Understanding and Managing Change

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Understanding and Managing Change

“Management is the art of getting things done through other people”. (Mary Parker Follett)

Having worked through the first unit, we hope you now have a good sense of what health sector management entails – the key management and leadership functions, how these change across levels, the generic roles managers play and the values they need to embody to be effective. We also hope you have a good idea of your own strengths and weaknesses as a manager or potential manager, and have tools to assess and analyse the specific management needs of your own work environment.

Pause for a moment to consider where we have come so far. Do you think you have a better understanding of the role of leading and managing in the health system, and the difference between the two roles? Did you learn more about different levels of leadership, and where you are on the leadership ladder, and in terms of your own style of management?

The next three units (2-4) elaborate on aspects of the management and leadership functions and roles outlined in the first unit. We have grouped these into the broad areas of managing change (addressed in Unit 2), managing people and teams (Unit 3), and managing resources (Unit 4).

Managing change is the “getting things done” part of the popular definition of management quoted above, and encompasses functions such as the scanning, focusing and planning required to improve the quality of services and strengthen health systems. It is about managers taking the initiative to make positive changes in their work environments. You will have no doubt realised, however, that a great idea and even a great plan do not necessarily lead to action or change. Implementation difficulty is a constant theme of organizations, because having to “do things through other people” poses challenges; the resources required (time, money, know how etc.) are always in short supply; and change happens through complex organisational environments facing multiple demands simultaneously.

Managing change is not just about making changes but also about coping with change – especially unplanned or unwelcome change. The health system is not a static organisation waiting for managers to impose change on it – one view of organisations is that “planned, episodic change” occurs against a backdrop of “emergent, continuous” change (Weick 2000). This background of ongoing change can be viewed as the backdrop of opportunities and constraints against which planned change is implemented; where this involves creative adaptations by frontline providers it can even be regarded as an organisational resource. Being able to “read” these ongoing changes is one of the competencies which managers need to learn, which we referred to in Unit 1 as “paying attention to the goings on of the work environment in a new kind of way”. Finally, managers need to recognize their role in ensuring continuity in the face of unexpected and often unwelcome change, such as the resignation of a key team member or new demands from higher levels of the system.

This unit discusses techniques and tools for analyzing problems and planning change in health care environments, including your own. We also consider the role of the manager/leader in maintaining continuity in the face of unplanned or unexpected change.

We see these as concepts and approaches to help you think and reflect on your own practice and environment, more than straightforward recipes for action.

Study Sessions

There are three study sessions in Unit 2:

§  Session 1 explores a number of concepts which others have found useful in thinking about change. These are the theories of small wins, emergent continuous change, and organisational responses to unplanned change

§  Session 2 takes you through a practical process of problem identification and analysis, priority setting and action planning, and concludes with a brief overview of planning concepts, purposes and methods

§  Session 3 discusses change methodologies at the coal face of service delivery – which can be broadly referred to as “quality improvement” methods.

Session 1: Change as part of organisational life

1 Introduction

This session looks at three ways of thinking about change. First, we look at the role of the manager in effecting change, and ways of thinking about making changes. We then look at the ongoing change that happens, emerging all the time in different ways, which can be used as a resource or base for building other changes. Lastly we look at the unplanned or unexpected changes that may happen in an organization - the ‘curved balls’- and how a manager can cope with these and respond constructively.

2 Learning Outcomes

In the course of this session, you will be addressing the session outcomes in the first column; they are part of the overall Module Outcome/s in the second column:

Session Outcomes / Module Outcomes
§  Understand the concept of a “small win” and consider how it might be relevant to your own or other health settings.
§  Explain the distinction between planned, episodic change and emergent, continuous change, providing examples from your own experience.
§  Describe change as transition, and the manager’s role as “sense-giver” in this process. / §  Understand approaches to the concepts of leadership and management.
§  Have conceptual tools for thinking about organisational change

3 Readings and Video Material

Weick, K.E. (1984). Small wins: Redefining the scale of social problems. American Psychologist, 39(1): 40–49.

Weick, K.E. (2000). Emergent Change as a Universal in Organizations. In M. Beer & N. Nohria, eds. Breaking the Code of Change. Boston, MA: Harvard Business School Press: 223–241.

I-Tech. (2011). Everyday leadership course Managing Organisation Change and Transition

http://everydayleadership.org/sites/everydayleadership.org/files/documents/S1.3_FG_MngChange_post-pilot_March2011.doc

SOPH. (2011). Case Study of Waitola Community Health Centre: Introduction and Part 2. UWC

Video: Everyday Leadership Profile: Dr Mehari Dessalegn Tesfay http://everydayleadership.org/people/mehari-dessalegn-tesfay

4 Timing

There are five fairly short activities in this session, as well as the four readings listed above, and the video clip to watch. The two Weick readings are relatively demanding; the Everyday Leadership course notes are less so, and the case study you have been introduced to before. The session should take you about 10 hours to complete.

5 A Manager Who Leads

You were introduced to Dr Mehari Dessalegn Tesfay in the last session. He is the medical director of Wukro Hospital in Tigray, Ethiopia. He is the son of a Tigrayan farmer and was only 25 years old when he graduated from Jimma medical school and was sent to work in a remote hospital in Northern Ethiopia. His assignment was to work as its medical director and the only doctor. As you will recall, the video describes his reactions on arrival and his approach to coping with being a manager at the hospital.

Activity 1 - Think about Dr Mehari as a leader

Watch the video of Dr Mehari Dessalegn and answer the following questions:

§  What challenges did he face when he arrived at the hospital for the first time?

§  We are given to understand that Dr Mehari is a successful manager when the video concludes with the following words “Dr Mehari has partnered with many organisations to upgrade Wukro Hospital with a new pharmacy, patient wards, a lab, an HIV clinic, updated water systems and staff training. His hospital was honored with a special award form the Ethiopian government.” In what ways was he was able to achieve this?

Feedback:

This is what we know of Dr Mehari and what we can surmise from the video. You might be able to add to the lists below:

Personal factors / Came from another area of Tigray region, father was a farmer i.e. suggesting that he was the first generation university educated
I was committed, they saw my commitment “I myself would pick up stones, I was leading them”
Transparent, accountable, integrity
Problems / Sent to work in remote area
Depressed, alone
Hospital very dirty
Staff did not consider cleaning as their job – “How can we? The government has to do that”
Strategy / Focus on reminding people they were serving their own families
Consulted management team
Regular “open house” in my office so they can talk
Talk repeatedly about change
Introduced mandatory staff cleaning days
Three meetings before staff agreed to pull down the old “traditional” waiting area that was an eyesore, blocking flow
Appreciate, recognize and motivate staff
Committed leadership and committed staff
Enabling factors / Motivated and recognized by a mentor

While we have limited knowledge at our disposal, we can speculate the following about Dr Mehari:

§  He had a strong view of what he thought the hospital should look like (a vision)

§  While not from the specific area, he understood and identified with the users of the service (commitment)

§  Had an appreciation of the cultural context (tacit knowledge)

§  He sought to model transparency, integrity and accountability and got directly involved in activities such as cleaning (role model)

§  He chose concrete, do-able actions – whether instituting an open house or introducing mandatory cleaning days (small wins) to achieve his vision, which led to bigger things (new buildings and perhaps new visions)

It is very unlikely that he entered the new environment with a plan or blueprint, or that he had thought through a very clear sequence of steps required to achieve his vision, or even that his vision remained static. However, if the conclusion of the video is correct, he ultimately achieved a major turn-around of this hospital.

6 The power of small wins

This case study of Dr Mehari illustrates clearly the idea of “small wins”- an approach to thinking about change proposed by organisational theorist Karl Weick in the 1980s.

We ask you to read the article “Small wins: Redefining the scale of social problems” (Weick, 1984). While this article is not particularly easy to read, we strongly encourage you to spend time working through it. Previous students on our management programmes have indicated that the concept of small wins was one of the most memorable and empowering ideas they had learnt.

“A small win is a concrete, complete, implemented outcome of moderate importance…Small wins are controlled opportunities that produce visible results.” (Weick, 1984:43)

If a situation is seen as a serious problem, this can in itself be a problem, in that people are inhibited from action by stress and a sense of helplessness. For example, in overwhelming situations you may hear people say: “Nothing can change until…

o  The government gives us more staff/money/attention

o  We have a change of leader/party/system

o  The system changes fundamentally

o  We have a complete moral regeneration of society

o  Patients/communities change their attitudes and behaviour

o  We have a new global order/capitalism ends

o  etc. etc.”

However, as Weick says,

“When social problems are defined this way, efforts to convey their gravity disable the very resources of thought and action necessary to change them. When the magnitude of problems is scaled upward in the interest of mobilising action, the quality of thought and action declines, because processes such as frustration, arousal and helplessness are activated.” (Weick 1984: 40).

Conversely, focusing on small wins can make a problem situation more comprehensible, give people a sense of control and encourage them to use their skills and be innovative in tackling the problem.

Activity 2 – Guided Reading

Here are some key pointers, ideas and questions to guide you as you read:

-  The introductory sections of the article set up the argument for social/management problems as potentially overwhelming. Weick uses the term “arousal”, which in this instance can be read as “anxiety” – too much arousal limits creativity and leads to paralysis. Here Weick is explicitly making a psychological argument, no doubt because he is writing for a psychology journal and he himself comes from the field of social psychology.

-  The “inverted U” relationship between arousal and performance is represented graphically above. Explain the relationship described in this diagram briefly in your own words?

-  Weick provides a series of examples of small wins. Which stand out for you?

-  In the example of the Steelers Football Team, you will note that they became league winners by what Weick later refers to as “the steady application of a small advantage” – can you explain this with reference to the example?

-  With respect to the US Environmental Protection Agency, Ruckelshaus “did not tackle everything nor did he even tackle the most visible source of pollution, which is air pollution. Ruckelshaus identified quick, opportunistic, tangible first steps only modestly related to the final outcome. The first steps were driven less by logical decision trees, grand strategy, or noble rhetoric than by action that could be built upon, action that signalled intent and competence.” (page 42).

-  Explain in your own words what you think Weick means by the following: (page 43)

-  “Small wins often originate as solutions that single out and define as problems those specific, limited conditions for which they can serve as the complete remedy.”

-  “Once a small win has been accomplished, forces are set in motion that favor another small win.”

-  “Small wins do not combine in a neat, linear, serial form, with each step being a demonstrable step closer to some predetermined goal. More common is the circumstance where small wins are scattered and cohere only in the sense that they move in the same general direction or all move away from some deplorable condition.”

- “Small wins stir up settings, which means that each subsequent attempt at another win

occurs in a different context. Careful plotting of a series of wins to achieve a major

change is impossible because conditions do not remain constant.”

- After a fairly extensive discussion of the psychology of small wins, Weick goes on to explore

“the politics of small wins” in which he responds to the criticism that the idea of

small wins may be naïve. Why is this so?

- Going back to Dr Mehari – in what way do you think the theory of small wins may explain his success?

Some local examples of small wins could be: