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Embracing Change in Tough Environments

Change is difficult for most people. It usually feels easier and less risky to keep the status quo. People settle into certain procedures and relationships to accomplish work, and, over time, these patterns become expectations and rules for all to follow.

When making changes in organizations, it’s important to manage both socio-technical change– the changes of people and work processes– and emotional change– the change process itself as experienced by the people involved. If you are implementing a new dining program, the socio-technical changes would be the menu changes, the different roles of staff, new food items needed, etc. The emotional changes would involve how CNAs feel about serving in the dining, how department managers feel about increased responsibilities, how the foodservice director feels about less oversight over the food program, etc.


Change Management in 8 Steps

John Kotter, a well-known leadership professor from Harvard Business School, has studied change initiatives extensively. Specifically, he has looked at why some change efforts succeed while many other change efforts fail. (Kotter estimates that 75% of large organizational change initiatives fail.) Based on his extensive research, Kotter has developed an eight-step model for improving change processes. (Kotter, Leading Change, 2012) The steps are:

1. Increase the sense of urgency: People need to understand why they must change. Whether it’s a new payment model or different resident expectations, it’s important to make the case for change. A common example is to imagine you are on a burning off-shore platform. While jumping into the ocean seems terrifying, it is the only way forward with a chance at survival.

2. Build the right team: Once again, the team is crucial to success with changes. Make sure you work hard at building a strong, committed team. In the old days, it may have been important to have staff that followed instructions and didn’t rock the boat. Now, however, we need people who can problem solve independently and aren’t afraid to speak up when they notice a way to better serve residents.

3. Get the right vision: Know where you are trying to go. For most organizations, focusing on the needs of the person served is at the core of their mission, and it’s usually fairly easy to align the vision with this mission.

4. Communicate for buy-in: Communicate, communicate, and communicate. Use a variety of methods and materials, be frequently present, and engage staff to ensure understanding. Rarely has a change initiative in any organization been over-communicated. Remember that communication is a two-way street, too: don’t just shovel out memos and information—listen to feedback and make sure to engage all in the process.

5. Empower action: Leaders cannot do everything themselves. Instead, work hard to empower staff to make decisions, and support them, even if the decisions turn out to be wrong. Mistakes are usually the best way to learn how to do better, so take those opportunities to mentor staff rather than punishing them.

6. Create short-term wins: Don’t begin with a giant, long-term overhaul, as people will tend to lose interest and commitment to progress. Focus on small, visible goals first to build excitement and engagement. One of the reasons why 5S is a great starting place is that it’s both easy and plain to see. People see and experience the change and are much more likely to work on larger projects.

7. Don’t let up: Once a change begins, understand there will be peaks and valleys. Don’t give up on the goals and vision. Push forward with focus and dedication to the team.

8. Make it stick: For change to be successful long-term, it has to become part of the culture. This is as true for Lean and improvement as anything else. Build improvement thinking into every part of the culture, from orientation to evaluations to celebrations. Ensure that respect for people is practiced by everyone in the organization and that everyone spends time thoughtfully reflecting on how to do better. (Kotter, Getting Change to Stick, 2011)

Emotional Transitions

William Bridges, in Managing Transitions, developed a model for managing the emotional impact of transitions (Bridges, 2009, pp. 4-5):

1. Letting go, losing, endings:
When implementing change, it’s important to recognize the loss associated with letting go of old ways. Oftentimes, the people who struggle the most with this will be the best employees—after all, they have been the most successful in the old system. Spend time preparing for the transition by talking about the reasons for the change and how it will benefit residents. Build up the need for improvement. Also, understand that people are generally more likely to take a risk to minimize a loss (holding on to the status quo, for instance) than to take a risk to obtain a gain (a better process or outcome). That’s why even a positive change can be hard for people to accept.

2. The neutral zone:
The neutral zone describes the uncertain area between the old and new. Things are different, but not quite settled. Staff experience confusion and uncertainty in what’s happening and where the organization is going. Communicating a strong vision, encouraging people to try even if mistakes occur, and finding short-term goals to mark success are all crucial waypoints to guide the team through the neutral zone.

3. New beginnings:
New beginnings can be exciting, but there is often a tendency to slide back. To fight this tendency, active engagement from leaders is a must! You must work hard to build the new way of working into the very culture of the work area, from training new staff to ensuring that resources and rewards are aligned with the new way.

Moving Forward

TeamworkThe need to change is neither going away nor slowing down. But applying a good change management framework, along with proven tools and techniques, can help ‘grease the wheels’ that will lead to better adoption, less frustration and better outcomes for residents.

Embarking on a change initiative in your organization? Feel like you are stuck in the mud? Get in touch and learn how we’ve helped organizations just like yours move ahead of the pack.

What We’re Looking For at HIMSS14

We’re excited to be a part of the 38,000 IT and Healthcare professionals gathering in Orlando for HIMSS 2014. With speakers including Hilary Clinton, Karen DeSalvo, and Marilyn Tavenner, along with a massive education schedule, we’re bound to see and hear some amazing ideas and stories. We’re also looking forward to the vendor Expo to see what’s up and coming on the technology/ product side.

A few things we’re hoping or would like to see:

  • Collaborative care platforms, such as Caremerge, with focus on LTC settings.
  • E-call systems with integrated RFID tracking, motion/ moisture/ impact sensors, texting input and output, and NFC-activated staff response and care plan availability.
  • Mobile based or other innovative “over-bed careplans.”
  • EMRs that facilitate person-centered practices rather than institutional documentation needs.
  • New passive sensor deployments and opportunities in community-based living.
  • Massive Open Online Courseware ideas and deployments for staff/ resident/ family training, including those with a focus away from long, static lecture styles.
  • Medical devices with seamless integration into EMRs and point-of-care databases.


If you’re attending the conference, drop us a line; we’d love to get in touch!

Software to Support Self-Managed Care Teams

Self-managed work teams are ideal for providing resident-focused quality care. For communities utilizing self-managed care teams, one of the biggest challenges is facilitating communication effectively between team members who work on different shifts and different days of the week. Shift-to-shift communication books are challenging to keep up, and information oftentimes is quickly lost; team meetings are effective, but rarely can all team members attend. While unfortunately EMRs are far behind on collaboration features, several software solutions are available to help overcome communication obstacles, share documents and projects, and strengthen a community within teams.

Here are three of our favorites:

1) Confluence by Atlassian: A combination wiki, task management and enterprise social feed. With pricing that starts at $10/ 10 users, Confluence is a fantastic bargain. Information can be organized through separate wikis; for instance, each team or neighborhood can create their own with resident profiles, team agreements and workflows, while group spaces can be used for workgroups and departments. Policies and procedures can be developed and updated collaboratively, and then deployed for all to see. Because each space can be edited easily, it’s easy to create answers to common questions, and provide routine guidance that allows for greater decision making at the staff level.

2) Yammer: A private social network perfect for connecting teams. Think of it like Twitter and Facebook, but structured for a workplace. It allows for easy team discussion, facilitates document sharing and group announcements, and can be organized around multiple groups (by neighborhood, license type, department, etc.).

3) MangoApps: An enterprise social feed, project management, and wiki solution that also provides online meeting and event management support. Sharing documents is a snap, and it’s even easy to track page views and downloads, which can help ensure accountability within a team. Groups and projects can invite guests to either provide comments or participate fully, which expands opportunities to connect with vendors, providers and family members.

Enterprise social networking tools can dramatically improve communication and provide true empowerment opportunities to work teams. They can also expedite staff announcements and drive engagement on important workplace issues. Project management support can help integrate quality improvement activities, and social components can allow for better cross-shift and cross-functional relationships.

Whatever tool you utilize, it’s important to ensure policies and staff training address potential HIPAA concerns. Hosting software locally allows for tighter controls, but SAAS solutions can be appropriate with sufficient safeguards in place.


(For a great primer on self-managed work teams in long-term care, I highly suggest Empowered Work Teams in Long-Term Care: Strategies for Improving Outcomes for Residents and Staff By Dale Yeatts, Cynthia Cready, Linda Noelker.)

Design for Adoption, Not Implementation

Talking with a colleague at UNC Healthcare (currently undergoing an EPIC adventure), I’m reminded that most healthcare organizations approach EHR transitions from a misguided perspective. Driven by software vendors’ implementation teams, providers try to recreate old workflows with the new systems.  The new processes, rather than being rethought for efficiency and effectiveness, are designed to closely resemble the old way of doing things, and either become more complex or, worse, fail to capture the massive power of EHRs. Occasionally, when blocked by the software (obviously not designed by anyone remotely connected to practice), a new process is developed and thrust upon staff. Not only does this complicate workflow, it tempts line staff to develop workarounds to retain their old way of functioning.

Predictably, providers struggle to realize the benefit of EHRs. In a recent study, HealthLeaders Media reported 27% of healthcare leaders felt EHR systems were a waste of money. In a great article written several years ago, Jon Roberts aptly describes the dilemma still true today:

Traditionally hospital staff learn to use a new IT system the following way: The IT vendor designs classes to teach staff how to use the new system. Classroom time and content vary based on the job that each person does. Some staff are anointed as “super-users” and meant to be a resource to the standard “end users” who will need help in the future. Once the coursework is completed, staff are given time to practice using the system, often with super-users present to help navigate through problems.


The problem with this approach is a matter of context. People are taught how to use the new system according to the system’s functionality, not according to how staff will use the system to do their job. That’s a major distinction. I’ve observed many of these classroom sessions, and when the instructor asks, “Does anybody have any questions?” the room gets quiet. People don’t know what they don’t know.


When the system is up and running, it becomes immediately clear to staff when they have a question, but it is rarely clear where to turn, and patients are waiting. This is when the hidden costs of a new EMR begin to reveal themselves and productivity drops.

I remember working with one community that had adopted an EHR several years before. CNAs charted bowel movements in the point-of-care application and in a notebook at the nurses station. Then, at shift change, the information was communicated yet again, verbally, to the next shift. Even though the EHR provided a system for tracking bowel movements, the nurses had found it too cumbersome to use the reporting feature and thus recreated a paper binder. Then, because not everyone looked at the binder, the information was communicated in person.

When the process was redesigned to incorporate the customized alerting feature of the EHR, the nurses were provided with more timely notice of needed action, and 1.25 hours of daily CNA time was recovered.

What can be done?

First, we need to stop thinking of the process of bringing on an EHR as implementation and start thinking about it as adoption. It’s a new way of doing work: expect it to be complicated; expect the EHR vendor to misunderstand your community; expect hiccups and roadblocks and brick walls. Implementation focuses on a “go-live” date, whereas adoption focuses on successfully achieving certain predetermined outcomes. Thus, adoption continues long after an implementation ends.

Second, evaluate your current practices carefully. Examine the new workflows proposed by the EHR system. Collaborative redesign workflows to integrate EHR tasks into other work without relying on one-to-one transition from old paper-based recording to electronic means.

Third, ensure the training plan is reflective of future users. The train-the-trainer model used by most vendors misunderstands communications practices, adult learning styles, shift-based schedules, and workplace dynamics. Instead, training should be designed for specific roles and tasks and include a process of evaluating mastery.

Finally, leadership must commit to actively supporting, monitoring, and adjusting the adoption as an ongoing priority, not as a delegated task or finite project. When adopted correctly, EHRs can vastly simplify cumbersome processes, drive enormous efficiencies, and increase staff satisfaction. Incorrectly, EHRs can drive exactly the opposite.

For further reading, I strongly suggest Beyond Implementation: A Prescription for Lasting EMR Adoption.

No Bench Players: The Role of Senior Leadership in Pre-work to Adopting Lean Six Sigma

A key precursor to beginning a lean six sigma program is accurately determining the current state of your organization and its readiness for a significant philosophical change. Senior leadership plays a key role in determining the success of lean six sigma adoption. Consider the following questions:

A)     Does senior leadership understand LSS?

B)     Is senior leadership committed to LSS philosophies and practices?

C)     Does the organization have an established practice of open communication and strong alignment between leadership layers regarding organizational goals and priorities?

D)     Does the organization have sufficient resources available to provide needed support and nurturing of a beginning LSS program?

If you cannot answer yes to each of these questions, you should consider adopting lean six sigma tools only, and delay any wholesale adoption of an organization-wide program. Failure to have a strong platform in place before beginning will result in not only a likely failure of the program, but also lead to decreased confidence and increased cynicism of future change initiatives.


First, senior leadership must understand lean six sigma: what it is and what it isn’t, and what it does and what it won’t do. While it is not necessary for leaders to understand the intricacies of LSS, they must be able to confidently articulate LSS philosophy and intelligibly describe tools, processes and goals. Many organizations that fail to adopt lean six sigma effectively do so when leadership mistakenly believes LSS will do or be something that it isn’t. While some improvements will yield immediate results, full adoption takes more than a year, and improvement plateaus (or even dips) should be expected during this time.

Long-term care organizations, in particular, need to be cautious about alignment throughout the organizational structure, as there frequently are significant disconnects between line staff, front-line supervisors and executives. Third-party facilitated staff surveys and focus groups to identify communication patterns and levels of trust are highly recommended. (For an excellent resource on psychological safety in healthcare organizations, check out Team Effectiveness In Complex Organizations: Cross-Disciplinary Perspectives and Approaches.)


Merely understanding LSS and providing tacit support is not enough for a successful adoption: senior leadership must be involved. It’s important to structure this involvement properly, however, striking a balance between controlling too little and too much. Organizational practices must be examined for alignment with LSS philosophy, as line staff typically are keen observers of organizational doublethink—particularly if they have experienced a history of undiagnosed failed initiatives. Policies and procedures, for example, need to be rethought in terms of alignment with actual practice and employee-centeredness.

Staff must also have sufficient time to participate in improvement projects. While organizations are oftentimes loath to increase staffing hours, it simply is impossible to adopt an LSS program without dedicating time to learn, practice, and improve.

If the organization doesn’t have a trained LSS staff member, a trained consultant should be retained for three to six months during adoption and periodically over the first year until internal staff champions are trained. Experience with change process and LSS is critical to respond effectively to challenges and obstacles that are sure to occur.

Bottom Line:

If the above conditions aren’t met, the organization can still use Lean Six Sigma tools to assist with performance improvement projects. Indeed, most LSS tools can offer strong benefits even without total adoption (a 5S event is an easy start). Users should be cautious, however, about long-term sustainability of results, as organizations that don’t adopt LSS as an organizational philosophy will find inertia creeps in and reduces gains over time.

Ready to get started? So are we!