Leading, guiding and nurturing through change: An essential capability for healthcare leaders

Leaders are faced with many conflicting pressures that create environments that demand agility and compassion while leading change. These pressures are within the context of challenges facing society such as civil unrest and funding for education, infrastructure and other community/state needs. They also relate to healthcare-specific challenges: low reimbursements, staff shortages, technology changes, information security, staff burnout, regulatory burden, legislative uncertainty and, more recently, a pandemic.

All of these combined create a “permanent white water” of opportunities amid constant turbulence.1 Navigating this turbulence requires effective utilization of change management strategies to learn, lead others through developing relationships, and guide organizations in striving for excellence.2

Effective change management involves integrating the ideas of others, balancing present issues with vision of the future, and considering uncertain scenarios characterized by volatility, uncertainty, complexity and ambiguity. Failures and mistakes that impact results will likely occur, including lack of information, inertia, uncertain benefits and poor communication. Ineffective implementation, inadequate resources and a variety of other obstacles may also be present. There are many methods on how to lead change, and it is important to ensure leaders understand which approaches work best to effectively enact and sustain change in this uncertain environment.

Resources and approaches to consider

While influencing change in large, complex organizations can be challenging, an effective strategy is to focus on cultivating psychological safety by leading, guiding and nurturing all individuals involved in the change.3 Leaders who focus on the human experience are in tune when individuals need leading, guiding and/or nurturing during the change process.

Fortunately, several approaches have emerged in the leadership literature when facilitating complex change efforts. There are common threads among some, while others portray unique characteristics that can be deployed in relevant use cases by leaders who must remain agile and maintain trust while driving personal, professional and organizational change.

8-Step Process for Leading Change

John Kotter’s seminal work on failed change efforts describes a framework that includes:

1. Establishing a greater sense of urgency
2. Creating the guiding coalition
3. Developing a vision and strategy
4. Communicating the change vision
5. Empowering others to act
6. Creating short-term wins
7. Consolidating gains producing even more change
8. Institutionalizing changes in the culture.4

Each of these steps can be evaluated as a checkpoint/milestone to optimize the probability of success.

Use case

An organization transitioned to a new software platform to support its core business establishing a change strategy. Senior leaders conducted several “town hall” sessions for all employees to communicate the change vision, including a description, sense of urgency and timeline for the change. To create the guiding coalition of individuals interested in and passionate about the software change, the organization outlined the significant improvements and capabilities of the new software system through product demonstration sessions. To ensure the end users had the knowledge they needed to be successful and feel empowered to act, several “build” sessions were conducted to explain and configure the functionality of the software. Hands-on training sessions with the new software tools ensured end users had opportunities to create short-term wins and demonstrate benefits using the electronic environment. To reinforce use and institutionalize changes, the organization developed multiple quick reference guides, slide presentations and newsletters for employees.

Appreciating and managing transitions

William Bridges describes an approach in which change often requires transitions that may invoke an intense emotional and psychological reorientation as well as grieving loss of the past and present to a different future.5 This approach explicitly recognizes and identifies strategies to address the three phases: ending and letting go, a neutral in between stage and a new beginning.

Use case

The change from film to digital images in radiology required the department to manage a transition. The vision of this transition was an essential characteristic in the overall process, which helped create excitement for piloting a new approach. Volunteers were asked to pilot the change from film to digital imaging in radiology and orthopedic practices. This “neutral” stage allowed for an adaption to a different approach, recognizing the habits that had been acquired over the preceding decades utilizing films. The “letting go” stage was facilitated by sharing the benefits with those resistant to using digital. In this change, the leader establishes the line of sight and the vision of the new beginning, so that others can experience the benefits of the new approach and can let go of the past. Letting go becomes easier as new benefits are manifested.

Change formula

Beckhard and Harris describe a “formula” (DxVxF>R) that similarly can be utilized as a check on the variables that need to be considered/managed to effect change including: the level of Dissatisfaction with the status quo, the Vision and desirability of the proposed change, the First steps and practicality of the change, with the three collectively being greater than the Resistance or cost of changing.6 Leaders utilizing this approach can engage in meaningful discussions about each component to better understand where they need to lead, guide and nurture staff. This approach specifically identifies the potential resistance/costs that can and should be evaluated and leverages stakeholders’ dialogue. By leveraging dialogue about each of the components of the formula, those involved will “collectively create a new reality through language … and this new reality expresses itself in new ways of thinking and acting.”7

Use case

Leaders at Mayo Clinic working through complex change initiatives find themselves with many opportunities to practice the Beckhard-Harris Change Equation. It is encouraged as a leadership development activity to work in partnership with a leader colleague and determine a current, relevant and important change process occurring in the work unit. Through facilitated conversations, leaders populate a grid that allows them to think through and rate how individuals on their team may be experiencing change at each phase of the equation (DxVxF>R). The leaders are encouraged to look at the grid for themes to better understand how the change is affecting individuals or the collective team. This allows leaders to explore possible reasons for resistance and hold one another accountable to action items.

Managing complex change

Another approach in the leadership literature identifies five factors to effectively manage change: vision, skills, incentives, resources and an action plan.8 The absence of any of these factors may lead to confusion, anxiety, resistance, frustration and/or false starts. The presence of each factor can be evaluated by change agents.

Use case

The implementation of a new enterprise image viewer for radiology required a complex change model that incorporated all five factors. A detailed project plan provided the context of how different segments of the organization would be integrated into the solution, including purchasing, deployment and training. The plan’s documents were summarized in a charter that included the vision, as well as those elements that were in or out of scope so that the appropriate resources could be identified. The project plan included the role of the physician leaders in being advocates and champions for the change effort. The change impacted thousands of individuals across the enterprise, and ultimate approval and implementation of the change required recognition of the benefits/incentives of utilizing the system to replace the fractured system that did not provide the benefits: using the best-of-breed image viewing, sharing enterprise resources and sharing images at any time from any location.

Looking at polarities

Another approach to change recognizes the impact of differing points of view (polarities) when they are considered and allowed to exist at the same time.9 The polarity management approach identifies the potential pros and cons of each viewpoint. Strategies are identified to reap the benefits of differing approaches along with warning signs of potential negative consequences. This approach to change management respects and integrates the ideas of others, neutralizing the impact of unnecessary and potentially destructive polarization.

Use case

Negotiating a middle ground for leaders stressing quality versus those focusing on cost reduction is common in healthcare. Practice administrators often share their concerns with physicians about the intermediate and long-term impact of excessive staffing that is not sustainable. Concurrently, physicians share their concerns about the impact on quality of inadequate staffing. Balancing the need for staffing to provide adequate access and quality coupled with stewardship in utilizing resources in the most effective and efficient manner is the desired vision. At times clinicians may not understand the financial implications, whereas administrative leaders may not understand the potential quality impact. Understanding both perspectives can ensure the best outcome.

Understanding consensus

Consensus is an often-misunderstood concept. Frequently, change agents or sponsors look to voting or strive for unanimity before proceeding. The natural desire to please all stakeholders can lead toward circuitous and seemingly endless discussions and negotiations to reach a decision. Rather, the “understanding consensus” approach defines this as a process and outcome in which divergent views are expressed; voices are heard through fair and open discussion; and there is an understanding regarding agreement but not necessarily complete agreement.10 The degree of consensus between those involved in the decision is established by determining who:

1. Considers the idea great and wants to be a leader or champion
2. Considers the idea good and supports it
3. Does not agree with the idea, but will support it
4. Does not agree with the idea, but will not block it
5. Does not consider the idea good and is going to block the idea if implementation is attempted.

This approach is done transparently so that everyone understands each other’s views.

Use case

A department in an academic medical center sought to implement Lean principles. The ability to proceed with implementation required a clear understanding of Lean thinking to dispel perceptions that Lean implementation is simply a means to make people work harder or to lower costs. Other obstacles include beliefs that healthcare is not a business and that Lean is only applicable in business settings, not healthcare. The successful implementation of Lean in our large department required consensus on what benefits would accrue to the organization so that we could optimize the number of champions and advocates for Lean implementation, and minimize those that either previously had or could have an unfavorable disposition to the implementation of the program. This approach was very successful in achieving the desired benefits.

Process consulting  

The process consulting approach utilizes extensive questioning as a means to understand the phenomena at play in a situation.11 Specifically, descriptive questions are asked to elicit what is occurring. Simple questions such as, “How would you describe what’s been happening today?”, or, “How do you know this is a problem?”, may be sufficient to start the conversation and provide robust information.

Once the situation has been described, diagnostic questions are asked to reveal potential antecedents or causes contributing to the undesirable results that need to change. Diagnostic questions may include, “How often does this happen?”, “Where does this happen?” or “Who’s involved in this situation?” The third type of questioning is potentially more confrontational but provides suggestions for solutions. This type of questioning is used to help identify potential solutions or strategies to achieve the desired change. A question such as, “Have you considered changing the staff reporting time to 6:45 a.m.?”, is a reasonable question and suggests a solution. In the above use case, the leader uses a process consultation approach to discuss changes to improve on-time starts for patient appointments.

Much like some of the coaching literature suggests, this model utilizes questions as an approach to facilitate change efforts with the beneficiaries of the changes.

Use case

• Employee: “I’d like to talk to you about the way things are done around here.”  
• Leader: “OK, sure. What’s been happening lately?”
• Employee: “Many people either forget to do things or they do them in such a rush that I have to redo them to make sure it’s done right.”
• Leader: “OK, can you tell me more about the process you are thinking about? What’s supposed to happen? Who’s supposed to do this work?”
• Employee: “As the desk person, we’re all supposed to make sure everything is ready for tomorrow at the end of the day and before we go home.”
• Leader: “Have you considered creating a standard checklist that has all the tasks on it? Could this be something everyone is asked to use each day?”

ADKAR   

Hiatt describes the ADKAR (Awareness, Desire, Knowledge, Ability and Reinforcement) model from Prosci Research12 to systematically approach significant changes in personal, professional, organizational or community life. Hiatt asserts that to achieve organizational change, individual change must be first understood and managed effectively:

• The initial step is to create Awareness of the change that employees are about to experience.
• The Desire to change is next and looks to develop the desire within individuals to change.
• The Knowledge phase ensures employees know how to change and what they need to do during the transition to the future state.
• Ability is the next phase and represents the move to applying new knowledge into action by using the new tools, systems or processes during practice or simulation.
• Reinforcement is the final phase and is vital to the success of the change management process.

Reinforcement activities can include communications and events for employees that highlight performance of the new changes. The examples below outline the use of the ADKAR model for organization change management.

Much like the other models presented here, a careful review of each part of the model can help identify the need for further development and coaching for change.

Use case

Two work units were being merged into a single work unit. One work unit worked directly with customers to resolve complaints or concerns; the other work unit primarily conducted training and education on proper customer service for frontline employees. Proponents of the work unit changes met with staff members to describe the change, the need for the change, and the timeline for implementation.

To build desire, enhancements to job descriptions were depicted during a number of presentations for employees. Several discussions were needed with the two workgroups to develop shared knowledge and understanding, as well as identify similarities and differences. To ensure each employee had the ability to perform in this new role, cross-training sessions were held to make sure everyone was comfortable. Reinforcement was done through one-to-one coaching sessions and team meetings.

SBAR

The SBAR (Situation, Background, Assessment and Recommendation) technique has been utilized extensively in healthcare since 2002 as a communication vehicle for caregivers to quickly share important patient care information to other members of the healthcare team.13 SBAR has been adopted by numerous healthcare organizations because of its simple, concise way of framing a conversation and focusing attention on critical issues. This technique can also be used for many administrative, non-clinical situations to quickly provide leadership team members with necessary information to initiate important changes in an organization.

• The SBAR technique allows the user to briefly state the situation and answers the question, “What is the problem that needs to be solved?” 
• The background section is used to describe how the situation or problem evolved to the current state and allows the reader with sufficient context to better understand the situation.
• The assessment provides a description of the analysis that has been completed, options that have been considered, and any findings that resulted from the assessment.
• A recommendation should describe the pathway forward for the administrative team to consider.14 

Use case

• Situation: There is insufficient waiting room space for patients and family members to achieve recommended physical distance of six feet.  
• Background: Insufficient waiting room space existed prior to the COVID-19 pandemic. The chair arrangement within the waiting area includes back-to-back configurations and would require the removal of 14 seats if back-to-back chairs are removed. Family members accompanying patients use the waiting areas while the patient exam is performed. The plan-do-study-act (PDSA) technique was used to level-load patient exams by time of day; however, this has not adequately addressed the issue.
• Assessment: Additional support is needed to implement other mitigation strategies.
• Recommendations: Launch a new project to assess additional opportunities that may include expanded waiting area space, developing family lounge space elsewhere or modification of the arrival time on the patient appointment guide.

The example above illustrates the SBAR technique in a non-direct, patient care setting to succinctly communicate among administrative team members.

The SBAR framework can effectively communicate change in an organization and is easily adaptable to various topics and initiatives.

Appreciative inquiry 

Appreciative inquiry15 penetrates the realms of purpose, meaningfulness and spirituality. The leader acting as change agent explores the actions others have taken when they demonstrate living a life with purpose. This focus on the positive and inspirational can be a welcomed alternative to traditional problem-solving. Appreciative inquiry can be a means to find someone’s Ikigai, a Japanese concept meaning “a reason for being.”16

Use case

There are indicators of burnout, potential lack of joy or poor morale within the work unit. The leader, utilizing appreciative inquiry with staff, would explore the drivers impacting joy in the workplace (e.g., workload, workload efficiency, flexibility/control at work, work-life integration, meaning in work). At the same time, the leader looks at potential actions to influence those factors by the individual, leader, department/division or organization. Appreciative inquiry can be a strategy to cultivate joy in the workplace.

Conclusion

The approaches identified in this article are not inclusive of all potential strategies for change leadership. There is no shortage of obstacles when leading, guiding and nurturing change: addressing openness to new ideas; influencing others regarding the urgency of needed changes; developing strategies to overcome resistance; balancing the speed of changes so that they can be absorbed; understanding the conditions/variables needed for change, along with the challenges of initiating; redesigning processes and sustaining change efforts. All of these potential strategies and obstacles to effective change can be facilitated by also integrating coaching and mentoring of potential change agents, thus incorporating the wisdom of experienced leaders with those approaching these efforts for the first time. The approaches presented and examples of use cases provided will add to the arsenal healthcare leaders can utilize as they are challenged to influence change and achieve organizational objectives.

Notes:

1. Vaill PB. Spirited Leading and Learning: Process Wisdom for a New Age. San Francisco: Jossey-Bass Publisher, 1998.
2. Menaker R. “Leadership Strategies: Achieving Personal and Professional Success.” J Med Pract Manage. 2016;31(6):336-339.
3. France T, Matt-Hensrud N, Menaker R, Peters M. “Cultivating psychological safety: Activating humanness in healthcare.” MGMA Connection. 2020;20(3):40-46.
4. Kotter J. “Leading change: Why transformation efforts fail.” Harvard Business Review. 1995;May-June.
5. Bridges W. Managing Transitions: Making the Most of Change. 2nd ed. Boston: Da Capo Press, 2003.
6. Beckhard R, Harris RT. Organizational Transitions: Managing Complex Change. 2nd ed. Boston: Addison-Wesley, 1987.
7. de Caluwe L, Vermaak H. Learning to Change: A Guide for Organization Change Agents. Thousand Oaks, Calif.: Sage Publications, Inc., 2003.
8. Knoster T, Villa R, Thousand J. “A Framework for Thinking About Systems Change.” In: Villa R, Thousand J, editors. Restructuring for Caring and Effective Education: Piecing the Puzzle Together. Baltimore: Paul H. Brookes Publishing Co., 2000, 93-128.
9. Johnson B. Polarity Management: Identifying and Managing Unsolvable Problems. Amherst, Mass.: HRD Press, Inc., 2014.
10. Scholtes PR, Joiner BL, Streibel BJ. The Team Handbook. 3rd ed. Methuen, Mass.: GOAL/QPC, 2018.
11. Schein EH. Process Consultation Revisited: Building the Helping Relationship. Boston: Addison-Wesley Publishing Company, Inc., 1999.
12. Hiatt JM. ADKAR: A Model for Change in Business, Government, and our Community. Loveland, Colo.: Prosci Inc., 2006.
13. Institute for Healthcare Improvement. “SBAR Tool: Situation-Background-Assessment-Recommendation.” Available from: bit.ly/3hTW3sB.
14. Ibid.
15. Fry RE, Whitney D, Seiling JG, Barrett F (eds). Appreciative Inquiry and Organizational Transformation: Reports from the Field. Westport, Conn.: Quorum Books, 2002.
16. Garcia H, Miralles F. Ikigai: The Japanese Secret to a Long and Happy Life. New York: Penguin Books, 2017.