change, Freeze, Thaw, Change
• Complex Adaptive Systems

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Forces

• Driving forces
• Problem
• Opportunity
• Sponsor
• Legitimizer
• Champion
• Personal
• Gain
• New Challenge
• Anti-boredom
• Self-change
• Reinforces positive belief

• Restraining Forces
• Change capability
• Threat
• Imposed change
• Personal loss
• Personal criticism
• Security loss
• Effort gt status quo
• Potential harm and increased work
• Reinforces negative belief
• Unknown future

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Forces

• Driving forces
• Unmet demand
• Personal desire

• Restraining Forces
• You are forcing me to be overwhelmed!
• OK anyway

15
Competitive or Collaborative?

• Natural state is competition
• WII-FM
• Beautiful state is collaboration to compete
• Football teams
• Team must collaborate to win
• Goal must be clear

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Complex Adaptive Systems

• It is a collection of individual agents who
  have the freedom
• to act in ways that are not always totally
  predictable,
• and whose actions are interconnected such that
  one agent's actions change the context for other
  agents

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Complex Adaptive Systems (CAS)

• A mental model for Healthcare
• Systems theory and complexity science
• Characteristics
• Agents processing incomplete information in
  relationships
• Simple rules
• Dynamic - Adaptation will occur!
• Feedback loops of information

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Im very interested in the future because I plan
to spend the rest of my life there.

• Robert Wood Johnson

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Positive environment for individual change
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PSIMT version of PDSA

• Problems
• Solutions
• Implementation
• Monitor
• For compliance then success
• Tweak Two Week Tweak

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Change Management

• Gradual introduction Heads up!
• Management by walking around
• Behavioral expectations
• No Toxic Talk
• Walk the Talk

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Staff Support

• Physician/Nurse
• Super users
• Up staffing
• Information Services
• Command Center

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Staff Support

• Residents trained and already using CAPOE on
  other floors
• Less support with each facility
• Adjusted coverage

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There is nothing more difficult to take in hand,
more perilous to conduct, or more uncertain in
its success, than to take the lead in the
introduction of a new order of things

• Niccolo Machiavelli

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Leading System Change
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Leading the Change

• Offer opportunities in the chaotic healthcare
  environment
• Focus less on prediction and control and more on
  fostering relationships
• Creating conditions in which the new process can
  evolve to produce desired outcomes.
• Create psychological ownership

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Working the CAS Complexity Simplified

• Minimum specifications for change
• Open and honest communication - transparency
• Distributed control
• Self-organization/governance
• Emergence of solutions
• Leverage the relationships
• Small changes big effects

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Minimum Specifications

• CAS works by simple rules
• Hardest for managers but the most important
  concept Burns 2001 JNA
• Need to break apart a strategic project
• Increment with simple goals
• Timetable with milestones
• Allows change to be manageable by individual

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Minimum Specifications

• Apply for Strategic Initiative August 2003
• Present business plan December 2003
• Approval with revisions April 2004
• Develop team(s) I/S lead August 2004
• Implement by site December 2004
• Postponed one month
• Site Implementation CAPOE then T system Mar,
  May, June 2005

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Transparency

• Be the CAS feedback loop or the void will be
  filled
• Clear vision
• Open communication about path to vision
• Listen well
• Honest about data
• Regular communication is best
• Current changes
• Feedback on past changes
• Future changes tied to vision

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Communication

• Extended Senior Management Council presentation
• Network Governing Committee presentation
• Departmental presentations Vision
• Teams established with report to Steering
• Stat sheets Two Week Tweaks during
  implementation
• Management by walking scheduled

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Distributed Control

• Relationships are core to a CAS
• Give up control on the solution
• Also hard for the manager
• Distribute the problems
• Teams of stakeholders
• Create collaborative relationships leverage to
  your vision/goal

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Teamwork for New Processes

• Steering leaders/sponsors
• Physician workgroup
• Nursing workgroup
• Ancillary
• Billing
• CAPOE
• Reports
• Technical Hardware Interfaces

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SELF Governance

• The individual understands they must change
• Allow them to govern themselves
• Sincere understanding of change
• Set expectations of behavior be realistic
• Clarify their role in the change
• Clarify the changes in their role

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Allow Solutions to Emerge

• CAS will create solutions or organize resistance
• Keep teams focused on clear vision minimum
  specification goal
• Watch for scope creep
• Encourage self-governance to meet goal.
• Require evidence or commitment that goal will be
  met

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Key Points

• Change occurs at the individual level
• Create a positive environment for change for the
  individual
• Listen well and act with good judgment
• Minimum specifications
• Engage the staff
• Be transparent
• Remember, we are all human

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Technology has indeed taken a place next to war,
death, divorce, and taxes as a prime cause of
bone-shuddering anxiety

• John Seymour