Change, whether it is personal or corporate, is constant in today’s world. It is as much a reality as death and taxes. To survive, therefore, you must anticipate change and be ready to deal with it. If you don’t, the results can be disastrous.
Here’s an example: Put a frog in boiling water and it will immediately jump out. But put it in cold water and gradually bring the water to a boil and it will stay there until it dies. And so it will be if you ignore or do not react to changes in the environment. By the time you wake up, you are boiled.
I know that there is no need to scare the reader about the changes afoot but let’s look at a few recent changes to your healthcare world:
Pay-for-performance or value-based payments
Reduction in reimbursement for services provided regardless of model
Implementation of the electronic medical record and meaningful use and clinical integration
HIPAA
Hackers
Accountable Care Organizations, hospitals buying practices, mergers
Narrow networks and ultra narrow networks
Physicians retiring or giving up
Growth in the role of mid-level providers
Increasing expenses
Big data
Evidence-based care plans taking away some autonomy
Add your own experience to this list …
CHANGE THEORY
Kurt Lewin(1) developed his theory of force field analysis in the 1940s and I believe that it has a great deal of relevance for the healthcare practice today.
According to Lewin’s theory, organizations have equilibrium that is held in place by “driving” forces and “restraining” forces. Change is a driving force, but because there is always a resistance to change, there is also a counterbalancing restraining force. If equilibrium is maintained, there will be no change and the organization will continue as it always has.
However, in today’s healthcare environment, there is constant change, which makes it essential to deal with the two forces. Lewin argues that it is easier to implement change in an organization by dealing with the restraining factors, either by eliminating them or reducing their influence.(2)
Lewin points out that, in any organization, there are individuals and groups. We will look at each of these in greater detail shortly. Lewin’s main point, however, is to suggest that the interaction among the members of a group, or the group dynamic, must be understood before any change can be successful.(1)
We define a group as two or more people who are interdependent and who rely upon one another for their existence. A dynamic, Lewin finds, refers to the various forces that operate within the group itself. Because individual members are under constant pressure from the group, focusing the change process on individuals will not lead to success.
It is essential to understand the dynamics within the group before we can implement change. But there also must be a process in place to do so.
Lewin suggests that any change should be looked at as a three-stage process. The first stage is unfreezing. This is where the need for and the motivation for change are identified. We can call it the “why” and “when” of change. In this stage, old ideas and ways of doing things are cast aside as not as effective and new ideas are adopted.
The second stage is the change itself, which involves learning, the key to all of Lewin’s work. There is new information to be absorbed, new behavior models, new thinking, and new procedures by members of the group.
The last stage, refreezing, is the stage where everything that is learned becomes the new norm and the overall culture of the organization has changed to the new way of doing things.
Lewin made another key contribution that I want to highlight here. His study proposes that a person is influenced by the force field, which is the psychological environment that exists in the individual or in the group, whether it is negative or positive. The person’s actions are more likely to lead to success if the field is positive. Further, this success is more likely to occur if the person participates in the process of decision-making and change.
The term “change” scares many and is not one that is readily accepted. For years we heard that two things were certain in life: death and taxes. So rather than using the word or concept of change, you may want to substitute “transition” to your practice vocabulary.
William Bridges, in his book Transitions, offers us another three-step process which may be more acceptable to your culture.(3) His terms are ending, neutral zone, and beginning. The old way must end before the new beginning occurs. These are easy to understand and accept, with each requiring a certain amount of work. The big stage, though, is the neutral zone, which is the time of transition.
WHY AND WHAT OF CHANGE?
Your practice must constantly deal with change if it is to survive and thrive. There are external factors such as government legislation and administrative rules and regulations that have shrunk income streams from Medicare and other payers.
New technology and other government regulations have led to the growth of electronic health records. Pressures to develop programs to improve quality and performance require new monitoring procedures and new processes for providing service. Informed patients are bringing their internet-based diagnoses to the physician’s office when they come in.
All of these issues require change. You may need to look at things like electronic health records, for instance, or at compliance with healthcare protocols; additional services to be provided, either by new staff and equipment in the office or by an external vendor and provided in the office; improved purchasing procedures; and new computer hardware to support the necessary software.
Changes in your practice can be adaptive or basic, such as changing the way patients sign in when they arrive for the visit. This process may have been done the same way for years, but hackers now require us to look at our information system very differently than we did just a short time ago. HIPAA now requires more confidentiality and protection of patients’ rights. Therefore, we must change.
An innovative change could be the addition of a CAT-scan suite, which would mean changes related to employees, billing, purchasing, forms, reporting, and so forth. A radically innovative change might be one where the practice goes from a single-specialty model to a multispecialty model. This could be adding radiation therapy to a medical oncology practice or closing the single-specialty practice and joining a large group. All the changes on this continuum are designed to achieve the vision of the practice.(4)
Any change you implement has costs associated with it. With an adaptive change, the only expense may be the cost of printing new forms. An innovative change may require significant capital costs, as well as indirect costs such as general inconvenience, work disruption, and a learning phase for everyone from the receptionist to the doctor.
Obviously a radical change would be even more significant in terms of costs, which again can be the direct expense of the change, as well as the hidden costs of managing the change.
RESISTANCE TO CHANGE
We can define resistance as anything that might discredit, delay, or prevent a change from being implemented. Resistance can be found in individual and group behaviors and both must be understood by the person in charge of implementing the change, who is often called the change facilitator.
The facilitator must be aware of any overt efforts to resist, which are easily spotted. It’s the covert efforts to resist that are harder to identify and require a deeper understanding of human behavior and motivation.
Abraham Maslow’s theory on the hierarchy of needs suggested that individuals have various needs at various times in their lives and that these needs affect their behavior and motivation. It is the lower end of Maslow’s hierarchy that has the greatest impact on the success of any change effort. A person’s physiological need for safety and security and the psychological need to belong have an impact on his or her reaction to and involvement with the change process.(5)
An employee who is threatened by the idea or process of change will have many concerns. Will I keep my job? Will I have to drive to a different office? Will I have to work with that other employee I can’t stand? Will I have to learn new things? Will I have to leave the security of my group?
These and many other issues have an effect on how an employee will respond to any proposed change. Here is where you can revisit the concept of change.
The employee can play any one of several roles as he or she responds to the proposed change. Here are a few examples:
Aggressor — deflates the status of others, voices disapproval of actions of others, attacks, jokes aggressively, and shows envy.
Blocker — negative and stubborn, disagrees with others, wants to bring back the old way of doing things.
Recognition seeker — does anything possible to call attention to himself or herself through actions or words; does not want to be placed in an inferior position.
Dominator — makes every attempt to assert authority through flattery, seeking attention, interrupting others, and seeking to manipulate superiority.
Help seeker — seeks sympathy from others, is insecure and may be confused.
If we go back to Lewin’s theories, we can see that it is not as important to fix the individual as it is to understand the individual’s actions and how they affect the group. An effective change facilitator takes time not only to work with the individual, but also to use the group’s standards, which can limit negative actions. In extreme cases, the group may decide to exclude these employees from further involvement.
Not all reactions to change are negative. There are, for example, people who see their role as task oriented:
Information seeker — asks for clarification of facts, rationale, or activity.
Opinion giver — states what he or she believes to be the case, makes points of clarification.
Coordinator — tries to pull ideas and suggestions together.
Or socially oriented:
Encourager — praises, agrees with, and accepts contributions of others for the good of the group.
Harmonizer — mediates.
Compromiser — attempts to solve conflicts; may yield status, admit to an error, or compromise to reach a solution.
In any healthcare practice there is a need to deal with the role of the doctor in the overall picture, especially when facilitating change. The doctor is typically an owner of the practice and obviously has a vested interest in the practice as a whole and anything that might affect how well it is doing.
When it comes to change, the doctor may make a decision arbitrarily and authoritatively enforce the change. If the doctor is part of a group, he or she may either fully support or fully oppose the change, or may tacitly support the change and then oppose it when it comes time for action.
This little story shows that you need to be aware of the impact of a decision and to be flexible and not myopic when it comes time to implementing change:(6)
One night at sea, a ship’s captain saw what he thought were the lights of another ship heading toward him. He had his signalman blink to the other ship, “Change your course 10 degrees south.” The reply came back, “Change your course 10 degrees north.”
The ship’s captain answered, “I am a captain. Change your course south.”
Another reply came back, “Well, I’m a seaman first class. Change your course north.”
The captain was mad now. “Dammit, I said change your course south. I’m on a battleship.”
To which the reply came back, “And I say change your course north. I’m in a lighthouse.”
CHANGE MANAGER OR LEADER?
A manager sees to it that things are done right. A leader sees to it that the right things are done. Where do you fit in?
Change requires both management and leadership but the most important role for the facilitator is leadership. In today’s busy practice, this may be the single most important role that a practice manager plays. In fact, being a leader on all the change projects that may be undertaken can almost be a full-time job.
As a leader, you must be courageous. You must establish realistic goals for yourself. You must be willing to take risks. You need to see both the best- and worst-case scenarios that can be expected. You also need to understand that you may fail and that you can’t allow fear of failure to control your efforts. As Sam Walton once said about an idea that didn’t work, “Well, we got that dumb idea out of the way! What’s next?” A great philosophy!
The key lesson here is to understand the process. It is OK to both manage and lead, but it is your role as leader and facilitator of the change process that will make it successful. Lead the process, don’t do the process, and the change will happen. By leading, you develop your staff and yourself, which lets you manage future change more effectively.
Excerpted from Think Business! Medical Practice Quality, Efficiency, Profits, 2nd edition by Owen J. Dahl, MBA, LFACHE, CHBC.
References
Burnes B. Kurt Lewin and the Planned Approach to Change: A Reappraisal. Journal of Management Studies. 2004;41(6):977– 1002.
Garside P. Organisational Context for Quality: Lessons from the Fields of Organisational Development and Change Management. Quality Health Care. 1998;7(Suppl):S8–S15.
Bridges W. Transitions: Making Sense of Life’s Changes. New York: Lifelong Books. 2019.
Kreitner R, Kinicki A. Organizational Behavior. New York: Richard D. Irwin, Inc.;1995.
Maslow AH. Maslow on Management. Philadelphia, PA: John Wiley, & Sons, Inc.;1998.
Griffith J. Speaker’s Library of Business Stories, Anecdotes, and Humor. Englewood Cliffs, NJ: Prentice Hall;1990.