When the TransforMED national demonstration project began more than two years ago, the 36 practices involved were charged with exploring how a new model of family medicine worked in the real world. The practices were asked to make enormous changes, including implementing same-day scheduling, group visits and electronic medical records (EMRs).
One of the first lessons we learned, in the words of TransforMED CEO Terry McGeeney, MD, MBA, was that “many family medicine practices are poorly equipped for change, even when they want to change. You can't just ‘do it’; you have to create a culture where change is constantly anticipated and actively managed. It's not a one-time deal or push of a button.”
Struggling with change is not unique to medical practice; it's a challenge most organizations face when trying to alter entrenched patterns or processes. It's estimated that somewhere between 50 percent to 80 percent of change initiatives in Fortune 1,000 companies fail.1 Why? In her book Creating Contagious Commitment: Applying the Tipping Point to Organizational Change, author Andrea Shapiro writes about a typical change project gone awry:
“Some years ago, I asked the manager responsible for implementing ISO 9001 [a certification process that indicates whether a company meets quality management standards] at a high-tech company how the change was going. … His response was, ‘It’s going fine – except for the people.' The image of a disembodied change progressing perfectly, but leaving behind employees, who were supposed to change, was amusing. Yet this is exactly what we often attempt. We work hard at the details of new processes or new technologies, but expect magic metamorphoses of the people expected to use those processes and technologies. We simply forget or ignore that organizations change when the people in them change.”2
We observed the same thing as we talked with and traveled to the TransforMED practices. Time after time, we saw well-intentioned physician champions making detailed plans for change but being frustrated by their staff's inability to carry out those plans. The key problem was a failure to emotionally engage the people in the practice.
Addressing the emotional components of change
Change often begins with an emotional response. Stripping feeling and emotion from the process and instead focusing on making a detailed plan and following it to the letter can be counterproductive to the change effort. Make no mistake: You do need strategic plans, supportive data and structured time lines to succeed at change. However, those elements risk falling short without some preliminary work:
Understand that people are galvanized to change at an emotional level; the motivation for change is visceral rather than cerebral.
Distinguish between emotions that undermine change and those that promote it.
Develop ways to foster those feelings that facilitate change, and minimize those that prohibit it.
Attention to feelings may seem like a luxury in a hectic medical practice. Nonetheless, it is a necessity because change brings long-standing differences to the surface. Anger, frustration, exhaustion, cynicism and anxiety tend to remain beneath the surface during times of stability, but they can erupt with chaotic consequences during times of change. This can undermine the change process and leave the physician champion, and the practice, back at square one.
Working through the issues is not as scary as it may sound, especially if you use some key tools such as training in conflict resolution, constructive feedback and viewing problems as process issues instead of people issues.3 It can also be helpful to have an outside person guide your group through the process of conflict resolution. Where plans for change have stalled, the solution often begins with repairing the relationship infrastructure.
Among the demonstration practices, getting buy-in from all of the practice employees was a consistent challenge, from which two promising strategies emerged.
First, think about how best to explain the planned changes, because “choosing the right words [increases] the space … for new possibilities.”4 Presenting the changes as a way to deliver better patient care, for example, can make it easier for staff members to feel good about the changes and become more invested in the initiative.
Second, understand that modern medicine needs to be team-centered (as opposed to the traditional, physician-centered model), and recognize each staff member for his or her contributions. This team-centered message helps staff members feel valued.
The story of one practice in the national demonstration project illustrates the importance of these strategies. The practice unveiled its participation in the TransforMED project with a big splash at an all-staff meeting where the physician champions presented the future changes with impressive amounts of information and data. As reinforcement, the information was later posted prominently throughout the practice, and the leaders developed several diverse teams to carry out the work. But rather than inspiring the practice, this effort demoralized the staff.
Why did the staff members react that way? Most were unable to see the big picture and what it meant for them personally. In fact, many began to see the initiative as a punishment. A few staff members even asked, “What did we do wrong to bring this on ourselves?” Once the champions sensed this negativity, they decided to call another all-staff meeting, this time with a catered lunch. The champions talked about what the initiative meant to them and why they were so committed to the change. In most cases, their stories included a convincing case for why this new medical model would result in better patient care. The act of storytelling engaged staff members in a powerful way because it made the planned changes personally meaningful to them.
At this same meeting, the idea that medicine should be a team effort and not a physician-centered endeavor was emphasized. Viewing the change this way helped many in the practice embrace the change as an honor and privilege, and soon afterward many took an active part in the initiative. Of course, this new enthusiasm would have quickly waned if the physician champions had not followed through with actions that demonstrated the importance of the team.
Another important step was addressing staff members' fear of change. Many clinical staff members have been trained to work in structured environments. As a result, ambiguous projects can be frightening to them. For example, for some TransforMED practices, one fear-inspiring initiative was the suggestion that they begin offering group visits. In these case helpful to acknowledge staff s, it was members' feelings of fear about the unknown and the potential for failure, and reassure them that mistakes would simply be a natural part of the learning process.
Eventually, the fear of group visits was replaced with good feelings about creating a time and place where patients could interact with the health care team and help one another. Positive patient feedback from the group visits served as a powerful motivator for both physicians and staff members, and many began to view the risks and unknowns as a worthwhile exchange for the opportunity to improve patient care.
CHANGE MANAGEMENT STRATEGIES
Short of organizing a facilitated retreat, what can a practice do to inspire its staff to become personally invested in a potentially overwhelming change process? Data from the TransforMED national demonstration project suggest that the following strategies can be helpful:
Use words and stories that will resonate with your staff members' values. Sharing specific examples of how change will lead to better patient care can personalize the process, making staff members feel more invested and more valued. This can also transform the abstract idea of change into a concrete and palatable process.
Emphasize that medicine in the 21st century needs to be team-centered rather than physician-centered; ensure that each team member is given a specific role in the change and acknowledge his or her contributions.
Introduce conflict resolution tools so differences in feelings can be resolved constructively.
Remember that positive words and feelings mean nothing to staff members without concordant action. Model the progress you hope to see.
The positive feelings associated with good patient care were also an important motivator when individual tasks seemed tedious or trivial. For example, two TransforMED practices struggled to get staff to consistently populate the chronic disease registry feature on their EMR system because the process required manual data entry. The solution for both practices was to share actual patient scenarios that demonstrated the importance of catching missed screenings. Although the data-entry work remained unchanged, staff members were more willing to do the tedious work after they connected it to the concrete business of saving lives.
Stepping outside the practice
Sometimes feelings can best be managed outside the workplace. As co-workers become more human to one another, the risk of misunderstandings triggered by stress is greatly reduced. Some TransforMED practices started planning social activities outside the workplace (e.g., cookouts, hikes and charity fund-raisers) and found that these activities fostered more respectful communication within the workplace.
Practice-wide retreats are another great way to engage staff and strengthen their commitment to the change initiative. (See “Change management strategies” for additional ideas.) The idea of closing down for a half-day or longer might sound impossible to a busy practice; several TransforMED practices felt that way. (See “Be creative in finding time for retreats, meetings” for a helpful tip.) Yet our data suggest that a facilitated retreat was the catalyst for change in those practices. The success of these retreats was due in large part to the role they played in breaking down barriers erected as coping mechanisms to survive the daily pressures of a busy family medicine practice. Within the safety of the retreat environment, both practice leaders and staff members could talk openly about what was and wasn't working, and they could contribute to more productive brainstorming of potential process improvements.
One important tool at the retreats was a personality assessment, such as the Myers-Briggs Type Indicator. The assessment tool helped the physicians and staff gain perspective on the different ways in which people process information, renew themselves, make decisions and relate to others. The assessments also helped individuals realize their blind spots in conflicts, their needs during change and the behaviors that irritate them. It also revealed their own behaviors that may irritate others. Stressors were addressed, and as staff members sought to understand one another's perspective and establish common ground, it became easier to engage staff in the overall vision and later implement process improvements and new technologies.
The art and science of change
Don't be afraid of feelings. Like conducting a patient encounter, leading a practice through change is both a science and an art. While the science requires strategic thinking, the art requires paying attention to the emotions involved. That simple step can be a powerful tool in the quest for practice transformation.