Work in progress – do not distribute
How can ‘change management’ make management change management?
Mattias Elg
Division of Quality Technology and Management
Department of Management and Engineering
Linköping university, Sweden
and
The Jönköping Academy for Improvement of Health and Welfare
Jönköping University, Sweden
Introduction
The following paper presents an overview of management trends in Swedish healthcare during the latest 20 years. Much has been written about how to manage and organize change. Witness for instance the popularity of the subject by Kotter (1995), Beer and Nohria (2000), Kanter (1990), and Peters and Waterman (1982). The ambition to summarize this period of research will inevitably be selective. Therefore the discussion will be directed towards some of the aspects that I find particularly important. By the notion of ‘management trends’, I refer to two things that will be discussed in detail. First, management trends refer to specific management concepts that have been introduced, developed, institutionalized and sometimes even abandoned in various healthcare contexts. Examples of such concepts are Quality Improvement, Balanced Scorecard, Lean production and Patient Involvement. Second, I will refer to management trends in relation to a process of how to organize for sustainable change. In short, management trends involve both a content dimension (e.g. the concept) and a process dimension (e.g. the way that healthcare organizations organize their efforts). These two sides of the coin are also sometimes added by a third dimension: the context in focus. Michael Beer, a prominent researcher within the field discusses the dilemma of these aspects by asking if it is the seed or the soil that matters in change management. This is a question of vital importance; giving us plenty of food for thought.
There are thus many different questions that change management need to answer. People need to keep attention towards new ideas. This is a problem because organizations are more focused on harvesting and protecting current practices rather than devoting themselves to innovation activities and creative endeavors. Words such as inertia and path dependence are better in describing what is going on in our organizations. So a big challenge for change managers is to manage good ideas into practice (Van de Ven, 1984). Organizational researchers point out that independently of the type of innovative idea (e.g. lean, process orientation, new reimbursement models, structural changes), there is a need for knowledge of principles and concepts for understanding the social and political dynamics involved in change management.
A general assumption in relevant research studies is that healthcare organizations exist and operate under various conditions. This requires that change management strategies must be flexible and their applications adapted to the individual organization’s own history and conditions. Proceeding from this assumption, there are a series of questions that may be addressed in initiatives in change management:
· How do we create awareness of the need for change? This question puts emphasis on the driving forces behind improvements and change.
· What results do we expect from change management (e.g. improvement work)? Here, the discussion in theory focuses on the idea that patients are healthcare’s most important customers, and that the goal-setting for the organization should pay attention to value-creation for this group as well as strive for good health on equal terms in the general public.
· What resources do we need in order to succeed in changes at work? The leadership has an important role in producing the resources required in order to pursue a long-term development process.
· How and where do we start change management? One way to choose strategic areas is to proceed from where the greatest value for the customers can be attained in relation to the organization’s mission and goals.
· How do we work with processes of healthcare from a patient perspective? Every operation functions through processes which create value for patients and relatives. In many cases these processes cross organizational boundaries.
· How can we increase our organizational learning? Strategies which minimize the effects of failures and make it easier to succeed are important. The idea is to start by testing, to a limited extent, how ideas can be adapted to a local context. This way of testing and adapting ideas to local situations provides an opportunity to discover and learn how healthcare systems respond to change.
· How do we create long-term thinking and commitment? Entering into change management is a long-term undertaking. Upper management ought to ask itself how a sense of purpose can be maintained. Thorough changes often take many years to implement.
· How do we design IT systems which support new and better work procedures? The potential of information technology is put in its proper context when the starting point is that the value of the organization is created in the microsystems.
· What do we need to cease doing in our work? Often organizations continue to do things in the same old way, even though they have found a new way which is more effective. Then in practice the planned increase in effectiveness does not occur.
In my presentation I will touch upon these questions and refer both to empirical research in the context of healthcare and theory development in other fields such as organization and management theory. I will consistently make reference to the various works that has formed the basis for the paper.
The paper is presented as follows. First, I will make an overview of some of the drivers that initiate change in Swedish healthcare. This overview is based on a longitudinal study that the author of this paper has conducted. Thereafter I will present some findings showing the trends in application of various change management concepts. This is followed by an overview of important findings within general change management literature. Finally I will readdress the questions posted above and suggest ways that are relevant in making change management theory’ change management. First, I will point out some important drivers for change in Swedish healthcare.
Drivers of change in Swedish healthcare – an overview
New ideas for change are triggered when people reach a threshold of dissatisfaction with current conditions (Van de Ven, 1984), i.e. when there is a sufficiently large tension for change. As a consequence, there are always some external or internal factor that leads to the initiation of change and renewal (Child, 2005). Broadly, there are two ways in which this may occur: either as continuous adaptation or by planning specific development initiatives (Weick and Quinn, 1999). In line with this Dunphy (1996) argue that organizations that do not enable routines and ways to continuously adapt usually need to initiate planned change. Political initiatives, technological advances, cultural changes, demographical changes and the growth of new forms of knowledge (e.g., Lean, Quality Management, Six Sigma, BPR) are all example of external factors that may trigger change. Internal factors such as change of leadership may also trigger change.
The question, however, is not only if change is to be produced but also what that change responds to. Research on change management indicates the importance of awareness among those working within the organization of the problems and challenges it is facing (Beer et al., 2000). Leadership has an important role when it comes to driving the process of change (Berwick, 1996), to be able to motivate those involved and respond to the question: Why should we change? Establishing a sense of urgency is also one of the first points made by the popular management guru Kotter in his famous model for change management (1996). Similarly, Van de Ven et al. (2000) suggest that a key issue in increasing the likelihood for innovation is “placing people in direct personal confrontations with sources of problems and opportunities is needed to reach the threshold of concern and appreciation required to motivate most people to act” (p. 670). For instance, a strategy for healthcare organizations who strive to become more patient focused would thus be to continuously gain insight into the problems confronting their patients; this in practice requires some extent of patient involvement.
Drivers for change are based on aspects that influence change initiatives. In order to characterize them we studied the influence of drivers in a paper that was published 2011 (Swedish healthcare management practices and quality improvement work: development trends by M Elg, J Stenberg, P Kammerlind, S Tullberg, J Olsson in International journal of health care quality assurance 24 (2), 101-123). The study is briefly presented below.
We distinguished between drivers of change that come from within the organization and those that come from outside. First, drivers that are related to the organizational inner context consist of the structure, activities, problem areas, applications and usage of methods of improvement within the organization. Second, drivers connected to organizational outer context are related to the immediate environmental aspects of the organizations such as patients, higher management and other healthcare providers. Third, the external environment, which, through policy makers and various professional organizations, influences improvement activities within the studied organizations.
Answers to the question “To what extent have the following items been driving forces for your improvement work?” are shown in Table 1 below. This data is based on a study carried out at two occasions between 2003 and 2007 and based on 11 variables. We surveyed the managers of all primary healthcare centers (n = 1031) and hospital clinical departments (n = 1542) nationwide in the spring of 2007.
The most important trends in drivers for change are derived from patient needs/complaints, decisions from higher-level managers and directives from official authorities. Also, problems regarding the quality of healthcare and the fact that daily work does not function optimally show significance change. In addition to these factors, problems regarding access to health care have slightly increased as a driver.
Drivers that show no significant difference are financial problems, that is, financial issues have not changed in any direction. This driver is also low ranked (number ten of the eleven drivers for change) with a mean of 2.85 on a scale from 1 to 5. No significant change is identified for the driver Medical innovations. The two drivers, Desire to increase market share and Problems regarding staff/the work environment have not changed during 2003 and 2007.
Good ideas from employees is the only driver that shows a significant decrease since 2003.
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Work in progress – do not distribute
Table 1 Drivers for change: ranking according to the difference in means from 2003-2007. Significant variables are highlighted.
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Work in progress – do not distribute
Change management concepts in practice
Change management concepts play a fundamental part when handling tensions for change in healthcare organizations.
Enhancing the understanding of how healthcare organizations deal with these pressures was therefore studied in the article by Elg et al (2011). A central question for the study was: What are the developmental trends in management practices and improvement work in healthcare organizations? The change management concepts were defined in accordance to the table 2 below.
Table 2. Classifications of change management concepts
Classification categories / Definition / Examples / ReferencesProblem analysis / Formal activities for collecting, structuring, rearranging, analyzing and interpreting practice based data / Risk analysis, Analyses of incidents, Process mapping / Bergman and Klefsjö (2003); Ellström (2006)
Organizational behavior change / Rearrangements of organizational members patterns of behavior so that work flows and other activities are improved / Breakthrough type efforts, changing care pathways, treatment methods, change division of tasks / Beer et al. (2000); Olsson (2003); King et al (2006)
Medical/management control systems / The formal, information-based routines and procedures managers, clinicians and policy makers use to maintain or alter patterns in organizational activities / Electronic medical records, Balanced Scorecards, Quality registers, Administrative information systems / Simons (1995); Neely et al. (2002); Elg (2001)
Patient orientation / Activities made by members of the organization aiming at increasing the patient’s role within the healthcare system / Quality Improvement based on patient satisfaction / Bergman and Klefsjö (2003); Thompson et al (2003)
Information/communication /training / Types of activities focusing on changing attitudes and knowledge among members of the organization / Developing method descriptions and guidelines, Information to patients and staff, support from consultants, educational initiatives / Kazandijan and Lied (1999); Davenport and Prusak (1999)
Financial control / Activities directed towards the financial aspects of the organization / Acquisition of additional financial resources, Reward systems / Simons (1995)
Organization structure change / Initiatives aimed at merging, splitting or rearranging the relations between organizational units / Physical work environment, Administrative organizational structure change / Pugh et al. (1968), Pettigrew et al. (1992);
Olsen (1998);
Mintzberg (1979)
The results are shown in Table 3 below (Methods/concepts that have increased in use between 2003 and 2007), Table 4 (Methods/concepts that have not changed in use 2003-2007), and Table 5 (Methods/concepts that have decreased in use between 2003-2007).
Each table presents the method/concept, category, number of respondents (N), mean, standard deviation and significance. The order of presentation is based on the rank (i.e. differences in means between 2007 and 2003).
Significant positive trend
The greatest difference between 2003 and 2007 is found in the use of Other systematic development methods which are used systematically. Breakthrough-type efforts show a big difference and is the single method/concept that shows greatest difference from 2003 to 2007. Methods/concepts – which we have classified as medical/management control systems – such as the electronic medical record, national quality registers, administrative information systems, balanced scorecard and management review systems also show significant greater use.
Patient orientation is another important aspect that is of increased importance within the studied organizations. A third emerging trend is the increased focus on problem analysis, i.e. Formal activities for collecting, structuring, rearranging, analyzing and interpreting practice-based data.