Guiding change in the ED: Teamwork, communication are key
August 1, 1997
Guiding change in the ED: Teamwork, communication are key
A department-wide coalition of nurses, physicians, managers, and administrators can be an effective force to achieve rapid results
Knowing how to create widespread change isn’t merely important for today’s ED managersit’s an essential tool of survival. "The pace of change is accelerating so rapidly, whether you look at managed care, patient acuity, competitiveness, or customer service," says Thom A. Mayer, MD, FACEP, FAAP, chairman of the department of emergency medicine at Fairfax Hospital in Falls Church, VA. "If you don’t understand the science available on how to make those changes occur, you’re making a big error."
ED leaders must possess the skills to keep up with rapid changes. "Unless we have some sense of how to manage change in a professional, scientific fashion, it’s like trying to take care of a trauma or cardiac patient starting from scratch every time instead of taking advantage of well-recognized clinical protocols to help guide us in our direction," argues Mayer. "Change management is a way of dealing with the extraordinary pace of change but with a road map, using the experience of other people who have been through it."
More than any other speciality, emergency medicine is a hotbed of change. "All the changes that occur in health care are reflected in the ED," says Jim Augustine, MD, FACEP, CEO of Premier Health Care Services in Dayton, OH, and chairman of the department of emergency medicine at Miami Valley Hospital. "People should expect that change is going to continually take place, especially in emergency medicine."
It follows that emergency physicians are prime candidates to drive change. "If we don’t do this, who will?" asks Mayer. "Emergency physicians represent the best of not just medicine, but medical leadership. We have more experience than anyone at juggling different balls and managing change."
An emerging breed of physician managers are emergency physicians who will lead change in the coming years, notes Mayer. "Our COO is an emergency physician, and many of the people running HMOs are," he adds. "We need to move forward with force and confidence and look at change management as a specific set of skills which can benefit us personally and professionally."
ED managers must be ever-vigilant when confronting change. "You have to keep fighting for it because your environment is constantly changing," says Lindy Rose, RN, BS, director of the ED at Harris Methodist Medical Center in Fort Worth, TX. "What worked a year ago might not fix the problem now, so you need to keep making changes to keep your target."
The need for change should be assessed on an ongoing basis. "If you start to see your complaints or waiting times going up, or any of the dials moving in a direction that’s not positive, it’s a sign. But, that’s not enough," says Mayer. "You need to keep your ear to the ground and constantly talk to staff and patients, always asking the question, how can we do this better?"
Act as a team
Leaders shouldn’t look at change as a one-person crusade. "One of the key principles is having a powerful guiding coalition to advance change," advises Mayer. Familiarize a core group of physicians, nurses, and nurse managers with the principles of change management, so they can actively participate in the way change occurs, he says.
"Any time a change is anticipated, follow those guidelines and discuss how the change will be managed among that coalition," says Mayer. "That way, there are no secrets, the information is there for everyone, and change is occurring in a managed fashion instead of willy-nilly."
It’s essential to get input from staff on how to achieve change. "We asked the people on the front lines how to get the result we wanted, so they would own the process," says Rose. "When put into effect, their ideas had the best results."
Don’t proceed until you have the buy-in of staff and administration. "If you have a group of administrative people surrounding you who are consistently unwilling to support your efforts, the change effort has very little chance of success," emphasizes Mayer. "You cannot continue without the help of other people."
Identify allies you can work with as well as those who resist the change effort. "Try to figure out who the biggest opponent of any change is going to be, and put them on the guiding team," says Mayer. "That way, they’re inside the tent and vested in its success instead of being on the sidelines saying, That’ll never work.’"
Communicating the urgency of the situation
One example of broad-based change that requires the entire team’s involvement is a "customer service revolution," a process undertaken by Fairfax’s ED. Hard data were used to prove the current process wasn’t working. "We established a sense of urgency by showing the number of complaints we had and also showed that certain behaviors were very effective in bringing about change," says Mayer.
Mayer was careful to frame the need for change in a positive light. "We didn’t say, You guys are terrible, and we need to fix this right now,’" he says. "Instead, we said, It’s a difficult job. Let’s see if we can help you come up with some skills and techniques to allow you to do that job more effectively.’"
A core group of nurses, physicians, managers, and administrators were pulled together. "That way, the physicians and nurses who would have to enact it were on board instead of having change forced upon them," says Mayer.
Staff were encouraged to air their anxieties so areas of resistance could be anticipated. "If you make it clear publicly that anyone who has an opinion needs to let the coalition know, you’ve done pretty much all you can do at that point," says Mayer. "You’ve let them know their voice is important, but you’ve also protected your flank by saying, Any comments need to be directed toward the people who will be enacting the change.’"
The vision of better customer service was communicated in department meetings, on bulletin boards, and with personally addressed letters sent to staff members’ homes. When the decision was made to post a sign in every treatment room announcing the ED’s missionto provide the best critical care and customer service of any ED in the countrythe staff was asked for input on the wording.
After the ED’s customer service goal was decided, the way to achieve it was largely left up to the staff. "You need to encourage others to act on the vision. That’s the step where a lot of people fail, and it becomes management’s change instead of the staff’s change," says Mayer. There are a many different ways to achieve results, he notes. "What you really want is conformity of results and diversity of methods. There are a lot of ways to end up with the result of satisfied patients."
The ED’s customer service "wins" became a regular topic of discussion at staff meetings. "We celebrated them very publicly, praising people openly and sharing letters from patients who had written to say they were satisfied," Mayer notes.
Positive customer service experiences were shared. "One of our docs told a story about a father who was up with his child all night, and the lab had lost the blood and all kinds of stuff. She thought, Man, we are getting a letter on this one,’" recounts Mayer. "The doctor walked up to the man and said, You look like you’ve had a bad night, let me get you a cup of coffee.’ Sure enough, we got a letter but it was a letter of praise." Sharing success stories can help accelerate change, he adds.
Customer-friendly behavior has become part of the ED’s standard practice. "We took all those little pieces and institutionalized them, so they became a policy," Mayer explains. "It’s not necessarily a written policy, but it’s the way we do things here.’ It’s not uncommon for staff of any kind to offer a blanket or get some orange juice for a patient."
Constantly challenge the status quo
Resist the urge to accept things as they are. "Leaders need to articulate and challenge the status quo relentlessly," says John P. Kotter, the Konosuke Matsushita Professor of Leadership at Harvard Business School and author of six bestselling business books, including Leading Change, published by the Harvard Business Review. "You should constantly look for ways to make things better and create some short-term wins to keep you going."
Get in the habit of looking at traditional ways of doing things with a new perspective. "If patient satisfaction is low with triage, and you have four nurses in back and one triage nurse out front, and five patients come in at once, you’re backlogged. But why can’t triage be done in the back?" asks Mayer. Look at each individual step in the process and ask if it adds value to the process. "If not, why are you doing it? It’s not clear that keeping five people in line for triage adds value," he says.
Even small parts of a process are candidates for change, says Mayer. "If you ask an ED tech what one piece of information they need to get a set of crutches for a patient, they’ll tell you instantly, height. But if you ask how many times in 10 years someone has said, Would you get a pair of crutches for me5 feet 7 inches,’ it’s almost never," he notes. "Now, there’s a process you need to fix so the person ordering them has the courtesy to ask the patient how tall they are, so the tech doesn’t have to make two trips down the hall to ask them."
Gather disconfirming’ data
In order to get staff to participate fully, they have to believe change is a necessity. "You don’t necessarily have to come in and say, This place is a disaster.’ But you need to create a true sense that we need to change," says Mayer. "There needs to be a group commitment on the part of the staff to say, We’re going to move forward with this.’"
Gather evidence to show things need to be changed. "You’ve got to make sure they know the process is broken and needs to be fixed, and you need disconfirming data to show that," underscores Mayer. The data should be convincing and highly visible. For example, announce at a meeting that there are a large number of patient complaints about triage.
"Disconfirming data" is evidence that a process needs to be changed. "It’s a perfectly logical question for anyone to ask, How do we know it’s broke?’ It may be broke because we’ve gotten constant complaints about it or because we’ve gone out and searched for that data," Mayer observes. "It may come from a number of different sources but needs to be to some extent unimpeachable and not just somebody’s opinion."
The more specific the data, the more staff will comprehend the benefits. "Use as many real situations and data as possible to back up what you’re saying," says Rose. "Instead of just telling staff, We’re waiting way too long for lab results.’ We used actual data to show exactly how much we wanted to improve. If you can show staff that making this improvement will have a specific benefit to the patient, you get their buy-in. If it’s abstract, it’s hard for them to exert the energy."
Straightforward comments on a personal level can bring the need for change home. "Tell people how it will affect them where they live," says Mayer. "Say, if the ED across town takes a competitive strategy, and they do it better and faster than we do, we’re out of business."
Identify all stakeholders’ in change
Stakeholders are individuals or groups with a vested interest in the change. "They will effect change, either by resisting or helping to implement it," says Mayer. "Change is a deeply emotional experience, and people will retreat to the needs that are essential for them. So try to anticipate and meet those needs."
Once all the stakeholders are identified, get input to be sure the change is addressing all their needs. "Don’t let your fears drive your assumptions about their attitudes. Let their responses guide your opinion as opposed to saying, Oh, they’ll never accept that,’" says Mayer.
Consider both internal and external stakeholders. "Everything we do in the ED is multidisciplinary," Mayer notes. "External stakeholders may hear things from physician group, and another from administration, so it’s important to come across as a unified whole."
When planning a process change, consider everyone who could be affected. "We typically think of the effect a change will have on patient care and our immediate staff, but changes can also affect the medical staff in the community or some other distant area of hospital," explains Augustine.
Consider the entire process, from start to finish, to identify everyone who is affected. "If you’re changing your triage setup, there is a major effect on the people who are driving up in a car," says Augustine. "How are they going to unload somebody who is hobbling or in a wheelchair or holding a child, once you’ve moved triage?"
If triage is moved closer to the entrance, people waiting to enter the ED could be left standing in the cold, or auto exhaust could become a problem. "On the other hand, if you move triage away from the door because it’s more secure, there could be a sudden traffic buildup in that area," says Augustine. "Also, any time you change your triage, it will affect the way EMS operates."
Likewise, treatment plans may affect the hospital’s home health care or social services agencies. "ED managers need to think globally and think about who else might be affected," says Augustine. "Then if they are affected, make them part of the decision-making process. Maybe they can tell you something about your area that you didn’t already know."
During Miami Valley’s ED renovation, the entranceway will temporarily have a single access point where cars and EMS vehicles come in together. "We knew this would affect EMS, so we asked them to come in and design the process," Augustine recounts. "They brought their own vehicles and helped us determine turning radiuses. Many times when critical care patients come in, an engine comes with them because a lot of our EMS is fire-based, so we had to consider that."
In addition to addressing their own requirements, the EMS crews provided insight into the needs of the public. "They helped us redesign our entranceway so it would be compatible with their needs and the general public," says Augustine. "We thought we had solved most of the public access problems, but they helped us think it through much further and improve it."
Administrators may be concerned that getting outside parties involved can let the cat out of the bag. "At some point, you always worry that the competition will know what we’re doing, but if you don’t have the design right to begin with, the competition will eat you up," notes Augustine.
Inviting potential customers or other affected groups to give input on planned changes is a good idea. "Don’t just run things by them," says Augustine. "Make sure they know you will use their input to affect your design, that it isn’t just for show."
Here are some tips to implementing successful change:
• Issue an invitation. Invite staff members to a face-to-face meeting to plan the change. "At the meeting, let data drive the train and move in a direction responsive to it," Mayer recommends.
This may involve bringing people to the table who have never been there before, he says. "If you talk to people who’ve done physician acquisitions and mergers, they’ll tell you that frequently good deals start out with two people who didn’t want anything to do with each other," says Mayer. "Often, individuals other than the usual suspects’ can make things work when it wouldn’t have otherwise," he says.
• Don’t play the "blame game." When inevitable glitches occur, there is a tendency to find someone else to point a finger at. "One of the biggest problems is when we turn on each other, nurses turn on doctors, doctors turn on nurses, and everybody turns on the administrators like a bunch of piranhas feeding on each other," says Mayer. When friction occurs, emphasize common ground.
• Keep current with business literature. "If you want to keep your job, it’s very important to stay on top of that with a great deal of vigilance," says Mayer. "Not many people read Harvard Business Review, but you’ve got to have a high degree of intellectual curiosity if you want to survive these days."
• Look toward the future. It’s not always easy to have long-term vision in the ED’s often-hectic environment. "The short-term pressures may be so overwhelming it makes it hard to think beyond 15 minutes," Kotter advises. An effective leader is able to keep his or her eye on the long-term and not be distracted by immediate demands.
• Plan for short-term wins. Although it’s necessary to have a long-term vision of the future, that’s not enough to keep ED staff motivated. "Leaders need to make some progress toward that vision within a time frame people can relate to," says Kotter. "You need to find the areas that simply don’t take so long, and find the low hanging fruit that is easy to grab."
At Harris Methodist, ED staff were continuously updated on their progress with patient satisfaction scores, both at meetings and in the ED’s monthly newsletter. "It was motivating as they started to see our scores gradually improve," Rose recounts.
• Don’t allow yourself to become complacent. Major changes demand ongoing attention. "Don’t assume that as long as you’re marching in the right direction it will happen," says Kotter. "That’s naive, because the forces of status quo, cynicism, and skepticism can wipe these things out even if you are moving in the right direction."
Since Harris Methodist’s ED met its patient satisfaction goal, there has been a challenge to keep up the momentum with new staff. "We had a group of people who had been immersed in this project for three years, and when we hired new people, it was hard for them to understand where everyone was coming from," says Rose. "In their perception, we had gone totally overboard on patient satisfaction." A three-hour talk is now given to every new staff member to explain the history of the project.
• Share the vision. Don’t be afraid to give a stirring speech now and then. "Vision is not only a directional tool, it’s a motivational tool," says Kotter. "Done correctly, it appeals to something in all of us that says, This can be better, and it’s not a pipe dream, it is feasible.’"
Change mandates leadership. Although staff input is invaluable, leaders should guide the overall vision. "This is not democracy we’re talking about," Kotter argues. "Getting everyone involved and we all vote is not what produces big changesbold leaps do not come that way."
• Simulate before implementing a change. Instead of changing a process such as patient registration throughout the ED, work with a smaller area first, says Augustine. When the Miami Valley’s parking problem needed to be solved, temporary lines were drawn on the ground so bottlenecks could be spotted. "We stood outside and watched how traffic moved at busy times for a couple days," he says.
Likewise, when the ED implemented bedside computers, one module was done initially. "We had staff get used to the change in that area and debug it," he recalls. "By doing a small scale simulation, we could figure out whether the computers should be hung on wall or from ceiling."
Here is a partial list of texts to learn more about change management:
The Empowered Manager by Peter Block, Jossey Bass, 1987.
Building Your Company’s Vision by J.C. Collins. Harvard Business Review, 1996.
Leading Change by John Kotter, Harvard Business Review, 1996.
Reengineering the Corporation by M. Hammer and J. Champy, Harper Collins, 1993.
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