Healthy Transitions – Change in the Face of Health Technology

Healthcare is changing to meet current and future demand. How can we weather change successfully? What does a healthy transition look like?

Take a few moments to reflect on change. What words come to mind when you think about changes in your personal life? If it’s a change you’re choosing for yourself, you may be excited. If the decision isn’t your own, you may have some resentment. Think about the last major personal change you made. What went really well, and what didn’t?

Now, think about a time you led a significant change at your organization. What words would you use to describe organizational change? Are they different from those you chose for personal change? What elements of a recent organizational change went well and what didn’t?

Mastering the art of change does not require a PhD in psychology. We can all improve the process with a few simple steps.

Which brings us to today’s question: How can healthcare organizations support successful transition as they move to electronic information systems?

Change is coming…
Let’s start with communication and engagement.

One of the most common complaints people make about change is that they don’t know what’s going on. A large change initiative can be given a fancy name and eye-catching posters, but in the absence of ongoing information, stakeholders start to formulate their own ideas about what is happening and what the change means. Rumors spread, and often they are not positive. When people talk about the changes that affect their own jobs, the less positive the rumors will be.

Why is this?
Has evolution killed the optimists? There is a distinct survival advantage to be able to predict and protect ourselves from worst-case scenarios. This is why, in the absence of information, people are most likely to imagine negative situations. But we can control this urge and promote successful change by choosing the way change is communicated throughout the process. This is an important first step to successful change.

How to Start
Announcing change without adequate engagement creates one of the biggest barriers to successful change. The following scenario is all too common: strategic planning takes place, months go by, a project is designed, announcements go out, and nobody in the organization feels they have been engaged, even if they have been consulted during the strategic planning process.

In an ideal scenario, stakeholders are engaged from the beginning, starting with identification of the need for change, through strategy development, and ending with post- implementation stabilization efforts. But few projects are ideal, and that’s okay. It’s not too late to start.

Wherever you are in the process, when you are ready to engage stakeholders, start by asking — not telling. You may have plans and budgets, timelines and resources lined up, but stakeholders will not be ready to see them until they have had the opportunity to go through the process of realizing that change is necessary, and understanding what it will involve.

Consider beginning this engagement by asking stakeholders what they would be proud to have said about them at the end of their careers. Do they wish to be known as the physician who cured cancer or the nurse who put an end to patient falls? What do they need to help them accomplish their goals? Are they experiencing current barriers or frustrations that keep them from focusing their energies where they want them to be? Will the new organizational change help remove these barriers?

Find a way to ask these questions that will align the desired organizational change with people’s personal goals, but introduce the change as a result of the discussion. When people view change as something that will support their goals, you will gain at least some diehard advocates from the start.

Engaging Communities
The engagement process should not end within the walls of your own organization. If the changes affect the community, community members will need to be engaged as stakeholders as well. Health information systems affect patient care, the dynamics of the examination room, the accessibility of care and the availability of information to patients, among other things. Understanding how these changes align with patient needs is key.

Healthcare professionals commonly think that we can put on our patient hats and provide feedback for large changes from a patient perspective. Though it is always healthy to relate to our patients and try to walk a mile in their shoes, we can’t truly understand the perspectives of people who have no inside information about healthcare. We often take our knowledge of the system for granted, and don’t appreciate the fear and confusion patients can experience.

Consulting with community stakeholders means getting outside the hospital walls and truly finding out what people think. Getting feedback from different cultures is especially important. If your organization is composed of specific cultural or socio-economic communities, such as indigenous communities, then ask them about their experiences and expectations, and learn how you may be falling short. How could the proposed change address some of these shortcomings?

Proposing a Solution
Whether the stakeholders you are engaging are inside or outside of your organization, begin by asking “What do you need?” and bring the following elements to the meeting:

  • Your full attention
  • An open compassionate attitude
  • The intention of being influenced (as opposed to influencing)
    If you are attached to an outcome, this might be hard. So think about who is the best person to lead this engagement. Is there a person in your team who has exceptional skills as a listener? Someone who has an open mind and makes people feel heard? Someone who is less invested in the project moving forward and more invested in the opportunity for positive outcomes?

During each consultation session, encourage the stakeholders to be mindful of their own experience and ask them to express their own priorities and values. Take note of any alignment or misalignment of values, since both are important. Use the following strategies to find and foster common purpose:

  • When participants bring up opinions that align with the planned change, emphasize them.
  •  If the participants come up with better ideas, make sure to bring the ideas back to the planning team with the intention of considering modifications to improve outcomes.
  • When people complain or express fears, view this information as highly valuable.
  • Name emotions. Create a space where expressions of emotion are welcomed and praised, not pushed away.

At the end of the engagement, ask for feedback. Did everyone feel heard? Was there enough time for everyone? If not, arrange a follow-up session or some other method of communication. Within a few days of the session, communicate with the participants. Provide a summary of their input and an introduction to how the project aligns with their needs. Arrange for a second session to present the project in more detail and gather feedback about how to successfully communicate with them through all stages of the project.

Collaboratively create
a communication plan with the stakeholders to ensure that you share common expectations for future engagement and communication. Once the plan is crafted, stick to it, perhaps touching base periodically to see if all stakeholders feel the communication plan is still adequate, or if modifications are required. Collaboratively create a communication plan with the stakeholders to ensure that you share common expectations for future engagement and communication.

Address the Elephant
Whatever you do in your initial engagements, do not forget to address the elephant in the room. There is a lovely analogy offered by Dan and Chip Heath, authors of Switch. They describe leading change like leading an elephant and its rider. The rider is the rational brain. The elephant is the emotional brain. How much control do you think that rider has if the elephant decides to move in a different direction?1

I cannot tell you what a relief it is to me that people in the business of leading others through change are now increasingly talking about emotions! For years we have pushed them away with some notion that emotion is not appropriate in the workplace. Ignoring the elephant in the room does not remove either the elephant or any of its needs.

If during your engagements and communications you find people are being silent, expressing more consent than you imagined, or are not expressing emotion at all, you should be very afraid. It does not mean that the elephant is not present. It means that it is hiding and watching you closely.

When you encounter anger or frustration, celebrate. This means you’re truly seeing the conflicts, fears and needs of the people you are asking to change. When you can see it, you can address it. Your challenge is to ensure that it is addressed.

So, how do you encourage people to express their emotions?
Generally, asking people to tell you their fears does not work so well. One of my favorite tricks is to turn the tables on the participants and ask them, “What would you do to make this change a complete disaster?” This turns expressing fear into a purposeful task, not something to hide. The barrier of shame is removed, people are distanced from their own emotion and can express their fears with more detachment.

Sometimes it is not the facilitator that is creating fear, but the other participants. Starting in self-selected pairs can establish the trust needed to encourage communication. Once conversation is occurring in pairs, you can expand to small teams and then share with the group as a whole. If challenges still exist, check to see if any of the core needs of motivation are being threatened:

  • Do the members of the audience feel they are being allowed their autonomy, or are they feeling coerced?
  • Do they feel like they have needs and interests in common with the other stakeholders, or are they feeling alienated?
  • Do they feel competent to provide answers and feedback? Do they feel intimidated by others in the room?

Addressing all of these needs in planning helps drive motivation.

Emotions will arise not only in the initial phases, but throughout the project, and you must be prepared to address them. Many models are available to help your team manage stakeholder emotions. Here is one I have put together over the years from a combination of therapy modalities and real-life experience.

Address the situation by asking the following questions:

  • Is this an emotion that can be acknowledged and allowed to exist
  • Does this require action?
  • Does this require humor?

When emotions such as shame or grief arise, it is important to recognize and allow them to be present. Acknowledging and allowing can sound like this: “It is not unusual to have a sense of loss, something is coming to an end.” “Thank you so much for feeling comfortable enough to share your concern about not being able to type. I know many people are struggling with this and feel too ashamed to talk about it.” “It’s okay to not want this. Change is hard.”

When emotions such as shame or grief arise, it is important to recognize and allow them to be present.

Sometimes the emotion being expressed is causing chronic suffering and is not responding to the strategies above. In this instance, laughter can be a very valuable tool if done with compassion. For example, in one of our implementations we created of a “no-no” word board, which we used to record all the words that seemed to trigger negative emotions in members of the team. My own word was “order sets”, and the IS manager’s was “emulate” and “access”. When a word was added to the board, we took the opportunity to understand why that word was so upsetting to a member of the team. This allowed them to share their feelings. It also gave us a place to go when these topics came up and emotions arose. We could say, “Oops! Was that a ‘no-no’ word?” Coming up with other ways of phrasing “no- no” words to get our work done was a source of creativity and amusement, and allowed us to build empathy and trust.

When deciding your course of action in the face of strong emotion, you will know quickly if you pick incorrectly! When this happens, there is no value in beating yourself up about it; simply apologize and make another choice. When in doubt, you can always ask, “What would be most useful right now?”

Engage Throughout
This kind of intense emotional and rational engagement is required at all steps of the process, from conception, through planning, building, piloting, implementing and supporting.

Sitting with emotion, acknowledging it and letting it be, is one of the most difficult tasks for people in healthcare. We have been taught to take action, to fix things, and if we can’t fix them, then refer the problem to a specialist. We have never been taught the benefits of welcoming emotion, sitting through its brief stay and finding that it is impermanent. Allowing emotion can help healing, while pushing emotion away may actually result in the persistence of emotions. That which we resist often persists.

Sometimes the problem identified by an emotion means that action is required. Perhaps it can be addressed by an adjustment in plans or problem solving. For example, if someone reveals their shame at not being able to type, and they have been allowed to sit with that emotion for a day or two, then it might be good timing to start talking about ways other people have learned to type. This might include providing positive role models, resources for typing classes, or computer games that help improve typing skills. Introducing alternative skill sets or competencies might also be helpful. For example, speech recognition might be available as an alternative to typing.

Audiences will vary in size through the different stages. Broad engagement for the “Why” of the change is essential. Cascading engagement through existing structures for requirements gathering is adequate, so long as the end users have ample opportunity to be informed, engaged and consulted. If management is speaking for them, you will have problems. When a project gets to the implementation phase, broad engagement is required again. This is where we focus on training.

Creating a Revolution
It is very common for project teams to view training simply as an opportunity to teach the new system to end users, without assessing their current skills base or knowledge gaps. If you wait until the last minute to train people how to do physician documentation, and only then realize that it could take months to practice the data entry skills like typing or speech recognition, you will have a painful go live. On the other hand, if you train months in advance, then everyone will have forgotten the new workflow by the time the go live
happens.

The best case scenario is to identify the required skills early in a project, assess the users’ current skill base, plan to develop the needed skills before the pre-go-live training, and build momentum for a successful go live by celebrating successes along the way. Let me show you what this can look like.

Identify required skills early in a project, assess the users’ current skill base, plan to develop the needed skills before the pre-go-live training, and build momentum for a successful go live by celebrating successes along the way.

At a large community hospital, we knew the physicians would have to move from a predominantly paper environment to a completely digital world. The physicians understood the expectation, but were not sure how they would get there. We started by telling them that nobody would expect someone to run a marathon without training, and 10 minutes on the treadmill was probably not going to cut it.

All physicians were “invited” to meet with a trainer to do a digital fitness assessment. The trainer was equipped with a list of competencies that the team believed would be required for successful adoption of the new technology, along with the skill set to gently coach the physicians through change. The test helped the physicians identify their own skill gaps, outlined clear expectations for what skills training the organization would provide, and what work was required of the physician. At the end of the session, a contract was created where the trainer committed to providing the identified training material and the physician committed to doing the necessary learning. This contract was signed by both parties and, if the physician was willing, a picture was taken to be included on a mosaic poster shared with the hospital at large. This process was designed to prepare the physicians, obtain their commitment, and allow them to model change adaptive behavior to their colleagues. We then developed pilots to test (and help train) skills. New functions were piloted on the current information system by those who would benefit from gaining skills. For example, we piloted front-end speech recognition for those who were typing adverse or who showed interest in using it as their primary mode of data entry. Additional processes were also piloted, such as electronic discharge summaries, medication reconciliation and problem list entry.

Along the way, physicians saw their colleagues being open to change, gaining new skills, and celebrating success. In general, people respond well to modeled behaviour. Momentum for change can be built by crafting opportunities to showcase the behaviours you want to promote.

Throughout the process, we paid attention to social norms and used them to our advantage. If there was a healthy pocket of competition in a department, or between departments, we used it to motivate change and create some fun along the way. Some physicians competed in online typing games to race virtual cars based on their words per minute. Other physicians volunteered for every pilot so they could one-up their buddies by being the most technologically advanced before we even started. Department chiefs challenged other departments to increase their participation numbers: “If you can beat my department’s participation in the digital fitness test, our department will donate X dollars to your department through the
foundation.” All of these efforts increased engagement and promoted change readiness as a desirable norm.

Getting Education Right
Finally, after all that preparation, it is time for the classic training.

The KLAS Arch Collaborative study for physician satisfaction with health information systems provides important guidance for successful implementations. This study found that the number one predictor of satisfied physicians was EDUCATION. Here are their conclusions:

  • Providing six hours plus of training for new physicians increased satisfaction.
  • Incorporating physician training into department meetings was one of the most effective ways of providing education.
  • Include something other than the traditional online, classroom, at-the-elbow and department meetings training.

This last point is intentionally vague because in reality, there is no formula. It will be dependent upon the culture and the social norms of your organization. Consider the “something other” as an opportunity to meet the specific needs of your organization with creativity and insight.

Here are some examples from the study, and from my personal experience:

  • Establish a buddy system where an experienced user is paired with a new physician.
  • Have a trainer shadow a new learner for their first shift (remember the rule 70-20-10, 10 percent of our learning comes from classrooms, 20 percent from our peers, 70 percent from actually doing the job).
  • Customize training based on each individual’s learning style and competency; some people are visual learners, some need to be hands on, and others may need to hear or read the content.
  • Provide simulations, real-life scenarios and parallel runs.
  • Create brief, readily accessible, “show-me” tutorials or tip sheets for specific functions.

Training content should include the various functions within the system presented as isolated practical lessons, and as components of a complete workflow. Are there ways you can divide the 37 training into functional modules? Can you summarize the education by having the user follow a work simulation, putting together many of the functions to accomplish a daily task?

The KLAS Arch Collaborative also emphasized that it is essential to teach users how to personalize the system [3]. Most HIS systems allow users to set personal favorites for viewing and entering data. Ideally, this system would be personalized prior to go live, but often the only system available before the official “turn-on” date is the test environment. This means users would need to choose their favorite settings again in the live environment once it becomes available. Though expecting users to personalize their settings while working to learn new workflows may be unrealistic, users who have customized their environment are more likely to quickly adopt the new system. Ensuring that every user has a customization session with a support person during go live can significantly improve global adoption and satisfaction with the system. This can be another idea for “something other” in the training plan as well.

After the Flip is Switched
Skills acquisition and system training should happen pre-go live, but customization and optimization training needs to continue after go live as well. Within two to three months of go
live, many users have forgotten their training and created cumbersome work-arounds. Catching these work-arounds before they become too entrenched is a key factor for happy clinicians and smoother future change initiatives. Once a system is live and running, schedule yearly refresher sessions to reinforce skills. Adding a clinician help hotline, making sure clinicians know who to call, and roaming support workers for on-going help can increase satisfaction!

If you find yourself frustrated with a poor performer after implementation, start by being kind to yourself! It is difficult to see others struggling, especially when you have worked hard to support the best outcomes. Frustration and disappointment are natural, but it’s never helpful for those struggling to perceive your emotional reaction. Treat them with compassion. There are no poor performers, only those who need more help. Assign poor performers to your best trainer, one with emotional intelligence and coaching skills.

When things are tough and emotions high, make sure that your support staff know how to take care of themselves and their clinicians. Watch for times when people are holding their breath and have tightened their shoulders or facial muscles. When this happens, encourage them to connect with their physical senses. Bringing a clinician a cup of coffee, tea or water can have benefits on so many levels:

  • It shows someone really cares about them and is going out of their way to do something nice, so people feel connected and supported.
  • It draws attention to the senses, and shifts neuronal firing from the fight, flight, or freeze of feeling overwhelmed, to something tangible in the present moment.
  • It provides a familiar object to focus on when they feel everything is new and slipping out of control.

Having a coffee maker or tea station as part of the command centre can be a valuable investment!

If things are still feeling out of control, encourage people to take a break, a breath, a walk or fifteen minutes in the gym doing some spinning, yoga or zumba, whatever brings them joy.

Navigating the J curve of Change
Although dealing with emotions is the bulk of the implementation and adoption challenge, it is important to help the rational brain through the process as well. It is not uncommon for people to have unreasonable expectations. They may think that the project will bring immediate, perceptible benefits, and not appreciate the length of time it takes to get used to a new workflow, or for functioning to return to baseline, and for benefits to be seen.

The length of time to establish a new norm is dependent upon three factors: the quality of the preparation in advance, the human factors in design of workflow, and the adequacy of supports in place. The following graphic of the Jerald Jellison J curve shows the difference between expectations and reality.

To avoid the pain of unmet expectations, openly acknowledge and discuss the gap between expectations and reality. Encourage people to congratulate themselves for getting through one more day of pain. Emphasize that their hard work has a purpose, and that they are getting closer to the new status quo.

Measure the Impacts
In addition, the rational brain wants to know what the impacts of this change are on a day-by-day basis. Are any people being harmed or dying? Are people waiting excessively long? How far behind are the clinics? Is it improving day by day?

Advance planning can ease post-implementation impact concerns. Find out which impacts are most important to clinicians? This information should be gathered in the stakeholder consultation process, when people report their fears. Common examples include:

  • Number of patients seen
  • Time differences
    • Time to open a chart
    • Time to document a visit
    • Time to create a problem list
    • Time to perform medication reconciliation
    • Time to admit
    • Time to results
    • Patient wait times
    • Time to antibiotics in Sepsis
  • Medication Errors
  • Clinical Outcomes
  • Mortality
  • Length of stay
  • Readmissions
  • Frequency of Catheter Associated Urinary Tract Infection or other harm indicators

It is important to make sure that baseline measurements have occurred prior to implementation. If people do not know the current statistics, then they will not appreciate the variability from after implementation. Data gathering can be cumbersome in the pre-electronic state, so make sure to gain consensus about what data is needed, leverage what you are already gathering, and set expectations for what data points will be monitored during and after the implementation.

Bring in the Cheerleaders
While monitoring the expectation gap and reporting on impacts, it is important to advertise the positive. Perhaps you are doing better than your realistic predicted J curve. Plot it out and show them! Celebrate the users who have quickly adopted the new workflows and praise those who learned new skills.

In addition to promoting the good news, make sure to have a stack of thank you notes for those key change agents. Although emails are easy and paperless is a goal, genuine, personal thank you notes are treasures for years to come.

Collaborate
It is not uncommon for one group of users to get the majority of the attention during implementation. This may make other groups less engaged. It can also create conflict, which may present as people saying things like: “I’m doing this… what are you doing?” or “you’re doing that and it’s messing up what I’m doing.”

When this happens, it is time to identify those who have yet to join the change and get them on board. Engage under- committed groups in problem-solving activities and give them active contribution roles.

Rediscovering the Organization
Once you have moved out of the “J curve” of implementation and into the new status quo, it is easy to think the project is completed. Chances are that project funding has ended, so, you may be surprised to hear that you are NOT DONE, you are JUST BEGINNING.

It is now time to re-discover the organization. The new system will require new processes and procedures. Users and departments are now more interdependent, which means they are less able to make change without wider stakeholder consultation. It will probably take a few “oops” experiences before this realization settles in.

It is time to start your change initiatives again to define the new status quo and establish new operating procedures. The momentum of change must not slow down. To maintain it, make sure the whole organization understands prior to go live that this re-discovery process will happen after implementation.

How does change work in our new Environment?
The new system creates a level of integration that will not be understood by all. Plan an education and change process around teaching the new integration. Start it early and engage widely. Ensure that formalized change request processes are in place, with adequate governance for prioritizing and monitoring change, and that they are well communicated and exercised to perfection. Then leverage your technology to improve your new world. It is time to ask more questions about how you can make a better world. Then do it.

Refining and Beginning Again
Now it is time to go back to the engagement in the first step. What would we like to do better? What is getting in the way? How can we mess it up? How are we already messing it up?! What do we need to change?

One of the benefits of health information system implementation is the opportunity to become a change-competent organization. Don’t stop now! Use this skill to drive quality improvement and improve patient outcomes.

Learning more about Facilitating Change
If this introduction has sparked your interest in learning more about facilitating change, consider exploring the following resources:

  • Susan Fowler. Why Motivating People Doesn’t Work… And What Does.
  • Daniel Pink. Drive.
  • Ken Blanchard et al. Who Killed Change?
  • Chip and Dan Heath. Switch: How to Change Things When Change is Hard.
  • JP Kotter. Leading Change.
  • JM Hiatt. ADKAR Model for Change in Business, Government and Our Community.

Bibliography

  1. Heath, C. and Heath, D. Switch: How to change things when change is hard. Random House Canada, 2010.
  2. Fowler, Susan. Why Motivating People Doesn’t Work… And What Does. Berrett-Koehler Publishers, 2017.
  3. KLAS ARCH Collaborative. www.klasresearch.com.
  4. Jellison, Jerald. Managing the Dynamics of Change: The Fastest Path to Creating an Engaged and Productive Workplace. McGraw-Hill Education, 2006.
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