September 2, 2008

All Aboard! — Building Consensus to Make Change Happen
By Elizabeth S. Roop
For The Record
Vol. 20 No. 18 P. 12

When implementing new technology, keep the moaning and groaning to a minimum by using an effective change management strategy to ease the transition.

Atlantic Health had spent four years implementing a wide array of clinical and IT systems, so when it came time to deploy computerized physician order entry (CPOE), there was a real concern that it might just be the straw that would break the clinical team’s backs.

“They were just fatigued. It was technology fatigue, so it was really difficult,” says Linda Reed, RN, MBA, vice president and chief information officer for the two-hospital healthcare system serving northern and central New Jersey. “Our biggest issue was to not sell [this] as a technology project.”

To keep that from happening, Atlantic Health brought in Greencastle Associates Consulting and tasked it with managing the human element of the project, freeing up the IT department to focus on service issues and the vendor to focus on the technology aspects.

Greencastle started with a readiness assessment to pinpoint areas of skepticism and resistance and measure overall perceptions of the project among operational and medical staffs, information that proved invaluable when it came to ensuring that the project’s focus remained on adoption by the clinical staff rather than the technology’s deployment.

“It gave us some early warnings [and] the ability to not do some of the things we might have done in the past,” says Reed. “It let us address some of the perceptions and avoid some of the things that the clinicians were really concerned about. … You have to go in expecting that there will always be resistance, but it’s good to know what kind of resistance to anticipate.”

In addition to the assessment, Greencastle optimized the engagement of the clinical and physician staffs and project management by organizing such clinician-facing deliverables as process development, order set standardization, process integration with ancillary units, and training. While those efforts were important to the implementation’s success, they were not the most significant chip Greencastle brought to the table.

“The biggest benefit was that they were a neutral third party. That was big-bang benefit No. 1. They weren’t the IT department, and they weren’t McKesson [the project’s vendor]. They had a clean slate,” says Reed. “The other thing is that it allowed our people to vent. We’ve been doing IT for a long time, and everyone is aware that not all projects go well. People get annoyed over different little things. This gave everyone the opportunity to vent to a neutral third party, which was a good thing.”

Given the naysayers’ ability to bring any IT project to a halt—or at the very least to hinder end-user adoption—placating them is one reason organizations should focus as many resources on the change management aspects of an implementation project as they do on the technical aspects. But it’s not the only reason.

By paying attention to the impact that the new technology will have on the staff that must incorporate it into their daily activities, the end result is greater adoption and higher satisfaction. Unfortunately, it remains an area that is often overlooked in the overarching project plan.

“Installing a system and just turning it on is not easy work, and it can take a lot of resources within an organization just to get something up and live,” says Greencastle Senior Partner Mark Stabile. “Because people are doing [the IT] work, they assume that they’ve put in the effort. Quite frankly, the energy should be put into getting those folks who are going to have to perform engaged in the early decisions, engaged in the design of the solutions, and engaged in the process of rolling the systems out and in the follow-up.”

From the Greencastle perspective, the most effective IT implementations focus first on gaining a clear understanding of which processes will be impacted by the new technology and how the functionalities or features will deliver the best results for those processes. From there, the focus should be on addressing concerns and winning support of the individuals who are expected to adopt the process changes.

That is why change management must begin well before the technology is selected and continue well after go-live. Otherwise, any forward progress that is made with user adoption can be lost.

“Once you start to get people on board with the process and the idea that there will be change and that technology will be part of that change, you begin to experience the benefits. You need to reinforce them,” Stabile says. “Often, organizations will stop because they think the project is over, not realizing that they need to reinforce and really leverage the benefits that they’ve gotten in order to get maximum value.”

Change Leadership
Talk with enough change management experts, and one thing becomes perfectly clear. Although they may not agree on the specific approaches or methodologies, they do agree that if a new technology is going to be embraced by those forced to use it, the change management process has got to start early and have the support of the organization’s top leadership.

“When we diagnose successful implementations we’ve been involved with vs. unsuccessful ones, there is one clear differentiator,” says Charles Fred, CEO of The Breakaway Group, whose research indicates that 50% of a successful adoption effort is change leadership. “The successful ones had a change leader, a tone at the top, and a method to get people through the change. They didn’t leave it to chance.”

Fred advocates starting change management by breaking down the roles that will be impacted by the new technology and then breaking the roles down to specific tasks. That activity provides a road map back to the leaders (executive or departmental) who are best positioned to help people get through the change by conveying not only the reasons for the change but also the real impact the change will have on their daily activities.

“That’s what we mean by ‘tone at the top,’” he says. “It’s a constant drumbeat of why, for your job role, we are changing the application or workflow. … The telltale sign that we’re not doing the change leadership process well is that [you’ll hear] ‘The system doesn’t work for me’ or ‘It’s not designed for my workflow, and it takes more time to treat patients.’ These are the telltale canaries in the mine that we’ve got to go back and retrench the change leadership approach.”

Most important, the leadership must be consistent both in its commitment to the change management process and in its presence at the table throughout the project. One thing that cannot happen if any technology implementation is to succeed is for the project leaders to back down in the face of resistance, says Fred. The cost of poor adoption is simply too high—much higher than the cost of the system itself.

“You really have no choice. If you want to have an effective implementation and save money, you have to have leaders with the fortitude to push this through,” he says. “You can’t waver. Now you’re committed, and it’s a pretty big commitment. It’s unnerving to watch how many people waver postdecision.”

And while C-level buy-in is critical to ensure ample resources are dedicated to change management, the best leaders aren’t only found in the executive suite. In fact, most consultants agree that there needs to be a mix of both formal and informal leaders comprised of executives, department heads, and those individuals held in high regard by their colleagues.

The ideal change leadership team will include not only IT and clinical experts but also individuals who are flexible and articulate, so they can adequately represent the project to their colleagues, as well as bring their coworkers’ concerns to the table. Whenever possible, the leadership team should also include individuals who have already experienced the kind of change that awaits the staff.

“Pick natural leaders. Natural leaders don’t necessarily have prestigious titles. They’re just the people others go to because of their knowledge, experience, or communication abilities,” says Gwen Hughes, RHIA, CHP, director of e-HIM consulting services at Care Communications, Inc. “Moving into any change is scary. One way to minimize the fear is by having people on the team who can say, ‘I felt the same way, but we did it and you can do it, too.’

“The smaller challenge is really the technology. The larger challenge is leading the change and … walking people through the emotional side of change, so it’s constructive rather than destructive,” she adds.

Communicate Honestly, Openly, and Often
Change management experts also agree that communication is critical to encouraging end-user adoption of new technology. For change management, those communications should focus on conveying the reasons behind the new technology, as well as on managing expectations and addressing concerns.

One of the most important aspects of communication during the transition is to be up front and honest with the staff about the disruptions.

“The worst thing you could ever do in an adoption program is go in and sugarcoat it for clinical workers. They are the most pragmatic people I know. If there was ever a ‘BS’ test, they’ve got it figured out,” says Fred. “If you can tell them the business mechanism and the reason for doing this, they’ll get it. But if you go in and say it’s going to change their world and it’s the greatest thing since sliced bread, it looks so contrived, and they’ll immediately resist.”

To avoid this means frequent meetings to discuss not only the new processes but also to give staff the opportunity to vent frustrations, offer opinions, and raise issues that need to be addressed to ensure that when go-live happens, everyone is on board or at least feels as though their concerns have been heard.

In some cases, this could mean daily meetings with affected departments. That was the case for one implementation Hughes led. In addition, she made it a point to work one on one with the more resistant staff members to help them understand the need for the new technology, address their individual concerns, and help them understand the part they would play during and after the change.

“People have to understand that change can be messy and chaotic. They need to understand that the team will meet frequently during the change to discuss any unexpected issues that arose and share how those issues were handled on the fly, to discuss how those issues will be handled moving forward, and to decide whether new processes work or need to be adjusted. It’s important to normalize the chaos that’s part of change,” she says. “It’s important they understand that it’s normal to feel a loss of control when you’re doing something new. If you can acknowledge their anxiety and respond constructively, that helps.”

Hughes also stresses the importance of approaching staff communications with patience, as well as finding multiple ways to communicate. It also means keeping the lines of communication open for as long as necessary to accommodate everyone, including new staff members.

“Different people learn differently and hear differently, so we have to be willing to communicate over and over again,” Hughes says. “It’s especially important that we actively listen.”

Don’t Forget IT
Although much of change management focuses on non-IT staff, the technology folks cannot be overlooked if the final rollout is to be a success. If IT struggles, it can create a domino effect that will only add to the chaos.

One of the biggest culprits here is scope creep. Under ideal circumstances, the project will have a clearly defined scope against which the implementation process and timelines are developed. If that scope changes, it delays the entire project and can create an environment of frustration within IT and for the end users—both of which will negatively impact all the associated change management elements.

“It has a ripple effect where everything associated with the decision making is going to impact the bottom line, which is your activation date,” says Shirley A. Pruitt, vice president of Coastal Healthcare Consulting, Inc, who advocates having many of the key decisions about system design and use made before the project is handed off to IT for building and testing.

For example, in a multifacility organization, decisions must be made regarding standardization across facilities and within units of a single facility vs. allowing each to customize the application, identifying best practices up front, and who the primary system users will be for each function.

Other decisions include who will be leading the standardization, if that is the direction the facility chooses to take, as well as responsibility for any policies, procedures, and training materials that must be developed or updated because of the new technology.

“It really needs to come from the organization leadership and then, once the design decisions have been made, they are handed over to IS [information systems] for build and testing,” Pruitt says. “IS cannot be the driver. That is why at times, individuals, especially end users, feel that projects are IS driven when, in reality, they are driven by the end users.”

A process must also be established for requesting changes, particularly those that fall outside the established scope. “That process needs to be documented, and everyone needs to follow it for change management. It can’t just be the IT staff following it,” says Pruitt. “If it’s defined that ‘here is the process’ yet everyone gets to bypass the process, [IT] will never know what they’ll be able to accomplish, so they’re going to be frustrated.”

The Price of Failure
Regardless of an organization’s size or the project’s scope, failing to address the human side of IT implementation can cost more in the long run than the technology itself. That is why organizations should take a hard look at whether they can handle the change management process internally or need to seek the assistance of expert consultants to at least assist with establishing a framework for change management that can be applied to future projects.

“What the right consulting firm can bring to a healthcare organization is that extra capacity and expertise to get them through the painful points,” says Fred. “It’s a little like having a personal trainer when you want to get into shape. At some point, you’ll have to do it yourself, but we can put in the routines, give you the exercises, and get you through the process so you can change what you’re doing on a daily basis.”

Atlantic Health brought in a consulting firm, the funding for which was carved out of the overall project budget and reassigned to the change management process. And it also hired a full-time director of medical informatics and established a permanent clinical excellence committee, both of which are charged with managing the clinical aspects of IT deployment, as well as long-term change management.

“You can bite off your nose to spite your face, or you can go with the flow,” says Reed. “We decided that CPOE was really important. We want it to work, and we want it to be pleasant for the people who really want to use it. You don’t want to create more animosity that you have to, so be realistic about what you can and can’t do and strive for more adoption.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.