Managing Change: Tools and Techniques


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A detailed look at lessons from mental health systems change and transformation initiatives in this presentation.

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Managing Change: Tools and Techniques

  1. 1. Managing Change: Tools and Techniques Vijay Ganju Director, Center for Mental Health Quality & Accountability NASMHPD Research Institute, Inc. 703.739.9333 ext. 132 [email_address] Lessons from Mental Health Systems Change and Transformation Initiatives Presentation at the CMS Conference: New Freedom Initiative Access to Community Living Transforming Systems: Keys to Success Baltimore, Maryland  April 10-12, 2006
  2. 2. Mental Health System Recovery / Resilience Transformation Mental Health / Health Consumer / Family Driven Eliminate Disparities Early Intervention Evidence-Based Practices Training / Research Technology & Information
  3. 3. The Quality Pyramid Performance Measurement SYSTEM OUTCOMES Evidence-Based Practices Quality Improvement
  4. 4. Evidence-Based Practices: Some Definitions <ul><li>An evidence-based practice is considered to be any practice that has been established as effective through scientific research according to a set of explicit criteria (Drake et al, 2001) . </li></ul><ul><li>Evidence-based treatment is the use of treatments for which there is sufficiently persuasive evidence to support their effectiveness in attaining desired outcomes (Rosen and Proctor, 2002) . </li></ul><ul><li>Evidence-based practice is an approach to healthcare wherein health professionals use the best evidence possible to make clinical decisions for individual patients (McKibbon, 1998). </li></ul><ul><li>Evidence-based practice is the integration of best research evidence with clinical expertise and patient values (Institute of Medicine, 2001) . </li></ul>
  5. 5. Number of States Implementing EBPs: FY 2003 N = 47
  6. 6. Implementation of Evidence-Based Practices for Children, 2003 N = 47
  7. 7. Moving Forward with Evidence-Based Services <ul><li>Federal Initiatives </li></ul><ul><ul><li>SAMHSA National EBP Demonstration Project </li></ul></ul><ul><ul><li>NIMH/SAMHSA Planning Grants </li></ul></ul><ul><ul><li>SAMHSA/CMHS EBP Implementation Grants </li></ul></ul><ul><ul><li>SAMHSA National Registry for Effective Practices </li></ul></ul><ul><ul><li>HRSA’s Federal Qualified Health Centers </li></ul></ul><ul><ul><li>NRI Center for Mental Health Quality and Accountability </li></ul></ul>
  8. 8. Preliminary Lessons from Toolkit Project <ul><li>Organizational development component is critical </li></ul><ul><li>Outcomes must be integrated into EBP implementation </li></ul><ul><li>Cultural competence issues need to be addressed </li></ul><ul><li>Ongoing consultation was a great facilitator </li></ul>
  9. 9. Lessons Learned from “Toolkit” Trainers, Consultants and Evaluators Desired Consumer Outcomes Practitioners Consumer Family Agency Implementing EBP Steering Committee State or County Mental Health Authority Strategies for Consumer/Family Strategies for the SMHA Strategies for the Agencies Strategies for the Steering Committee Training/TA Strategies for Practitioners
  10. 10. Factors Affecting State-Wide EBP Implementation <ul><li>System leadership </li></ul><ul><li>Organized culture/consensus </li></ul><ul><li>IT capacity/outcomes measurement </li></ul><ul><li>Policies/procedures </li></ul><ul><li>Integration with performance/quality improvement </li></ul><ul><li>Human resource capacity/training </li></ul><ul><li>Funding methods </li></ul>
  11. 11. Statewide Implementation of EBPs <ul><li>Demonstration projects </li></ul><ul><ul><li>Training </li></ul></ul><ul><ul><li>Supports </li></ul></ul><ul><li>Organizational assessment </li></ul><ul><li>Standards/ regulations </li></ul><ul><li>Financing/fiscal incentives </li></ul><ul><li>Training and support </li></ul><ul><li>Contractual requirements </li></ul><ul><li>Intensive technical assistance / support </li></ul>Early Adopters (“enthusiasts”) Late Adopters Non-Adopters
  12. 12. Public Mental Health Authority <ul><li>Practitioner </li></ul><ul><li>Knowledge </li></ul><ul><li>Perceived advantage </li></ul><ul><li>Feedback </li></ul><ul><li>Consumer/Family Member </li></ul><ul><li>Choice </li></ul><ul><li>Commitment </li></ul><ul><li>Perceived advantage </li></ul><ul><li>EBP </li></ul><ul><li>Cost </li></ul><ul><li>Compatibility </li></ul><ul><li>Payoffs </li></ul><ul><li>Complexity </li></ul>Provider Organization <ul><li>Leadership </li></ul><ul><li>Policies </li></ul><ul><li>Regulation </li></ul><ul><li>Resources </li></ul><ul><li>Leadership </li></ul><ul><li>Organizational Culture </li></ul><ul><li>Administrative Support </li></ul><ul><li>Information Technology </li></ul>
  13. 13. Lessons Learned from National EBP Demonstration Project INFORMATION TECHNOLOGY Implementation Leading to Transformation System Leadership/ Implementation Plan Policies and Procedures Organizational Structures Funding Methods Human Resource Capacity Quality/ Performance Improvement
  14. 14. Causal Connections Recovery Infrastructure Goal: <ul><li>Interaction with </li></ul><ul><li>Provider </li></ul><ul><li>Evidence- </li></ul><ul><li>based and </li></ul><ul><li>“ best” practices </li></ul>
  15. 16. Transformation Logic Model Outcomes - Impact Target Systems Outputs Activities Inputs Situation <ul><li>Inefficient use of resources </li></ul><ul><li>Lack of information </li></ul><ul><li>Inade-quate value orientation </li></ul><ul><li>Ineffective-ness regarding outcomes </li></ul><ul><li>Stakehold-ers </li></ul><ul><li>Staff </li></ul><ul><li>Resources </li></ul><ul><li>Leadership commitment </li></ul><ul><li>Develop-ment of new structures </li></ul><ul><li>Resource development reallocation </li></ul><ul><li>Information/ technology development </li></ul><ul><li>New cadre of leaders </li></ul><ul><li>Restructur-ing </li></ul><ul><li>Availability of new information and technologi-cal capacities </li></ul><ul><li>Internal </li></ul><ul><li>External </li></ul><ul><li>Short-Term </li></ul><ul><li>Leadership development </li></ul><ul><li>Training capacity </li></ul><ul><li>Information (services, money, competen-cies) </li></ul><ul><li>Innovation opportunities </li></ul><ul><li>Policy development/changes </li></ul><ul><li>Interagency coordination </li></ul><ul><li>Intermediate </li></ul><ul><li>Multi-stakeholder engagement/consensus </li></ul><ul><li>Identifica-tion/flexibility of resources </li></ul><ul><li>Increased competenc-ies </li></ul><ul><li>New models /protocols </li></ul><ul><li>New structural arrange-ments </li></ul><ul><li>Long-Term </li></ul><ul><li>Consumer outcomes </li></ul><ul><li>Population outcomes (e.g. anti-stigma) </li></ul><ul><li>Resource efficiencies </li></ul><ul><li>Disparity reduction </li></ul><ul><li>Data </li></ul><ul><li>Leadership capacity </li></ul><ul><li>Policy changes </li></ul><ul><li>Workforce competencies availability </li></ul><ul><li>Use of data </li></ul><ul><li>Values orientation </li></ul><ul><li>Resources available </li></ul><ul><li>Data </li></ul><ul><li>Consensus/ engagement assessment </li></ul><ul><li>Resource allocation/ development </li></ul><ul><li>Contract expectations </li></ul><ul><li>Data </li></ul><ul><li>NOMs </li></ul><ul><li>Recovery/ resilience </li></ul><ul><li>Community indicators </li></ul><ul><li>Financial indicators </li></ul><ul><li>Technology </li></ul><ul><li>Fragmenta-tion </li></ul><ul><li>Stigma </li></ul><ul><li>Lack of EBPs </li></ul><ul><li>Lack of technology application </li></ul><ul><li>SMHA </li></ul><ul><li>CMHAs </li></ul><ul><li>Other agencies </li></ul>
  16. 17. NRI Conference on Change Management in Mental Health Systems <ul><li>Agenda: </li></ul>June 22-24, 2005, Albuquerque, New Mexico Hodges, Wotring Use of Evaluation Ganju, Isaacs Cultural Competence Power, McCracken Leadership Development Hudgens, Reynolds, et al. Mental Health Change Models Blasé Implementation Research Findings Mulkern, Hills Supporting Creativity / Innovation Morris, Kanary Workforce Development / Training Clark, Armstrong Funding McCracken Tools for Change McCracken, Aarons Change Management: The Science
  17. 18. Definition of a Change Project <ul><li>Cuts across organizational boundaries </li></ul><ul><li>Has defined start and completion dates </li></ul><ul><li>Generates observable, measurable results </li></ul><ul><li>Requires significant change in both attitudes and the way work is performed </li></ul><ul><li>Creates both active and passive resistance </li></ul><ul><li>Requires a dedicated change team </li></ul>
  18. 19. Role of Change Management <ul><li>Training </li></ul><ul><ul><li>Explains objectives and provides information on desired activities and outcomes. </li></ul></ul><ul><li>Project Management </li></ul><ul><ul><li>Involves tracking, monitoring, measuring, and reporting. Establishes performance standards and metrics; provides objective measures of progress against plan; anticipates obstacles and recommends corrective action. </li></ul></ul><ul><li>Change Management </li></ul><ul><ul><li>Intensive, field-based exercise in changing behavior. Focuses on communicating the initiative; creating alignment; identifying and overcoming resistance; embedding change into the organizational culture. </li></ul></ul>
  19. 20. Organizational Culture of a Mental Health System Solidarity Sociability Networked Communal Fragmented Focused
  20. 21. Change Tools and Techniques Index 30 <ul><li>Payoff Matrix </li></ul>23 <ul><li>Stakeholder Analysis/Influence </li></ul>22 <ul><li>Attitude Charting </li></ul>19 <ul><li>Elevator Speech </li></ul>17 <ul><li>Threat/Opportunity Matrix </li></ul>16 <ul><li>Is/Is Not </li></ul>12 <ul><li>Team Competency/Influence </li></ul>11 <ul><li>Sponsorship Alignment </li></ul>10 <ul><li>Backwards Imaging </li></ul>Page Number Tool
  21. 22. Launching the Product <ul><li>Desired Outcome </li></ul><ul><ul><li>Well-defined project that is doable, yet challenging </li></ul></ul><ul><ul><li>Clear agreement and commitment from sponsor </li></ul></ul><ul><ul><li>A team with competency, influence, and representation that has been prepared for the challenge </li></ul></ul>
  22. 23. Backwards Imaging <ul><li>Imagine a point in the future when your project or initiative is very successful </li></ul><ul><li>Find words to describe what you see, hear, feel as you observe the key constituents functioning in the new, changed environment </li></ul><ul><li>Discuss and reach consensus with your team members on what this new, improved future will look like </li></ul><ul><li>As a team, develop the obstacles you will likely have encountered and overcome during the impelmentation </li></ul>
  23. 24. Sponsor Discussion – Typical Questions <ul><li>Describe the initiative in your own words. </li></ul><ul><li>Why is this initiative important? </li></ul><ul><li>What will success look like to you? </li></ul><ul><li>What is outside the scope of this initiative? </li></ul><ul><li>What else is on your agenda – where does this project fit? </li></ul><ul><li>Who are the key players and how do they view this initiative? </li></ul><ul><li>What excites you the most about this initiative? </li></ul><ul><li>What concerns you the most about this initiative? </li></ul><ul><li>What do you think our biggest challenge will be? </li></ul><ul><li>Who should be on the core working team, and how can we get their commitment? </li></ul><ul><li>What role do you see yourself playing? </li></ul><ul><li>How involved do you want to be? </li></ul><ul><li>What key decisions do you want to make or be involved in? </li></ul><ul><li>Do you have any words of advice or suggestions for me in the meantime? </li></ul>
  24. 25. Tool: Team Competency/Influence Tool: Team Competency – A useful tool to help the team determine if they have the right team members relative to the competencies and influence necessary to execute the initiative Competency/Influence Team Member H = High M=Medium L=Low Uses: This exercise is particularly useful for two situations: (1) when initially forming the team, it can help the sponsor and/or team leader determine who should be on the team; (2) if the team is already in place and they may be struggling due to lack of ability to do certain facets of the initiative, this tool can be used to determine if adjustments in team members are warranted. Timing: Before starting the initiative and/or anytime during the initiative when the team seems to be struggling due to lack of competency or influence. This often occurs when a new phase of the initiative begins.
  25. 26. Team Start-Up: Levels/Types of Decisions <ul><li>I’ve made the decision. Here’s what it is and why I had to make it. </li></ul><ul><li>I’m leaning strongly in this direction. Tell me what the team thinks, then I’ll make the decision (your input, my decision). </li></ul><ul><li>We need more information before the decision can be made. Help us see all sides of the issue, then we’ll make the decision based on consensus. </li></ul><ul><li>I’m willing to go with whatever the team decides on. Let me know your decision and I’ll support it. </li></ul>
  26. 27. Team Start-Up: Consensus <ul><li>Consensus is reached when everyone can state: </li></ul><ul><ul><li>I believe that you understand my point of view </li></ul></ul><ul><ul><li>I believe that I understand your point of view </li></ul></ul><ul><ul><li>Even though this may not be the way I would decide things by myself, I will support the decision 100% because it was arrived at in an open and fair manner </li></ul></ul>
  27. 28. Creating Organizational Alignment <ul><li>Desired Outcome: </li></ul><ul><ul><li>A clearly defined project scope </li></ul></ul><ul><ul><li>A sense of urgency and commitment among key stakeholders </li></ul></ul><ul><ul><li>Clear, consistent, organization-wide communication of the project </li></ul></ul>
  28. 29. Is / Is Not <ul><li>Is </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>Is Not </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul><ul><li>________________________ </li></ul>Helps a team to think through the project by more clearly defining what is inside and outside its scope. Often the “ is not ” portion of the discussion is more important than the “ is ” part – that’s where the disagreement usually lies. It can be used during the definition phase as well as later when the team is stuck and needs to be refreshed on the projects boundaries.
  29. 30. Tool: Threat/Opportunity Matrix 1 3 2 4 Tool: “Best Practice” organizations know how to frame a change initiative as more than a short-term threat. They work to find ways to frame it as both a threat and an opportunity. By doing so, they are able to create a sense of urgency and commitment among key stakeholders. Threat Opportunity Short Term Long Term Uses and Timing: Building the case for change is one of the most important tasks of the team. This simple tool helps it to redirect the initial focus on short-term threats and generates a clear sense of why the initiative is essential. Gain Pain
  30. 31. Example: Threat/Opportunity Threat Opportunity Short Term Long Term Physician Group Initiative <ul><li>More flexibility/agility </li></ul><ul><li>Improved patient satisfaction </li></ul><ul><li>Able to provide measurably higher quality care </li></ul><ul><li>Increased capacity through improved asset utilization </li></ul><ul><li>Able to recruit and retain better administrative and clinical staff </li></ul><ul><li>Physicians will be more productive </li></ul><ul><li>Won’t achieve our objective </li></ul><ul><li>Will have to work with fewer staff </li></ul><ul><li>Control our future </li></ul><ul><li>Shake up the organization </li></ul><ul><li>Will create uncertainty and staff anxiety </li></ul><ul><li>Physicians will resist any change </li></ul><ul><li>Productivity will drop </li></ul><ul><li>Won’t be able to fund other projects </li></ul><ul><li>Patients are likely to be confused </li></ul><ul><li>Overhead burden may rise </li></ul>
  31. 32. Measuring and Overcoming Resistance <ul><li>Desired Outcome: </li></ul><ul><ul><li>Identification of sources of both active and passive resistance </li></ul></ul><ul><ul><li>An effective strategy to influence key stakeholders </li></ul></ul>
  32. 33. Resistance to Change: What Does it Look Like? <ul><li>Resistance to change is typically divided into two distinct categories: </li></ul><ul><ul><li>Active resistance </li></ul></ul><ul><ul><li>Passive resistance </li></ul></ul>
  33. 34. Attitude Charting Innovators (5%) Early Adopters (10%) Early Majority (35%) Late Majority (35%) Resistors (15%)
  34. 35. Stakeholder Analysis Steps: 1. Plot where individuals currently are with regard to desired change. (  = current) 2. Plot where individuals need to be (X=desired) in order to successfully accomplish desired change-identify gaps between current and desired 3. Indicate how individuals are linked to each other, draw lines to indicate an influence link using an arrow to indicate who influences whom 4. Plan action steps for closing gaps Names Strongly Against Moderately Against Neutral Moderately Supportive Strongly Supportive
  35. 36. Example #1: Stakeholder Analysis Chief of Surgery Dr. Bobbitt Dr. Clampett CEO Chief of Staff Medical Director Chief of Medicine CFO Asst. Med. Director Chief Administrator Dr. Barnes Chief of Nursing Sharon Reams, RN       Strongly Against Moderately Against Neutral Moderately Supportive Strongly Supportive       
  36. 37. Example #2: Stakeholder Analysis Chief of Surgery Dr. Bobbitt Dr. Clampett CEO Chief of Staff Medical Director Chief of Medicine CFO Asst. Med. Director Chief Administrator Dr. Barnes Chief of Nursing Sharon Reams, RN       Against Moderately Against Neutral Moderately Supportive Strongly Supportive       
  37. 38. Example #3: Stakeholder Analysis Chief of Surgery Dr. Bobbitt Dr. Clampett CEO Chief of Staff Medical Director Chief of Medicine CFO Asst. Med. Director Chief Administrator Dr. Barnes Chief of Nursing Sharon Reams, RN       Against Moderately Against Neutral Moderately Supportive Strongly Supportive       
  38. 39. Some Examples <ul><li>New Mexico Purchasing Collaborative </li></ul><ul><li>Oklahoma Department of Mental Health </li></ul><ul><li>Washtenaw Community Health Organization (Michigan) </li></ul><ul><li>Licking and Knox Counties Mental Health Services (Ohio) </li></ul><ul><li>Australia </li></ul>
  39. 40. “ They always say time changes things, but you actually have to change them yourself.” ~Andy Warhol