Success in Change Management: The Flexibility Factor
To create innovative change in healthcare, quality improvement teams and learning collaboratives must be rigorous in every step of their efforts. Factors like meticulous testing and robust data collection are essential for successful change; It is also important to match that rigor with a certain flexibility.
“Like so many things in life, improvement requires meeting people where they are and building from there,” says NICHQ Senior Director Jennifer Ustianov, MS, BSN, RN, IBCLC. “It’s about recognizing the strengths of project participants and the work that they’ve already done, then guiding them along so that they can understand opportunities for change.”
Flexibility plays a central role in one of the key aspects of sustained improvement: empowering team members to generate ideas and to test and implement successful changes.
“There’s a saying about how culture eats strategy for lunch, and I truly believe that,” says Ustianov. “No matter how good your ideas are, there’s the danger that teams or organizations might slip back into their old ways once a project is over. So from the very beginning, you’ve got to think about how to hardwire these new approaches so that efforts will sustain.”
In many cases, hardwiring begins with recognizing resistance to change and working with people to overcome that resistance. “In any project, we know that a percentage of people effected by change are going to be laggards,” says Ustianov. “Instead of ignoring them, we have to validate their concerns—especially since it can help us to gain a better understanding of the overall culture.”
Along with embracing open communication in overcoming resistance, improvement teams should take the time to determine what most effectively motivates each participant and be open to testing around the resistance to learn what might inform it.
“You might need to spend more time on building will than you’d anticipated,” notes NICHQ Associate Director of Improvement Patricia Finnerty, MSc. “But when you’ve got participants who are resistant to change, you need to work with them to answer that question of ‘What’s in it for me?’ before you can move them along to the next phase.”
For many participants, motivation may come from sharing stories of those who will benefit from that change—children and families. For others, the influence of peers may be a powerful motivator.
“A project leader can repeat the same point 100 times, but if someone the participant knows and trusts says the exact same thing, it’s probably going to ring more true,” says Finnerty.
Keeping flexible in your testing approach can also promote motivation. “If someone says, ‘This won’t work because of XYZ,’ then why not say, ‘Okay, let’s use XYZ as an example of a condition that we need to test under,’” says Jane Taylor, EdD, MBA, MHA, a NICHQ improvement advisor. “Most people don’t resist without a pretty good reason, and some real value can come from hearing them out and working with that resistance.”
Ustianov recommends taking time to target the unique strengths that each team member might bring to Plan-Do-Study-Act (PDSA) cycles. “You want to find out who’s a planner, who’s a doer, who’s happiest looking at data,” she says. “Identifying those personalities within the group can really help move testing along.”
During the testing phase, contingency is also a vital factor in improving theories. One of the core tenets of quality improvement is learning from your work over time, which means improvement teams need to learn from testing ideas, revise their theories and let go of some of the assumptions they held early in the project.
“Being too rigid keeps you from challenging your own assumptions, or even being aware of what those assumptions might be,” says Finnerty. “It’s about striking the right balance of staying flexible in your theory but remaining rigorous in your application and methodology.”
To illustrate the importance of flexibility in theory, Finnerty points to the issue of safe sleep. A team might have a theory that lack of access to cribs is keeping families from carrying out the safe sleep practice of ensuring that the baby always sleeps alone, she says. A solution that a team might try would be to provide portable cribs to families. However, through testing, the team might learn that access to cribs is not the main issue for some populations, which would mean they would then need to revise their theory of change.
Once teams begin the implementation phase, project leaders should support participants by carefully guiding them through making change permanent.
By meeting participants where they are and bringing a sense of adaptability to each component of change efforts, project leaders can achieve a major hallmark of quality-improvement success—learning one’s way to results.