Overview

Mastering Change . . . helping organizations view change as an opportunity for new alternatives . . . (Health Care Forum, 1994).

The history of organizations in the United States has been one of continuous growth and change. In fact, the American way of doing things is to expect, and even encourage, change. Progress in technology, in human relations and in society all cause changes that must be accommodated. The primary health care center is no exception. When the yearly assessments are performed and the services adjusted, change is to be expected. A primary care center that can cope with change, adjusting quickly to different circumstances, will be better suited to today's rapidly changing environment. The challenge will be to balance the amount and timing of change the center/organization undertakes to meet the primary care needs of the community.

Each community differs markedly in its reaction to change; some communities are comfortable and will welcome frequent changes, while others require stable and unchanging conditions and do not welcome frequent changes. Regardless of the type of community, it is inevitable that change will occur. How that change is managed will in large part direct the success of adjusting services at your center.

FORCES FOR CHANGE

Forces for change come from a variety of sources. Externally, the primary care organization depends on and interacts with a larger community. Therefore, any factor that interferes with its ability to attract and keep human resources, or interferes with its ability to deliver or market its services, becomes a force for change. Other external factors that will require change will be generated by the analysis of the organization's strengths, weaknesses, opportunities and threats. Still other factors requiring change will be generated by an analysis of community service needs.

Internally, new strategies, technologies or personnel may also demand organizational change. For example, a new computer system may call for a complete change in work routines, training programs and compensation arrangements. New clinical treatment protocols may dictate new working relationships and decision making.

Changes are often made in three areas:

• structure, i.e. new services or programs;
• technology, i.e. alteration in equipment and/or automation; and
• people, i.e. selection, hiring, training, relationships, attitudes and so on.

Because organizations are interrelated systems, a change in one of these three areas is likely to involve a change in the other two areas as well.

THE EFFECTS OF CHANGE

Planned change can have a far reaching effect. Any initiated change may produce unforeseen and potentially undesirable side effects in addition to the expected result. Further, change has a ripple effect, in that even a small change in one part of an organization can have disruptive effects on individuals and groups throughout the entire structure as well as in the community. For this reason, it is critical to permit those affected by the change to express their opinions and wishes during the planning and execution stages of change.

There are risks inherent in change that should be considered in the planning phase. They include risk of making mistakes and losing efficiency, the risk of failure and loss of face, the risk of excessive personnel or supply costs, the risk of physical and mental exhaustion, and the risk of lower morale and increased turnover. Each of these risks is real and must be considered when change is undertaken. The objective is to minimize, where possible, these risks and/or their effect.

THE CHANGE AGENT

A change agent is an individual who is responsible for taking a leadership role in managing the process of change. A change agent may be an internal person or may also be an external consultant. Internally, the administrator or medical director often assumes the change agent role. For complex or lengthy change programs, an outside consultant is preferable given the specialized expertise and skills required, the time needed daily to manage the process, and the perceived "objectivity" of an outsider. Regardless of the source, it is important that a change agent spearhead the change effort. This person's role is to ensure that the change process is managed in such a way so as to achieve the desired result in the least disruptive manner possible.

THE PROCESS OF CHANGE

While change is inevitable, the challenge is to control is as much as possible so that it occurs at the right time, at the right speed, in the right direction, and as smoothly as possible so as to achieve the desired results with the minimum of disruption. Generally speaking, the larger the organization the longer the process of change. The time frame for change is also affected by the complexity of the proposed changes. The annual strategic planning process will result in a plan that will direct the change activities and their timing. The objective now is to manage the change process to take the organization from its current to its future position.

Kurt Lewin, known for his work on change, studied the process of bringing about effective change. He developed the three step sequential model shown in Exhibit 17-1 and summarized below.

Often, the most difficult aspect of change is to motivate a movement away from the status quo. Staff motivation can be facilitated by means such as:

• holding focus groups to encourage dialogue between those individuals most opposed to change;
• introducing a change agent to help create situations where new values, attitudes and behaviors are appropriate; and/or
• linking the planned objectives to personal goals to show the benefits of the planned change.

When it comes to changing behavior, a change agent might start the process by first identifying those individuals most receptive to change:

• management;
• community leaders; and/or
• grass roots organizations.

One strategy is to find unique ways to motivate individuals or groups to change. Because each group is motivated by different factors, it is important to link the change and its results to the interests of the group. Another strategy for facilitating change is to prepare individuals for the relationships by providing the necessary education and training. However, training alone will not ensure the desired results if the group or individual does not want to change. If this is the case, refer to the next section of this chapter entitled "Methods for Dealing with Resistance to Change."

Still another strategy in facilitating change is to manage the communication about the change process. Regular meetings should be scheduled with the community and center representatives to provide information and status updates, share ideas, ventilate feelings, and identify problems and timely solutions. The change agent will want to schedule these meetings at the completion of one step and before proceeding with the next step to ensure that the communication process is a continuing one.

METHODS FOR DEALING WITH RESISTANCE TO CHANGE

Resistance to change can come about for many reasons, usually related to uncertainty about the effects of the proposed changes. We all enjoy the comfort of established procedures; therefore, any change in approach or scope can be disruptive to our routine and can make us less productive and secure in our activities. Even though service or operational changes may benefit the individuals or the community, it is not necessarily true that it will benefit the staff or practitioners. For some individuals, the drawbacks of change in terms of lost power, prestige, salary, quality of work, or other benefits may not be sufficiently offset by the promised rewards of the change. Finally, some may resist change because they are aware of potential problems that have been overlooked by the change initiators. They may disagree with the proposed changes, making it difficult to support the change process.

Significant resistance to change should be taken as a signal that something is "amiss" demanding attention. Start with determining the real causes for the resistance and remain flexible enough to overcome them in an appropriate manner. Kotter and Schlesinger offer six ways to overcome the resistance to change (see Exhibit 17-2). They include education and communication, participation and involvement, facilitation and support, negotiation and agreement, manipulation and co-optation, and explicit and implicit coercion. Overcoming resistance to change may involve using more than one approach. The most appropriate techniques and actions will depend on the specifics of the situation.

FACTORS FOR SUCCESSFUL CHANGE

There are three important factors essential to bringing change:

• coordination or teamwork where a center pulls together groups of stakeholders vested in the outcomes;
• initiative, cooperation and a high level of commitment from the management; and
• new competencies such as knowledge of the organization, analytical skills and interpersonal skills which are critical to identifying and solving the problems associated with change.

Plans to effect change will need to consider these three factors, ensuring that each one is addressed before proceeding.

Beer and Eisenstat have developed six steps to effective change as follows:

• Step One: Mobilize commitment for change by encouraging the joint diagnosis of problems. By encouraging people within the community and the center to develop a shared view of what is wrong or what is needed, an initial commitment to change can be established. Focus groups, performance improvement teams, town/neighborhood meetings are but three ways to bring people together to jointly diagnose problems.
• Step Two: Develop a shared vision of how to organize and manage the change. Once a core of people is committed to change, the center can lead an exercise to define the structural, technological and people changes required to achieve the vision.
• Step Three: Foster consensus for the new vision, competence to enact it, and cohesion to move it along. Simply letting the community, staff and practitioners develop a new vision is not enough to overcome resistance to change or to foster the skills needed to make the new/or expanded project work. Strong leadership is critical to the change design and to ensuring that staff members have a clear understanding of the new roles and responsibilities. Leadership should also ensure that staff members have the right support to enact the change, e.g., training, resources, and encouragement.
• Step Four: Spread change throughout the center without pushing it from the top. This is especially true if the changes planned significantly affect one area more than others, for example, a modification in a substance abuse program or the addition of dental services. The temptation to force change on other areas in your center can be great especially when rapid change is needed. However, a topdown push can be a fatal mistake. It is better to let each area or department find a way to adjust its services to accommodate the planned changes.
• Step Five: Institutionalize change through formal policies, systems and structures. It is important to ensure that the change is institutionalized so that it will continue even after the initial focus subsides. In some cases, depending on the change, this will mean a revision of existing policies or the development of new policies. It may mean realigning personnel, changing roles and responsibilities, new committees, and other activities. The challenge is to ensure that the change is significantly entrenched into the day-to-day operations.
• Step Six: Monitor and adjust strategies in response to problems experienced in the change process. The purpose of the change is to enact improvement, not create more problems. Consequently, it is important that the center know how to monitor its actions relative to the shared vision to ensure that the employed strategies are being effective.

IMPLEMENTING CHANGE

To implement the change process, the change agent needs to assign specific individuals to carry out each action and then provide the coaching and support to ensure that the actions are performed effectively. It is also the change agent's role to coordinate the efforts of all individuals involved in the change process. These functions will require specific skills including an understanding of the center and the strategic plan, group process and dynamics, interpersonal relations, project organization and management and perseverance. A GANTT chart is often used to manage the process of change because it shows the sequencing and timing of specific activities. It can also include a column denoting the responsibilities of specific individuals. Regularly scheduled meetings are needed to track and adjust the specific activities and their timing. Where possible and appropriate, the community should be involved in the change process. Readers interested in learning more about the use of Gantt Charts may wish to examine the Web site http://www.me.umn.edu/courses/me4054/assignments/gantt.html for a Brief Tutorial on Gantt Charts.

EVALUATING CHANGE

Finally, when the change process has run its course, it should be evaluated. In the interest of fairness and accuracy, both the changes and the change process should be considered in the evaluation. The criteria to be used in the evaluation should be driven by the strategic plan and the goals and objectives set forth in that plan. The central question to ask is: has the change produced the desired results? Further, the satisfaction of the community, staff and practitioners with the results of both the process and the outcome needs to be evaluated. Satisfaction can be determined through interviews, surveys, town/neighborhood meetings and/or focus groups. Hopefully your ongoing assessment of change will lead to improved organizational performance and ultimately to better service for your patients.