Keynote Presentation “Change Management & Processes in a Complex Care Environment”

CHANGE MANAGEMENT THE NEW LEADERSHIP

CHALLENGE

T Forcht Dagi MD, MPH, MBA, DMedSc

Harvard Medical School

Queen’s University Belfast

The Institute for Health Transformation CMIO Forum

Disclosures

Consultant to Masimo, Inc.

Investor in and Director of Aventura

Partner in HLM Venture Partners

This presentation is not intended to contain or convey any

commercial content

No compensation offered or received in conjunction with this presentation

Introduction Transformation

HCIT and HIMS From the Mountaintop

• Better medicine • Automation • Optimize patient care by optimizing

– Information archiving and retrieval – Clinical processes – Administrative tasks – Cause and effect (outcomes)

• Move from anecdotes to series • “The study of homogeneous populations allows one to

make statements with measurable and verifiable validity”

The State of HCIT in Medicine

• Past the point of questioning the place of HCIT • Questions about ultimate utility of all components • Familiarity with a PC does not translate into comfort with HCIT • A people issue, not a technical one.

– Most clinicians know remarkably little and want to be engaged – Resistance to change is deeply embedded in medical culture

• Distinguish between – Installation – Adoption

• Requires constant attention and engagement • The CMIO is changing

– Clinical leader – Part of institutional management

Near Term Issues

• Communications, training, workflow and assessments of utility

• Interface between technology, clinician, administration, nursing and other hospital staff

• Redefinition of certain roles requiring a different level of access to information – Nursing as care management

– Protocol based treatments

The CMIO Role

• Agent of change – New expertise – Roles as a physician, teacher, trainer and informaticist – Interlocutor and translator – Unique position in hospital and in medicine

• Hardware or software driven? – Early on, hard to say – When the mainframe was king, both – Now the question was irrelevant

• Important shift – Not hardware, not software – People

CMIO Role, Part II

• Traditionally, physicians positioned as clinical leaders, but administrative managers

• Because of the new role of information and informatics, this model is obsolete

• The CMIO must move from information management to information leadership

• Hence HCIT transformation involves learning – Whom to lead – What to lead – What results to lead towards – A systems approach to informatics – How to lead

Transformation of Healthcare

Transformation of Healthcare

• Over the next 10 years: – Episodic and non-episodic care will be differentiated and

separated from chronic disease management – Hospital and outpatient treatment and outcomes will be

integrated – Disease management and situation management will be

emphasized over symptom management – Better diagnosis and achievement of points of balance between

personalized treatment and population medicine

• Introduction of new processes • Broad acceptance of certain tools

– Data accumulation and verification – Prospective analytics

Transformational Context

• Diagnoses are likely to change

– What we think of as diseases may not actually be diseases

• Manage diseases, not just symptoms

• Predict and rationalize the outcomes of treatment

• HIM central to these initiatives

Change Issues in Healthcare

• External v internal mission

• Imposed v native strategies

• Political v operational goals and tactics

• Government mandates v professional ethics

• Primary v specialty care

• Definitions of “optimal care,” other quality measures

• Structures for healthcare delivery

• Uses of information

Short Term ONC Agenda

This Year’s Priorities Dr. Farzad Mostashari

• Meaningful use

• Interoperability

• Data exchange

• Consumer Health

National Coordinator for Health Information Technology

Address to the Health IT Policy Committee, January 10, 2012. http://govhealthit.com/news/mostashari-says-meaningful-use-will-soar-year

Meaningful Use

• “Meaningful use will soar.. [and] continue to be the cornerstone of our activities.”

• “We’re going to do everything we can to ensure that every provider can be successful at meaningful use.”

• In 2011, MU paid $2.5B in incentives, but the goal –

“success at meaningful use” - is articulated curiously.

• A target in many ways disconnected from the provision of care.

Interoperability and Exchange

• The “second and more complex challenge,” following meaningful use.

• The emphasis will be on containing the costs and reducing the risks and liability of exchanging health data.

• Information “will flow at the speed of trust.” Providers share

only with providers they know on a first-name basis.

• What does this actually mean?

Care Coordination

• In 2012, the business case for care coordination, which requires the exchange of healthcare information, will be driven by payment reform, at the federal, state and private level.

• “As we increase the value of data exchange and

reduce the cost, information will flow.”

• What information? From whom? Where to? To what end? How measured?

Consumer eHealth

• Consumer health IT is the third emphasis for the year.

• The government will look to find ways to encourage the uses of consumer eHealth, apart from EHRs.

• Is this a metaphor for consumer engagement or something else?

Quality Measurements

• Quality measurements are the fourth initiative slated for this year.

• “We will be moving forward on the next

generation of quality measurement, [and] we need the infrastructure for measuring quality, but also for improving quality.”

• The three elements of quality, definition, measurement and improvement, are connected but distinct.

Real and Stipulated Meaningful Use

Meaningful Use The CMIO’s Bête Noire

• “Real” or Natural language – Appropriate HCIT/EMR system – Installation, instruction, maintenance and support – Physical access – Comprehensiveness (nothing more needed) – Consistency (use everywhere) – Comprehensibility – Data entry/data retrieval – Integration with workflow – Relevance – Utilization

• Stipulated – Used as an external, possibly irrelevant metric of compliance (?) – The CMIO is at risk – Very poorly understood and to be fully flushed – Measureable use

CMIO Role Managers or Leaders

The Task of the CMIO has Evolved

• Change management

• Clinical leadership

• CMIO 2.0 – the place of the CMIO in clinical and administrative leadership structures

Managers

• Subordinates • Vested, externally derived authority • Transactional style • Like a happy ship. Avoid conflict • Seek comfort and stability, not change • Achievement oriented • Often very friendly • Avoid risk • Seek out causes of and reduce risk

Leaders

• Voluntary and inspired followers, not subordinates • Charismatic authority • Transformational style based on appeal and

communication. • Engagement leading to satisfaction and transformation • Happy with change • People focus – quiet style, accountability. • May be aloof, may be achievement oriented • Focus on accomplishment • Seek risk – natural to ecnouter conflict. • Respect rules, but break when needed

Operational Differences

Managerial Focus • Administration

• Copy, routine, replicate

• Status quo

• Systems and structure

• Control

• Short term perspective

• How and when; instructions

• Constraints (eg budgets)

• Imitation

• Status quo (low entropy)

• Good followers, including self

• Eliminate risk

• Efficiency

• Manage systems

Leadership Focus • Innovation

• Origination

• Development

• People

• Trust

• Longer range perspective

• What and why; understanding

• Accomplishment

• Origination

• Improvement and change

• Individualists and thinkers

• Manage risk

• Effectiveness

• Create systems

Measurement v Implentation

• Measure Process and (not or) Outcomes – Adoption – Utilization – Satisfaction

• Clinicians • Administration • Patients • Enterprise marketing

• Meaningful use is external, but not enough – Costs? – Error? – Tracking? – Quality? – Access to care

• Achieve consensus on what to measure and use this consensus as a means of engagement

• Become an expert and demonstrate your expertise through engagement • Become a diplomat: your allies are clinicians, not devices

Change Management

Change Management

• Structured approach to managing and coordinating change • IT

– Service component of organizational change effort – Target modifications in IT infrastructure and use – Intended to minimize impact on workers – Avoid distractions

• Includes – Implementation and optimization – Business justification – Transitioning individuals and teams

• A critical and continuous function – Changing demands on HCIT infrastructure – New systems – New modules – ICD 10

Change Management First Efforts

• 1980s – early discussion – Julien Phillips (McKinsey) publishes change management

model

– Michael Hammer, Reengineering the Corporations

– Consulting firms rebrand reengineering services as :change management”

• 1990s - top down change implementation fails – Linda Ackerman Anderson, Beyond Change Management

– 1994 “Change management industry” begins

– 1995 John P Kotter Leading Change

– 2002 John P Kotter The Heart of Change

Change is a Staged Process From Kotter and Others

• Create urgency and a timeline

• Create a guiding team

• Articulate vision and strategy

• Communicate and engage

• Empower action and remove impediments

• Stay objective

• Maintain and align both short term and long term objectives

• Create short term visible achievements

• Maintain momentum

• Reinforce value proposition and reward leaders

• Integrate change in culture

• Remind the organization over time of achievement and value

• This process is not unemotional

Types of Change

• Mission

• Strategy

• Operations

• Technology

• Attitudes and behavior

Change Management Simplified Traditional Model

• Top down

• Plan and direct

• Dictate, instruct, impose and enforce – remote leadership

• Rigid and granular

• Feeback at the end

• Moulding people

Change Management Simplified New Model

• More matrixed

• Consult and prepare

• Engage, communicate, interpret and enable

• Workshops?

• Think systematically, anticipate problems, allow for points of flexibility

• Feedback loops part of the process

• Negotiation with those affected

Successful Process Change Breeds Insecurity

• Process needs to address and overcome fear • Consultation • Defined steps with interim milestones • Optimize communication

– Why? – Explain rational and benefits – Timetable – Impact upon and involvement of personnel

• Upgrading skills across the organization • Personal discussions • Monitoring and revision if needed • Honesty and promise keeping

Simple Questions

• What do we want to achieve with change? • Who are the “we?” • So what and who cares? • Where are the misalignments? • Who is affected, how and how will they react? • How do we measure change? • What are interim/process milestones? • Is change the only measure of success? • How do we measure success? • What else needs to be discussed?

Upgrading Skills Training or Learning?

• Training – Measured by task competence – Improves skills – Unconcerned with engagement – Unconcerned with alignment of individuals

• Learning – Engages the individual – Measured by understanding as well as task competence – Curiosity and commitment, as well as skills – Results in individual development – Builds leadership and innovation

Methods I

• What elements of the organization’s mission and culture drive change

• Articulate aims when teaching skills

• Focus on consistency and integrity

• Consult and discuss with clinical and administrative leadership

• Identification with and pride in the organization is key

Methods II

• Involve – All clinical staff, not just physicians – All physicians, not just primary care – Administrators – The small people – Compensate them for their time

• Think of these as individuals, not just stakeholders and use as change emissaries

• Consider workshops • Anticipate problems • Establish feedback loops

The Importance of Face to Face Discussions

• Consultative communications

• Individualize the process of change

• Bestow relevance

• Placate fears

• Make champions

• Create emissaries and ambassadors

• Email, messaging, written communication is weak

Implications for CMIO

• Change process is creative, not mechanical

• Don’t sit in the office

• Don’t talk only to your staff

• Don’t talk only to technical personnel

• Wander the floors

• Become a roving help desk

• Sample the work flow

• Put yourself in the clinicians' shoes

• Develop a kitchen cabinet

• Elicit feedback often

• Provide transparency

• What can be fixed and what cannot

• Insist on dialogue with your IT vendors

Issues for the CMIO

• Position within hospital hierarchy

– CIO

– CMO

– C suite

– Allied medical personel

• Time management – need for clinical credibility?

• Support staff

Conclusion

• The time is right for the CMIO to lead • Convey

– Importance – Individuation – Relevance – Feasibility – Engagement – Communication – Translation – Satisfaction

• Invest in the position and train the next generation • The future of medicine depends on information

Thank You

EMRs Need to Advance

• EMRs are paper charts in electronic form with results

• Need to become tools for care management

• CMIO have reached the third level in the development of the profession

1st hardware and software

2nd compliance and stipulated meaningful use

3rd care management and true meaningful use

How Physicians Learn

• See one, do one, teach one

• Respected mentors

• Read and analyze papers anchored in patient encounters

• Follow guidelines, protocols and Washington Manuals

• Rounds

• Meetings

• Training – create a routine