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Organizational Change. Martin P. Charns, DBA Director COLMR. Greenhalgh et al. Very comprehensive systematic literature review of diffusion & implementation Addresses multiple perspectives Characteristics of innovation Process of implementation Context.

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organizational change

Organizational Change

Martin P. Charns, DBA

Director

COLMR

greenhalgh et al
Greenhalgh et al.
  • Very comprehensive systematic literature review of diffusion & implementation
  • Addresses multiple perspectives
  • Characteristics of innovation
  • Process of implementation
  • Context
slide3

Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation

LINKAGE

User System

Resource System

System antecedents

The Innovation

Knowledge

purveyors

System readiness

Diffusion

Adoption/assimilation

Dissemination

Change agency

Implementation

LINKAGE

Consequences

Outer context

queri focus
QUERI Focus
  • Largely on the innovation (EBP) & process of implementation
  • Less detailed focus to date on organizational context, including history
slide5

Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Innovation

LINKAGE

User System

Resource System

System antecedents

The Innovation

Knowledge

purveyors

System readiness

Diffusion

Adoption/assimilation

Dissemination

Change agency

Implementation

LINKAGE

Consequences

Outer context

the innovation
The Innovation
  • Relative advantage
  • Compatibility
  • Low complexity
  • Trialability
  • Observability
  • Potential for reinvention
  • Fuzzy boundaries
  • Risk
  • Task Issues
  • Nature of knowledge required
  • Technical support
adopter
Adopter
  • Needs
  • Motivation
  • Values & goals
  • Skills
  • Learning Style
  • Social networks
  • Adoption Decision: Stages
    • Preadoption
    • Early use
    • Established users
communication influence
Communication & Influence

Diffusion (informal, unplanned)

Social networks

Homophily

Peer opinion

Marketing

Expert opinion

Champions

Boundary Spanners

Change agents

Dissemination (formal, planned)

slide9

Greenhalgh et al. Model for Diffusion, Dissemination, & Implementation- Showing Emphasis on Organizational Factors

LINKAGE

User System

Resource System

System antecedents

The Innovation

Knowledge

purveyors

System readiness

Diffusion

Adoption/assimilation

Dissemination

Change agency

Implementation

LINKAGE

Consequences

Outer context

outer context
Outer Context
  • Sociopolitical climate
  • Incentives & mandates
  • Inter-organizational norm-setting & networks
  • Environmental stability
system antecedents for innovation
System Antecedents for Innovation
  • Structure
    • Greenhalgh et al. note that structural features account for 13% of variation among organizations in their innovativeness
  • Absorptive capacity for new knowledge
    • “…knowledge must be enacted and made social”
  • Receptive context for change
    • Leadership, culture
system readiness for innovation
System Readiness for Innovation
  • Tension for change
  • Innovation-system fit
  • Power balances (supporters v. opponents)
  • Assessment of implications
  • Dedicated time/resources
  • Monitoring & feedback
implementation process
Implementation Process
  • Decision making devolved to frontline teams
  • Hands-on approach by leaders & managers
  • Human resource issues, esp. training
  • Dedicated resources
  • Internal communication
  • External collaboration
  • Reinvention/development
  • Feedback on progress
successful transformation beyond projects
Successful Transformation Beyond Projects
  • Most organizations can manage individual projects – even many individual projects
  • Making specific projects a priority
  • Getting people to work extra hard
  • Often achieves project change
  • Is not sustainable
  • By focusing on individual projects it is easy to forget:
    • that many others things are happening in the organization
    • that other things outside of the project need to be addressed to achieve project success
successful transformation beyond projects1
Successful Transformation Beyond Projects
  • Model of transformation utilizes many of the organizational concepts reviewed by Greenhalgh et al.
  • Model is more dynamic
model overview
Model Overview
  • Transformation begins with a sense of urgency
  • Permanent, organization-wide change builds iteratively
  • To maximize effectiveness, organizations align & integrate efforts
  • Organizations develop infrastructure to support the new way of functioning
  • Improvement becomes part of organizational fabric – “the way we work”
  • Success motivates staff to continuously strive for higher goals (e.g., patient satisfaction & high reliability)
change is iterative
Change Is Iterative
  • Fundamental organization change takes longer than 2-3 years
  • Organizations learn from prior experiences
    • Failures are instructive
  • Redesigning care & implementation involve multiple, iterative cycles – “the more we improve, the more there is to do…”
      • Testing new models
      • Training
      • Facilitation
      • Resolving barriers
      • Changing culture
impetus to transform
Impetus to Transform
  • Creates sense of urgency to overcome inertia & fear of change
  • Examples
    • Critical incident
    • Financial crisis
    • Financial stability
    • Growth
    • Mission (patient-centered)
    • Combination of two or more
the impetus to transform
The Impetus To Transform
  • External sourcesof urgency (Crossing the Quality Chasm,JCAHO, VA Mandate, etc.)
  • Sentinel events & benchmarking data make staff realize that care & quality not as good as they should be
  • Maintain sense of urgency
improvement projects
Improvement Projects
  • Vehicle for process/outcome improvement
  • Vehicle to engage multi-disciplinary front-line staff in meaningful problem solving
    • Concrete (vs abstract vision statement)
    • Clinical & important focus to engage clinicians
improvement projects1
Improvement Projects
  • Builds skills, motivation & culture that will support & sustain quality improvement
    • Activelyengage staff around priority clinical issue
    • Collaborative, interdisciplinary work, including MDs
    • System re-design to build evidence-based practices into daily work
    • Goals & measures (monitor progress & whether improvement is sustained)
    • Project support (training, tools, measures, facilitation)
    • Shared learning & spread
infrastructure
Infrastructure
  • “Hard” Infrastructure
    • Information systems
    • Clinical support systems
  • “Soft” Infrastructure
    • Workforce skills, values, expectations (engagement)
    • Organizational culture
  • Key role of infrastructure in transformation:
    • AMI example
alignment
Alignment
  • Managing the “vertical” = consistent organizational vision, values & behavior from top to bottom
  • Both strategic & operational
  • Improving quality is top priority; support, resources & rewards are aligned accordingly
  • Align improvement projects with strategy & organizational goals throughout the organization
tools structures to support strategic alignment
Tools & Structures To Support Strategic Alignment
  • Strategic planning
    • Strategic plan linked to everyone’s job (SSM & Baldrige)
  • Management structures
  • Measurement & Reporting
    • Dashboards, scorecards
  • Communication
    • Transparency
  • Resource allocation
  • Accountability & performance evaluation
  • Recognition, rewards & incentives
    • P4P, performance awards
  • Information Technology
integration
Integration
  • Managing the “horizontal” = consistency across the organization(s)
  • Breaking down silos across:
    • departments & workgroups
    • organizational units
  • Integrating across improvement initiatives
  • Improving coordination of patient care
examples of integrating mechanisms processes
Examples of Integrating Mechanisms & Processes
  • Service Lines
  • Cross-organizational teams, workgroups
  • Quality management oversight structures
  • Steering committees (e.g., integration across organizational/community boundaries)
  • Project teams with overlapping membership
  • Clinical effectiveness departments moving innovations from one team to others
  • “Clinical Systems Integration” unit
  • Collaboratives
  • Integrating quality into operations
  • Information systems
leadership drives facilitates alignment integration
Leadership Drives & Facilitates Alignment & Integration
  • Leadership team & leaders at all organizational levels
  • Board, administrative, clinical leaders
  • Commitment to & passion for quality improvement – “walks the talk”
  • Constancy of purpose; unrelenting pursuit of goals
  • Translates commitment into action
  • Investment of own time in quality activities
  • Fosters learning
  • Holds staff & teams accountable
  • Provides resources & infrastructure for improving quality
  • Integrate activities across organizational boundaries (facilities, workgroups, functions)
  • Communicates & builds relationships
  • Gets the right people “on & off the bus”
  • Facilitates a well organized & well run effort
leadership drives facilitates alignment integration1
Leadership Drives & Facilitates Alignment & Integration
  • Establish structures to link improvement efforts to senior management:
    • Create accountability through measures, reporting and monitoring progress
    • Actively support the projects and resolve problems
    • Identify senior (e.g., quadrad) champion
    • Recognize & reward success
    • Don’t allow continuance of inappropriate behavior
    • Use of key opportunities & events
conclusions
Conclusions
  • Quality improvement activities that are limited in scope are unlikely to be sustained
  • Organizational transformation requires addressing all key model elements
conclusions building change over time
ConclusionsBuilding Change Over Time
  • QI projects cornerstones of organizational change
      • Demonstrate that change is possible
      • Build involvement
      • Engage clinicians
      • Bring about spread
  • Infrastructure development (e.g., information technology)
  • Building culture & skills (e.g., workforce development)
  • Frontline/microsystem efforts
  • Patient involvement in redesign efforts
  • Success builds knowledge & stimulates momentum