Medical professionals excel at finding solutions in patient care. “We are great at coming up with the ‘next big thing’: we have brilliant people who are at the front lines of innovation,” says Louise Keogh Weed, program director of the Leadership Strategies for Evolving Health Care Executives program and a practice transformation specialist at the Harvard Medical School Center for Primary Care. “Where we fall short is actually implementing it, because it’s a different skill set and fewer people want to do it.”
Thus, it can be easy to ideate and harder to execute on brilliant ideas in health care—which means, generally, that the industry is constantly at risk of coming up with ideas but not delivering on maximum impact. The challenges are manifold, but the unique systemic, monetary, and hierarchical challenges in these environments make change particularly thorny. “Health care is filled with moral injury, because you’re constantly failing—you want to help people, and the system isn’t built to do that,” says Keogh Weed.
But change management takes into account the various barriers to success. When done properly, it lays out a step-by-step process to identify a challenge, make changes, and execute successfully. It’s not as easy as it sounds. “Change management makes you use every tool in your leadership toolbox to be successful,” says Keogh Weed.
Kotter’s 8-Step Process for Leading Change
As originated by Dr. John Kotter, there’s an 8-step process to execute change management:
- Create urgency: get the attention of the team/community about the importance of making change. This step involves convincing them that it’s important to act immediately, and highlighting the consequences of not changing.
- Form a guiding coalition: make a team with key stakeholders to drive this change forward. Prioritize finding multidisciplinary, potentially even opposing members with a wealth of cognitive diversity to ensure efficacy.
- Create a vision: make a vision statement and strategic initiatives that will guide the coalition. This allows for accountability in decision-making and centers a commitment to shaping and improving the community culture.
- Rally and communicate: balancing both support for and opposition to the goal, bring people together around this shared vision but allow for anger, resistance, and debate. Model this behavior and show openness to feedback and error.
- Remove barriers and empower: get rid of obstacles (institutional or otherwise) to the changes that the coalition identifies. Share information as it arises, encourage risk-taking, and work cross-functionally to help the coalition move forward.
- Execute on and celebrate short-term wins: have an easily achievable goal in mind that you can tout as proof of the goal’s efficacy. This also helps to reward team member contributions and build momentum for future action items.
- Don’t let up: as the coalition moves forward with recommendations, make necessary institutional changes. This can involve hiring, promoting, implementing tools or training, establishing new projects, and other systemic improvements.
- Further cultural and institutional change: make these recommendations part of the organization. Forming new habits and unlearning the old ones can involve training and a new reward system for workers. Monitor efficacy and find ways to improve.
To Kotter’s steps, Keogh Weed adds two core concepts that play a role in effective change management:
- The Three Dimensions of Success: framed as a triangle, the three points stand for results, process, and relationships. Each is as important as the others—it’s not just about the end result, in other words, but about how the results are obtained and how team members work together. As Keogh Weed notes, “We are very results-oriented in health care, but process and relationships make things sustainable.”
- Kurt Lewin’s Stage Theory of Change: the circular process of “unfreezing” the current status quo, “changing” operational and cultural norms, and “refreezing” with new changes in place. Critically, this process repeats as necessary when a leader identifies the need.
Pitfalls to Avoid in Change Management Execution
Keogh Weed cautions that, while Kotter’s steps don’t necessarily always proceed in order, the latter steps are impossible without the former ones. It’s critically important to think through the change(s) in a systematic, methodical way. The first step, for example, poses a particular problem in health care because so much is urgent. COVID-19 was and is a perfect example of something that’s truly time-sensitive; Keogh Weed saw practices change their health delivery systems in a week to account for remote access and safe patient care. Knowing why a problem needs solving, right now, is essential to change management.
The steps that will pose the greatest challenges for leaders will depend on their personality and leadership style. When set up properly, though, the steps can cascade in a positive way and get easier over time—or they can cascade negatively if leaders don’t implement proper planning and strategy at an earlier stage. For example, skipping immediately to execution (steps 5 and 6) based on an executive decision is another common mistake, since it can come off as superior and patronizing. In the hierarchical, fast-paced world of health care particularly, a leader may feel tempted to gloss over the strategic steps.
“You’re constantly wrestling with the stakes being high and feeling like we need to move fast—but, if we don’t slow down and do this right, we’re not going to do a very good job. It’s a leader’s responsibility to sit with both of those things and manage people through it,” says Keogh Weed.
The same goes for excessive rigidity. If a guiding coalition starts work on a particular problem, and then decides that they’re actually focusing on the wrong issue, it may be necessary to go back several steps, realign the vision statement, and execute on a different goal—taking more time in the process. If a leader forces the process of change and innovation to go step by step without any flexibility, the intervention won’t be as effective.
What to Look for in Effective Change Management
Good change management means leaders identify the correct problem(s) that need to be solved before they even get to step 1 and communicate effectively throughout, encouraging coalition members instead of dissuading them. Reducing hierarchy is critical. Change management might mean bringing physicians and medical assistants in the same room and having both perspectives matter equally in the context of problem-solving. This can be challenging, so it’s up to the leader to ensure discussion remains productive and respectful—creating and sustaining psychological safety.
A leader also needs to pay close attention to burnout. Coalition members who attempt to make changes but are unsuccessful can feel exhausted and lose confidence. This is particularly true if, mid-way through solving a problem, the groups need to abandon or switch focus. Change management isn’t as effective when the guiding members are burned out—already a common problem in health care—and feeling like they’re not getting anything done. Thus, step 6 is particularly tricky, and particularly essential. “How do you define success in a way that’s tangible enough for people that you’re moving things forward without it being disingenuous?” Keogh Weed explains.
Throughout the process, leaders need to work on refining and growing their leadership and management skills. Change management requires them to toggle effectively between the micro- and macroscopic needs of the project quickly and effectively, without being either overconfident or indecisive. “It brings us back to those fundamentals that we need to be continually working on throughout our careers,” says Keogh Weed. “We often feel like we’re good on that front as we’re thinking about the bigger picture, but without that piece, we’re not getting anywhere.”