Change Management


Out with the old – in with the new
– new disease pattern raises fears of human-to-human transmission
 

With several leading international hospitals being brought in to manage hospitals in the region, a number of issues typical of the change management process have arisen. Dr Abrar Khan, MD, MS, MPhil, FACS, looks at these issues and discusses how positive change can be implemented in the Middle East by foreign hospital systems.
 



The rapid economic and infrastructural development of many GCC countries has resulted in an increased population whose medical needs require attention. In response to the increasingly sophisticated health care needs, some GCC countries have decided to partially privatise their healthcare facilities. This era of privatisation has been ushered in by the arrival of well known medical entities – such as Johns Hopkins (US), Cleveland Clinic (US), InterHealth (Canada), to name a few – to manage various hospitals. The management of hospitals is in itself complex, but this move to privatisation has introduced another and rather interesting layer of complexity. Senior managers arriving from abroad to run these hospitals are faced with a different culture, a new attitude, and perhaps most importantly, rather large pockets of entrenched people and systems that stubbornly resist change.

In order to look at how positive change can be implemented by foreign hospitals in the Middle East, this article looks first at the basic principles of change management followed by their specific application to hospitals.

Humans instinctively resist change. Why? Because all change, whether negative or positive, usually involves some loss or uncertainty. People initiating change must study the whole environment carefully and systematically to determine who will resist change and why. People resist change for four reasons – parochial self interest, misunderstanding and lack of trust, different assessments, and low tolerance for change. Usually, most people display a combination of two of these.

Types of Resistance


Parochial Self-Interest: This is a very common cause of resistance to change and generally surfaces when a person or group believes that change will result in a loss of power, influence, money, or anything they hold dear. Such people have either no understanding of or completely ignore institutional interests and focus solely on their own. This resistance is manifested as “political” behaviour, which constitutes subterfuge, obfuscation, sabotage and other chicanery that will block change.

Misunderstanding and Lack of Trust: There are few, if any, organisations where there is complete trust between employees and managers. This inherent mistrust leads to misinterpretation of the underlying reasons for and implications of change. Thus, it is very important for managers to clearly state the reasons for change and the benefits that employees would get from such change.

Different Assessments:
It is pivotal that both employees and managers have access to the same information so that similar assessments can be made by both. In many cases, senior management does not release crucial information that clearly shows change is needed. It logically follows that employees will not see the need for change.

Low Tolerance for Change: This can be one of those paradoxical situations where the employee resists change even when it might be good for him/her. This behaviour is driven primarily by a personality which is inherently afraid of change. Usually such employees intellectually understand the need for change but are emotionally unable to weather it. For example, they may be afraid they will not be able to acquire the skills necessary to function in the job they might be promoted to or may be unwilling to give up old habits and relationships they feel good about.

Choosing strategies


The options available to implement change can be thought of as a continuum. At one end there is a clearly identified problem, an immediate need for change, and little need to involve many people in the decision process. This strategy requires that senior management have the ability, authority and charisma to implement such change. On the other end of the spectrum the change process is slow, the plan for change is not entirely clear, and input is needed from various parts of the institution (Figure 1).

There are, in general, four considerations that will determine how to implement change. First, the amount and kind of resistance that is anticipated: if a very large degree of resistance is predicted it may be more difficult to simply force it on the institution. In this case one needs to move to the right on the continuum. Second, the position of the initiator with respect to the resistors: if the change initiator has significant power in the institution then he/she can afford to move to the left of the continuum. Third, how many people have the relevant expertise to create a coherent plan for change: if the plan for change requires the expertise of many different parts of the organisation then moving to the right of the continuum is better. Fourth, the degree of peril the organisation is in: if only rapid action can save the organisation from perishing then one has to be on the extreme left of the continuum.

Once a decision has been made regarding how to implement change it should be executed in a manner consistent with that position. For example, moving slowly and yet involving very few people would clearly result in a dismal failure. Similarly, moving fast and trying to involve too many people could be equally perilous.

Common errors


True institutional change, especially in hospitals, takes time and such change generally requires a stepwise approach. Skipping steps gives the illusion of progress but in reality leads to eventual failure. The essential steps, and the consequences of omitting them, are reviewed briefly.




■ Error 1: Not establishing a sense of urgency: Whereas this sounds like a relatively straight forward initial step, fully 50% of the companies that fail to implement a successful change falter at this step. The seriousness of the problem and the need to address it immediately needs to be communicated to everyone.

■ Error 2:
Not accumulating a critical mass of supporters over time: Even though most changes start with one or two people in the organisation, there needs to be a steady accumulation of supporters to create a critical mass of people termed the “guiding coalition”. For example, in large companies this group of leaders needs to grow to about 20-50 people.

■ Error 3:
Lacking vision: The “guiding coalition” needs to formulate a clear and easyto- communicate picture of the future. This vision clarifies to all concerned where the organisation is headed and what the eventual goals are.

■ Error 4:
Not communicating the vision properly: There are three patterns here. First, a great vision is created, but is then communicated to the rest of the organisation through a single email. This does not work. Second, the communication of the vision is very thorough and pervasive, but the vision is poorly thought out and hard to understand. Third, both vision and communication are stellar, but some or several senior executives continue to behave in a manner contradictory to the vision. In the vernacular, senior management does not “walk the talk”.

■ Error 5:
Not removing obstacles to the new vision: Obstacles will appear in many forms but need to be removed. The problem could be in a person’s head (“I can’t do this”), but more often the obstacle is a person or a group of people. Sometimes the obstacle can be the organisational structure itself. Regardless, all obstacles need to be removed as expeditiously as possible.

■ Error 6:
Not planning for or creating short-term wins: Most people may sign up eagerly for change, but if they don’t see any visible changes in one or two years, they will abandon ship. Thus, it is important to create and plan for short-term wins.

■ Error 7:
Declaring success too soon: One or two short term wins do not make a successful transformation. Until the changes embed themselves into the psyche of the entire organisation, all short-term victories are susceptible to regression. In large institutions successful and permanent change can take 5-10 years.

■ Error 8:
Not anchoring change in the institution’s culture: Short-term wins should be celebrated, but not as “mission accomplished”. Unless these short term changes are anchored into the institution, they will regress and disappear. This requires a deliberate and persistent effort to put in place the next generation of leadership that personifies the essential elements of changes already made.

Application to hospitals


The healthcare sector is undergoing significant change in many GCC countries. Change management in hospitals in the GCC is a challenging arena and herein are provided some initial analyses and basic recommendations.

The work force in the Gulf region is extremely diverse. For example, in the United Arab Emirates (UAE) approximately 80-85% of the population is foreign. This diversity is reflected in the work force of most hospitals and anyone instituting change has to understand and interact with dozens of different ethnic groups, cultures, and their work ethics. Of course, variety and diversity generally makes for a stronger workforce, but nevertheless makes instituting change more challenging.

Since the majority of the work force is from abroad, it is by definition transitory. As such, this segment of the population will generally have little long-term commitment or motivation. That is not to say that they do not work hard and honestly. They certainly do. These employees will generally do what is required for the job, and generally do it well, but will not make any special or extra efforts. They may not engage in what is called organisational citizenship, where employees not only do their own work, but also help others in the organisation “above and beyond” what they do. Organisational citizenship is the one necessary behaviour that leads to highly functional, efficient and superb institutions. Additionally, and perhaps more importantly, these employees will not invest any extra time in activities that lead to improving processes or innovation – after all if they are not going to be present in the future why invest in it? These employees are generally motivated by personal agendas, usually but not always, economic. It is thus difficult to institute change when dealing with such parochial self-interest.

Of the four major reasons that lead to resistance to change, parochial self-interest is the most difficult, perhaps impossible, reason to overcome. The other reasons, misunderstanding and lack of trust, different assessments, and low tolerance to change can be dealt with in a systematic fashion as described above with reasonable chances of success. However, parochial self-interest, especially when originating from a fear of loss of prestige, power, or influence, is almost impossible to negotiate around. This is especially true when outside hospital systems, e.g. from the United States or Canada, come in and institute change. Most of the change is perceived by entrenched employees as a threat to their power, sphere of influence, and their way of doing things. Logic or exhortations appealing to reason are not effective as the respective goals of the entrenched employees and the hospital administration are diametrically opposed to each other. Swift identification of such employees, especially if they are leaders, is crucial and they need to be replaced all the way down to the divisional level within each department. This will contribute to rapid creation of the necessary “guiding coalition” described above.

Diversity

The other major issue facing hospitals in this region is also based on diversity of the work force. Wherever there are several ethnicities, there will always be formation of groups by ethnicity. This leads to groups engaging in activities that are directed at preserving power and influence for employees of their group without considering their abilities. This is detrimental at several levels: first, it undermines the fundamental advantage of diversity. Diversity, in theory, is desirable because you can harness the best and sharpest minds from different groups, bring their different perspectives together, and allow them to come up with innovative solutions to problems that face the hospital. However, if groups fight, undermine and sabotage each other to preserve the status quo based solely on ethnicity, not only does it undermine the basic advantage of diversity, but also engages everybody’s mind in activities that add no medical or economic value to the hospital. In fact, such behaviour destroys value as a large number of very intelligent people get ensnared in non-productive scheming and obfuscation. Consequently, patient care, the primary reason for a hospital’s existence, not only takes a back seat, but suffers. Usually, but not always, there is a predominant group of such employees in the hospital and this group needs to be rapidly identified and dealt with appropriately (see below for recommendations).

The new management of a hospital bears equal responsibility for resistance to change. Hospitals are generally full of intelligent, educated and clever people and they can judge very quickly whether the hospital administration is truly committed to instituting change for the good of the hospital, the city and the country, or is it only serving the parochial self interests of the foreign hospital system they work for. Health care in general, and health care in the US in particular, is not a very profitable industry and in the context of past, present, and predicted future economic woes, many foreign hospital systems see the GCC region as a cash-rich area, which can help them increase revenues. Clearly, if hospital personnel sense that there is no real intrinsic commitment on the part of the hospital system to institute long-lasting change, then there will be resistance to change and this will fall under the category of misunderstanding and lack of trust. Thus, it is pivotally important that senior administrators “walk the talk” so to speak. Any actions, statements, or behaviour on the part of senior management that can remotely be perceived as disingenuous can significantly affect the pace of change.

As far as patient care is concerned it is vitally important that change in these hospitals start both at the top and at the grass roots – that is at the level of patient care. Too often, new hospital administrations will get bogged down in all of the potential issues and battles discussed above, while the actual quality of patient care remains unchanged. It is crucial that actual processes that take care of patients, simple things like rounds in the morning, be looked at and improved right at the outset. This has a number of benefits. First, most of these processes do need improvement because they may be performed in the context of the employees’ parochial self interests as described above. For example, the major concern may be that the employees wish to finish rounds as fast as they can so they can go home, which is understandable but not acceptable when rounds are incomplete and patient care is suboptimal. Basic, very basic, issues need to be addressed, such as how to properly write orders for transferring patients (from one ward to the other) so that no crucial care delivery issues or medications are omitted. All too often, there are as many ways of writing transfer orders as there are physicians (again because of the diversity in the hospital) leading to missed medications, missed orders, multiple phone calls from nurses to physicians to clarify orders – all adding up to a significant waste of time. Second, paying attention to these seemingly minor details gives a very clear signal to the employees that hospital administration is very serious about changing and improving the actual delivery of health care. This helps minimise resistance to change based on misunderstanding and lack of trust.

Recommendations for hospitals


Instituting change across cultures and different levels of training is exceptionally challenging. Any change, no matter how well planned or finely executed, will have surprises and major hiccups during its course. However, these obstacles can be overcome. The following issues should be kept in mind when initiating change in hospitals in the GCC:

Establish a sense of urgency. This is the most important starting point. It will force administration to create channels of communication which can then be used liberally in subsequent phases of the change process. It will also begin to establish credibility. The vision for the next 3, 5 and 10 years should be communicated clearly at this time.

There will need to be a healthy mix of change strategy that employs the left and the right part of the strategy continuum (see figure 1) depending on which problem is being tackled (see below).

It should be established within 6 months (or sooner if possible) which departments, divisions, individuals, or groups of individuals will resist change. The reasons for resisting change should be clearly and rapidly indentified and all individuals whose reasons are parochial self interest should be replaced. This process will use mostly the left part of the strategy continuum.

It is important that replacements, if necessary, be made not only in senior management positions, but as far down the hierarchical chain as possible. This will require budgeting and resources which should be secured from the sponsoring government ahead of time. Changing or placing personnel as far down the hierarchy as possible may be slightly more costly up front, but will create an instantaneous “guiding coalition”. This will entail replacing resistors at least down to the individual division level within each department. This will save money and effort in the long run as change will be smoother, battles will be fewer and the “way we do things” will change faster. This will also address the issue of initiating change both from above and below, as discussed previously.

It is absolutely essential that all administrative personnel, especially senior administrative personnel, “walk the talk” at all times. Not doing so can lead to serious mistrust on the part of the employees and increased resistance to change.

It is important to plan for short-term wins, celebrate them and promote them, but not declare them as “mission accomplished”. Permanent change takes time.

Success, described as permanent change in the psyche of the institution, cannot be declared for at least 5-10 years – most likely closer to 10 years.

It is also important, once change is clearly and palpably underway, to start thinking about anchoring the changes – i.e. initiate searches or groom future leaders at all levels of the hospital so that the change (presumably useful and successful by now) can be perpetuated into the foreseeable future.

References

● Kotter, J.P. Leading change: why transformation efforts fail. Harvard Business Review. January 2007

● Kotter, J.P., Schlesinger, L.A. Choosing strategies for change. Harvard Business Review. July 2008

● Garvin, D.A., Roberto, M.A. Change through persuasion. Harvard Business Review. February 2005

● Heifetz, R.A., Linsky, M. Survival guide for leaders. Harvard Business Review. June 2002

● Cialdini, R.B. Harnessing the science of persuasion. Harvard Business Review. October 2001

● Herzlinger, R.E. Why innovation in health care is so hard. Harvard Business Review. May 2006,

● Moon, H. Organizational Citizenship. Organizational Behaviour course work – London Business School. 2008

■ Abrar Khan, MD, MS, MPhil, FACS is Senior Consultant and Director, Transplantation and Hepatobiliary Surgery at Sheikh Khalifa Medical City-Cleveland Clinic Foundation (SKMC), Abu Dhabi. He is a multiorgan Transplant Surgeon and Immunologist and has successfully started, from the ground up, two multi-organ transplantation programmes – one in the United States and one in Abu Dhabi. He is the author of many clinical and basic immunology papers, and has been educated, trained and employed variously at University of California - Berkeley, McGill University, University of California - San Francisco, Harvard Medical School, Yale University - Graduate School of Immunobiology, University of Pittsburgh - Starzl Transplantation Institute, University of Vermont - School of Medicine, and Columbia University (NY). He came from the USA to Abu Dhabi in October 2007 to help start the Transplantation Programme at SKMC.



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ate of upload: 16th May 2009

                                  
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