Launching and Leading Change Initiatives in Health Care Organizations

Managing Successful Projects

David A. Shore

• Publisher: Jossey-Bass
• Year: 2014
• ISBN:
  9781118415986
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Implement change that fosters sustainable growth and better patient care

Health care projects depend on astute management of change. But more than anything else, they depend on leaders who pay attention, who understand the importance of starting right, and who know how to launch projects that succeed. If leaders can increase the percentage of successful projects, patients, and practitioners everywhere will be better off and so will the organizations that depend on these projects for innovation.

In Launching and Leading Change Initiatives in Health Care Organizations: Managing Successful Projects. Author David A. Shore of the Harvard School of Public Health speaks directly to the health care leaders and managers who see the need for change, but keep encountering nearly insurmountable challenges. Through his research, Shore discovered that most implementation failures occur because of a poor launch, and that strengthening processes and operations during the early weeks of a new project is a key to continued success. The book covers issues like:

• The preliminary groundwork that cultivates a stronger launch
• Systematic and selective project selection
• Building the team that accomplishes change
• Skill-building and record-keeping systems that foster sustainable growth

Launching and Leading Change Initiatives in Health Care Organizations gives leaders and managers the practical, easy-to-implement ideas and methodologies to start and manage projects successfully.

Part 1

Changing Health Care

Introduction: The Need for Change

As anyone who works in and around health care knows, it is an unusual environment. It is both a mission and an industry. It is a high-tech scientific enterprise and a high-touch human service. The overarching objective is simple enough, albeit often beyond our grasp: to help people recover from illnesses and injuries and stay healthy. But the subordinate goals are numerous and often in conflict. Health care organizations try to deliver care that is consistent with the best scientific evidence and that patients and their families also find helpful and comforting. They try to do so in a businesslike and cost-effective manner, so that their revenues exceed their expenses. (No margin, no mission, as the common phrase has it.) Perhaps most relevant for our purposes, they try to continually learn and improve, so that the care they offer tomorrow will be more effective, more helpful, and more efficient than the care they offer today. Change initiatives and projects are the route to organizational learning and improvement. They are the method by which people can make health care better.

There is little doubt that health care needs to get better.

Granted, U.S. health care in some respects is the best in the world. People from around the world often fly to the United States for treatment. Many Americans pronounce themselves satisfied with the care they receive. Still, the list of challenges is long, the failures persistent. U.S. health care is far more expensive than care in other countries, and the outcomes are often poorer. Costs continue to increase every year. Many people—close to half, according to one influential study—do not receive standard recommended care for their ailments.¹ Some failings seem almost intractable. “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented,” wrote the Institute of Medicine in its landmark 1999 report.² The numbers have been debated—some think the record is worse—but no one is arguing that things have improved much since then.

The amount of waste in health care is another of those seemingly intractable problems, and one that is particularly germane to the subject of this book. Data from various studies indicate that about 30 percent of health care spending in the United States is wasteful, in the sense that it does not improve health. This represents about $750 billion in annual expenditures, or more than 5 percent of U.S. gross domestic product. Waste comes in many forms, and several different studies have tried to categorize them. Donald Berwick and Andrew Hackbarth, for example, have identified six major categories of waste: failures of care delivery, failures of care coordination, overtreatment, administrative complexity, pricing failures, and fraud and abuse.³ The omnipresent business meeting in health care organizations is both a symptom and a cause of waste. For example, a community hospital affiliated with a medical school in the western United States holds a monthly one-hour meeting for its 110-plus managers and supervisors. Many attendees gain little from this meeting; in fact, a significant number of people admit to “dreading” it. Yet every single meeting costs the hospital at least $11,660 in direct costs—the time of the participants—and untold thousands more in opportunity costs. One might ask why the hospital leadership isn't dreading spending so much on this meeting each month. Why are they embracing the meeting that so many of its participants dread?⁴

The contradictions in the health care system—care that is often superb juxtaposed with skyrocketing costs, countless errors, and enormous waste—are reflected in what people on the front lines see and hear every day. On the one hand, it seems that everyone is talking about change. Executives and administrators issue pronouncements on the need to improve. Organizations launch initiative after initiative. New laws, new technologies, and rising consumer expectations all push institutions to improve the way they operate. On the other hand, lasting change seems hard to come by. Initiatives fail. Clinicians and other health care workers continue behaving today much as they did yesterday and the day before that. Not long ago, the Harvard School of Public Health and the consulting firm Towers Watson joined forces to conduct a survey, asking hospital CEOs and other senior administrators about their efforts to change. “There remains what we would call a ‘say/do gap’ in how hospitals currently address and implement new initiatives,” the study concluded. “The hospital executives who responded to our survey said they understood the steps essential to successful project implementation. But they also acknowledged that their organization's follow-through on some of these steps is inconsistent at best.”⁵ If a visitor from Mars were to assess hospitals and other health care organizations, he or she might conclude that they all want to get better—indeed, to be the best in their class. They just do not want to change.

There are reasons for this reluctance. Health care has many stakeholders, and it is a rare occasion indeed when all of them share the same interest in change. A reform that one group supports may be adamantly opposed by other groups. What one stakeholder views as an elimination of waste may be seen by another stakeholder as an assault on his or her income or prestige. Then, too, medicine as an enterprise is necessarily conservative. “First, do no harm” is still a time-honored precept, as it should be. Clinicians rightly want to know that a proposed change really will do no harm, and that the chances that it will lead to better outcomes are high. Of course, this conservative attitude can be, and often is, taken to a harmful extreme. One unit of a health care organization may mistrust the motives of another, and so refuse to have anything to do with a change that the other unit proposes. And all organizations have their share of what I call CAVE people—those who are Constantly Against Virtually Everything.

But these aren't the only reasons for health care's failure to change. There has also been a chronic deficiency in leadership and vision. Most health care organizations do not go about change in the right way. They start things they never finish. Sometimes they get bogged down in details when they should be looking at the big picture; other times they focus on a vision of the future while ignoring the messy details of reality. Most important for our purposes, they pay too little attention to the launching of an initiative, and then are surprised when it never takes off. They are like a pilot who assumes the plane is airborne before it ever leaves the ground.

What nearly every health care organization I have seen needs, and often lacks, is a deep understanding of how hard the process of change really is, and how the difficulties can be eased by a systematic approach. That is the subject of this part of the book. We will look closely at the process and see what is required to address it. We will examine what it means for an initiative to succeed, and how good planning can put it on the path to success. Along the way, I hope, you will begin to understand how to create that systematic approach to change that really can begin to improve health care.

Summary

• Despite its accomplishments, U.S. health care faces significant challenges.
• Most health care organizations have many projects under way, but few organizations have been successful in actually changing the way they operate.
• The chief reason for this failure is the absence of a systematic approach to change.

Notes

¹ Elizabeth A. McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine 348 (2003): 2635–2645.

² Institute of Medicine, To Err Is Human: Building a Safer Health System (Washington, DC: National Academies Press, Nove...

Table of contents

• Cover
• Title Page
• Copyright
• List of Figures and Tables
• Dedication
• Preface
• Acknowledgments
• The Author
• Part 1: Changing Health Care
• Part 2: Select the Right Projects
• Part 3: Choose the Right People
• Index
• End User License Agreement