We need speed, change, resistance management
(Editor’s note: This is the first article in a new feature to appear regularly in QI/TQM. Here you’ll find quality leaders talking about tough issues and industry-shaping trends. This month we talk with Chip Caldwell, senior vice president with Premier Performance Services in Charlotte, NC, a leading health care consulting and information services company specializing in strategy deployment, managed care, decision support products, benchmarking, and re-engineering. He is the editor of a major new publication, The Handbook for Managing Change in Healthcare, along with noteworthy co-authors like Dennis O’Leary, Paul Plsek, Gene Nelson, Paul Batalden, and Maureen Bisognano. The book is available in the Interactive Research Library at www.iiac.com.)
Question: Among the trends shaping quality improvement today, which present the greatest challenge for health care quality managers?
Answer: One of my mentors, Paul Batalden, MD, now at Dartmouth College in Hanover, NH, told me of a social visit with a Nobel-prize winning physicist from England. The physicist observed that technology is getting information or knowledge to us in an exponentially faster rate every day. Unfortunately, this ability can be counter-productive and certainly not useful until we change our methods of knowledge application. The physicist showed Paul a little graph he had devised that tracked knowledge acquisition as an almost straight line upward, while the line representing our ability to use that knowledge is rising only slightly.
His point, and I think it a good one and particularly applicable to health care, is that until we change our methods of training employees, of re-engineering and process improvement all that knowledge is not put to good use.
Stated another way, results from benchmarking, applied research via such sites as interactivechange.com and iiac.com, the IHI’s Breakthrough Series, and other vehicles, are populating change databases at an alarming rate, yet our ability to implement and apply these breakthroughs can not keep up unless we also redesign our models of knowledge application and training for speed.
Process improvement lags behind
Today, our dilemma is that we’re making our largest investments in decision support systems, yet the investment in process improvement is woefully behind. Let me give you an example. A large, nationally known teaching institution in New England has invested $5 million per year in decision support. Now they can drill down instantaneously to the process level to determine where they have issues to be dealt with. But their budget for performance improvement, for quality management, is less than $200,000. That includes salaries; they have one FTE. Still they don’t understand why their costs continue to go up at 8% a year when they have all of this information. They’ve got $5 million invested to find the answer, and $200,000 to fix it. This is not to suggest that decision support is not a worthy investment, it is to point out that knowledge gained does not equal knowledge applied. Application is a process just like all processes. This one begins with decision support, with benchmarking, collaborative participation, and accelerated replication in the middle, and ends with redesign or process improvement. I think this poses a major dilemma across the industry.
Question: Why is it that provider executives and managers fail to see this link?
Answer: I think it’s twofold. First, it is the perception at least on the part of senior executives that process improvement is just too slow. And so, they think pouring any more resources into re-engineering staffing or clinical facilitators will produce results too slowly for their strategic needs. That is not true, of course; process improvement and re-engineering moves as fast as the organization’s model for deployment. The Mayo Clinic, for example, achieves radical clinical process change in 5-week cycles. Speed is particularly achievable in light of some of the innovations going on with accelerated methods. Nonetheless, their thought is "well, we’ll just get this information to the managers and tell them to get going with it." That, in a nutshell, is the second reason many fail. They fail to allocate sufficient resources toward implementation. Their bosses assume the managers know what to do with this information. But the managers don’t know what to do because that is not a skill that has been transferred in most organizations. The "how to do it" is the part most quality professionals and management engineers are struggling with today, and much of the "how-to" is wrapped up in the management of resistance to change.
Question: Aren’t most health care quality managers using accelerated methods more now than traditional CQI approaches?
Answer: Well certainly that is true to some extent, but it is not as widespread as you might think. I would say no more than 20% of the folks that I run across in consulting and at the talks I give at conferences are truly accelerating the implementation.
The very first ingredient of an accelerated change model would be designing the model itself for speed. But we never thought of designing the model for speed in the past, so what might that look like? The Juran Institute blitz clinical teams that were piloted at the Mayo Clinic are an example. They are designed for speed: The accelerated clinical model has eight meetings, and those eight meetings occur in just five weeks. The Center for Interactive Change (interactivechange.com) in Charlotte, NC, a rapid change group that uses the Internet, has one organization that has implemented 174 changes in less than 60 days, with only 60 people involved 60 managers. So the accelerated replication model, in this case over the Internet, is designed for speed. So that’s the first critical factor. Is the design itself, the method or the model being used by the organization, designed for speed?
Question: What are some of the accelerated improvement models?
Answer: There is the Premier Fast Track Benchmarking Series, Juran’s blitz clinical improvement method, and the Center for Interactive Change Internet-based model I mentioned. The General Motors’ PICOS model is also designed for speed. That’s a one week process in which you design the change and then implement it as fast as you can. The IHI Breakthrough Series is designed for speed. (See QI/TQM, August 1997, p. 97, "Special Report: IHI’s rapid improvement model.") But there’s no reason why any model cannot be redesigned for speed.
Question: How crucial is it for quality managers today to adopt an accelerated model as opposed to traditional methods?
Answer: Our research, as well as that of the ASQC, says that the plaguing issues are three-fold. First is our need to integrate the health system in a logical way. The second is to remove non-value added cost or to remove cost without negatively impacting quality, and the third is speed. And of the three, speed is the most important.
Question: The need for using accelerated methods sounds like it may take care of itself as more quality managers become aware of these models. However, the other part of the problem managing resistance to change sounds more problematic. What do health care quality managers need to know about that?
Answer: The management of resistance is my current passion right now, and I’m not finding good answers. I’m not an applied researcher; I’m like most internal and external consultants. I look for others who are trained researchers to provide the answers. But in my own mind, the management of resistance as a structure in an organization can be flowcharted just like any other process.
In my opinion, there are two parts of managing resistance. Part one is mastering the psychology of organizational change. There’s more research there than anybody would ever want. It would fill the Library of Congress. It probably already has. It’s all that stuff we do for managing the quality culture, helping people share values. We call that the soft side. That’s important. It’s one of the two critical competencies that organizations, I think, have to master. The one that I find grossly lacking is part two mastering the process of change.
Think about that a minute. Take this example: We’re proposing to a group of cardiac surgeons that we substitute Ancef for Vancomycin for heart surgery because that’s been well researched by the Mayo Clinic, Stanford University, and other leading organizations. We suggest the idea to the cardiologists, they consider it, then they go through a process of assessment that ends in either buy-in or rejection.
Several process subroutines exist as they work through the concept. We can flowchart how this assessment process functions just like we flowchart any process, in fact, I highly recommend it.
My point is that mastering that process or flowchart of change is as critical as mastering the psychology of change.
Question: Is there a good model for mastering the process?
Answer: I haven’t seen one. I think the field is struggling for some very interesting applied research in that area. I was doing a keynote presentation for the Ohio Deming conference with 350 people, and I broke them into groups of 10 and asked them to flowchart the way that particular decision would happen in their organization. Then I had a few of them present it. Again, I haven’t found any answers. But their flowcharts were amazingly consistent in the sense of here’s how an individual will consider a change being suggested.
Question: Will health care have to develop its own models to get through these issues of speed and management of resistance to change, or can we adapt?
Answer: I think we can adapt. The interesting thing here, and I’m proud of this for the first time in the process improvement/re-engineering, quality profession, or change management consulting profession, health care is leading the rest of the world.
Question: In what respect?
Answer: Our models are faster. While I was at the Juran Institute, many of the manufacturing clients were screaming for us, the health care team, to teach manufacturing speedy methods. They were saying "Let us learn from you; teach us and help us understand what to do."
Question: What kind of projects should quality managers look at now?
Answer: I think the basic blocking and tackling of process improvement and re-engineering still apply. It is just a matter of continuing process improvement and applying it to proper situations.
To become more productive in any process is to be inquisitive on the resource side. What would it take for every nurse to take one more patient per shift per day without negatively impacting our pre-established quality standards? Let’s look at those breakdowns and constraints in the process and see if we can’t redesign them.
In practice, what begins to happen is the nurse or patient care managers begin to say "well, look at this, we’re plotting the vital signs in four different places in one hour. Lets see if we can’t get by with one place every four hours." That’s a real case study from Louisiana. When they were asked that question, they stumbled across several constraints and went systematically about solving those constraints. A good strong benchmarking study would tell you specifically where those issues are.
Question: There isn’t much benchmarking going on by health care providers outside their own industry. Is this a significant handicap?
Answer: Personally, I think not. I think in terms of a hierarchy when I think about benchmarking or looking for best practices. The first place I encourage an organization to look is at internal variation in clinical and operational processes. Invariably, we find that there is tremendous internal variation, sometimes as much as 80%.
To me, mastering internal benchmarking is the most effective form because we all know each other. After decreasing our internal variation to about 10%, then we can look to the health care best practice and achieve the 10th percentile in that process. After achieving this benchmark, we have no choice but to seek knowledge outside our industry. This is, of course, not to suggest that we can learn nothing by external benchmarking, but rather that internal benchmarking is faster and more effective.
Question: And if you clean up your own house eliminate those variations you may find that you’re at the top of the industry?
Answer: It’s interesting you make that observation because what we’ve found is that when we look at the average performances across the country and then look at internal benchmarking, we usually find that someone in the medical staff is already better than the best average in the country.
Most organizations already have better than the best practice sitting right there in their back yard, but they just never look for it. In all of the data that I have seen of internal variation analysis, we have only seen one case where there wasn’t a physician that was already better than the average of the best.
[Chip Caldwell is senior vice president of Premier Performance Services in Charlotte, NC. If you’d like to chat with Caldwell, you can reach him at (704) 679-5062. Or e-mail him at [email protected].]
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