John Britt and Ray AlbertinaHealth Sciences Advisory Services, Ernst & Young
Continuous quality improvement (CQI) is a well-accepted discipline within healthcare ranks. It is both required by a number of regulatory agencies and a logical and natural fit for what providers produce--patient care. The nomenclature evolution from quality assurance to total quality management to CQI perhaps reflects our adaptation to a concept which has evolved from an ill-defined abstraction to a measurable and concrete reality. For many providers, CQI is no longer separate and distinct from the service they provide and is no longer considered either a capital expense requiring budget justification or an effort to appease a regulator. Indeed, CQI is simply embedded into services provided.
In the healthcare arena, the concept of change management has not experienced the same accelerated evolution as CQI in that change management is still viewed by many as an external influencer of process or motivator of work behavior and is not necessarily “baked” into actual work process or employee motivation. Hence, unlike CQI which tends to become self perpetuating, change management often must be constantly proselytized--particularly to clinicians--for it to stay alive and have an impact.
However, both CQI and change management are essentially about recognizing the current state of a process or work behavior, envisioning the future state, and implementing actions to achieve the future state. If CQI and change management share a common lineage, perhaps we can identify the divergent chromosomal strands of their DNA which have contributed to their respective evolutionary outcomes. The chromosomal strands to be examined include scope, context, and urgency.
Scope
It must be understood that a deliberate change management effort and CQI are both designed to facilitate – well, change. Perhaps the perceived scope (size, frequency, and intensity) of the change on the part of the staff (clinical staff, for example) who are ultimately responsible for or affected by the change may have an impact on the outcome. A comparative analysis of CQI and change management might reveal the following in regard to these parameters:
CQI
Change Management
Size
Small, focused
Large, diffuse
Frequency
Low
High
Intensity
While this matrix is not necessarily always the case, it is apparent that change management, in general, simply requires a much higher level of energy and attention in comparison to CQI. When change comes in frequent and large doses, those involved in the change can become overwhelmed and fall victim to change fatigue.
Perhaps a lesson learned, then, is to look at change management in “bite-sized” pieces. That is not to say to compromise on the level of change that is required but, with deliberation, to plan for the change implementation in a work breakdown structure that is manageable rather than exhausting.
Context
To expect successful change, the change must have context for the people involved. For many clinicians, the context must be inclusive of quality patient care. With CQI, the Q is for quality and many CQI initiatives are centered around clinical outcomes. Change management, on the other hand, is often dealt in the context of such areas as revenue cycle improvement, staffing, productivity, etc. Most clinicians understand there is a business side to their practice, but a value proposition may need to have a tie to quality to affect their work behavior significantly. If the organization has a healthy culture, this type of proposition should not be a stretch. Clinicians desire training, education, tools, and equipment to provide better patient care. By helping clinicians see the relationship between a positive financial outcome of service and being able to fulfill some of these desires, leadership and management may be able to provide some context which motivates the clinicians toward desired work behaviors.
Not all change efforts will be able to be linked easily to improved quality care. However, it is important to determine if a potential link exists and to solicit clinicians’ input early in the assessment phase, inviting them to help articulate the quality link that management or leadership missed or did not clearly communicate.
Urgency
Healthcare leadership and management work in dynamic environments and are highly sensitized to fast-paced change in response to economic, regulatory, and political pressures. On the other hand, most clinicians are not. Kurt Lewin, known as the father of change management, believed that for effective change to occur the work behavior must be unfrozen, molded to the desired behavior, and then refrozen. In Leading Change, Kotter [Lewin] offers an eight-step model for change management, with one of the primary steps for leadership being to create a sense of urgency. How can we both allow for “unfreezing” and create a sense of urgency?
Let’s examine the CQI Model. An opportunity is identified. Plans are made to change processes or work behaviors. Accountability is assigned, and results are generally reported monthly. Actions are calibrated in expectation of an improved outcome and incremental gains are expected.
In contrast, with change management an opportunity is identified. A change management effort is announced by leadership with a definitive sense of urgency. Management is dispatched with their targets, but not necessarily the tools, training, and resources to reach and sustain the target metrics. Using Lewin’s model, we might compare this approach to taking a steak out of the freezer, throwing it in the oven for a few minutes, and then expecting a great dining experience. This type of change facilitation, like the steak, is tough to chew and does not digest well.
Change should be filtered for urgency. The current processes and work behaviors needing to be changed, most likely, did not form quickly and are more likely to be effectively changed through actions and reforms that promote some thawing of the current state. Leadership should, in fact, create the urgency to act, but with restraint and awareness that expectations of dramatic shifts in work behaviors may result in only temporary effectiveness if unlearning and relearning have not occurred. Leaders should consider their communication style and tone when discussing change with clinicians. Avoid hype and lay out the “business case” for change. Enlist the clinicians to act and communicate an expected implementation time. Do not allow for undue delays in the process but reserve the “super-urgent” card for a critical need.
Summary
CQI today is ubiquitous in the healthcare industry. It is a focused methodology for looking at specific outcomes and determining what can be changed to improve those outcomes. Because many typical CQI focus areas have at least a tangential relationship to some aspect of patient care, clinicians, in general, accept the CQI model.
Change management, by contrast, is more episodic in nature, larger in scope, and invasive. It too offers a methodology to improve specific outcomes but often does not always have a self-evident relationship to quality patient care. Hence, buy-in on the part of the clinicians is more difficult to obtain. But change management and CQI are both creatures of the same species. Leaders who can offer a change management effort
are more likely to gain the respect and followship of the clinicians.
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The views set forth herein are those of the authors and do not necessarily reflect the views of Ernst & Young LLP.
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