How to Enact Change Dissertation Defense

Leadership Action
Required to Enact
Change
By:
Barbara Julian Garner
July 12, 2013

1

Nature and Background of Issues

• Chapter 1:


2

• Introduction
– Interest in topic
– Definition of terms

• Nature of the Issue:
– Many changes being implemented at Preston Memorial for
all employees
– Non-Clinical employees were being asked to interact with
patients within the clinical setting


3

• Internal Stakeholders:
–
–
–
–

Non-Clinical employees
Clinical employees
Hospital leadership
Staff physicians

• External Stakeholders
–
–
–
–

Patients
Patients’ family members
Community at large
Accrediting Boards
• The Joint Commission
• Medicare

4

• Issue Background & Context: Examination of the
Beginning of a Cultural Change
– Patient-Centered Care Model
– Six Pillars of Excellence & the No Pass Zone (Studer 2003)


5

Pupose of the Study

– Identify challenges to hospital leadership during a
change process at Preston Memorial Hospital


6

Research Questions

1. If there were leadership challenges in executing
this cultural change, especially in regards to nonclinical employees, what were they and why did
these challenges arise?
2. If there were issues with the implementation of
this cultural change, especially in regards to nonclinical employees, what were the leader lessons
learned?


7

Literature Review
• Chapter 2:


8

Literature Review
• Chapter 2:
• Leadership Role in Change Management
–
–
–
–

Kotter (2007)
Hiatt (2006)
Luecke (2003)
Randall (2004)

• Leadership & Employees Shared Role: Teaming
– Edmondson (2012)
– Ul-Bien & Ospina (2012)


9

Literature Review
• Chapter 2:
• Preparation for Change:





Dudink & Berge (2006)
Duncan, R.D. (2012)
Hiatt, J.M. (2012)
Kotter, J. (2012)

• Importance of Teamwork
 Edmondson, A. (2012)

• Engagement of Employees
 Galunic & Hermreck (2012)

• Barriers to Change
 Shaller (2007)


10

Methodology

• Chapter 3:


11

Research Desgin
Research Design: Single Case Embedded Design (Based on Yin 2009)
Context of Single Case: The Change Process Related to
Implementing a Patient-Centered Care Model

Embedded Case
Analysis 1

Embedded Case
Analysis 2

Embedded Case
Analysis 3

• Non-Clinical
Employees

• Clinical
Employees

• Hospital
Leadership

The Three Embedded Areas of Analysis Reviewed for the Change Process


12

Single Case Study with Embedded Design
• Case Study:
–
–
–
–
–

Allowed the use of varied methods and dives into people’s behaviors
The interest in the process—How things work and why
Provided understanding of a program or event of an organization
Provided understanding to a complex issue
Added breadth and depth to data collection and assisted in bringing data
together from multiple sources (Yin, 2009)

• Embedded Design:
– Allowed for the investigation into non-clinical, clinical, and leadership
employees in the changes related to implementing a patient-centered care
model


13

Method

• Explanatory Mixed Method
– Quantitative/Qualitative
• Surveys: Quantitative
• Open ended interviews: Qualitative
• In what ways do the qualitative data help explain the
quantitative method?


14

Validity & Reliability
The following procedure was recommended by Creswell (2009)
– 3 peers reviewed inputted data for accuracy
– 2 doctorally prepared professionals were consulted to
expand or deny themes
– Validity was achieved by sending the interviews back to the
interviewees for verification
– Average length of the interviews were 45 minutes


15

Data Collection
• Surveys were distributed by the Community Development Director
• Surveys returned in sealed envelopes without any personal
identification. Colored coded for either Non-Clinical, Clinical, or
Leadership
• Interviews were conducted in the researcher’s office
• All questions were answered and interviewees were at ease
• Consent form was explained to and signed by participants
• Audiotaped
• Transcribed
• Transcripts verified by participant
• Themes analysis verified by 3 other reseachers


16

Data Processing & Analysis

–
–
–
–
–

Survey data were calculated and bar graphs were used to present data
Data were used to provide focus for interviews
Individual verified transcript was read
In the analysis themes were identified
Themes were then re-examined for patterns common to all 3 groups


17

Data Processing & Analysis
• Rigor
• Ethics
• Limitations

• Delimitations


18

Results

• Chapter 4:


19

Survey Distribution & Returns
• Total Surveys Distributed
– 105 Non-Clinical Surveys
– 141 Clinical Surveys
– 6 Leadership Surveys

• Total Surveys Returned
– 49 Non-Clinical Surveys
– 60 Clinical Surveys
– 3 Leadership Surveys

• A Likert Scale was used for each question with room for
comments at the end of the survey


20

Survey Analysis
• Survey Analysis
– A simple percentage was used
– If a 50% or higher of respondents disagreed or strongly disagreed with
the question, that topic was expanded on in the interview questions.
– Each group’s survey contained a comment section

• Some survey questions did not add to the understanding of the
issues and were not used in the interviews. These can be found
in Appendix F
• The data collected were used to answer research questions


21

Survey Results
I Understand the Need for the Six Pillars of Excellence
100%

95%

Percentage

91%
90%

86%
85%

80%

75%
Non-Clinical

Clinical

N=109 Respondents Agree or Strongly Agree


22

Survey Results
I Support the No Pass Zone
90

82%

80

Percentage

70
60
50
40
30

20
10
0

N=49 Non-Clinical Agree or Strongly Agree


23

Survey Results
Non-Clinical Employees Feel Comfortable Entering a
Patient's Room

120%
100%

PERCENTAGE

100%

80%
68%
60%

40%

20%

0%
Non-Clinical Staff

Leadership

N=52 RESPONSES OF DISAGREE & STRONGLY DISAGREE


24

Survey Results


25

Survey Comments
• Constant Positive Themes
– PMH Employees supported the changes that were implemented
– PMH Employees understood the changes

• Constant Negative Themes
– Preparing employees for the changes
– Addressing the fear of employees with the changes


26

Interview Information

• Interviews were voluntary and offered to all employees

• Interview Participants:
– 6 Non-Clinical Employees
– 5 Clinical Employees
– 3 Leadership


27

Research Questions & Discoveries
1. Part A: If there were leadership challenges in executing
this cultural change, especially in regards to non-clinical
employees, what were they?
–
–
–
–
–

Preparation for changes
Feeling a part of the change
Lack of engagement
Communication about the changes
Fear of the unknown


28

Common Themes
Coded Interviews - Common Themes

Fear of the Unknown - 9

Communication on changes
being implemented - 10

Explanation for the Lack of
Engagement - 11

1

Inclusiveness in the Change
Process 12
Preparation for the Changes 13

0

2

4

6

8


10

12

14

29

Other Issues
Coded Interviews - Other Issues

Improved Employee
Identification 1

Patient Acceptance and
Training - 2

Employee/Patient Safety 2

0

0.5

1

1.5

Employee Identification

Patient Acceptance


2

2.5

Patient Safety

30

Interview Findings
• Fear of the Unknown:
NC1 explored the idea that the fear for the non-clinical employee was how that
patient feels about a non-clinical employee coming into his/her room: NC1
imagined wondering “What are you [non-clinical employee] doing in my room
if you can’t help me and why are you in my room?”
C5 stated: “It is kind of the fear of the unknown…I think that the non-clinical
staff does have some issues with the No Pass Zone because they don’t know
and they are scared.”


31

Interview Findings
• Communication About The Changes:
NC6 explained the idea of a breakdown in communication as follows: “There
was not only a breakdown in communication between leadership and nonclinical employees, but there was also a breakdown in communication within
the leadership team. The leadership team was not on the same page and there
was a conflict between them on how all the changes were presented… I was in
the room when this was all presented and you could feel the tension in the
room… There is a communication breakdown that we continue to have
problems with. It is the expectations of people, and again I have said since the
day I got here; the expectations for clinical and non-clinical need to be clearly
defined and they are not. They are blurred and merged.”


32

Interview Findings

Avoidance of the No Pass Zone:
11 of the 14 interviewees admitted to avoiding the patient care
area so as not to engage in the process.


33

Interview Findings
• Lack of Inclusiveness:
NC3 stated: “I haven’t really been invited to give input or anything. That [being
asked] would be nice. ”
C4 stated: “I feel there is a separation of how much clinical and non-clinical employees
have been involved. Clinical, especially nursing, have been involved more than nonclinical, and that is what I mean by a separation. ”


34

Interview Findings
• Preparedness
NC3 stated: “It is intimidating if you are non-clinical because you don’t know what to
do… I wouldn’t know where to go to look for a nurse… Are they at the nurse’s
station?”
C1explained that clinical employees who are not on the patient care floor also need
training: “We could have done a better job preparing our people. I couldn’t tell you
where the call light is…I know how to do a certain procedure, but I just don’t know
how to get in and out of the room.”
HL1 felt more training needed to be done with both clinical and non-clinical
employees: “I think they [all employees] know bits and pieces, but I am not sure they
know how to put it all together. They can regurgitate the information but they can’t
connect the dots. I think both clinical and non-clinical employees need more training
on all the changes we are asking them to make.”


35

Research Questions & Discoveries
1. Part B: Why did these challenges arise?
- Failure to communicate the changes being implemented
- Lack of preparation of employees for the changes
HL3 commented on the survey: “I don’t think we did a very good job with many
things in [with] the No Pass Zone…We did not explain the importance of non-clinical
staff in answering a patient call light…We did not prepare or train them[non-clinical
employees] on what to do. We just told them what to do and to do it.”
Although leadership realized they did not communicate or prepare the non-clinical
employees they did not identify a reason why.


36

Research Question & Discoveries
2.

If there were issues with the implementation of this cultural change
especially in regards to non-clinical employees, what were the lessons
learned?
- Lack of preparedness of the employees for the changes
- Inclusivity of employees in the change process
- Communication of the change process
- Better framing of the Six Pillars of Excellence as an over arching theme

NC 32: “ There should be more information given to non-clinical employees about
A-I-D-E-T and the 6 Pillars [of Excellence].” From Survey
C15: “I feel that managers need to review A-I-D-E-T with employees and potentially
do some role playing to help non-clinical employees feel comfortable using it.”
NC4: “Maybe we could have been given examples or scenarios that would have helped
us to understand what we need to do.”


37

Conclusions & Recommendations

• Chapter 5:


38

Results & Findings Summary
• Non-clinical employees supported the No Pass Zone in
theory but not practice.
• Non-clinical and clinical employees understood the need
for the Six Pillars of Excellence.
• Non-clinical employees did not feel prepared for the No
Pass Zone.
• Non-clinical employees stated they were afraid to enter a
patient’s room.
• Non-clinical employees felt a lack of inclusiveness with the
changes.


39

Recommendations for PMH Leadership

• Overall Plan for PMH for Future Change
– Understand the rationale for preparedness of those involved in a
change process
– Create a clear vision and common direction
– Provide the preparedness needed for employees to make the change
– Communicate the change and involve people in the process
– Assign or hire a change agent to oversee any profound change projects
• Example New Hospital Building Project


40

Leadership Actions Arose During this Study
– Implementation of a pilot hospital wide shadowing program.
– Internal electronic employee engagement survey distributed to all PMH
employees on the changes being asked of them. Survey data is still
being gathered.
– Hospital leadership have started to visit NEO to explain the 6 Pillars of
Excellence.
– A LEAN Project is being developed for identification of infectious
rooms: This training will be for all employees. This researcher has
been asked to be a member of the LEAN Project Team.


41

Recommendations for Future Studies
– Do patients want non-clinical employees coming into their
rooms?
– When you ask non-clinical employees to interact with
patients in a clinical care setting how does this impact
employee and patient safety?
– Will patient satisfaction scores improve or decline due to
non-clinical patient interaction in a clinical care setting?


42

Contribution to the Theory & Practice of Leadership
The 7 Elements of Organizational Change
Based on Randall 2004, p.38

Analyze the Organization
& Its Need for Change

Create A Shared Vision
and Common Direction

Create A Sense of
Urgency

Support a Strong Leader
Role

Craft an Implementation
Plan

Communicate and
Involve People

Reinforce &
Institutionalize Change

43

– Organizational side of change
– Kotter’s Eight Stage Change Model 2002
•
•
•
•
•
•
•
•

Establish a sense of urgency: Inspire people to move
Build the guiding team
Get the vision right
Communicate for buy in
Empower action
Create short term wins
Don’t let up
Make the change stick

– Prepare employees for the change
– Communicate and involve people
– Create a shared vision and common cirection


44

– The People Side of Change
• It is people who change not organizations
• Successful change occurs when the individual’s change matches the stages of
organizational change (Hiatt 2006)

– The Fear Involved with Change
•
•
•
•
•
•

Fear of not having the ability to make the change
Fear that the change will fail
Fear that the change is inconsistent with his or her values
Fear that the risks of change outweigh the benefits
Fear that the change is going to make their jobs more difficult
Fear that those who are responsible for the change can’t be trusted (Kotter 2002)


45

Self Evaluation: A Tool for Future Research
– Being an employee in the organization was a plus and a minus.
– I wish I would have drilled down on some questions. Example: When
leadership failed to give reasons for their admitted failure to
communicate, I wish I would have asked why.
– The importance of asking for recommendations on surveys and in
interviews.
– Employees felt comfortable and safe for interviews. Had minimal
issues with obtaining volunteers.
– Had to constantly remind self not to lead the interviewees and at times
got off track and was too chatty.


46

Acknowledgements
My Committee:

Dr. John Barnette
Dr. John Sidor
Dr. Ruth Panepinto
Dr. Kathleen Jackson
DEL Cohort WV01
– David
-Bill
– Kathleen
-Kimberly
– Stephanie
-Dena
Dedicated to my parents:
John & Rose Abruzzino Julian


47

Questions & Comments


48

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