RS MGMT CH 5 Change Management in Health Information Management
Change Management and Negotiation cont'd Two other concepts that must be considered within a negotiation are anchoring and understanding who has the power within the negotiation.
Anchoring is making the first offer in a negotiation, and this is the foundation upon which the rest of the negotiation builds. Power in negotiation refers to any unique attributes or position a particular negotiating party possesses. Power is the ability to make things happen, and the individual who possesses the power within a negotiation setting is able to negotiate the situation within his or her direction. Depending on the circumstances and the relationships between the parties, different negotiation styles may be required. A good change leader will know when negotiation needs to occur and where there is no negotiation option. -An example of this is within an electronic health record design, build, and implementation—negotiations may take place regarding what type of electronic document tools will be employed, but negotiation will not take place about whether or not to remain in a paper environment.
Decision-making is an important aspect of strategic planning.
Decision makers within an organization must be able to prioritize organizational needs in order to optimize organizational performance. A standardized method for evaluating critical issues (as in figure 5.1, for example) should be used to assist upper management in the evaluation and prioritization of organizational issues during the strategic planning process (Akdere and Altman 2009). The strategic planning process often results in organizational development that impacts all departments and employees within the organization.
The strategic plan revolves around the healthcare organization's mission and vision statement.
A mission statement is a written statement that sets forth the core purpose and philosophies of an organization or group; it defines the organization or group's general purpose for existing. A vision statement is the prescription for carrying out the mission and is a short description of an organization's ideal future state. The critical success of any healthcare organization requires development of a meaningful mission statement that is transparent throughout all levels of the organization. The mission statement is considered a strategic tool for most organizations and it is critical to the ongoing success of the organization's development. The two most important elements of an effective mission statement are that (1) the content is relevant to the healthcare organization and (2) the mission statement is clearly communicated throughout the entire organization. There are three factors that enhance the quality of the communication regarding the mission statement and strengthen the effectiveness of the mission statement overall: • Communication channels must be used that are appropriate for the audience. For example, if the main mode of communication within a healthcare organization is an email announcement, the mission statement along with any other additional communications regarding the mission statement should be shared via email. • All levels of management should be included in how to communicate the mission statement appropriately. • The mission statement should align closely to the actual vision of the healthcare organization so as to add strength to the statement
Thomas Kilmann Conflict Mode Instrument
A questionnaire tool used to assess the manner in which individuals manage conflict is the Thomas Kilmann conflict mode instrument. This instrument is relevant to HIM assessment of conflict management styles as it has been applied in the majority of studies on conflict management in healthcare (Sportsman and Hamilton 2007). This tool assesses conflict management styles by using two parameters—assertiveness and cooperation—which manifest in five distinct styles. The five conflict styles (displayed in figure 5.5) are to avoid, compete, collaborate, accommodate, and compromise. see image Avoid - To delay Accommodate - To yield Compete - To win Compromise - to find a mutual ground Collaborate - to find a win-win solution Table 5.1 outlines each conflict management style and the advantages and disadvantages of each of the styles in managing conflict. (page 99) The standard TKI uses a questionnaire that consists of 30 two-choice questions. Individuals respond to each question by selecting one of the two conflict reactions (assertiveness or cooperation) based how they would typically respond to a conflict situation within a superior-subordinate relationship. The results place the individual into one of five distinct styles. The five styles fall into the matrix and are determined by questionnaire scores on two axes (Slabbert 2004). This questionnaire can be used by anyone within an organization to assess the manner in which individuals are managing conflict and to develop strategies for negotiating the conflicts. Once an individual's conflict management style is identified, the individual will tend to use the same pattern over and over again in conflict situations. In some situations the typical response will resolve the conflict but in other situations it will escalate the situation. It is important for HIM professionals to select a conflict management style that best matches the conflict situation occurring at the time.
When a change is introduced in an organization there will be a significant drop in organizational performance before the change is adopted.
An effective change agent or change leader needs to know how to minimize the drop in performance, minimize the time needed to achieve the desired performance levels, and improve the organization's capacity to initiate, implement, and sustain successful change. Effective change leaders also need to know when change is necessary by comparing what is happening now within an organization and what the actual optimal performance level should be for the organization
There are four tactics that he or she uses to overcome obstacles to change as well to create a culture of acceptance with regard to change.
An effective change agent stays focused on the tasks that need to be completed throughout the change initiative. A change agent must focus on: • Identifying the problem, framing the problem, then solving the problem • Waiting for a solution rather than forcing a solution to the problem • Leading through collaboration • Learning rather than the ultimate outcome
Healthcare organizations can revise their mission and vision statements during the strategic planning process when the organization needs to achieve significant changes in performance or when the organization is in need of a facelift in terms of branding.
Branding is a marketing strategy that helps to define a healthcare organization's image and that helps the entity differentiate itself from others within the healthcare arena. After a healthcare organization completes the strategic planning process, the branding communication that occurs can increase the awareness and enhance the image of the organization within the healthcare marketplace.
Kotter's change management model example
By deploying a change management model such as Kotter's, a coding manager will have a solid framework when implementing a CAC program. Step one: The coding manager can create urgency to adopt CAC to improve employee productivity particularly with the implementation of new coding classification systems such as ICD-10-CM/PCS and eventually ICD-11. Kotter's steps two through four will engage the coding staff in the decision-making process and create a vision for the coding department. Step five will empower coding staff to provide recommendations for the best product for the workgroup, develop implementation and training plans, and collaborate as a team while improving work processes. Step six allows coding staff to feel accomplished as the team celebrates positive impacts of the coding product on workflow and work processes. Step seven encourages the coding manager and coding staff to incorporate efficiencies into the use of the CAC product, thereby resulting in additional gains for the healthcare organization. Step eight anchors the change to the coding area as improvements and efficiencies gained are tangibly noted through increased productivity and adoption of the change by all coding staff.
Change initiatives are new plans or processes that require an action or instance of becoming different.
Change initiatives in healthcare often result from a fluctuation in trends or process improvement that require a healthcare organization to move from one state to another. Initiatives that require change to take place can be external or internal to the healthcare organization. Internal Change Initiatives -Prime examples would be implementation of, or major upgrades to, an electronic health record and implementation of a clinical documentation improvement program. -There are also other clues within the organization that might result in a need for internal change, such as an increase in the formation of workgroup silos and a decrease in the communication and collaboration between workgroups or units. -Every change within the organization does not have to be a major initiative, and the more often an organization undergoes varying and periodic change initiatives, the better the organization will manage change -HIM professionals typically do not embrace change, and the longer a process is in place, the more difficult the transition to another process is, such as updating from ICD-9-CM coding to ICD-10-CM/PCS. External Change Initiatives Change initiatives that are external to a healthcare organization often require major actions in order to meet these external forces. Examples of external change may include the launch of a new government-required reimbursement system or the arrival of a new healthcare organization within a region that directly competes with services being provided by an existing organization. These change initiatives would require the healthcare organization to move from their current state by putting into place new processes and workflows to meet the government regulations or offering additional services to be able to complete with a new healthcare organization. HIM professionals need to make sure that they are performing environmental scans on a regular basis to keep abreast of external changes that could directly impact their organization and be ready to lead or guide their change initiatives. Adaptability to change and willingness to lead change initiatives are essential attributes for all health information professionals to model and to encourage others to embrace
The ability to successfully manage change is a skill necessary for all health information management (HIM) professionals.
Change is to make or become different change within a healthcare organization usually is a direct result of strategic planning and the need for organizational development to meet strategic initiatives
Change Agents
Change strategies must be guided by change agents who are invested in improving the organizational culture. The individual (or individuals) selected to lead change in the organization depends on the significance of the change to the organization, the span of control or power within the organization, and the change skills expertise of the individual. The individual or group that undertakes the task of initiating and managing change in an organization is known as a change agent A change agent is an individual who voluntarily undertakes extraordinary interest in the adoption, implementation, and success of a cause, policy, program, project, or product. A change agent's role can either be internal or external to an organization and the goal of the change agent is to facilitate the transformation needed by people within the organization to accept changes in technologies, structure, and tasks An internal change agent is an individual who is employed within the organization and is familiar with the inner workings of the organization. This individual has been a proponent of change initiatives in the past and is feels that he or she can successfully lead a change initiative. An external change agent is an individual such as an external consultant who is employed by the organization temporarily to escort the organization through the change.
Steps for preparing for a negotiation
Checklist for preparing for a negotiation: - Prioritize the issues and outcomes - Set goals - List items to swap or trade - List alternate outcomes - Determine who has the power within the negotiating relationship - Describe projected outcomes - Describe consequences for winning and losing from both sides - Create an alternative to the agreement
Change Management and Collaboration
Collaboration includes the relationships and interactions that occur between coworkers within an organization and requires individuals to work jointly with others, especially in an intellectual endeavor Collaboration within healthcare involves the joining of two or more healthcare professionals to work on achieving similar goals Collaboration between and within healthcare teams is a very complex dynamic process in most organizations. Some of the collaborative attributes that are valued within a multidisciplinary healthcare team are shared power based on knowledge, lack of hierarchy (everyone is equal), open communication, cooperation, assertiveness, negotiation, and coordination Although the concept of teamwork is often used in place of collaboration, teamwork is actually an attribute of a collaborative relationship
Communication and Change Management
Communication is an essential component while managing change. Communication is a "process of using words, sounds, signs, or behaviors to express or exchange information" Change communication is a key element for an organization undergoing transformation. The manner in which internal messages are conveyed to the individuals experiencing the change greatly impact individual behaviors and the overall perception of the change process. The design and execution of effective change communication requires the same diligence as any other strategic organizational process. Internal communications for change initiatives should have proactive plans in place to support anticipated events and reactions to the messages. Internal change communications should be assessed for all organizational levels in which change occurs: • Among and between people in small group meetings • One-on-one between the manager and employee • Within large group meetings with organizational leadership Change messages should be consistent no matter the level to which the information is communicated.
Collaboration within healthcare workgroups can be hindered when the specific expectations of individuals are not met relating to communication, professionalism, mutual respect, climate of collaboration, and quality of work.
Communication should be clear and concise so ideas can be exchanged, and information should be transparent to all team members. There should be a mutual respect or a balanced relationship within a collaborative workgroup, no matter what level of education or position the individuals hold within the organization. All workgroup members should be respected for their professional knowledge and the skills they bring to the collaboration. The last essential facet of collaboration is that the quality of work produced by the workgroup is enhanced rather than hindered by collaborative efforts
Conflict management is a problem-solving technique that focuses on working with individuals to find a mutually acceptable solution.
Conflict is inevitable because of human nature, so the best way to manage conflict is through the use of effective conflict management strategies. Conflict management involves designing effective strategies to minimize the dysfunctions of conflict and enhance the constructive functions of conflict in order to enhance learning and effectiveness in an organization. Healthcare organizations need to provide strategies that embrace conflict to individuals within the organization so that the organizational learning and effectiveness is maximized, the needs of all individuals are considered, and all situations are handled ethically Whenever there are two or more people, conflict is inevitable. Conflict is about people, emotions, and negative energy or an atmosphere that blocks a group from doing its work successfully. Conflict occurs as naturally as cooperation and a workgroup should strive to constructively solve conflict when it occurs. Conflict has both benefits and risks Conflict in workgroups is very complex and can have detrimental effects on the health and morale of employees.
Conflict Management Best Practices
Conflict management techniques can be used to mitigate or resolve a conflict. A seven-step problem-solving method can be used to get to the bottom of the conflict and find a solution. Often conflict is associated with emotions, so employing a standardized method keeps everyone involved within the conflict focused on the issues at hand. The steps are outlined as follows. 1. Define the problem or the conflict—is it a relationship issue or a process issue? 2. Identify and clarify all possible options for a solution. 3. Evaluate options for the solution. 4. Decide on an acceptable solution. 5. Develop an implementation plan. 6. Develop a process for evaluating effectiveness of the solution. 7. Talk about the experience. Providing a constructive conflict management strategy such as the seven-step problem-solving method to HIM professionals is essential to creating a healthy working environment.
Resistance to change is a force that slows or stops the motion of change efforts, which then increases the amount of work and energy needed to propel the efforts forward.
Examples of resistance by employees that impede organizational operations on a day-to-day basis are being late, missing meetings, complaining, and not following directions; these are often magnified during a change initiative. Examples in HIM Resistance to Change Dr. Smith, a surgeon, was recently assigned to the HIM committee and is regularly late for the committee meetings. The healthcare organization feels that physicians should serve on hospital committees, but Dr. Smith does not feel this is a reasonable expectation. Dr. Smith is always complaining about the fact that physicians are pulled away from patient care roles to participate in "useless committees." The committee members within the team accept his behavior and go over the missed conversations when he eventually arrives at the meeting. Knowing that resistance is often a byproduct of the interjection of change, change agents are effective in reducing everyday resistance by applying methods that neutralize resistance to the change The change agent can assist the committee in upholding the guidelines and not allowing members to backslide when resistance to the process is evident. Resistance is not always detrimental to the change process and it can identify issues that need to be handled early in the process. Internal change agents may have an advantage in overcoming resistance as they may already have existing relationships with the individuals involved and may know how these individuals react to change in terms of resistance
Communication and Change Management cont'd Fundamental communication methods
Fundamental communication methods should be promoted in the change communication process, which includes sharing the change message multiple times and exercising different channels of communication to share the change message. It is important to assess the message source and medium used to convey the change communication. The three modes for communication within organizations are face-to-face interactions (such as one-on-one or group meetings), print media (such as flyers, newsletters, and monthly reports) and electronic media (such as a healthcare organization's intranet, emails, and social media). All of these modes of communication should be utilized to support communications throughout the change initiative One-on-one exchanges between the manager or change agent and employees are an essential component of the change communication initiative. Communication is a two-way interchange of information in that the manager needs to communicate changes to employees but, in turn, the manager or change agent listens to how employees perceive the changes. -The type of activity that needs to occur within the communication process is active listening. -Active listening is when an individual makes a conscious effort to hear and understand the message being conveyed. -Active listening engages both parties in the communication process with an intent to solve problems before they occur and also helps strengthen and maintain work relationships while facilitating change in a meaningful manner. -The key steps to active listening are to show interest in what the employee has to say; ask questions to clarify, gather information, and focus on the conversation; and let the employee know you understand what he or she is trying to convey. -Active listening is an important component of the communication process, particularly when critical conversations, negotiations, and conflicts need to be managed during a change initiative.
Within healthcare organizations, change at the organizational level often is disbursed to the managers of departments. Two different models can be deployed to enable change within the healthcare organization and within each department.
In one model, change responsibility is deployed by a change agent who works alongside the manager of a department where the change is occurring. In a second model, the change responsibility is delegated entirely to the manager of a department and this manager must serve as the change agent for the department.
There are four ways that individuals usually respond to conflict.
Individuals may: • Collaborate with others through problem solving and make trade-offs or compromises within the conflict situation • Yield to the other party, letting go of their own needs or wants within the situation • Impose their will on others with the use of threats • Withdraw from the situation by performing no action
Change Management can best be described as the formal process of introducing change (becoming different), getting it adopted, and diffusing it throughout the organization.
It is the process, tools, and techniques to manage the people side of change to achieve the required business outcome (Creasey 2009). Constant change is a way of life in most healthcare organizations today. Change can occur singularly among individuals within the organization or simultaneously within teams, units, departments, or the entire healthcare organization. In order for change to occur in healthcare organizations, a large number of individuals need to adapt their behaviors in order for performance to be improved or enhanced. A structured approach to change needs to be employed to ensure the individuals, teams, units, departments, healthcare organization, or healthcare delivery system transition from a current state to the desired future state. An example of change that impacts how work is done by both individuals and the entire healthcare organization re-engineering of the revenue management cycle process or implementation of a CDI program. Planned change dominates the theory and practice of change management, but emergent change is another aspect of change that evolves within organizations as well. Planned change is a formal process that is introduced methodically and is actively influenced by managers or change agents. Emergent change is a continuous, open-ended process of adaptation to changing circumstances and conditions. Emergent change is managed through a more informal process and sometimes not really managed at all.
Kotter's Change Management Model
John P. Kotter; Leading Change Kotter outlines eight steps that management needs to perform in order to transform an organization through change. Leadership needs to: 1. Create a sense of urgency encouraging others that the change is necessary. 2. Form a coalition, a group of individuals who will assist the organization through the change process. 3. Determine a vision for the change and develop a strategy for the change process. 4. Communicate the vision and what the changes will look like to the organization. 5. Eliminate or dissolve the resistance to the change. 6. Share short-term wins that appear as a result of the change. 7. Build on each short-term win to capture all the positive components that are happening within the change process. 8. Adopt the changes as they occur so that the organization moves to its desired state of change
input-output process model, a seven-component model that evaluates the effectiveness of collaboration within teams.
Joseph E. McGrath; focused on the interaction between and among team members as well as the team as a single functional entity. Input refers to group composition and structure as well as the resources need to complete the tasks within a particular work environment. Processes are the group's activities based on the workflow and interactions among team members. Outputs are the group's tasks and actual performance or end product, group development, and the overall effect of the group dynamics on an individual team member's performance within a collaborative work situation This model assesses the impact of collaboration or lack of collaboration within a particular workgroup and the resultant effects. This model could be used during a change management initiative to assess the inputs—that is, the group composition, resources needed to complete the tasks, work climate, and group structure—along with how the group processes the changes. The resultant outputs—the actual performance or product, effects on members, and actual group development—will provide a measurement if the change initiative was effective or if additional improvements need to be made. The key foundation for building a collaborative work environment is to invest in healthy work relationships that avoid competition and circumvention of problems. HIM managers should adopt a collaborative perspective by attempting to see things from others' viewpoints and commit to problem solving as a way to building better relationships within the workgroup (Gunderman and Saravanan 2010). Being aware of the barriers that impact collaboration and the expectations of individuals within a workgroup can assist the HIM manager in creating and maintaining a collaborative work environment.
Kotter's change management model see image
Kotter's model was developed to address fundamental changes within organizations but it may not be applicable to all scenarios without some modifications. Kotter asserts that all eight steps should be completed in sequence without overlap, but in some instances overlap of the steps may be required in order for the change to progress. Not all the steps may be relevant within certain change contexts, and the steps do not specifically outline how to handle difficulties during a change situation. Kotter's model is an excellent starting point for embarking on change but it may need modifications in order to be applicable to all change management situations.
Change Management and Negotiation
Negotiation is a formal discussion between people who are trying to reach an agreement The ability to negotiate is an important skill for all HIM professionals to learn in order to be successful change leaders. HIM professionals at any level may negotiate change in hours, salary, or working conditions. When negotiating, there are three different values or points associated with the negotiation: • Target value or point: the best possible outcome for the negotiation in which both parties are in agreement (referred to as a win-win situation or optimal agreement) • Reservation value or point: the lowest possible outcome for the negotiation in which neither party comes to an agreement • Best alternative to a negotiated agreement: an outcome that may not be the target value of the negotiating parties, but one in which both parties are in agreement that it is an acceptable alternative to the optimal agreement The purpose of a successful negotiation is to resolve situations where the desired outcome conflicts between the parties involved.
Organizational Culture and Change
Organizational culture plays a big role in an organization's performance and, in particular, how OD (organizational development) evolves over time. Organizational culture consists of the shared values and beliefs that guide behavior within organizations. Assessing the need for change based on the internal factors of an organization is often measured by employee surveys, a tool used by healthcare organizations to assess the culture of the organization. It is essential during an employee survey that employees understand the structure of the questions within the survey, that they recognize their role in the survey process, and that the results of the survey are shared. The results of the employee survey, particularly negative results, prompt management to focus on changes that are required to improve future survey results. Positive survey results should be shared with all employees and management. The overall culture of a department or entire healthcare organization can be improved by engaging employees and management in performance improvement initiatives directly related to the employee survey. Surveys and the work environment scale—used to assess organizational culture.
Organizational Development
Organizational development (OD) is the application of behavioral science research and practices (as discussed in chapter 1) to planned organizational change. In addition, organizational development is a "systemwide application and transfer of behavioral knowledge to the planned development, improvement, and reinforcement of the strategies, structures, and process that lead to organization effectiveness" Organizations develop through change management techniques OD is a blueprint for an adaptive process for planning and implementing change within an organization. the assumption is made that OD is associated with strategic planning and change. Strategic change involves improving the alignment of an organization's strategy, culture, and design
Managing Critical Conversations
Poor communication creates obstacles for managing critical conversations in conflict situations. Critical or crucial conversations are about challenging issues where emotions are involved and the outcomes of the conversation have a large impact on relationships or workplace dynamics Planning prior to entering a critical conversation will result in a better outcome to the situation The planning steps for managing critical conversations are: • Develop awareness of your own communication patterns and how you typically react to difficult conversations—for example, how you act or react to anger or withdrawal • Identify and clarify what you want from the conversation; stay focused and keep a handle on your emotions • Establish a mutual purpose or shared goal for the conversation • Establish respect by demonstrating respect for the others' position even if you may not agree with their stance • STATE your course: ○ S = Share your fact ○ T = Tell your story ○ A = Ask for others' input and viable compromise solutions ○ T = Talk about what is fact ○ E = Encourage differing views • Let others STATE their course • Finish clearly by recording commitments, developing measurable results, and setting a follow-up time to meet. The end result of a critical conversation is that all individuals feel like their stance was heard and that some mutually agreeable solution evolved from the conversation. Critical conversations often happen spontaneously, which may not allow the individuals to be prepared for the conversation. If emotions are too high, it is best to delay the conversation until emotions subside and a productive conversation can take place.
Preparing for a negotiation situation is important.
Prepare by prioritizing the issues and noting which items are the most important and least important. Set goals for the negotiation, taking into account the prioritized list. Make a list of the items you are willing to trade or swap in order to come to an agreement. Outline a list of alternatives for the negotiation and name the reserve target or point for the negotiation. The negotiator should analyze the relationship with the other parties within the negotiation and ascertain who has the power within the relationship. The negotiator should describe projected outcomes and consequences when the agreement is reached. Determine the consequences for winning or losing the negotiation from both parties' perspectives. The negotiator should list the best alternative to the agreement (Berlin 2008). During a change initiative, negotiation is a give-and-take discussion that requires preparation in order for positive outcomes to occur. Good negotiators are able to get what they want from the negotiation while still allowing the other party to feel like he or she won as well.
Surveys (assess organizational culture)
Sound survey methodology should be employed by healthcare organizations when deploying employee surveys. The survey questions should demonstrate reliability and validity as tested within a formal research setting or by using standardized questions created by a company or organization experienced in employee survey development. The same survey should be administered to all employees in the organization, although management-level employees may have additional questions within the survey that deal with topics specifically related to management issues. The process of administering the survey should be standardized throughout the organization and provide for unbiased selection and results. Manager-employee reporting relationships should be clear as statistics are aggregated by work teams, departments, and service lines within the organization. Prior to taking the survey, employees should be educated on the importance of identifying their appropriate manager (to whom they directly report) when taking the survey. Specific results from each employee will remain anonymous, but aggregate information for each manager will be collected. In order for results to be meaningful to a particular work team or department, the data must be collected from the appropriate employees within that work area. Results of the survey should be calculated using descriptive and analytical statistics and a report should be shared with all employees who have completed the survey. if performance improvement initiatives are deployed in direct relation to employee survey results, survey data can be a powerful tool for change (Wiley 2012). HIM professionals can utilize data analytics to derive important information from employee survey results. The knowledge gained from employee survey results can trigger process improvement changes within an HIM department.
Strategic Planning and Organizational Development
Strategic planning evolves in healthcare organizations when drivers such as rising healthcare costs, major regulatory and policy reform, implementation of new technologies, and a competitive market for new services emerge.
Health Information Management Roles in Strategic Planning
Strategic planning must be initiated from the top down and the process must be embraced by the management team in order for the process to be effective. Strategic planning requires ownership within the organization and the ownership needs to start with the chief executive officer and the board of directors (who are ultimately responsible for setting the strategy and direction for the organization). Health information managers and directors fall into the middle manager role in terms of healthcare innovation and change that result from strategic planning and OD. The roles that middle managers play in healthcare innovation are to: • Diffuse information about the implementation or plan: Middle managers must provide the necessary information regarding the change implementation from a middle management perspective. • Synthesize information: Middle managers must culminate all information particular to the healthcare innovation or change in an understandable manner and make it useable within their own departments or units. • Mediate between strategy and day-to-day operations: Middle managers put into work the flexibility and adaptability needed to translate the broad strategy into concrete tasks. • Encourage employees to consistently and effectively use the technology or change in order to implement the change or innovation successfully (Birken et al. 2012). HIM professionals must be knowledgeable in terms of the roles individuals play within the strategic planning process, how these individuals will help drive changes necessary to successfully implement strategic goals, and the behaviors associated with change experienced throughout the process. These individuals are often called change agents or change leaders
The ADKAR Model (change management model)
The ADKAR model is a change management model that is used to assess individual change management issues The five building blocks in regard to the change initiative—awareness, desire, knowledge, ability, and reinforcement—are necessary components for individuals to understand in order to participate in change. The five building blocks: Awareness—An individual's understanding of the need for change Desire—An individual's need to participate and support the change Knowledge—An individual's acquisition of information about how to change Ability—An individual's capacity to implement required skills and behaviors during the change Reinforcement—An individual's capability to sustain the change These building blocks are sequential and are the typical steps that individuals experience throughout the change process This process can be applied to any change initiative within a healthcare organization, from a change in the type of health insurance being provided by the healthcare organization to individual procedural changes within a job. HIM managers need to engage employees in change initiatives by making them aware of the changes that are internally and externally impacting the healthcare organization. In addition, HIM managers should create a collaborative work environment that motivates employees to change by providing employees with knowledge about the change and opportunities to develop skills to implement the change. A manager must also provide positive reinforcement as employees are experiencing the resultant changes.
For a healthcare organization implementing an electronic health record (EHR), this typical adoption of change or innovation curve will mostly likely be demonstrated by the healthcare providers and others within the organization.
The EHR champion for the organization (the change agent) should: • Communicate advantages of the change or innovation • Communicate commonalities between current record processes workflows and the new technology • Minimize the complexity of learning the new technology through hands-on-training • Allow healthcare providers and others to practice operating the new technology before the technology becomes part of the routine work processes • Provide feedback on tangible improvements associated with implementation of the technology (Boston University School of Public Health 2013) • Offer incentives to individuals who are innovators, early adopters, and early majority of the technology • Provide additional support to the late majority and laggards who are not readily embracing the technology
In a change process using Lewin's model, the change agent should ask what significant events need to happen from both the managers and employees so that that the change will occur.
The fundamental principle of effective change management within this model is that the individuals experiencing the change participate in the change and support the changes occurring. A demonstrative HIM example using Lewin's model is the implementation of a computer-assisted coding (CAC) product. Unfreezing: The first stage of Lewin's model Most change initiatives related to implementation of new technology fail due to a lack of effective communication at the beginning of the change process. -Allowing coding staff and stakeholders to be involved from the start is an excellent way to enter the unfreezing stage for this change. If coders and stakeholders understand the strategic plan and vision for purchasing such a product and see the benefits this product will provide to their work processes, unfreezing will start to occur. Transitioning or moving: The second stage of Lewin's model is reflected in the actual change process when the CAC product is implemented. -The coding manager should actively participate with coding staff during the implementation process to increase acceptance of the change process -Even though coding staff were involved in the selection process and received regular communication about its implementation, the actual move to use the CAC product still may not be an easy transition. Refreeze: The third stage of Lewin's model requires commitment by the coding manager and the coding staff to remain actively involved in the effective use of the CAC product. Lewin's model does not offer an estimated amount of time needed to move through each stage, but the impact to work process and how far individual's comfort levels are moved will be indicative of the time that it takes an individual, department, or healthcare organization to move through the stage of the change
Adoption of Change
The human behaviors associated within change management initiatives are often explained in terms of the diffusion of innovation theory, which was introduced in 1962 by Everett M. Rogers, PhD The diffusion of innovation theory explains how a typical population embraces the adoption of innovation or adoption of change. Innovation is the act or process of introducing new ideas, devices, or methods Adoption of innovation or change relates to how individuals adapt to the situations presented to them.
Often there is a preplanning stage prior to the actual creation of a new strategic plan that helps set the organizational structure for the strategic plan.
The mission and vision statement of the organization are assessed along with organization's values. A plan for communicating the goals and strategies of the plan are developed within this preplanning phase
Conflict Management
The opposite of collaboration is conflict, and barriers within collaborative workgroups can cause conflicts Change can also result in conflict as behaviors and paradigms within organizations evolve. Conflict is a clash between opposing or divergent drives, ideas, wishes or forces Conflict can also be described as any difference in opinion, value, need, want, and such that causes frustration in one or more interdependent people and blocks them from achieving their tasks or goals. Negative connotations usually surround the concept of conflict, but if conflict is managed effectively, a negative situation can be turned into a positive outcome. Emotions play a big role in conflict situations and how individuals manage conflict over time. The type of behaviors that individuals demonstrate during a conflict situation can be expressed nonverbally, verbally, physiologically, and cognitively. The amount of emotional intensity an individual exhibits during a conflict situation can vary greatly depending on the level of stress the conflict causes each individual. There are five principles of conflict and emotion, listed as follows. • Conflict is innately emotionally defined. • Conflict is emotionally charged. • Conflict invokes a moral stance in most individuals. • Conflict is identity-based. • Conflict is relationally-based
Conflict Management The ways individuals approach conflict within a workgroup directly impacts individual job performance as well as the entire workgroup's performance
The supervisor or manager is often brought in as a third party to the dispute to offer conflict management tactics. The job of a supervisor or manager includes role setting and monitoring employee behavior, which can encompass conflict situations. Conflict within workgroups and across workgroups can be very costly to organizations. Ensuring that supervisors and managers have the tools and intervention techniques necessitating conflict management skills is a key management training element for any organization. The supervisor or manager can turn negative conflict situations around by promoting fair and consistent conflict management processes such as the ones described in the following sections
The ways individuals approach conflict within a workgroup directly impacts individual job performance as well as the entire workgroup's performance
The supervisor or manager is often brought in as a third party to the dispute to offer conflict management tactics. The job of a supervisor or manager includes role setting and monitoring employee behavior, which can encompass conflict situations. Conflict within workgroups and across workgroups can be very costly to organizations. Ensuring that supervisors and managers have the tools and intervention techniques necessitating conflict management skills is a key management training element for any organization. The supervisor or manager can turn negative conflict situations around by promoting fair and consistent conflict management processes such as the ones described in the following sections
The Work Environment Scale (assess organizational culture)
The work environment scale (WES) is one of the most rigorous and validated measures for assessing healthcare organizational culture. developed by Rudolph Moos; conceptual framework that assesses the interplay of individuals and their work environment The WES was designed to measure the social environments of different types of work settings through completion of a questionnaire. The WES assists organizations by surveying employees' perceptions of productivity, assessing employee satisfaction, and clarifying employee expectations of a healthy work environment. The three dimensions assessed using the WES questionnaire are: • Relationships in terms of involvement, coworker cohesion, and supervisor support • Personal growth or orientation relating to autonomy, task orientation, and work pressure • System maintenance and change addressing clarity, control, innovation, and physical comfort Aggregated scores from completion of the WES questionnaires are used to describe the workgroup's perception of the social functioning of its work environment. Results of a WES can assist in evaluating problems and risks within the organization; can be performed before a change, to promote change, and after change to evaluate the organization's culture; can evaluate and improve leadership within the organization; and may help build teams within the organization
Values and Change Management
Value-based leadership is an approach that emphasizes values, ethics, and stewardship as central to effective leadership. In leading change, the values of the individuals within the organization must be considered. Depending on the incongruence or congruence with the change to the values, the transition or transformation to change will be impacted
In the first model, a change agent will work closely with the department manager or director to ensure change occurs.
When the change agent works closely with the manager, the manager needs to provide open, positive support to the change agent as well as for the employees. -The manager can provide the change agent with insight into employee relationships and values that will be essential to the acceptance of the change by the employees. -The manager can also assist the change agent when employee resistance to the change is observed. - The manager must not lose sight of the vital role of managing the department when a change agent is being utilized to facilitate change. - He or she must continue to support and assist employees in a positive manner to overcome the employee resistance to change
In a second model, the change responsibility is delegated entirely to the manager of a department and this manager must serve as the change agent for the department.
When the manager of a department is assigned the role as the change agent of the department, it benefits the manager greatly to work with someone in the healthcare organization who can assist him or her in developing change management skills. Communication is essential to the change management process and the manager should communicate the future desired state or change to employees using appropriate communication methods. It is important for the manager to involve employees in the change process and create a sense of ownership for the change for each individual as well as for the entire team, and to systematically use the change experience from existing systems including people as well as technology. The manager needs to be clear about the rationale for improvements associated with the change and who benefits from the change. He or she should always strive to introduce change that aims to improve productivity for employees and continuously manage the expectations of employees regarding the change.
The most commonly noted barriers to collaboration within healthcare workgroups include lack of time; gender, generational, and cultural differences; and lack of role clarification of team members
Whenever these barriers are experienced within a collaborative environment, conflict may result.
Strategic planning process
a typical strategic planning process within an organization. The overall strategic planning process is to outline steps designed for the entire organization as whole, rather than development of goals for a specific division or department. see image Applying the model outlined are best practices in healthcare strategic planning are to: • Review the organization's strategic plan and make sure the plan is congruent with the organization's mission and vision. • Assess the critical issues impacting the organization and evaluate how these issues may change the strategic plan of the organization. • Establish new strategic goals based on the issues impacting the organization in the previous step. Develop focused and clear strategies that will differentiate the organization from its competition. • Achieve real benefits of a strategic plan by creating targets and measures for assessing the efficacy of new strategic goals. • Manage implementation of the strategic plan by assessing the outcomes of the plan. • Manage the plan strategically by reevaluating the plan whenever critical issues impact the organization Healthcare organizations often employ experienced outside consultants to facilitate the strategic planning process. The request for proposal for obtaining an external consultant should contain a comprehensive outline of the exact expectations from the consultant. At the end of the strategic planning process there would be clear objectives, deliverables, and timeframes, described within a final comprehensive report that management would use for implementing the new strategic plan.
Senge's Theory of Change
how businesses and other organizations adapt to complex and rapid organizational changes The Fifth Discipline; highlights the concept of systems thinking in terms of a learning organization. A learning organization is an organization that quickly adapts to environmental changes and thus attains knowledge and skills that can be utilized in the future when experiencing change. Senge outlines disciplines that contribute toward a learning organization: personal mastery, mental models, building shared visions, and team learning. A discipline is an orderly or prescribed conduct or pattern of behavior. These disciplines revolve around organizational team collaboration that occurs as part of the organizational change process. This is a complex model that eventually results in the entire healthcare organization moving to a higher level of understanding as to the type of organizational learning that has occurred during a change initiative. The higher level of learning is noted to be systems thinking, which is coined as the fifth discipline within Senge's model. Systems thinking is the discipline that integrates the four other disciplines of personal mastery, mental models, building a shared vision, and team learning into a logical body of theory and practice
Kubler-Ross Phases of Grief (change management model)
how individuals experience change within organizations; Death and Dying The five grief stages are denial, anger, bargaining, depression, and acceptance. Stage 1. Denial: The initial defense mechanism most employees exhibit when a change is initiated is to deny the action and refuse to listen to any of the change initiatives. Stage 2. Anger: The second emotion that employees who are the target of change may exhibit is anger, which is projected resentment of the change. Stage 3 Bargaining: Employees may then bargain by trying to postpone the change. Stage 4 Depression: Depression happens when employees start letting go of old behaviors and realizing there is no turning back. Stage 5 Acceptance: The last emotion is acceptance; employees accept the change is occurring and start to embrace the positive elements of the change. It is important that individuals work through all of these emotions during change initiatives so the change can be sustained long term
Strategic planning
is the process in which the leadership of a healthcare organization develops the organization's overall mission, vision, and goals to help guide the direction of the organization as a business entity. Strategic planning includes all the measures taken to provide a broad picture of what must be achieved and in what order, including how to organize within a healthcare organization to achieve the goals of the plan.
Bridges' Transition Model (change management model)
organizational consultant on managing change in the workplace, William Bridges; Managing Transitions This model provides a guide for how individuals experience change by transitioning through different phases. The three phases noted by Bridges are: Stage 1: Ending, losing, and letting go. This is the first stage of transition after you present employees with a change initiative. Employees may reflect many emotions such as fear, anger, denial, frustration, uncertainty, and a sense of loss. These emotions may be exhibited as a resistance to the change, but managers must understand these emotions and accept that resistance to change is expected. Managers should listen to employee concerns but also try to mitigate some of these fears by educating and communicating positive outcomes of the change. Stage 2: The neutral zone. The neutral zone is the second stage of transition employees experience when confronted with a change. In this stage the emotions exhibited by employees most likely will be resentment toward the change, low morale and low productivity, anxiety about future job roles, and general skepticism toward the change. Managers should meet with employees on a regular basis to improve morale and curb productivity loss. Managers should provide positive feedback on each employee's performance and how his or her role is important to the change initiative. Stage 3: The new beginning. This is the third stage of transition employees experience when confronted with a change. In this stage employees usually exhibit acceptance to the change and a high energy level in regard to learning. Employees begin to adopt the change and managers need to make sure this positive adoption of the change is sustainable. Managers should work with employees to set realistic performance goals and celebrate the goals achieved thus far through the change process Bridges' transition model provides a very clear and concise way for assisting employees through the transitional stages associated with change initiatives.
Contemporary Change Management Models and Techniques Kurt Lewin's Three-stage Change Management Model
research on experiential learning and group dynamics. His studies of group dynamics in relation to change initiatives resulted in the creation of a three-stage change management model The three stages of this model are unfreezing, transitioning, and re-freezing. • Unfreezing. This first stage of change management requires employees to discard and let go of existing behaviors or processes to prepare for change. The change agent must identify and communicate the need for change as well as mobilize others to see the need for change. The employees experiencing the change need to feel safe in this environment in order to let go of current behaviors. The change leader or change agent needs to provide psychological safety by listening to employees' concerns and supporting the employees' feelings while continuing to communicate the need for change. • Transitioning (or moving). In this second stage, Lewin's theory relates to change as a process rather than one single event. This is the inner movement employees make in reaction to change. The change leader or change agent needs to communicate the expected behaviors and model these behaviors. The change agent or leader needs to make sure employees understand and embrace the mission and vision of the organization so new behaviors are ingrained into daily operations rather than as temporary adjustments (Dannar 2011). • Refreezing. This final stage requires that change stabilizes so that it is embedded into the organization's culture and daily practices. The change leader or agent needs to ensure implementation and follow-through is inherent to all employees and employees do not regress to former behaviors. Organizational transformation occurs as the change has moved from an initial state to the desired state. In this stage, it is important the change is locked in so the organization can sustain this higher level of desired performance
There are four competencies that make an effective change agent:
• Broad knowledge. The change agent should have broad multidisciplinary knowledge of healthcare operations. • Operational and relational knowledge. The change agent should be familiar with the operations and the relationships within the organization. • Sensitivity and maturity. The change agent should be sensitive to the needs and emotions of all individuals associated with the change process. The change agent should also be able to handle with maturity the inevitable conflicts that occur within a change initiative. • Authenticity. The change agent should be actively involved and vested in the change initiative to understand the dynamics occurring throughout the process
The five established categories noted within the adoption of innovation or change model are innovators, early adopters, early majority, late majority, and laggards.
• Innovators are individuals willing to step up to try the innovation or process first. These individuals are risk takers and not afraid of change. Innovators are the individuals who buy into the change immediately and persuade others to come along. Innovators are usually a small percentage of the individuals involved in the process and are essential to engaging others while leading the change (Law 2009). In general, about two and a half percent of the population involved in the change initiative will fall into this category. • Early adopters are a little more cautious than the innovators but these individuals are the change leaders within the organization. These individuals do not require information to change but they like to have how-to-manuals and information sheets on how to participate within the change, which can be provided by the change agents. Approximately 13.5 percent of the individuals participating within a change initiative or innovation fall into the category of early adopters. • The early majority are those individuals within the organization who tend to adopt change quicker than the average person. The individuals who fall into the early majority require evidence or proof of the effectiveness of the change initiative or innovation in terms of success stories and statistics from early adopters. Approximately 34 percent of the individuals fall into this category during a change initiative or innovation. • The late majority are individuals who are skeptical of change and will only participate in the change or innovation after it has been tried by the majority of the people involved in the change initiative or innovation. The typical percentage of individuals that fall into this category is about 34 percent of the population involved. • Laggards are those individuals who resist change; they are bound by tradition and are very skeptical of change. Often these individuals only participate in the change process when there are adverse outcomes outlined such as job loss or lower pay scales for not participating within the change. About 16 percent of the population associated within a change initiative or innovation fall into this category (Boston University School of Public Health 2013). These Individuals require additional support and evidence of how the technology can positively impact their jobs.
there are different types of change agents based on the characteristics and methods utilized for implementing change.
• Outside pressure. The change agent in this model works to change systems from outside of the organization. An example of this would be a union representative who stages picketing for a contract negotiation. • People-change-technology. The change agent in this model focuses on the individuals within the organization and is concerned with employee morale and motivation as technology is implemented. The premise behind this type of change is if individuals change their behavior in regard to embracing rather than fighting new technologies, the entire organization can move forward faster with the technology changes. • Analysis from the top. In this model, the change agent focuses on changing the organizational structure and improving the output and efficiency of the organization. • Organizational development. The focus of this change activity is associated with a cultural change approach, as the change agent strives to work on intergroup relations, communication, and decision-making. Depending on the change required by the organization, any one of these models may be used or a combination of the models can be employed to ensure that the change process is appropriately implemented
