How to Enact Change Dissertation Defense

Leadership Action

Required to Enact

Change

By:

Barbara Julian Garner

July 12, 2013

Barbara Julian Garner 1

Nature and Background of Issues

• Chapter 1:



• Introduction

– Interest in topic

– Definition of terms

• Nature of the Issue:

– Many changes being implemented at Preston Memorial for

all employees

– Non-Clinical employees were being asked to interact with

patients within the clinical setting



• Internal Stakeholders: – Non-Clinical employees

– Clinical employees

– Hospital leadership

– Staff physicians

• External Stakeholders – Patients

– Patients’ family members

– Community at large

– Accrediting Boards

• The Joint Commission

• Medicare



• Issue Background & Context: Examination of the

Beginning of a Cultural Change

– Patient-Centered Care Model

– Six Pillars of Excellence & the No Pass Zone (Studer 2003)


Pupose of the Study

– Identify challenges to hospital leadership during a

change process at Preston Memorial Hospital


Research Questions

1. If there were leadership challenges in executing

this cultural change, especially in regards to non-

clinical employees, what were they and why did

these challenges arise?

2. If there were issues with the implementation of

this cultural change, especially in regards to non-

clinical employees, what were the leader lessons

learned?


Literature Review

• Chapter 2:


Literature Review

• Chapter 2:

• Leadership Role in Change Management

– Kotter (2007)

– Hiatt (2006)

– Luecke (2003)

– Randall (2004)

• Leadership & Employees Shared Role: Teaming

– Edmondson (2012)

– Ul-Bien & Ospina (2012)


Literature Review

• Chapter 2:

• Preparation for Change: Dudink & Berge (2006)

Duncan, R.D. (2012)

Hiatt, J.M. (2012)

Kotter, J. (2012)

• Importance of Teamwork Edmondson, A. (2012)

• Engagement of Employees Galunic & Hermreck (2012)

• Barriers to Change Shaller (2007)


Methodology

• Chapter 3:


Research Desgin


Embedded Case Analysis 1

• Non-Clinical Employees


• Clinical Employees


• Hospital Leadership

Context of Single Case: The Change Process Related to

Implementing a Patient-Centered Care Model

Research Design: Single Case Embedded Design (Based on Yin 2009)

The Three Embedded Areas of Analysis Reviewed for the Change Process

Single Case Study with Embedded Design

• Case Study: – Allowed the use of varied methods and dives into people’s behaviors

– The interest in the process—How things work and why

– Provided understanding of a program or event of an organization

– Provided understanding to a complex issue

– Added breadth and depth to data collection and assisted in bringing data

together from multiple sources (Yin, 2009)

• Embedded Design: – Allowed for the investigation into non-clinical, clinical, and leadership

employees in the changes related to implementing a patient-centered care

model


Method

• Explanatory Mixed Method

– Quantitative/Qualitative

• Surveys: Quantitative

• Open ended interviews: Qualitative

• In what ways do the qualitative data help explain the

quantitative method?


Validity & Reliability

The following procedure was recommended by Creswell (2009)

– 3 peers reviewed inputted data for accuracy

– 2 doctorally prepared professionals were consulted to

expand or deny themes

– Validity was achieved by sending the interviews back to the

interviewees for verification

– Average length of the interviews were 45 minutes


Data Collection

• Surveys were distributed by the Community Development Director

• Surveys returned in sealed envelopes without any personal

identification. Colored coded for either Non-Clinical, Clinical, or

Leadership

• Interviews were conducted in the researcher’s office

• All questions were answered and interviewees were at ease

• Consent form was explained to and signed by participants

• Audiotaped

• Transcribed

• Transcripts verified by participant

• Themes analysis verified by 3 other reseachers


Data Processing & Analysis

– Survey data were calculated and bar graphs were used to present data

– Data were used to provide focus for interviews

– Individual verified transcript was read

– In the analysis themes were identified

– Themes were then re-examined for patterns common to all 3 groups


Data Processing & Analysis

• Rigor

• Ethics

• Limitations

• Delimitations


Results

• Chapter 4:


Survey Distribution & Returns

• Total Surveys Distributed

– 105 Non-Clinical Surveys

– 141 Clinical Surveys

– 6 Leadership Surveys

• Total Surveys Returned

– 49 Non-Clinical Surveys

– 60 Clinical Surveys

– 3 Leadership Surveys

• A Likert Scale was used for each question with room for

comments at the end of the survey


Survey Analysis

• Survey Analysis

– A simple percentage was used

– If a 50% or higher of respondents disagreed or strongly disagreed with

the question, that topic was expanded on in the interview questions.

– Each group’s survey contained a comment section

• Some survey questions did not add to the understanding of the

issues and were not used in the interviews. These can be found

in Appendix F

• The data collected were used to answer research questions


Survey Results


86%

91%

75%

80%

85%

90%

95%

100%

Non-Clinical Clinical

Percen

tag

e

N=109 Respondents Agree or Strongly Agree

I Understand the Need for the Six Pillars of Excellence

Survey Results


82%

0

10

20

30

40

50

60

70

80

90

Pe

rce

nta

ge

N=49 Non-Clinical Agree or Strongly Agree

I Support the No Pass Zone

Survey Results


68%

100%

0%

20%

40%

60%

80%

100%

120%

Non-Clinical Staff Leadership

PE

RC

EN

TA

GE

N=52 RESPONSES OF DISAGREE & STRONGLY DISAGREE

Non-Clinical Employees Feel Comfortable Entering a

Patient's Room

Survey Results


Survey Comments

• Constant Positive Themes

– PMH Employees supported the changes that were implemented

– PMH Employees understood the changes

• Constant Negative Themes

– Preparing employees for the changes

– Addressing the fear of employees with the changes


Interview Information

• Interviews were voluntary and offered to all employees

• Interview Participants:

– 6 Non-Clinical Employees

– 5 Clinical Employees

– 3 Leadership


Research Questions & Discoveries

1. Part A: If there were leadership challenges in executing

this cultural change, especially in regards to non-clinical

employees, what were they?

– Preparation for changes

– Feeling a part of the change

– Lack of engagement

– Communication about the changes

– Fear of the unknown


Common Themes


Preparation for the Changes -

13

Inclusiveness in the Change

Process 12

Explanation for the Lack of Engagement - 11

Communication on changes being implemented - 10

Fear of the Unknown - 9

0 2 4 6 8 10 12 14

1

Coded Interviews - Common Themes

Other Issues


Employee/Patient Safety 2

Patient Acceptance and

Training - 2

Improved Employee

Identification 1

0 0.5 1 1.5 2 2.5

Coded Interviews - Other Issues

Employee Identification Patient Acceptance Patient Safety

Interview Findings

• Fear of the Unknown:

NC1 explored the idea that the fear for the non-clinical employee was how that

patient feels about a non-clinical employee coming into his/her room: NC1

imagined wondering “What are you [non-clinical employee] doing in my room

if you can’t help me and why are you in my room?”

C5 stated: “It is kind of the fear of the unknown…I think that the non-clinical

staff does have some issues with the No Pass Zone because they don’t know

and they are scared.”


Interview Findings

• Communication About The Changes:

NC6 explained the idea of a breakdown in communication as follows: “There

was not only a breakdown in communication between leadership and non-

clinical employees, but there was also a breakdown in communication within

the leadership team. The leadership team was not on the same page and there

was a conflict between them on how all the changes were presented… I was in

the room when this was all presented and you could feel the tension in the

room… There is a communication breakdown that we continue to have

problems with. It is the expectations of people, and again I have said since the

day I got here; the expectations for clinical and non-clinical need to be clearly

defined and they are not. They are blurred and merged.”


Interview Findings

Avoidance of the No Pass Zone:

11 of the 14 interviewees admitted to avoiding the patient care

area so as not to engage in the process.


Interview Findings

• Lack of Inclusiveness:

NC3 stated: “I haven’t really been invited to give input or anything. That [being

asked] would be nice. ”

C4 stated: “I feel there is a separation of how much clinical and non-clinical employees

have been involved. Clinical, especially nursing, have been involved more than non-

clinical, and that is what I mean by a separation. ”


Interview Findings

• Preparedness

NC3 stated: “It is intimidating if you are non-clinical because you don’t know what to

do… I wouldn’t know where to go to look for a nurse… Are they at the nurse’s

station?”

C1explained that clinical employees who are not on the patient care floor also need

training: “We could have done a better job preparing our people. I couldn’t tell you

where the call light is…I know how to do a certain procedure, but I just don’t know

how to get in and out of the room.”

HL1 felt more training needed to be done with both clinical and non-clinical

employees: “I think they [all employees] know bits and pieces, but I am not sure they

know how to put it all together. They can regurgitate the information but they can’t

connect the dots. I think both clinical and non-clinical employees need more training

on all the changes we are asking them to make.”


Research Questions & Discoveries

1. Part B: Why did these challenges arise?

- Failure to communicate the changes being implemented

- Lack of preparation of employees for the changes

HL3 commented on the survey: “I don’t think we did a very good job with many

things in [with] the No Pass Zone…We did not explain the importance of non-clinical

staff in answering a patient call light…We did not prepare or train them[non-clinical

employees] on what to do. We just told them what to do and to do it.”

Although leadership realized they did not communicate or prepare the non-clinical

employees they did not identify a reason why.


Research Question & Discoveries

2. If there were issues with the implementation of this cultural change

especially in regards to non-clinical employees, what were the lessons

learned?

- Lack of preparedness of the employees for the changes

- Inclusivity of employees in the change process

- Communication of the change process

- Better framing of the Six Pillars of Excellence as an over arching theme

NC 32: “ There should be more information given to non-clinical employees about

A-I-D-E-T and the 6 Pillars [of Excellence].” From Survey

C15: “I feel that managers need to review A-I-D-E-T with employees and potentially

do some role playing to help non-clinical employees feel comfortable using it.”

NC4: “Maybe we could have been given examples or scenarios that would have helped

us to understand what we need to do.”


Conclusions & Recommendations

• Chapter 5:


Results & Findings Summary

• Non-clinical employees supported the No Pass Zone in

theory but not practice.

• Non-clinical and clinical employees understood the need

for the Six Pillars of Excellence.

• Non-clinical employees did not feel prepared for the No

Pass Zone.

• Non-clinical employees stated they were afraid to enter a

patient’s room.

• Non-clinical employees felt a lack of inclusiveness with the

changes.


Recommendations for PMH Leadership

• Overall Plan for PMH for Future Change

– Understand the rationale for preparedness of those involved in a

change process

– Create a clear vision and common direction

– Provide the preparedness needed for employees to make the change

– Communicate the change and involve people in the process

– Assign or hire a change agent to oversee any profound change projects

• Example New Hospital Building Project


Leadership Actions Arose During this Study

– Implementation of a pilot hospital wide shadowing program.

– Internal electronic employee engagement survey distributed to all PMH

employees on the changes being asked of them. Survey data is still

being gathered.

– Hospital leadership have started to visit NEO to explain the 6 Pillars of

Excellence.

– A LEAN Project is being developed for identification of infectious

rooms: This training will be for all employees. This researcher has

been asked to be a member of the LEAN Project Team.


Recommendations for Future Studies

– Do patients want non-clinical employees coming into their

rooms?

– When you ask non-clinical employees to interact with

patients in a clinical care setting how does this impact

employee and patient safety?

– Will patient satisfaction scores improve or decline due to

non-clinical patient interaction in a clinical care setting?


Contribution to the Theory & Practice of Leadership

The 7 Elements of Organizational Change


Based on Randall 2004, p.38

Analyze the Organization & Its Need for Change

Create A Shared Vision and Common Direction

Create A Sense of Urgency

Support a Strong Leader Role

Craft an Implementation Plan

Communicate and Involve People

Reinforce & Institutionalize Change


– Organizational side of change

– Kotter’s Eight Stage Change Model 2002

• Establish a sense of urgency: Inspire people to move

• Build the guiding team

• Get the vision right

• Communicate for buy in

• Empower action

• Create short term wins

• Don’t let up

• Make the change stick

– Prepare employees for the change

– Communicate and involve people

– Create a shared vision and common cirection



– The People Side of Change

• It is people who change not organizations

• Successful change occurs when the individual’s change matches the stages of

organizational change (Hiatt 2006)

– The Fear Involved with Change

• Fear of not having the ability to make the change

• Fear that the change will fail

• Fear that the change is inconsistent with his or her values

• Fear that the risks of change outweigh the benefits

• Fear that the change is going to make their jobs more difficult

• Fear that those who are responsible for the change can’t be trusted (Kotter 2002)


Self Evaluation: A Tool for Future Research

– Being an employee in the organization was a plus and a minus.

– I wish I would have drilled down on some questions. Example: When

leadership failed to give reasons for their admitted failure to

communicate, I wish I would have asked why.

– The importance of asking for recommendations on surveys and in

interviews.

– Employees felt comfortable and safe for interviews. Had minimal

issues with obtaining volunteers.

– Had to constantly remind self not to lead the interviewees and at times

got off track and was too chatty.


Acknowledgements

My Committee:

Dr. John Barnette

Dr. John Sidor

Dr. Ruth Panepinto

Dr. Kathleen Jackson

DEL Cohort WV01

– David -Bill

– Kathleen -Kimberly

– Stephanie -Dena

Dedicated to my parents:

John & Rose Abruzzino Julian


Questions & Comments


How to Enact Change Dissertation Defense

Education