Implementation Change Management

The change management process must be carefully and strategically organized to attain widespread acceptance. To achieve an environment truly committed to patient safety, a successful TeamSTEPPS implementation requires a change in unit and organizational culture. This culture must view patient safety and well-being as the ultimate goal for patients and staff. Many organizations endorse the need for a patient safety culture, but to achieve this aim requires comprehensive planning that balances the intricacies among patient safety, financial success, and staff needs.

While individual teams or organizational units may be able to successfully implement TeamSTEPPS tools, the comprehensive use of TeamSTEPPS across an organization will require a culture of safety that must be continually reinforced. If you are involved in organizational efforts to change the culture, this discussion of change management will help guide strategic thinking about how the change management process can help foster the culture of safety needed to keep patients safe.

The change management discussion that follows will:

• Explain the Eight Steps of Change.
• Identify errors common to organizational change.
• Discuss what is involved in creating a new culture.
• Help you begin planning your organizational change strategy.

Harvard Business School Professor Dr. John Kotter has outlined an eight-step model for successful change efforts.¹ Steps 1-4 help unfreeze the status quo; steps 5-7 introduce new practices; step 8 grounds the changes in a new culture to ensure sustainability. Because implementing and sustaining change are difficult, they require a comprehensive strategy that encompasses the eight steps in the model:

• Step 1: Create a Sense of Urgency. Help others see the need for change and the importance of acting immediately.
• Step 2: Pull Together the Guiding Team. Make sure a powerful group is guiding the change, one with leadership skills, credibility, communications ability, authority, analytical skills, and a sense of urgency.
• Step 3: Develop the Change Vision and Strategy. Clarify how the future will be different from the past and how you can make that future a reality.
• Step 4: Communicate for Understanding and Buy-In. Make sure as many others as possible understand and accept the vision and the strategy.
• Step 5: Empower Others To Act. Remove as many barriers as possible so that those who want to make the vision a reality can do so.
• Step 6: Produce Short-Term Wins. Create some visible, unambiguous successes as soon as possible.
• Step 7: Don't Let Up. Press harder and faster after the first successes. Be relentless with instituting change after change until the vision becomes a reality.
• Step 8: Create a New Culture. Hold onto the new ways of behaving and make sure they succeed until they become a part of the very culture of the group.

Step 1: Create a Sense of Urgency

Ensuring a sense of urgency among people is crucial to getting cooperation for change. In almost all clinical settings, issues arise that most working in that area would agree are significant and require change. Focusing on one or more of these issues (e.g., delayed discharges, excessive wait times, substantial required staff overtime, ineffective scheduling, excessive infection rates, problems with transfers between units) will help create the needed sense of urgency. As long as staff view the status quo as acceptable, motivation to change will be lacking.

Regrettably, some organizations acquire a sense of urgency only when a tragic and publicized patient harm occurs, which may be one reason TeamSTEPPS and safety culture are more prominent in hospitals than in other outpatient or long-term care settings. Harms elsewhere may be invisible to those who caused them (e.g., diagnostic errors subsequently discovered during care in another setting or organization, infections in frail nursing home residents caused by inadequate handwashing resulting in hospitalization or death). In some cases, inconveniences are not taken seriously by healthcare organizations and harm results (e.g., passing a cold or flu virus to a healthy adult in the waiting room of a health clinic).

Rather than waiting for a tragedy to create a sense of urgency, proactive ways to achieve this aim include:

• Focusing on near-misses or patient harms occurring elsewhere that staff understand could have happened to their patients.
• Highlighting patient stories of both harms and harm avoidance that contrast a culture of safety with one lacking this emphasis.
• Having the board make safety and quality outcomes a top organizational priority.
• Aligning the incentives of organizational leaders, physicians, and other staff with safety goals and outcomes.

Step 2: Pull Together the Guiding Team

The Guiding Team may be the Change Team you assemble as part of your organization’s TeamSTEPPS implementation planning. For the change effort to be successful, a powerful group must lead the change, and members of that group must work together as a team. Key characteristics that must be represented on the team include leadership, credibility, communication, expertise, authority, and a sense of urgency.

No one person can implement wide-scale change; a coalition is essential. Most organizations or operating units have a Guiding Coalition, or a team of individuals who lead the change efforts, already in place. Think about your organization. Is a Guiding Coalition already established? Do they have the right mix of skills, knowledge, and capabilities?

In healthcare settings, having a physician champion on your team can be significant. Sometimes, such a champion already exists and can be obvious; other times, it is important to identify a physician, knowing who is most likely to be willing to serve as a champion. Another recommendation is to consider existing committees within the organization and designate the one most appropriate as the Guiding Coalition. Especially in larger organizations, a Change Team should be in place in each unit. These teams could all report updates to the Guiding Coalition.

Step 3: Develop the Change Vision and Strategy

An organization fosters a “culture of safety” with its practices, processes, and procedures. Patterns of behavior determine the commitment, style, and proficiency of an organization in relation to safety. A positive culture of safety has:

• A foundation built on mutual trust.
• Shared perceptions on the importance of safety.
• Confidence in the efficacy of preventive measures.

The next step in implementing change is deciding what to do. Leaders must create a compelling vision, one that answers the questions, “What do we want to achieve?” and “Where do we want to be in the future?” It is important that the vision engage both head and heart. Leadership must also develop the strategy to make that vision a reality. In addition, the Guiding Coalition should be instrumental in creating the vision and strategy. The vision and strategy must be understood by all involved in the change management process, so it must be concise and very clear.

Step 4: Communicate for Understanding and Buy-In

The next step in implementing change is making it happen. Once the vision and strategies have been determined, they must be effectively communicated. Failure to implement change is often the result of undercommunicating or communicating poorly. Everyone involved must both understand and accept the vision and strategy.

Mixed messaging is a common form of poor communication. Spending most organizational calls discussing finances, retention, facility upgrades, and other topics and then discussing patient safety for 5 minutes at the end as some staff are leaving is mixed messaging. Saying that safety is a priority but linking bonuses exclusively to nonsafety outcomes is another example.

Creating a vision and implementing change are time consuming and a great deal of hard work. It’s essential to build trust in the early stages within and among the Guiding Coalition/Change Team, staff, and leadership. It’s also important to establish an environment where concerns can be brought forward and discussed without fear of retribution. Every communication channel available should be used to put forth the vision and strategies in a planned way. It’s also essential that the Guiding Coalition and Change Team model expected staff behavior.

Accept and plan for resistance. Resisters help to clarify the problem. By addressing their concerns, you can improve the change. For example, a resister might object to plans for conducting debriefs after surgical procedures.

Exploring the reasons for resistance might surface a belief that current debriefs are relatively long, making them difficult for busy staff to attend. This finding could lead members of the Change Team to observe current debriefs and realize they are often too long and that staff leading them need better training. In this case, listening to the resister helps identify an important improvement that benefits all staff and overcomes the reason for resistance.

Use the following actions to overcome resistance to change:

• Acknowledge change as a process.
• Empower stakeholders.
• Encourage all stakeholders.
• Set concrete goals.
• Show sensitivity.
• Model process skills.
• Develop strategies for dealing with emotions.
• Manage conflict.
• Communicate.
• Monitor process dynamics.

Step 5: Empower Others To Act

Leaders must change the systems or structures that undermine the change vision and remove other obstacles to change. They should encourage risk taking and nontraditional ideas, activities, and actions. It is essential that leaders remove as many barriers as possible so that those who want to make the vision a reality can do so.

Empowering others to act involves:

• Giving people freedom and direction.
• Giving people permission to find their own team-driven solutions.
• Encouraging people to speak up, even with differing views.
• Encouraging people to take risks.
• Affirming and refining the vision – make room for others’ ideas.
• Telling people as much as you know.
• Encouraging teamwork and collaboration.
• Encouraging personal reflection and learning.
• Providing people with training and support.
• Using existing quality improvement methods in your organization to track activities daily.
• Setting short-term goals.

Step 6: Produce Short-Term Wins

Creating visible, unambiguous successes connected to the change effort as early as possible will help demonstrate the initiative’s success. The value of short-term wins that can be celebrated is one reason you should consider simple, less complex issues for your initial implementation.

When planning to create short-term wins:

• Think through the power of short-term wins in the first unit to be trained or with early adopters of the change.
• Think of the method you use to integrate lessons learned into your own process modification. Will that method apply here?
• Think about how you plan to leverage lessons learned to drive change in the second unit to be trained. Also think about how to design and drive change as you train up multiple departments across the organization.
• Ask what measures provide evidence of success.
• Think about how to handle resistance. It takes a lot of courage to openly communicate when resisters are present (e.g., at a staff meeting). What method do you find successful for communicating to staff when numerous resisters are present? How can you leverage your Change Team to strategize, plan, and control the impact of resistance?
• Consider what methods tend to build momentum. Is your facility a “storytelling” place? Are stories an effective manner to help staff hear and internalize the short-term “win”?

Step 7: Don't Let Up

Culture change is a gradual process likely to take years in any organization. Long-term changes are more likely if you press harder and faster after the first successes. Leaders must be relentless in instituting all the needed changes until the vision is a reality. To realize the vision, they may have to change systems, structures, and policies that don’t fit together and don’t fit the transformation vision.

Steps leaders can take include:

• Acknowledge hard work.
• Celebrate successes and accomplishments.
• Reaffirm the vision.
• Bring people together toward the vision.
• Acknowledge what people have left behind.
• Develop long-term goals and plans.
• Provide tools and training to reinforce new behaviors.
• Reinforce and reward the new behaviors.
• Create systems and structures that reinforce new behaviors.
• Prepare people for the next change.

Kotter recommends that to solidify the changes you seek to make, you hire, promote, and develop people who can implement the change vision and reinvigorate the process with new projects, themes, and change agents.

Step 8: Create a New Culture

Intentional efforts to create a new culture of safety should include various leadership activities:

1. Develop action steps for stabilizing, reinforcing, and sustaining the change:

• Give people time to mourn their actual losses.
• Provide skill and knowledge training.
• Develop new reward systems.
• Recognize and celebrate accomplishments.

2. Develop performance measures to continually monitor the results from the change and to identify opportunities for further improvements.
3. Modify the change vision and strategy to reflect new learning and insights.
4. Encourage people to be open to new challenges, forces, and pressures for the next change.

Persistence is essential to produce a durable safety culture. According to Kotter, the process of anchoring change in the culture has the following characteristics:

• It comes last, not first. Most alterations in norms and shared values come at the end of the transformation process.
• It depends on results. New approaches usually sink into the culture only after it’s very clear that they work and are superior to old methods.
• It requires a lot of talk. Without verbal instruction and support, people are often reluctant to acknowledge the validity of new practices.
• It may involve turnover. Sometimes the only way to change a culture is to change the key people.

Errors Common in Organizational Change

If a culture of safety is not constantly reinforced, other emphases can quickly surface and undermine it. Avoiding this error and other errors is key to achieving the culture of safety TeamSTEPPS promotes. Other common errors include:

• Allowing complacency.
• Failing to create a sufficiently powerful Guiding Coalition and Change Team.
• Not truly integrating the vision.
• Allowing obstacles to block change.
• Not celebrating short-term wins.
• Declaring victory too soon.

Change Management Models and Vocabularies

Healthcare organizations may already use one or more change management strategies. The list of strategies includes PDSA cycles (plan, do, study, act), DMAIC (define, measure, analyze, improve, control), Six Sigma, Baldrige, and others. All of these models are compatible both with TeamSTEPPS implementation and with recommendations for creating a culture of safety.

If your organization uses one of these models, you will be more successful in implementing TeamSTEPPS and fostering a culture of safety. If your organization doesn’t use any change management approach, choosing a basic approach and using it consistently may be most productive.

Note

1. Kotter J, Rathgeber H. Our Iceberg Is Melting: Changing and Succeeding Under Any Conditions. 2nd ed. New York, NY: Penguin Random House; 2016.