What To Expect When You are Integrating

1. What To Expect When You are Integrating CDR Rosemary Perdue Ms. Joan Loepker-Duncan

2. A little about us CDR Perdue JOAN • Active Duty Navy Nurse • Assistant Director for Medicine Directorate/Senior Nurse for Medicine Directorate • 20 years experience in Navy medicine • Army Civilian Nurse • CNOIC, Cardiology Department • 18 years of experience in Army medicine

3. Show of hands Who has had to endure significant change? Did you feel any of these? • Professional setting • Private life • Relationships • Routines • Fear • Frustration • Anxiety • Stress • Confusion • Apathy • Exhaustion

4. Background: Successful Grand Opening…just the beginning September 2011 – Disestablishing two major commands and establishing through integration the Walter Reed National Military Medical Center (WRNMMC) • The Nation’s Military Medical Center • 7,000 staff • 243 acres, 2 million square feet of clinical space serving over 1 million patient visits annually • “A historic day for military medicine” • “The largest and most complex series of moves and relocations that we have ever had within the military medical system” Admiral Mateczun (September 2011)

5. Objectives • Share from our experience - lessons learned • Explore Change Theories • Identify key leadership tools • Discuss Organizational Culture • Define Transformational Leadership • Identify key traits of transformational leaders • Discuss how to Alleviate Ambiguity • Ultimately … increase your comfort level when you are integrating or experiencing change in your workspace

6. Integration Challenge • Unprecedented Merger of Two Major Medical Center’s representing two separate Service cultures • 2005 Base Realignment and Closure • Core of an integrated military medicine system in the National Capital Region • Staffed by Army, Navy, and Air Force employees • Groundbreaking July 3, 2008 President George W. Bush • Located in Bethesda, MD on the grounds of former National Naval Medical Center

7. Army - Point of View • Walter Reed Army Medical Center • Premier Hospital of Army Medicine • Named after Major Walter Reed (Army Physician who discovered the transmission of yellow fever) • 102 year history of providing medical care • 2,500 employees

8. Navy – Point of View • National Naval Medical Center • Flagship of Navy Medicine • The President’s Hospital (Founded by Franklin D. Roosevelt) • 71 years of providing medical care • 3,800 of employees

9. Air Force – Point of View • 158 staff • Such a small percentage of the workforce • - Who advocated for their needs?

10. What was the same • Premier medical care and long standing history • Focus on our nation’s heroes - wounded, ill and injured • All military beneficiaries and their families • Patient and family centered care • Our Nation’s leaders • Rich in military tradition • Uniformed employees • Civil service employees • Contract civilians • Patient loyalties • Proud and strong culture of leading the way for other military organizations

11. What was different • Military specific organizations and culture • The way we did it before • Focused specialty care • Language/Jargon • Artifacts • Acronyms • Chain of Command • Culture, Culture, Culture

12. Cardiovascular Health & Interventional Radiology (CVHIR) • New area for the hospital combining 5 separate services (Cardiology, CT Surgery, Interventional Radiology, Neuro Interventional Radiology, and Vascular Surgery) • Patient Centered Experience • Multiple levels of ownership • Competing missions impacted forward movement

13. Here’s the story… • “Nothing is so painful to the human mind as a great and sudden change.” Mary Shelley- Frankenstein

14. Change defined (dictionary.com) • to make the form, nature, content, future course, of (something) different from what it is or from what it would be if left alone • transform or convert • substitute another or others for; exchange for something else, usually of the same kind • to give and take reciprocally; interchange • to transfer from one (conveyance) to another

15. Change Theory • What do the experts say about how to approach change successfully? • Lewin’s (Change process) • Lippit, Watson, & Westley (Change agent) • Prochaska & DiClemente (Person changing) • Social Cognitive (Behavior) • Use of variety of theoretical frameworks to guide and ensure success

16. Lewin’s 3 step Change Theory • Unfreeze: • Get rid of status quo • Movement: • Move to a new level • Refreeze: • Stabilize the equilibrium • Leadership considerations

17. Change Agent/Lippitt, Watson, & Westley • Expanded on Lewin’s Theory • 7 step approach • Focus on the roles and responsibilities of the change agent • Leadership Considerations

18. Behavior/Prochaska & DiClemente • 5 stages: focus on individual going through the change • Pre-contemplation, complementation, preparation, action and maintenance. • Cyclical not linear • Leadership Considerations

19. Behavior/Social Cognitive • Developing self-efficacy (belief in one's capabilities to achieve a goal or an outcome) • Behavior Change is affected by environmental influences, personal factors, and attributes of the behavior itself • Leadership Considerations

20. Optional Leadership Tools for Change • Make it as easy as possible: • Effective communication • Development of self-efficacy • Consider the human experience • Addressing physical requirements:

21. “Any real change implies the breakup of the world as one has always known it, the loss of all that gave one an identity, the end of safety.” • James Baldwin

22. Organizational culture • “Total beliefs, behavior, knowledge, sanctions, values, and goals that make up the way of life of a people.” • “Historically transmitted patterns of meanings embodied in symbols by which men communicate, perpetuate, and develop their knowledge about and attitudes towards life.” • “THE WAY THINGS ARE DONE AROUND HERE”… (Sara Breckenridge-Sproat, 2001)

23. Influence Organizational Culture • Physical structure • Rituals and ceremonies • Language • Stories and Legends • Leadership Considerations

24. Organizational Culture Artifacts -Army Artifacts - Navy • Pictures of Generals • Walter Reed Sword • Auditoriums – Joel • Uniforms – “Class A” • Statue of Walter Reed • Ward 72 (gifts from dignitaries/DV) • Pictures of Admirals • Hall of Flags • Auditoriums – Clark/Memorial • Uniforms – “Dress Blues” • Quarterdeck

25. Transformational Leadership • A leadership style that fosters positive changes in those who follow • Characteristics of a transformational leader • Embraces change • Endorses participative leadership • Challenges the way things are done and who does them • Active listeners • Toxic Handler • Ambiguity Alleviator

26. Toxic Handler • Definition: “Managers who voluntarily shoulder the sadness, frustration, bitterness, and anger of others so that high-quality work continues to get done.” (Peter Frost and Sandra Robinson, Harvard Business Review, July-August 1999) • Leadership Considerations

27. “Neurosis is the inability to tolerate ambiguity” Sigmund Freud

28. What is Ambiguity? Why is it important to explore? • Definition: doubtfulness or uncertainty of meaning or intention, unclear. (dictionary.com) • Can be harmful to a work environment • Decrease forward movement towards a goal • Staff can become paralyzed by it • Staff may create their own false realities and perceptions • Effects successful group direction and progress • Negatively impacts staff morale • Leadership Considerations

29. “The creative person is willing to live with ambiguity. He doesn't need problems solved immediately and can afford to wait for the right ideas.” Abe Tannenbaum

30. Ambiguity Alleviator • Characteristics • Actively assess • Accepts accountability • Asks and answers • Aides and abets • Avoids attack • Role Function • Close gaps of the unknown (ambiguity) • Connect staff who have the knowledge and answers • Establish actions on how to move forward • Know what to do when there are no good answers

31. Ambiguity alleviator: Actions words with positive movement • Align • Achieve • Amplify • Acknowledge • Apply • Advocate • Advance • Ascertain • Applaud

32. Summary • Change theory can help frame foreseeable challenges • Organizational Culture can positively impact change • Transformational Leaders are key • Identify them early and tap into their resourcefulness • Accept that even best laid plans will have to change • Seek out and celebrate success - no matter how small • Actively Alleviate Ambiguity • Find common ground and move forward

33. Final thoughts • All big changes in human history have been arrived at slowly and through many compromises. • Eleanor Roosevelt