Organizational Change Management: The Missing X Factor in Process Improvement, Simulation, and Facility Renovation
Our book, Simulation Solutions, has a chapter on organizational change management. In fact, this section is 3 times bigger than we initially planned. Why? In talking with simulation experts, we kept hearing the same thing: we’ve seen some excellent simulation models get built, but when we ask about implementation, we often find the results were never implemented. “Dr. Jones didn’t support it, the Nurse Manager didn’t buy in,” etc. Thinking about my own experience at conferences and talking to people about their poster presentations, I was often impressed by their improvement project. Still, the implementation either fell very short, or they implemented a sub-optimal solution because that was what folks “liked.”
We realized we were taking change management for granted. In 2000, the company where Andy Ganti and I worked was acquired by GE Healthcare. We quickly learned that at GE, every process improvement project had two tracks: a technical track and a change management track, and we knew that their research showed that most projects fail, not because they couldn’t find a technical solution, but because of a lack of change management. To be clear, Andy and I understood the importance of getting buy-in and not letting resistance derail a process improvement project before we joined GE. However, our GE experience provided a more structured way of dealing with change through their CAP program (Change Acceleration Process). We also learned about Kotter and Bridges and their work on managing change. Since then, we have learned and used Kotter’s 8-step model, Prosci’s ADKAR model, the Cerner CLEAR model, and some models we’ve created. Now, every project, whether of the simulation or process improvement type, always has a technical track and a change management track. Also, we recently spent two years providing organizational change management support to a large, multi-state hospital management company as they installed IT solutions for HR, Time and Attendance, Supply Chain, and Business Office in their 20-plus hospital network. Our experience with organizations that naturally considered change management a critical factor for success led us to overlook the fact that many organizations did not routinely practice change management, and many process improvement professionals lacked expertise in organizational change management.
So, what’s the missing X factor? Think back to high school Algebra when we would say, “Let x be an unknown variable.” Organization Change Management (OCM) is the unknown variable (at least little known). McKinsey reports that 70% of change programs fail to achieve their goals due to employee resistance and lack of management support. Also, Harvard Business Review suggests that about three-quarters of change efforts fail to deliver the anticipated benefits or are abandoned entirely. My experience as a Master Black Belt, coaching projects led by Black Belts, was that 70% to 80% of my conversations with the Black Belts were about change management issues, not Lean Six Sigma's technical issues. As an engineer and a Master Black Belt, I often longed for a good discussion on using One-way ANOVA or the Kruskal-Wallis test to determine if one sample stochastically dominates another. I have recently sat in on several webinars that fundamentally address change management, further evidence that OCM is still not embedded in how we work as process improvement professionals.
Let's start with the basics: what is organizational change management? The American Society for Quality says, “Change management is defined as the methods and manners in which a company describes and implements change within both its internal and external processes. This includes preparing and supporting employees, establishing the necessary steps for change, and monitoring pre- and post-change activities to ensure successful implementation.” According to their research, “Changes usually fail for human reasons: the promoters of the change did not attend to the healthy, real, and predictable reactions of normal people to disturbance of their routines. Effective communication is one of the most important success factors for effective change management. All involved individuals must understand the progress through the various stages and see results as the change cascades.” I agree with the second part 100%; effective communication is the most critical factor for success. And I would add that the trickiest part of communication is thinking it occurred.
Any change tends to bring anxiety, uncertainty, doubt, and even suspicion if we think about change. This is part of fundamental human nature. In our daily lives, even events that are happy or joyous can bring about a feeling of anxiety. For example, please take a couple of common situations many of us have faced. Buying a home or having a child. These would be considered good changes, but how many of us have faced these things without any anxiety, doubt about the future, or uncertainty about our ability to handle the change? And these are the changes we chose. Now, think about a staff member in our hospital who did not choose to have the process changed, things re-arranged, or a new location or facility to work in. Their anxiety, uncertainty, and doubt will be much greater. “Why is this happening?” “How will this affect my position/role?” “Will my work life become more difficult?” These are all questions staff will consider.
From this discussion, there are a couple of critical points. First, people want to know how this affects them personally. We often call this the WIIFM – What’s in It for Me. Second, people want to understand the “why”. It is important to remember that change management does not eliminate the anxiety, uncertainty, and doubt that comes with change; instead, it helps people cope and get through these feelings to return to normal quickly. To begin change management, we need to answer these two questions. We should note that the question, “What is in it for me?” will have different answers for different staff and stakeholders. The answer for an RN will differ for a physician or a Radiology tech, so we’ll need multiple answers depending on our stakeholder audience.
This is not because of resistance to process improvement, simulation, or facility renovation but resistance to change. It is important to note here that a group often appears open to change initially because they think everyone else will change. Their resistance starts, along with anxiety, uncertainty, and doubt, when they find out they will have to change. Unless we create a track to deal with these emotions, our project might have a good technical solution, but we won’t be able to implement it. So, we return to our concept that each project needs two tracks: a technical track to work on process changes, service changes, facility changes, etc., and a change management track to help people deal with their anxiety, uncertainty, and doubt.
Our book, Simulation Solutions: A Practical Guide to Improve Patient Flow & Facility Design in Healthcare Operations, uses the GE CAP model to take readers through an ED example. We chose the CAP model because, in our opinion, it is more tactical, and there is literature readily available for those who want to delve deeper into the model. We tend to think the CAP and Kotter’s 8-step models are more tactical, while the Prosci ADKAR and Lippitt-Knoster models have a more strategic bent. However, we used the ADKAR model in a tactical situation, and it worked well.
If we’ve solved for “x” and found out that change management is an issue, we’ll enhance our chances of success by inserting a change management track into every project. The advantage of these models is that they lay out a straightforward process for navigating the change. The CAP model's steps involve creating a shared need, shaping a vision, mobilizing commitment, making change last, monitoring progress, and changing systems and structures. This works well in our project-based improvements, whether driven by Lean Six Sigma, simulation, or facility renovation; CAP was created to help make projects more successful. The Lippett-Knoster model’s steps are Vision, Commitment, Skills, Incentives, Resources, and an Action Plan. This model focuses on complex change, though the steps could be adapted to micro-change efforts.
All these models list their steps linearly, but because these change management models focus on emotional variables, there is much moving forward and then circling back. If we iterate on the steps thoughtfully, we will implement the new process, etc., and the anxiety, uncertainty, and doubt will be minimized.
My favorite example of change management came from a project with a Texas hospital. This project involved reducing the hospital's Ventilator-associated pneumonia (VAP) rates. The hospital’s rate was above the national average, and they wanted to lower it to at least below the national average. Looking at our two tracks, the technical track was simple, as the science of dealing with VAP was well documented. Many of the process changes were simple, technically: good hand hygiene by the staff, oral hygiene for the patient, raising the bed to 30 degrees or 45 degrees, suctioning, etc. We will not go into the details because they are unnecessary, but it was important that we didn’t need to brainstorm a solution to the problem; it was already there for us.
Our stakeholders on the change management track included the ICU nurses, physicians, respiratory therapists, and others. In a hospital, the number of people impacted by change can skyrocket; a medium-sized ICU can have 50-plus staff associated with it, and when we add physicians, respiratory therapists, and others, we could find 100 people affected by the change. Also, we had 100 people who needed to adopt new habits.
This project was undertaken by staff at the hospital who received Green Belt training and some change management training and were coached by Master Black Belts. A typical project would run 3 to 4 months, but this project took 12 months. The project team was incredible in their persistence in following the change management steps, circling back and iterating until they achieved success. As a model, we used an amalgamation of the CAP model and Kotter’s 8-step model, which we won’t go into detail on.
As I thought about the team’s struggles, I thought about Lewin’s model from the 50s: Unfreezing, Moving, and Refreezing (Lewin influenced Lippett). The team changed the process, but to get the changes adopted consistently by everyone, it took a lot of refreezing, refreezing, and more refreezing to achieve a sustainable result. After their efforts, the team achieved a zero VAP rate and sustained this rate for several years with only an occasional VAP case. This project was a perfect example of how critical change management is to implementing new processes successfully.
As we’ve stated a few times, if we want more project success, we must incorporate this two-track system into each project. One track is our technical track, and the other is our change management track, which must be managed in parallel. A common mistake I’ve seen on simulation projects and other process improvements came out of running the technical track to its conclusion and then trying to get people to “buy in.” While occasionally successful, this generally is a recipe for failure.
We discussed managing these tracks in parallel, but the change management track should start before the technical track and extend after it. It begins before because we need to help folks understand the “why” for change. In my younger days, I often heard bartenders close up with the words, “You don’t have to go home, but you can’t stay here.” This is how I think of initial change management efforts; where we are going (what the change will be) is not crucial, but everyone must realize we can’t stay here (we must change). Next, each stakeholder's role in the change is identified by identifying stakeholders and using the RACI model (Responsible, Accountable, Consulted, and Informed). Their role will determine the types of efforts we put into our influence and communication strategies, and we begin communicating early.
The change management track extends after the technical track concludes because it is about refreezing new habits or ensuring sustainable change. For this, we must monitor the process and, when we have failures, evaluate whether this is a change management issue (and it usually is) or a technical issue that needs re-design. Often, long after we don’t have any additional need for re-design, we still have problems creating and “refreezing” the new habits. As such, this last step could be a whole discussion unto itself.
In summary, think about the two tracks for every project, then pick a model and jump in. Now, you’re set up for increased project success. There is a great deal of information available on these various models, and some organizations offer training courses. You may find that you have an affinity for one model over another; the model is not that important. What is essential is having a structured way to go about change management, and any of the models mentioned here will provide that structure.
If you are interested in how change management is critical to the simulation process, check out our book Simulation Solutions: A Practical Guide to Improve Patient Flow & Facility Design in Healthcare Operations, available from Amazon..