A modern pediatric intensive care unit (PICU) faces constant pressures to implement new clinical care practices, introduce new equipment, or assimilate new systems in response to rapidly evolving healthcare regulatory, economic, and patient-centered demands while maximizing healthcare value.
To meet new challenges and advance PICU care optimally, the process of change requires a combination of leadership and management in order to develop an intentional strategy and carry out a structured yet adaptable implementation approach.
The PICU team can increase the likelihood of successful and sustainable change in care practices by understanding the strengths and weaknesses of existing interprofessional team function and empowering distributed leadership, personal agency, and group identity among the diverse people who comprise the PICU team.
The fields of business administration and management, dissemination and implementation science, and quality improvement offer models and tools that can guide a PICU team embarking on new initiatives.
“If we could change ourselves, the tendencies in the world would also change. As a man changes his own nature, so does the attitude of the world change towards him. We need not wait to see what others do.” (in other words, be the change you want to see in the world.) —Attributed to Mahatma Gandhi “And it ought to be remembered that there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. . . . This coolness arises partly from fear . . . and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.” —Niccolò Machiavelli. The Prince, 1513. Chapter 6
Leading a change initiative in a complex system such as a pediatric intensive care unit (PICU) poses multiple challenges that cannot be accomplished by any single person. Just as caring for a critically ill child requires interprofessional team collaboration to achieve a desired patient outcome, introducing new care initiatives also requires a deliberate plan and customized approach. Without intentional leadership and management, change initiatives too often fail to achieve the desired outcomes, create tension that undermines a unit’s morale, and are soon forgotten even when initial success occurs. This chapter uses examples from successful initiatives in healthcare, specifically from the fields of adult and pediatric critical care medicine, to review the history of change management. It also describes models and tools that have been developed and used to facilitate and sustain change.
National change day: A case study in leading change
On March 13, 2013, the United Kingdom’s National Health Service (NHS) held a National Change Day in response to the 2010 Francis Report. This government oversight report condemned systemic and cultural failings on an organizational scale that led to “appalling and unnecessary suffering of hundreds of people [. . . who were] failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and their safety.” Founded as a grassroots movement, Change Day challenged NHS employees from all positions and professions to “Do Something Better Together” and to identify a concrete change in their own work and behavior that would impact positively on an aspect of their local patient care processes. The organizers set an initial goal of 65,000 pledges, which doubled to 130,000 by the morning of Change Day, ended the day at 182,000, and reached a total of 189,000 individual pledges by the end of March 2013.
The NHS Change Day transformed the world’s largest health system and was subsequently awarded the Harvard Business Review/McKinsey Leaders Everywhere Challenge in September 2013. Incredibly, this movement, credited as the single “biggest ever day of collective action to improve healthcare” evolved from an impromptu conversation between a general practitioner and a lecturer speaking on “Building Contagious Commitment to Change.” This chance encounter between a conference attendee and a program lecturer evolved into a core team made up of 12 people: a pediatric resident trainee, a family practitioner, and an NHS graduate management trainee who were mentored by five improvement leaders and supported by one administrator and three social media and communications experts. Since then, building on this overwhelming success, the NHS holds Change Day annually. Similar movements have spread to 17 other countries.
The success and spread of Change Day reflect change management principles that developed beginning in the 1960s, have evolved through the ensuing 5 decades, and have steadily been adopted in manufacturing and service industries, including healthcare. Change Day serves as a model for creating distributed leadership within a hierarchical system. It also highlights the potential for inspirational leadership combined with intentional management to design, implement, and sustain changes in behavior.
History and development of change management
The beginning of change management as a field of expertise began when leaders recognized the importance of addressing the psychology of change as an integral component of leading and managing change. This new field of expertise developed insights from the 1969 book On Death and Dying , by Elisabeth Kubler-Ross. This seminal book described how terminally ill patients and their loved ones reacted to a health-related event that resulted in the personal loss of a previously held image of both present and future selves. Kubler-Ross proposed five stages of grief: denial, anger, bargaining, depression, and acceptance. Adopting the psychological insights from the stages outlined by Kubler-Ross to address the common negative emotions triggered by an event leading to the experience of loss of current roles, changes to work environment or status, and a shift from the “old way,” initial change management models emphasized the importance of approaching change with more than just an idea and a plan. By the 1980s, Julien Phillips at McKinsey & Company proposed three critical components for successful organizational change: (1) new strategic vision, (2) new organizational skills/capabilities, and (3) political support. Phillips further described that these three core factors would have to carry out four sequential and often overlapping phases of the change process: (1) creating a sense of concern, (2) developing a specific commitment to change, (3) pushing for major change, and (4) reinforcing and consolidating the new course.
Over the next 2 decades, Phillips and his contemporaries from the “big 6” accounting and consulting firms of the time helped create the change management industry. Recognizing the importance of leveraging a crucial event to trigger Phillips’s first two phases of change, Daryl Conner coined the term “burning platform” based on the 1988 North Sea Piper oil rig fire disaster. Soon, the phrase “create a burning platform” became widely used to represent both creating a sense of urgency and establishing a commitment to change. Common to all of these initial change management approaches was the implied belief that organizational change could and should be accomplished using a top-down approach that inspired, convinced, cajoled, or forced frontline employees to enact and embrace the changes that leaders deemed necessary.
By the turn of the century, business leaders recognized the weaknesses of using a top-down approach when trying to enact lasting change. Further, as the rapidity of change accelerated, change leaders recognized the importance of distributed leadership. This strategic shift promoted individual initiative and created a business environment in which change was encouraged and able to develop incrementally in continuous fashion rather than in large disruptive shifts that occurred in a change-stasis-change pattern. Lean management principles, originally focused on elimination of waste, shifted the emphasis of change management to creating a pattern of behavior that allowed and encouraged continuous improvement led by frontline staff that fit within the broader goal of increasing efficiency and quality.
The role and importance of employee engagement in achieving sustained changes in workplace behavior was formally introduced into change models in 1996 by John Kotter in his book Leading Change . In his book, Kotter outlined an 8-step Leading Change Model ( Table 5.1 ) that distinguished change leadership from change management, described the importance of both of these executive skills in guiding change, and highlighted the role of distributed leadership and employee empowerment in the change process. The pace of extrinsic forces that drive the need for change has only increased. In the preface of his 2012 edition of Leading Change , Kotter highlighted each of these points as the foundation to achieving both efficiency and quality:
Management makes a system work. It helps you do what you know how to do. Leadership builds systems or transforms old ones. It takes you into territory that is new and less well known, or even completely unknown to you.
These trends (of an ever-increasing speed of change) demand more agility and change-friendly organizations; more leadership from more people, and not just top management.
Speed of change is the driving force. Leading change competently is the only answer.
|Kurt Lewin||Theory of Planned Change|
|Ronald Lippitt||Phases of Change Theory|
|Everett Rogers||Five-Stage Change Theory (Diffusion of Innovation Theory)|
|John Kotter||Leading Change Model|
Change management in healthcare
In 2006, the book entitled Redefining Health Care: Creating Value-Based Competition on Results , introduced the concept known as “value agenda.” In this approach, the goal of increasing efficiency and quality was reframed as maximizing healthcare value for the patient. This replaced simply reducing costs, increasing market share, or improving quality. In this sense, the audaciously titled article, “The Strategy that Will Fix Health Care,” defined value as “improving outcomes that matter to patients relative to the cost of achieving those outcomes.” In this paradigm, maximizing healthcare quality becomes a balancing force for minimizing or shifting healthcare costs and maximizing market share.
The NHS Change Day epitomized all these described principles. In change management terms, the 2010 Francis Report created the “burning platform” that galvanized not just people within the NHS but also the public at large. The report criticized and described the systemic failures of the NHS, misguided focus on healthcare costs rather than healthcare value, and provided a multitude of examples in which the inability of the NHS to address its known flaws led to unnecessary patient suffering. This unmitigated language created an overwhelming and uniformly shared sense of urgency and concern that led to a unifying commitment for change from political leaders and the British public at large, allowing development of a guiding coalition. , The inclusion of social media and communication experts among the core leadership team ensured that the vision for change was communicated broadly and consistently. Local groups were empowered to seek out input from community members and leaders about how the NHS could better serve patients’ needs and improve their healthcare value. Individuals were encouraged to each participate in their own way. As a result, a broad-based network of leaders, unified under the umbrella of the Change Day initiative, pursued and led team-specific actions and change initiatives. While this all-accepting approach allowed participants to make individual pledges as simple as “to meet and greet patients with a smile,” it also created space for city and regional health commissions to fold their local efforts into a national movement. Subsequent analysis of the psychological factors that led to Change Day success highlighted the impact of allowing daily participation and commitment to self-initiated, small tests of change. These small successes, in turn, affirmed both personal agency and group efficacy, promoting and restoring a sense of “vocational and organizational identity.”
Models and tools to facilitate change leadership and management
Theories of change
Others have described change theories with many similarities to Kotter’s eight-step model. Examples include Lewin’s Theory of Planned Change, Lippitt’s Phases of Change Theory, and Rogers’s Diffusion of Innovation Theory (see Table 5.1 ). The advantages of Kotter’s model over these four include the treatment of change as a continuous rather than a discrete event (Lewin), establishing distributed leadership and empowering frontline initiative and action rather than focusing on the change agent and a top-down approach (Lippitt), and description of active leadership rather than passive management and subsequent undirected diffusion of ideas and change (Rogers).
Despite these advantages, Kotter’s Leading Change model lacks specific details on how to best accomplish each of the eight steps. Additionally, Kotter’s model does not include a step that assesses current attitudes and receptivity for change or a step that focuses on identifying facilitators and barriers to change. Understanding current organizational culture, behavior, biases, attitudes, and knowledge provides extremely useful guidance. Change leaders and managers increase the likelihood of success if they analyze how various aspects of the existing organization must interact with internal and external variables when implementing a specific intervention. Without this tactical step that defines how to accomplish the strategic goal, the inspirational vision remains nebulous and can be dismissed as a grand idea but too hard or even impossible to enact.
Bringing theory to practice
The Consolidated Framework for Implementation Research (CFIR) provides a bridge between the inspirational vision and practical question of “How do we get there?” Proposed by Damschroder et al. in 2009 as a framework to understand adoption of new initiatives in health services, the CFIR gives a roadmap not only for accomplishing implementation research but also for achieving successful implementation of a proposed change. Five domains comprise the CFIR: intervention characteristics, outer setting, inner setting, individuals involved, and the implementation process (e Fig. 5.1 ). In turn, key constructs define each of these domains and are explicitly defined to facilitate use. Within 5 years of introduction, the CFIR model was described in 26 separate publications, a testament to the framework’s success and utility when introducing change in the form of new healthcare initiatives. One of these studies used the CFIR model to evaluate the implementation of the ICU Liberation improvement initiative across five adult ICUs and two additional specialty care units in a single tertiary care academic medical center. The authors outlined in great detail how their adoption of the ICU Liberation initiative fit within the CFIR model and provided a “lessons learned” summary of points to consider during ICU Liberation implementation. By applying the CFIR to their work, this multiprofessional group of ICU specialists outlined a roadmap to guide other centers seeking to replicate the work.