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.

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. 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 content
No compensation offered or received in conjunction with this
presentation

3. Introduction
Transformation

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. 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. 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. 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. 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. Transformation of Healthcare

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. 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. 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. Short Term ONC Agenda

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. 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. 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. 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. 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. 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. Real and Stipulated Meaningful
Use

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. CMIO Role
Managers or Leaders

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. 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. 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. Operational Differences
Managerial 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. 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. Change Management

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. 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. 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. Types of Change
• Mission
• Strategy
• Operations
• Technology
• Attitudes and behavior

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. 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. 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. 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. 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. 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. 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. 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. 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. Issues for the CMIO
• Position within hospital hierarchy
– CIO
– CMO
– C suite
– Allied medical personel
• Time management – need for clinical
credibility?
• Support staff

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. Thank You

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. 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