Clarity of Hindsight Lessons Learned from a Major Change Initiative

To survive the future and stay competitive within the healthcare industry today organizations are constantly changing (Nagaike, 1997; Villeneuve et al, 1994.). The work reported in this article addresses retrospective gathering of information associated with the development and implementation of Extendicare’s Program Management model of service delivery. Review of the project’s implementation process was part of a larger evaluation conducted in consultation with the Rehabilitation Research Center at the University of Alberta. The purpose of this part of the evaluation was to provide learnings for those who may implement major change initiatives in the future.

Background

Over the past two years, Extendicare (Canada) Inc. piloted a new service delivery model in four continuing care sites in Southern Alberta. The model was introduced in response to issues identified by residents, family, staff and community contacts across Canada. Issues such as higher care levels, increasing demands from clients and more complex processes and procedures led to the development of four strategic goals:

• Resident Focused Care
• “User-Friendly” Facilities
• Increased Staff Satisfaction through Involvement
• Cost Effective and Efficient Service Delivery

A Program Management approach (Morris et al, 1994) was selected to achieve these outcomes. Extendicare’s Program Management Model (EPM) is a method of integrating services around client groupings with common needs and outcomes, in order to effectively and efficiently maximize responsiveness. It is delivered through a team approach, allowing those working closest to the resident to make decisions and resolve problems.

Implementation required the replacement of functional departments and department heads by Clinical Program Teams and Support Services Teams. Staff were permanently assigned to Programs to work with specific residents. The primary care personnel’s role was expanded to include all tasks related to the everyday life of the residents, such as activities and light housekeeping, along with care. Program Manager positions were introduced to lead each Program Team in developing processes to better meet needs unique to their resident group.

Implementation Challenges

The Implementation Team received a mandate to complete the pilot within an 18- month time frame. “Develop as you go” became the working motto of the sites. Enhancement of the framework, defining facility structure, clarifying program characteristics, role definitions, job descriptions, relationships and reporting structures were necessary during initial implementation. All of this created much confusion in the beginning as the sites worked through new territory. Staff were guaranteed continued employment but asked to think differently about how they delivered service. New positions were filled with existing staff and everyone needed preparation and education to respond to changes in how they worked.

Implementation required major structural changes to support a philosophical shift from the traditional medical model toward a client-focused system. A cultural change involving a transition from a top down decision-making organization to one that encouraged staff ownership of problems and improvement opportunities was also required along with the development of a new skill base. All aspects of care and service delivery were affected resulting in the change not willingly being embraced by all.

Evaluation

In consultation with the University of Alberta, an evaluation to determine the impact on care and service delivery was conducted. The evaluation ran from pre to post implementation and a formative and summative framework (Patton, 1997) was applied to monitor and assist with project implementation. Key results respective to the strategic goals are summarized below.

Resident Focused Care

• Overall clients reported more choice available with a strong positive correlation between choice and perceived importance;
• An overall positive trend in degree to which needs were met was reported;
• Residents identified a shift away from staff, and more to themselves, as being most responsible for making sure that needs were met.

User Friendly Facilities

• Resident and family perception of problem resolution remained the same or improved;
• Community respondents remained extremely satisfied;
• Direct contact with staff remained the preferred method of raising issues but evidence indicated the contact person changed;

Increased Staff Satisfaction through Involvement

• Licensed Care Staff (RN’s, LPN’s, Therapists) reported positive effects on attitude and stress;
• Care Assistants reported more negative effects on attitude, stress and perceived influence but reported a decrease in resident sources of stress;
• Support Service Staff reported the least impact.

The data indicated EPM was taking the pilot facilities in the intended direction towards the project’s outcomes and that the change is still in transition. As the piloting of EPM was to be cost neutral, cost effective and efficient service delivery was not part of this evaluation but efficiencies were realised through process improvement strategies.

Implementation Review

The purpose of the review was to acquire qualitative learnings through a systematic investigation of the project’s implementation processes, thereby gaining an awareness of pitfalls and barriers for future implementation of major change within an organization.

By taking a critical look at how the process unfolded, with both those leading the change and those participating in it, valuable insights as to what contributes to successful implementation have been gained.

Method

• Fourteen individual semi structured interviews were held with the Vice President Western Operations, Regional Director, Project Facilitator, Site Administrators and Directors of Care.
• Focus groups, using a similar format to the interview structure, were held with staff in each of the sites. All levels and disciplines were represented but groups were segregated into Professional Staff, Non Licensed Staff and Program Managers. Focus groups were also held with the management teams in the two facilities that did not complete implementation. Sixteen focus groups were held in total.
• Data was recorded on a flip chart, validated by each group and analyzed for common themes. These themes were used to generate a series of lessons learned from those involved in the implementation process.

The results are presented below.

All levels of management must lead the change.

Senior management’s leadership is crucial, especially running interference, acquiring appropriate resources and providing mentorship.

All leaders must give people confidence, generate excitement and keep people calm.

Management must believe in the new direction, share the concept as well as the feeling, and communicate it effectively to their staff to inspire action and commitment.

Pay attention to the transition between planning and operations.

Transitions between implementation planning teams and operating teams must accommodate different levels of readiness for change. Those participating in original planning are more excited and share a passion making them better prepared than those subsequently brought on. This mixture of readiness can present problems with the team’s ability to grasp the vision and their ability to buy into the need for change.

Those who follow the original planning team require consistent, convincing presentation of the need for change.

Time to celebrate the past and accept the future must be encouraged.

Mentoring those that are new is critical.

Be willing to spread the word again and again and again.

People may be reluctant to share hesitations or ask for clarification. Exercise caution in assuming key players are committed and on board. Pay attention to inaction as well as action to identify these players. Take time to coach and provide support where necessary.

All players in lead positions must understand the concept and reason for change. A strong foundation is essential to guide the evolution and to respond to the unique characteristics within each site.

Staff must grasp key components of the model to make sense of revised roles and service delivery. Getting the message across requires repeated explanations, formal and informal communication strategies, concrete visual material and continuous reinforcement of the basic philosophy.

Champions of change are essential in each site, as is support and backing for these champions.

A plan outlining the path is critical but flexibility around implementation is mandatory.

Have an implementation plan that can be measured and shared with staff so they can see where they are going and what their responsibility is in carrying out the plan.

Solid parameters defining the approach are necessary but actual implementation strategies must be flexible to respect local cultural nuances. Some staff may interpret this to mean there is no plan guiding the project.

Flexibility and freedom to evolve is necessary but some structure needs to be provided to both those managing the change and those experiencing anxiety and insecurity regarding their roles in the new model.

Perception is reality; staff perceptions need to be managed.

The impact on staff and their jobs is significant. Perceptions that departments are being abolished at a whim, that it’s all about saving costs and asking people to do more with less, must be handled early on in the process before becoming firmly entrenched beliefs. The need for trust and honesty is exaggerated when control shifts and territories are redefined.

Help staff to understand how their individual roles contribute to the delivery of care and service. Performance must be described, goals and targets set and monitored, with appropriate and timely feedback given. The project leader must monitor success based on expected outcomes. People must be held accountable if they deviate from the expected outcomes.

Job descriptions are important for all staff to create a formal understanding of what is expected from the different job categories and must be written down so people can read them.

Education is one of the keys to success.

Understand the educational needs of staff, especially those competencies required for adequate performance in their new job.

Although it is hard to describe exactly what training and support is needed when new positions are being created and existing staff skills and knowledge base varies, once defined, allow adequate time for training to occur.

Training should be done before staff members move into their new role. Acknowledge the reality of continuing to provide ongoing service but give thought to how best to provide continuing education and training on the job.

Ensure all staff, old and new, receive orientation to the service delivery model.

Implementation of a new model should include all services and cover a 24-hour period.

Ensure all services and all shifts feel they are part of the change, by keeping them informed and involved as the model evolves.

Be ready to manage the challenges of business as usual and try to limit additional major changes.

Other demands and pressures occurring within the implementation time frame require energy to respond to and have an impact on how successful the process is. A major change in an environment still delivering service in the usual way is very confusing to those involved in the process. Pressures to conform from those outside of the project must be managed.

Don’t underestimate the strength of facility culture in presenting barriers to success.

Creating a culture that promotes flexibility and allows staff to function within an ambiguous environment is often challenged by past reliance on corporate direction. Do not underestimate the degree of resistance that this may present.

Some staff will refer to an “idyllic” time when teamwork was perfect, staff never called in sick, recruitment was easy and all resident needs were met. Be prepared to listen but challenge these perceptions with facts.

It takes time to develop a new culture and there will be moments when it may seem impossible. Strategies to address this potential resistance must be developed.

Be prepared for the magnitude of change, impact on staff and time required.

Managing change means managing the organizational context in which change can occur plus the emotional connections essential for any transformation.

Models can look deceptively simple on paper but implementation requires major adjustments to how business is conducted. These adjustments create a strain on all systems including staff, information, management, and routine processes. The greater the change, the more far reaching the impact is on these systems. Facilities must be prepared to respond to the uncertainties these strains will create. Such a shift necessitates attention be paid to the finer details of day-to-day routines and how they will be conducted.

All staff feel the impact to varying degrees. Feelings of loss, uncertainty about their future, anxiety regarding their ability to take on enhanced roles, perceived states of confusion regarding decision making and authority will occur and must be managed over time.

Residents and families must understand the intent behind the changes. Time to adjust to the new roles staff take on and reassurance that standards of care will not suffer is necessary.

Develop proactive steps to address concerns, both inside and outside the facility, that Professional Associations and Unions may have about the implications of the change.

Successful implementation is all about achieving delicate balances.

A balance between staff participation/input and time for hands on care;

A balance of the old with the new, determining what systems need to stay while new ones are implemented;

A balance between pushing for more change and taking time to celebrate even small successes;

A balance between providing a structured, staged approach to change so there is a sense of logic and clear direction, while encouraging the creativity and flexibility for staff and facilities to evolve in a manner responsive to their unique setting and customer needs.

Conclusions

Many people consider themselves masters of the change process and the knowledge gained through this project may appear at first glance as cliché in nature. However, the true meaning of this knowledge and value to other managers wishing to implement any major change are much deeper. The challenge lies in understanding and appreciating the significance of each of the learnings, then applying them in guiding the process of future change. Strategies to address each of the lessons learned is critical to the successful implementation of change. Such strategies cannot be listed as a universal template to follow because they must be unique to each situation, site and individuals involved.

Change of this degree and magnitude is hard work. Being aware of the challenge of implementing change and being prepared to manage the process are two different constructs. Consideration of the lessons acquired here will allow others to manage change more effectively.

Additional information about the evaluation, methods and data analysis can be obtained through the authors.