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(This month, Paul Plsek, MS, discusses the keys to sustaining organizational change, and the characteristics of health care organizations that make them a unique challenge in this area of continuous improvement. He is a health care consultant in Roswell, GA, and was recently tapped to serve as national chairman of Irving, TX-based VHA Inc.’s initiative to improve member health care organizations’ processes for disseminating new ideas and sustaining the resulting improvements over time. Plsek is a senior fellow at the Institute for Healthcare Improvement in Boston and is active in research projects with the Harvard School of Public Health and the Vermont-Oxford Neonatal Network.)
Q. Creating organizational change can be challenge enough, but sustaining that change sometimes can be even more difficult. What are some of the major barriers to sustaining change, and what strategies can help remove those barriers?
A. When people ask me about this notion of sustained change, my first reaction is to get them to realize that every entrenched idea in an organization is a past change that has been well-sustained. So we are really quite good at sustaining change. The same mechanisms that we feel we need to battle against to make change are actually the ones we use to sustain change.
Q. What are those mechanisms?
A. The first is routine. We can do better at sustaining change if we build it into our routines — make it feel like a natural part of the work. I see lots of examples where people have added on changes that are burdensome, that don’t flow with the work, and they don’t last. Then there’s vested interest. We tend to feel we have to battle against it, but after we’ve made a change, we need to ask in whom we can vest the interest of this change. This involves engaging people in understanding why the change was made at a deep enough level that they feel it’s the right thing to do and to fight for. A lot of leaders don’t take the time to do this; people don’t "get" the change, they don’t feel vested in it, and it goes away. Related to vesting are politics and formal structure. Change can threaten somebody’s turf or role. If you want to sustain change, build it into the structure, into job descriptions, into what people are supposed to do. So many times with health care changes, we don’t do that.
There should also be a performance expectation that the change is going to be sustained. Build that expectation into your annual performance review. Build in goals such as: By the end of the year, we still want this level of performance to be at 95%, and so on.
The final mechanism is measurement. Data make change real for people. If you want to sustain that change, you have to have a measurement process in place so you will know if the change starts to slip away. A lot of improvement methods have intense data collection when working on the problem, and that’s it. They declare victory, but they don’t keep on measuring change for a prolonged time.
This ties back to routine — if you can build measurement into the structure, you’ll expect to continue measuring. Eventually, it becomes a routine. Ironically, there’s a danger in that if you’re successful in sustaining change, you’ll create the "Oh, we’ve always done it this way" attitude, so you’re constantly swinging back and forth between these two polarities — between wanting to make the change, sustaining that change, yet needing to keep people open to change for the next round. It needs to been seen as a cycle; sometimes, we are sustaining change, and sometimes we are changing. It must be pointed out as a natural rhythm.
Q. Does the length of time an improvement process has been in place impact the ability to sustain that change?
A. It has more to do with whether the change has become routine. The length of time it takes to accomplish this will be different for different issues, but it’s somewhat related to how that process cycles.
For example, if I make a change in the way a telephone receptionist handles incoming calls and that receptionist gets 200 calls a day, in a couple of days that change becomes pretty routine. If, on the other hand, you’re implementing a change in a surgical procedure and the team of nurses only takes part in that procedure once a week, it will take a longer amount of calendar time for it to feel routine.
Q. Are certain kinds of changes more difficult to sustain than others?
A. Where there are more people involved and more vested interests to unfreeze and give new vesting to, it will be harder to sustain the change.
Q. What strategies should be employed in those situations?
A. The leader or change agent really can’t hope to have close interaction with everybody, so there need to be intermediaries, or opinion leaders. If you can convince a nurse considered by all to be an opinion leader, that opinion leader will influence others.
Q. What is it about the distinctive nature of health care organizations that can create unique challenges to sustaining change?
A. Several things. For one, there are the multi-professionalisms of those organizations. The vested interests can be even deeper; a situation can become nurses vs. doctors, which complicates things. The presence of regulation can make changes in health care difficult. Even if you decide locally there’s a better way to do something, if it violates regulations, it can be outside your span of influence and control. And if change has to do with technology, the imbedded investment can make it difficult.
Q. How can you overcome the challenge of multiprofessionalism?
A. Find points where people can rise out of their professional silos and find that common ground, like the patient. It’s a reasonable assumption that people working in health care do care about the patient, so if you can make the good of the patient the basis for sustaining change, I think you’ll have a better chance. But it’s hard work.
Q. What can quality managers do today to improve their chances of sustaining change?
A. One thing I’d like to see quality managers do is not declare the end of an improvement project until they’ve really tackled the issue of sustaining change. It’s not over when you get that first month’s data showing things are better than before; you must address those issues I raised earlier.
Expand the definition of improvement projects to include what Joseph Duran called years ago "holding the gain." The problem is that with today’s hectic work pace, people want to declare victory and move on. But then a few months later, they’re back to the same level of poor performance there was before.
[For more information, contact: Paul Plsek, 1005 Allenbrook Lane, Roswell, GA 30075. Telephone/Fax: (770) 587-2492. E-mail: Paulplsek@directedcreativity.com.]