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CHANGE MANAGEMENT THE NEW LEADERSHIP     CHALLENGE          T Forcht Dagi         MD, MPH, MBA, DMedSc          Harvard Me...
Disclosures                Consultant to Masimo, Inc.           Investor in and Director of Aventura             Partner i...
IntroductionTransformation
HCIT and HIMS              From the Mountaintop• Better medicine• Automation• Optimize patient care by optimizing   –   In...
The State of HCIT in Medicine•   Past the point of questioning the place of HCIT•   Questions about ultimate utility of al...
Near Term Issues• Communications, training, workflow and  assessments of utility• Interface between technology, clinician,...
The CMIO Role• Agent of change   –   New expertise   –   Roles as a physician, teacher, trainer and informaticist   –   In...
CMIO Role, Part II• Traditionally, physicians positioned as clinical leaders,  but administrative managers• Because of the...
Transformation of Healthcare
Transformation of Healthcare• Over the next 10 years:   – Episodic and non-episodic care will be differentiated and     se...
Transformational Context• Diagnoses are likely to change  – What we think of as diseases may not actually be    diseases• ...
Change Issues in Healthcare• External v internal mission• Imposed v native strategies• Political v operational goals and t...
Short Term ONC Agenda
This Year’s Priorities                    Dr. Farzad Mostashari•   Meaningful use•   Interoperability•   Data exchange•   ...
Meaningful Use• “Meaningful use will soar.. [and] continue to be the  cornerstone of our activities.”• “We’re going to do ...
Interoperability and Exchange• The “second and more complex challenge,” following  meaningful use.• The emphasis will be o...
Care Coordination• In 2012, the business case for care coordination,  which requires the exchange of healthcare  informati...
Consumer eHealth• Consumer health IT is the third emphasis for  the year.• The government will look to find ways to  encou...
Quality Measurements• Quality measurements are the fourth initiative  slated for this year.• “We will be moving forward on...
Real and Stipulated Meaningful              Use
Meaningful Use                  The CMIO’s Bête Noire• “Real” or Natural language    –   Appropriate HCIT/EMR system    – ...
CMIO RoleManagers or Leaders
The Task of the CMIO has Evolved• Change management• Clinical leadership• CMIO 2.0 – the place of the CMIO in clinical  an...
Managers•   Subordinates•   Vested, externally derived authority•   Transactional style•   Like a happy ship. Avoid confli...
Leaders• Voluntary and inspired followers, not subordinates• Charismatic authority• Transformational style based on appeal...
Operational DifferencesManagerial Focus                     Leadership Focus•   Administration                   •   Innov...
Measurement v Implentation•   Measure Process and (not or) Outcomes     – Adoption     – Utilization     – Satisfaction   ...
Change Management
Change Management• Structured approach to managing and coordinating change• IT    –   Service component of organizational ...
Change Management                  First Efforts• 1980s – early discussion   – Julien Phillips (McKinsey) publishes change...
Change is a Staged Process                From Kotter and Others• Create urgency and a       • Create short term visible  ...
Types of Change•   Mission•   Strategy•   Operations•   Technology•   Attitudes and behavior
Change Management Simplified          Traditional Model• Top down• Plan and direct• Dictate, instruct, impose and enforce ...
Change Management Simplified            New Model• More matrixed• Consult and prepare• Engage, communicate, interpret and ...
Successful Process             Change Breeds Insecurity•   Process needs to address and overcome fear•   Consultation•   D...
Simple Questions•   What do we want to achieve with change?•   Who are the “we?”•   So what and who cares?•   Where are th...
Upgrading Skills               Training or Learning?• Training   –   Measured by task competence   –   Improves skills   –...
Methods I• What elements of the organization’s mission  and culture drive change• Articulate aims when teaching skills• Fo...
Methods II• Involve   –   All clinical staff, not just physicians   –   All physicians, not just primary care   –   Admini...
The Importance of Face to Face               Discussions•   Consultative communications•   Individualize the process of ch...
Implications for CMIO• Change process is          • Sample the work flow  creative, not mechanical   • Put yourself in the...
Issues for the CMIO• Position within hospital hierarchy  – CIO  – CMO  – C suite  – Allied medical personel• Time manageme...
Conclusion• The time is right for the CMIO to lead• Convey   –   Importance   –   Individuation   –   Relevance   –   Feas...
Thank You
EMRs Need to Advance• EMRs are paper charts in electronic form with  results• Need to become tools for care management• CM...
How Physicians Learn• See one, do one, teach one• Respected mentors• Read and analyze papers anchored in patient  encounte...
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Keynote Presentation “Change Management & Processes in a Complex Care Environment”

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This session reviews the latest organizational behavior concepts allowing the attendees to learn how to best manage change in complex environments. At the conclusion of the session, attendees possess practical approaches to facilitating and managing change in their organization.

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  1. 1. CHANGE MANAGEMENT THE NEW LEADERSHIP CHALLENGE T Forcht Dagi MD, MPH, MBA, DMedSc Harvard Medical School Queen’s University Belfast The Institute for Health Transformation CMIO Forum
  2. 2. Disclosures Consultant to Masimo, Inc. Investor in and Director of Aventura Partner in HLM Venture Partners This presentation is not intended to contain or convey any commercial contentNo compensation offered or received in conjunction with this presentation
  3. 3. IntroductionTransformation
  4. 4. HCIT and HIMS From the Mountaintop• Better medicine• Automation• Optimize patient care by optimizing – Information archiving and retrieval – Clinical processes – Administrative tasks – Cause and effect (outcomes)• Move from anecdotes to series• “The study of homogeneous populations allows one to make statements with measurable and verifiable validity”
  5. 5. The State of HCIT in Medicine• Past the point of questioning the place of HCIT• Questions about ultimate utility of all components• Familiarity with a PC does not translate into comfort with HCIT• A people issue, not a technical one. – Most clinicians know remarkably little and want to be engaged – Resistance to change is deeply embedded in medical culture• Distinguish between – Installation – Adoption• Requires constant attention and engagement• The CMIO is changing – Clinical leader – Part of institutional management
  6. 6. Near Term Issues• Communications, training, workflow and assessments of utility• Interface between technology, clinician, administration, nursing and other hospital staff• Redefinition of certain roles requiring a different level of access to information – Nursing as care management – Protocol based treatments
  7. 7. The CMIO Role• Agent of change – New expertise – Roles as a physician, teacher, trainer and informaticist – Interlocutor and translator – Unique position in hospital and in medicine• Hardware or software driven? – Early on, hard to say – When the mainframe was king, both – Now the question was irrelevant• Important shift – Not hardware, not software – People
  8. 8. CMIO Role, Part II• Traditionally, physicians positioned as clinical leaders, but administrative managers• Because of the new role of information and informatics, this model is obsolete• The CMIO must move from information management to information leadership• Hence HCIT transformation involves learning – Whom to lead – What to lead – What results to lead towards – A systems approach to informatics – How to lead
  9. 9. Transformation of Healthcare
  10. 10. Transformation of Healthcare• Over the next 10 years: – Episodic and non-episodic care will be differentiated and separated from chronic disease management – Hospital and outpatient treatment and outcomes will be integrated – Disease management and situation management will be emphasized over symptom management – Better diagnosis and achievement of points of balance between personalized treatment and population medicine• Introduction of new processes• Broad acceptance of certain tools – Data accumulation and verification – Prospective analytics
  11. 11. Transformational Context• Diagnoses are likely to change – What we think of as diseases may not actually be diseases• Manage diseases, not just symptoms• Predict and rationalize the outcomes of treatment• HIM central to these initiatives
  12. 12. Change Issues in Healthcare• External v internal mission• Imposed v native strategies• Political v operational goals and tactics• Government mandates v professional ethics• Primary v specialty care• Definitions of “optimal care,” other quality measures• Structures for healthcare delivery• Uses of information
  13. 13. Short Term ONC Agenda
  14. 14. This Year’s Priorities Dr. Farzad Mostashari• Meaningful use• Interoperability• Data exchange• Consumer Health National Coordinator for Health Information Technology Address to the Health IT Policy Committee, January 10, 2012. http://govhealthit.com/news/mostashari-says-meaningful-use-will-soar-year
  15. 15. Meaningful Use• “Meaningful use will soar.. [and] continue to be the cornerstone of our activities.”• “We’re going to do everything we can to ensure that every provider can be successful at meaningful use.”• In 2011, MU paid $2.5B in incentives, but the goal – “success at meaningful use” - is articulated curiously.• A target in many ways disconnected from the provision of care.
  16. 16. Interoperability and Exchange• The “second and more complex challenge,” following meaningful use.• The emphasis will be on containing the costs and reducing the risks and liability of exchanging health data.• Information “will flow at the speed of trust.” Providers share only with providers they know on a first-name basis.• What does this actually mean?
  17. 17. Care Coordination• In 2012, the business case for care coordination, which requires the exchange of healthcare information, will be driven by payment reform, at the federal, state and private level.• “As we increase the value of data exchange and reduce the cost, information will flow.”• What information? From whom? Where to? To what end? How measured?
  18. 18. Consumer eHealth• Consumer health IT is the third emphasis for the year.• The government will look to find ways to encourage the uses of consumer eHealth, apart from EHRs.• Is this a metaphor for consumer engagement or something else?
  19. 19. Quality Measurements• Quality measurements are the fourth initiative slated for this year.• “We will be moving forward on the next generation of quality measurement, [and] we need the infrastructure for measuring quality, but also for improving quality.”• The three elements of quality, definition, measurement and improvement, are connected but distinct.
  20. 20. Real and Stipulated Meaningful Use
  21. 21. Meaningful Use The CMIO’s Bête Noire• “Real” or Natural language – Appropriate HCIT/EMR system – Installation, instruction, maintenance and support – Physical access – Comprehensiveness (nothing more needed) – Consistency (use everywhere) – Comprehensibility – Data entry/data retrieval – Integration with workflow – Relevance – Utilization• Stipulated – Used as an external, possibly irrelevant metric of compliance (?) – The CMIO is at risk – Very poorly understood and to be fully flushed – Measureable use
  22. 22. CMIO RoleManagers or Leaders
  23. 23. The Task of the CMIO has Evolved• Change management• Clinical leadership• CMIO 2.0 – the place of the CMIO in clinical and administrative leadership structures
  24. 24. Managers• Subordinates• Vested, externally derived authority• Transactional style• Like a happy ship. Avoid conflict• Seek comfort and stability, not change• Achievement oriented• Often very friendly• Avoid risk• Seek out causes of and reduce risk
  25. 25. Leaders• Voluntary and inspired followers, not subordinates• Charismatic authority• Transformational style based on appeal and communication.• Engagement leading to satisfaction and transformation• Happy with change• People focus – quiet style, accountability.• May be aloof, may be achievement oriented• Focus on accomplishment• Seek risk – natural to ecnouter conflict.• Respect rules, but break when needed
  26. 26. Operational DifferencesManagerial Focus Leadership Focus• Administration • Innovation• Copy, routine, replicate • Origination• Status quo • Development• Systems and structure • People• Control • Trust• Short term perspective • Longer range perspective• How and when; instructions • What and why; understanding• Constraints (eg budgets) • Accomplishment• Imitation • Origination• Status quo (low entropy) • Improvement and change• Good followers, including self • Individualists and thinkers• Eliminate risk • Manage risk• Efficiency • Effectiveness• Manage systems • Create systems
  27. 27. Measurement v Implentation• Measure Process and (not or) Outcomes – Adoption – Utilization – Satisfaction • Clinicians • Administration • Patients • Enterprise marketing• Meaningful use is external, but not enough – Costs? – Error? – Tracking? – Quality? – Access to care• Achieve consensus on what to measure and use this consensus as a means of engagement• Become an expert and demonstrate your expertise through engagement• Become a diplomat: your allies are clinicians, not devices
  28. 28. Change Management
  29. 29. Change Management• Structured approach to managing and coordinating change• IT – Service component of organizational change effort – Target modifications in IT infrastructure and use – Intended to minimize impact on workers – Avoid distractions• Includes – Implementation and optimization – Business justification – Transitioning individuals and teams• A critical and continuous function – Changing demands on HCIT infrastructure – New systems – New modules – ICD 10
  30. 30. Change Management First Efforts• 1980s – early discussion – Julien Phillips (McKinsey) publishes change management model – Michael Hammer, Reengineering the Corporations – Consulting firms rebrand reengineering services as :change management”• 1990s - top down change implementation fails – Linda Ackerman Anderson, Beyond Change Management – 1994 “Change management industry” begins – 1995 John P Kotter Leading Change – 2002 John P Kotter The Heart of Change
  31. 31. Change is a Staged Process From Kotter and Others• Create urgency and a • Create short term visible timeline achievements• Create a guiding team • Maintain momentum• Articulate vision and • Reinforce value proposition strategy and reward leaders• Communicate and engage • Integrate change in culture• Empower action and • Remind the organization remove impediments over time of achievement• Stay objective and value• Maintain and align both • This process is not short term and long term unemotional objectives
  32. 32. Types of Change• Mission• Strategy• Operations• Technology• Attitudes and behavior
  33. 33. Change Management Simplified Traditional Model• Top down• Plan and direct• Dictate, instruct, impose and enforce – remote leadership• Rigid and granular• Feeback at the end• Moulding people
  34. 34. Change Management Simplified New Model• More matrixed• Consult and prepare• Engage, communicate, interpret and enable• Workshops?• Think systematically, anticipate problems, allow for points of flexibility• Feedback loops part of the process• Negotiation with those affected
  35. 35. Successful Process Change Breeds Insecurity• Process needs to address and overcome fear• Consultation• Defined steps with interim milestones• Optimize communication – Why? – Explain rational and benefits – Timetable – Impact upon and involvement of personnel• Upgrading skills across the organization• Personal discussions• Monitoring and revision if needed• Honesty and promise keeping
  36. 36. Simple Questions• What do we want to achieve with change?• Who are the “we?”• So what and who cares?• Where are the misalignments?• Who is affected, how and how will they react?• How do we measure change?• What are interim/process milestones?• Is change the only measure of success?• How do we measure success?• What else needs to be discussed?
  37. 37. Upgrading Skills Training or Learning?• Training – Measured by task competence – Improves skills – Unconcerned with engagement – Unconcerned with alignment of individuals• Learning – Engages the individual – Measured by understanding as well as task competence – Curiosity and commitment, as well as skills – Results in individual development – Builds leadership and innovation
  38. 38. Methods I• What elements of the organization’s mission and culture drive change• Articulate aims when teaching skills• Focus on consistency and integrity• Consult and discuss with clinical and administrative leadership• Identification with and pride in the organization is key
  39. 39. Methods II• Involve – All clinical staff, not just physicians – All physicians, not just primary care – Administrators – The small people – Compensate them for their time• Think of these as individuals, not just stakeholders and use as change emissaries• Consider workshops• Anticipate problems• Establish feedback loops
  40. 40. The Importance of Face to Face Discussions• Consultative communications• Individualize the process of change• Bestow relevance• Placate fears• Make champions• Create emissaries and ambassadors• Email, messaging, written communication is weak
  41. 41. Implications for CMIO• Change process is • Sample the work flow creative, not mechanical • Put yourself in the• Don’t sit in the office clinicians shoes• Don’t talk only to your • Develop a kitchen cabinet staff • Elicit feedback often• Don’t talk only to • Provide transparency technical personnel • What can be fixed and• Wander the floors what cannot• Become a roving help • Insist on dialogue with desk your IT vendors
  42. 42. Issues for the CMIO• Position within hospital hierarchy – CIO – CMO – C suite – Allied medical personel• Time management – need for clinical credibility?• Support staff
  43. 43. Conclusion• The time is right for the CMIO to lead• Convey – Importance – Individuation – Relevance – Feasibility – Engagement – Communication – Translation – Satisfaction• Invest in the position and train the next generation• The future of medicine depends on information
  44. 44. Thank You
  45. 45. EMRs Need to Advance• EMRs are paper charts in electronic form with results• Need to become tools for care management• CMIO have reached the third level in the development of the profession 1st hardware and software 2nd compliance and stipulated meaningful use 3rd care management and true meaningful use
  46. 46. How Physicians Learn• See one, do one, teach one• Respected mentors• Read and analyze papers anchored in patient encounters• Follow guidelines, protocols and Washington Manuals• Rounds• Meetings• Training – create a routine
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