Managing Change in Healthcare Organisation - Essay Example

?Running Head: MANAGING CHANGE IN HEALTHCARE ORGANISATION Managing Change in Healthcare Organisation Managing Change in Healthcare Organisation Introduction The ABC healthcare organisation is a large multiple site facility providing a continuum of healthcare services from acute to long term care patients in hospital setting. One of its acute care facilities which provide emergency services to the community is in need of a new triage system in emergency departments. Both management and the emergency nursing staff have identified the need to improve the practice of triage in the emergency departments. Each has expressed, in written documents, the recommendation to change and implement the new national triage guidelines. At the same time, the emergency department staff has expressed dissatisfaction with how changes have been implemented in the past. They have expressed their perception that there is no formalised plan to implement change. In addition, they have also expressed, in meetings and discussions within the department, their unhappiness with the multitude of changes that have occurred within the organisation itself. The emergency staffs, themselves, have also undergone changes in their unit's management. They have gone from having their own individual managers to one manager for multiple facilities. They have also had a number of different managers over the past few years and identified a lack of consistent leadership within the department. Another issue that has also been identified in staff meetings and discussions within the department is the staff's unhappiness with how decisions are made within the department. It is their expressed perception that the system of decision making within the organisation is top/bottom. Decisions are made by management at the top and flow down to staff at the bottom, who are expected to follow them. The emergency department staff has expressed their feelings of not being listened to. They have also expressed their perception that others are making decisions and implementing changes that affect them, but no one has consulted them in the process. Lack of input and obvious planning are seen as fundamental problems. Changes are seen as being imposed without consultation or any visible change management planning or strategy (Paton & McCalman, 2008). According to Senge (1990), most organisations create fundamental learning disabilities by the way they have been taught to think, interact and do their jobs. In this top/bottom system there is a sense of "I am my position" from the top and "the enemy is out there" from the bottom (p.18-19). These learning disabilities limit the organisation's ability to implement effective and lasting change. A change that is planned and has the commitment of the emergency department staff could be implemented successfully and be of benefit to both the patients encountering the emergency department, and the organisation itself. Identifying the Problem Nurses value quality care and patient safety (Henderson et al, 2007). Accurate decision making is important to them. Nurses want to make the right decisions but do not necessarily like the idea of change. Emergency nurses like many other professionals resist change (Paton & McCalman, 2008). In addition, the tremendous amount of change the facility emergency departments have been through in recent years can be expected to increase this resistance. "However people attracted to a field as diverse and chaotic as emergency care are usually aggressive and motivated and do not tolerate stagnation any better then they tolerate change" (MacPhail, in Budassi-Sheehy, 1992, pl). One cause of the problem is continuous change within the organisation and the perception that change is implemented without consultation or a plan of action (Harvard Business Essentials, 2003). The root cause of the problem is a lack of trust. When employees trust the management they are more likely to be more prepared and open to undertaking change but less likely if they do not feel trust. Trustworthiness needs to be built into any change management approach in order for change to be successful (Clegg, 2006) The paradox here is that on one hand the nurses know a new triage system is needed, so they would welcome change but on the other hand they are so exhausted from all the poorly managed previous changes that it has resulted in a lack of trust. The purpose of this project is to apply change management techniques in a manner that will enhance trust and thereby enhance the effectiveness of a vitally important change in nursing practice within the emergency room setting. Effective Change Management Strategies In the literature on change management, it is clear that many authors share strategies that are similar in their approach to managing change (Poole et al., 2000). Threaded through out are several elements necessary for successful change. The challenge was to find those elements of the change management models that will be essential to implement change in the emergency department. Implementing change successfully requires an understanding of change management (Russell & Hailstone, 2003). A change that is planned, has the commitment of the emergency department staff, and can be implemented successfully would benefit the patients, the nurses and the organisation itself. Even the smallest change has risks and benefits. Careful planning can help minimise some of the negative impacts of change (Russell & Hailstone, 2003). In applying Beer's et al (1996 p.5-10) suggestions for effective change it is important to: mobilise commitment to change through joint diagnosis of the problem. This is important so that the emergency nurses understand the reasons behind the change to a new triage system foster consensus for the new vision, competence to enact it, and cohesion to move it along. This is similar to both Senge (1990) and Kouzes and Posner (1997). spread revitalisation to all departments without pushing it from the top monitor and adjust strategies in response to problems in the revitalisation process. This is similar to the Ackerman-Anderson's (1996) model in which she suggests the importance of learning and course correction in change management. institutionalise revitalisation through formal policies, systems, and structures (Fleming and Spicer, 2007) Brooten et al (1981, p.17 -20) suggests the following for effective change: identify the problem correctly. This is similar to Beer's et al (1996) need to diagnose the problem correctly find out if others want change determine beforehand if change is possible in your hospital convince others to work with you sort out what has to be done; formulate your goals figure out who can help the plan succeed figure out who will resist the plan. This is similar to Bridges (1991) recognition of people's response to change. choose a strategy for putting your plan across carry out the plan assess the results (what worked, what didn't) make the change stick (Paton & McCalman, 2008) In applying Kotter (1995) and Kotter (1996) strategies for effective change in the emergency department it is important to: establish a sense of urgency. Emergency nurses leading the change need to identify potential crises or major opportunities create the guiding coalition by putting together a powerful team to lead change. Nurse leaders should assemble a group capable of leading the change effort and encourage the group to work together as a team empower employees for broad-based action by removing obstacles to the change and encourage risk taking generate short-term wins by recognising and rewarding short-term successes consolidate improvements and produce still more change by identifying people who can implement change institutionalise new approaches by ensuring that the changes become part of the institutional culture for long-term transformation and growth (Fleming and Spicer, 2007; Paton & McCalman, 2008) The Ackerman - Anderson's (1996) model provides several stages necessary for effective change and contains all the necessary elements for the implementation of successful change. The Ackerman - Anderson's (1996) model for effective change has been adopted for this project. It has been selected because they provided emergency nurses with a systematic approach to change management using a model that enlists the cycle and recycle principles. The complete model includes nine stages. However, the scope of this paper involved utilisation of the first six stages of the model involving planning for the change. Method This project took information provided through the use of an action research approach to look at what emergency nurses identify as essential elements in a planned approach to change, when implementing a new triage process. This information was not obtained in order to either support or refute established views on change management but to provide emergency nurses the opportunity to lead this change and to identify those elements essential to its successful implementation. This study was conducted to establish what these nurses needed to implement the new triage process into their clinical practice. The Ackerman-Anderson model was chosen because it contained all the necessary elements and lent itself well to the continuous cycling of action research methodology by looking, thinking, acting and looking again. Each participant was asked to identify what elements they thought were essential to the successful implementation of a new triage process at each of the first six stages of a planned approach to change using the Ackerman­ Anderson change management model (1996). Implementing Change Management Technique Stage I - Prepare to lead the change At this stage of the model the nurses identified the following as essential: The identification of a clear need or purpose for the change, The need for leadership to be visible, and For leadership roles and responsibilities to be identified. Study findings support Brooten et al. (1981), Bridges (1991), Ackerman ­Anderson (1996), and Kotter (1995 and 1996) in that emergency nurses agree a clear purpose or need for a change must be identified and communicated for the implementation of a new triage process to be successful. In the facility staff document the need for change was clearly identified by all, as was the recommendation that the guidelines be implemented. The emergency department staff also identified the lack of consistent leadership as a barrier to successful implementation of change. This is consistent with Senge (1990), Kotter (1995 and 1996), as well as Kouzes and Posner (1997), that clear, consistent leadership and identified roles and responsibilities are essential for the successful implementation of this new triage process. Although a clear case for this change to the new triage system had been made several necessary elements were not identified in any of the participant's responses. For example none of the nurses identified the consideration of organisational culture and its importance in change management. Creating conditions to support the new process as well as developing strategies to deal with the predictable forces triggered by change were also not considered essential by the participants as well. According to Bridges (1991) and Ackerman-Anderson (1996) each of these elements are essential for change implementation to be successful. Another element not identified by any participant was the need to develop further change management knowledge or skills. These may prove problematic in the implementation of successful change if they are not considered. Stage II - Create the Vision and Foundation for Success At this stage of the model the nurses identified the following as essential: The need for a clear and compelling vision of the new triage process The importance of communicating the vision to gain support from the staff The need to identify resources required for the change Also consistent with Senge (1990), Beers et al. (1990), Kotter (1995 and 1996), and Kouzes and Posner (1997) is the fact that a clear and compelling vision of the new triage system must be identified and effectively communicated to the entire emergency department staff. This is essential in order to gain support for the successful implementation of this change. The need for more resources was a strong and consistent theme throughout each stage of the model to the exclusion of other elements such as the pacing of change or the development of strategies to sustain energy throughout the change. This may be reflective of the lack of trust that exists between the nurses and the organisation and may have also been further influenced by the job action. As well as the need to build more trusting relationships, this project also indicated that more knowledge of change management processes is needed if change is to be successful. More knowledge and skills would enable the nurses to have a broader view and to use systems thinking so that each element needed for change is included rather than focusing on a narrow and potentially problematic view of change. Stage III - Assess the Current Situation At this stage of the model the nurses identified the following as essential: The importance of recognising and continuing what works well with the current system of triage an the importance of identifying what needs to be stopped or discontinued as well as what needs to be created The need to inform staff of what are the 'best practices' by educating all staff about the triage process and guidelines The importance of keeping the provision of safe patient care as the driving force for the change These findings are consistent with Bridges (1991) that it is important to recognise what works well, and what needs to be change. Participants recognised that they have specialised skills and knowledge important for assessing and triaging patients. They recognised that the provision of specialised skills needed to continue no matter what system was implemented but that change was needed in order to provide better patient care. The participants also recognised that they needed to start taking more responsibility for patients in the waiting room and to include more use of vital signs and pain scales as part of their patient assessments. Although the nurses identified each of these in this stage they did not identify what needed to be created or what aspects of the current system could be used to gain commitment to the change with other staff. According to Ackerman-Anderson (1996) each of these is necessary for change at this stage. Stage IV - Design the Desired State At this stage of the model the nurses identified the following as essential: Identification of who are the participants and the importance of communication throughout the process of change These findings are consistent with Bushy (1992), Larkin and Larkin (1996), as well as Kotter (1995 and 1996) that effective communication and communication strategies are essential elements for successful change. Other critical elements that were not considered, were those at the strategic, managerial or operational levels of the design. According to Senge (1990) systems thinking is essential to change things more effectively. Emergency nurses need to consider the interconnectedness of the new triage process, the emergency department and the organisation as a whole for this change to be successful. Stage V - Analyse the Impact In this stage of the model the nurses identified the following as essential: Recognition of who is impacted by the change. Recognition of the predictable human impacts of change such as resistance, anger, frustration and feelings of loss These findings are consistent with Bridges' (1991) suggestions that individuals will go through various stages related to change and that it is essential for successful implementation of change to recognise and develop strategies to deal with the predicted impacts of change at each of these stages. Participants also identified the importance of the human impacts of change and how essential it is to recognise these as being normal and not something that can be avoiding. Stage VI - Plan and Organise for the Change In this stage of the model the nurses identified the following as essential: The need for the staff to participate and be committed to the change and The need to identify what resources are needed. Resources were once again identified as a major need for nurses. Literature has identified a lack of resources as a major concern of nurses and was one reason they attributed to standards not being appropriately implemented or met (Henderson et al, 2007). At this stage of the model the nurses did not identify important strategies for pacing change, sustaining energy throughout the transition or strategies to gain maximum commitment from the staff. This would indicate their continued focus on lack of resources has limited their ability to see what is also necessary for successful change and prevents them from seeing the whole picture. Change will be problematic if their views do not broaden to include each of the elements identified for effective change. In order for this to be done successfully though, trusting relationships need to be established between the nurses and the organisation. One step towards building trust would be to address the nurses identified need for more resources. Trust is difficult to establish when needs are not being met. Conclusion and Recommendations The purpose of this project was to identify elements of a planned approach to change that will enable emergency nurses to successfully incorporate a new triage process into their clinical practice. Using the Ackerman-Anderson Model, emergency nurses identified several elements that would enable them to successfully incorporate a new triage process into their clinical practice. Following are some recommendations that would enable the organisation and emergency nurses to achieve desired change. This project suggests: the organisation and emergency nurses continue to work collaboratively together to create a work environment that encourages a planned approach to change management with the implementation of this change and future changes as well. The momentum established during this project attests to the fact that both can work together and continue to lead change initiatives together; the need for more change management knowledge and skills for all staff dealing with change so that those elements identified are considered for change to be successful; educational workshops need to continue so that all staff working in the emergency department will have the opportunity to become familiar with the new triage system in order for this change to be successful; Once additional staffing/funding resources are established, nurses may feel that their need for more resources has been met and they may then be better able to focus on other change management issues necessary for the implementation of the new triage system. Meeting the nurses need for more resources may begin to build a more trusting relationship between the nurses and the organisation. Trust will be needed for them to work together to complete the first six stages of the Ackerman- Anderson model; an evaluation of the new triage process should be conducted within 6 months of its implementation and changes made as needed and identified by all stakeholders. This will continue to foster trusting relationships by evaluating and course correcting as needed. References Ackerman-Anderson, L.S. (1996). Change process methodology overview: facilitating large systems change. Being First Inc. Durango, Colorado. Beer, M., Eisenstat, R.A., Spector, B. (1990). Why change programs don't produce change. Harvard Business Review. Boston. Bridges, W. (1991). Managing transitions - making the most of change. Addison-Wesley Publishing Company. Reading, Massachusetts. Brooten, D., Naylor, M., Hayman, L.L. (1981). To change what needs changing ... doesn't take wonder woman. Nursing (3) p. 81-87. Clegg, S. R. , Courpasson, D. and Phillips, N. (2006) Power and Organizations. 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