DOMENICO di Bartolo’s 1440 painting titled “Cura degli infermi”, or patient care, is said to portray the earliest depiction of a medical ward round. In the painting, a surgeon is examining a patient’s wound while an entourage gathers around him, either observing or in deep discussion.
If we somehow transported this surgeon 600 years forward in time to the present, and inserted him into one of our current hospitals, that surgeon may feel entirely out of place among the computers, fancy equipment and modern technologies that exist today. But the moment that surgeon from the Middle Ages happens to come across a medical ward round, I would suggest that he would feel instantly at home – the round led by a consultant doctor followed by a string of junior clinicians has not significantly changed in over half a millennium, and that testifies to the entrenched cultures existing in our health system that make them resistant to change.
All of us are aware of the wicked problems that exist in health that seem impermeable to change. Our complex health funding models, the gap that exists between Indigenous and non-Indigenous health, the lack of integration of primary and tertiary care in this country – these are but a few examples of a long list of problems that we face, where solutions may seem obvious, but meaningful change always seems unreachable.
One reason for this is that the health system is a complex adaptive system – a system in which a perfect understanding of the individual parts does not automatically convey a perfect understanding of the whole system’s behaviour. The health system exists in a homeostatic state, and it will always attempt to revert back to the status quo in order to remain stable, because of the many components of the system that constantly exert forces to remain in their relative positions. Doctors who deal with biological systems are well aware of the self-healing nature of the human body – this is no different in complex adaptive systems, in particular one as complicated as our health system.
So how do we, as medical practitioners, implement and lead divergent, innovative change within our organisations?
When constructing a new piece of flat-packed furniture, it is very tempting, at least for me, to ignore the written instructions, skip the first few steps, and start the construction by trying to work backwards from the final drawings. However, I have learned the hard way that this is a sure-fire method to failure, ending with leftover screws and parts, and a complete deconstruction and redo.
In the same way, change management requires that the right steps be taken in the right sequence in order to maximise success and reduce the chances of having to start the change process all over again.
A well known change management model is John Kotter’s Eight steps to successful change. I use this as a framework to describe the steps required, not only because it is one of the most popular models used and cited, but it is also the most granular, breaking down the stages of a change process into distinct actions that must be carried out in the correct order.
The first step is to “establish a sense of urgency”. We know that people have a true sense of urgency only when they believe that action is required now, and not later when it fits easily into their schedule. In fact, there is nothing quite like a crisis to engender a sense of urgency, and we can all agree that the health system does seem to be constantly in a state of crisis, whether it is due to funding issues, increasing pressure on acute service, or workforce shortages.
In health, and in particular in public health, the challenge for change leaders is to remind people that we may already be in the middle of crisis. Just like the proverbial frog in a slowly boiling pot, “crisis fatigue” may mean that people are so used to being in crisis that a state of urgency loses all meaning.
Having a sense of urgency does not necessarily mean acting in haste, or in a rushed panic. As Bob Proctor once said, “Everyone should have a sense of urgency – it is getting a lot done in a short period of time in a calm confident manner”. You need to progress calmly, and surely, into the next change step.
The second step is to “form a powerful guiding coalition”. For change to be successful, you need to identify the change champions and innovators, those who will be the early adopters and support the change, in order to create “a coalition of the willing” who can help you lead the change forward. At the same time, it is incumbent on you to also identify the stakeholders who may doubt, as well as the potential opposition. It is at this point that three specific analytical methodologies can come in helpful.
- First, a formal stakeholder analysis can be undertaken, using Mendelow’s power–interest grid, and classifying stakeholders into four types. Stakeholders with low interest and low power need to be monitored. Those with high interest, but low power, need to be kept informed. The ones who have high power, but low interest, need to be kept satisfied. The stakeholders with high interest and high power need to be encouraged and actively influenced during the change process.
- Second, perform a relationship analysis. Again, there are four categories – competition, when both entities are in direct competition for the same resources, and this creates a potential lose-lose or lose-win situation in a zero-sum situation; coexistence, when both entities are not in competition and can coexist independently; coopetition, a new word I recently learned, is when competitors can still cooperate to mutual benefit; cooperation, with a win-win outcome for all concerned and resources and efforts are shared. The idea here is to identify those in competition with you and move them to the other states.
- Third, we can frame our audience and stakeholders according to the Rogers’ adoption–innovation curve. Some of the people you will be dealing with during a change process will be “innovators”, who form 2.5% of the population. These are the people you can bring on-board to form your guiding coalition, and are the natural change champions. About 13.5% are “early adopters” and will be the initial part of the masses to accept and implement the change. The bulk of the bell curve can then be divided into 34% of the “early majority”, and 34% making up the “late majority”. At the tail end of the curve, we then have the “laggards”, who form 16% of the rest. Spend most of your time consulting, engaging and guiding the innovators, early adopters and early majority, and don’t waste too much effort on the laggards. But, If the laggards happen to be individuals who also have high power and interest according to your stakeholder analysis, you may need to come up with strategies to neutralise their influence so that they don’t derail the change process.
The third of the eight steps to successful change is to “develop a clear shared vision”. It is not sufficient to just develop a vision – it has to be clear and easy to understand. A vision statement is something that people should be able to visualise clearly and imagine as a future state.
The fourth step is to then “communicate the vision”. A vision is useless unless it is shared and accepted by the rest of the organisation through strong communication. As Simon Sinek has said: “Great leaders must have two things: a vision of the world that does not yet exist and the ability to communicate that vision clearly”.
The fifth step is to “empower people to act on the vision”. A clear vision needs to be supported by a strong strategy, but ultimately, every strategic plan requires the power of the people to achieve its goals. There are four ways to effectively communicate your vision: define the problem, propose the solution, use an engaging story, and end with a call to action for the audience – this puts the burden of responsibility back on the people who need to implement the change and gives them the authority to do so.
The sixth step is to “plan for and create short term wins”. Remind people that the first few steps have been successful, and there is more success on its way. To do this you have to create obtainable targets. Break up any change into stages – have an initial trial or pilot stage and ensure that this is carried out in an area where the chances of success are high. Then, encourage and convince people that these targets can be reached. Last, and most important, recognise and reward the “winners” and communicate the wins to the rest of the organisation. These early successes, usually with the early adopters, will create the optimism, momentum and movement necessary for the early majority to come on board.
The penultimate step is to “consolidate and build on the gains”. Continue celebrating success. Communicate the short term wins and address all the low hanging fruit so that the people on the ground can see that things are changing for the better. At this stage of the change management process, resist the temptation to declare that the war has been won. Change is fragile, and the resistance to change and the unconscious desire to regress to the previous status quo remains. Celebrate the won battles but remind the troops that the war is still ongoing, and you still need all hands on deck. At this stage, the intensity to push the change forward should increase. Do this with the help of your guiding coalition. Ensure that your initial vision remains compelling, and that everyone continues to keep their eyes on the goal.
The final step in Kotter’s change model is to “institutionalise the change”. Once the change has been implemented, the work does not stop there. For change to be sustainable, it needs to be embedded into the culture of the team or organisation being changed. For that to happen, we need strong and effective leadership overseeing the process, new policies, procedures and guidelines that outline the new process in place, appropriate training and credentialling of staff so they understand what they need to do; a robust monitoring and audit system to ensure that there is compliance with the new policies and processes; and appropriate rewards for compliance, with non-compliance dealt with in a fair and just manner.
At this point, I want to share with you two models that may be useful in helping us understand the potential reactions that we may get from the people we are trying to change. Clinicians like us are familiar with the Kübler-Ross model of the five stages of grief. The change curve is based on this grief model. The curve itself has the approximate shape of a capital letter N, that shows that there is an initial peak of motivation with any change over time which leads to a low before it finally picks up. With any change, people go through an initial period of denial, which leads to realisation, shock and confusion, and which later transitions to resistance, anger, blame and defensiveness. This leads to a dip in performance and a period of depression, before there is a letting go of resistance, a period of searching, anxiety, uncertainty, fear and frustration as people deal with the new processes, before an evolution into a subsequent understanding of the change, optimism and new ideas. Over time, if things go right, there is acceptance of the change, commitment, enthusiasm and, finally, trust.
There is a difference between change management and change leadership.
Change management deals with the operational side of change – as the change manager, ensure that stakeholders buy into the change, that the change process stays under control and follows the change plan, and that the overall project keeps on budget.
Change leadership, however, refers to the strategic and governance side of change. The change leader needs to articulate a clear, compelling vision of the future, mobilise the resources needed to make the change, and is responsible for the governance and oversight of the whole change process, acting as a catalyst for change.
As clinicians, we need to have the skills to both manage and lead change.
As Gandhi said: “Be the change you wish to see in the world”. As doctors working on the front line, you know what changes are required to ensure the best care is provided to our patients. Have the courage to step up, be the change agent, and lead the change.
Professor Erwin Loh is chief medical officer at Monash Health, and clinical professor at Monash University.
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