| The Practice Change Leaders program uses John Kotter’s 2006 book Our Iceberg Is Melting: Changing and Succeeding Under Any Conditions to teach strategies for overcoming institutional resistance to change. The book’s main character, a penguin, must persuade the rest of his colony that to survive they must adopt a new way of life, which is a tough sell. Quality Matters asked some current and recent participants how they applied Kotter’s eight pieces of advice to their own efforts. Their answers follow. |
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TIP #1: Help others see the need for change and the importance of acting immediately Kyle Allen, M.D. Project: Reducing the incidence of treatment-induced dementia in hospitalized patients Approach: I used case reports to illustrate the impact of delirium on our older hospitalized patients. I framed it as a patient safety issue, but also attracted the attention of the financial and operations officers by demonstrating the costs associated with not addressing preventable conditions in the hospital. That enabled us to launch a pilot prevention and treatment protocol that was ultimately scaled across the system. |
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TIP #2: Build a team with leadership skills, credibility, communication ability, authority, and analytical skills Nancy Wilson Project: Implementing evidence-based models of treating depression in older adults Approach: Our efforts to transform the way frontline community social service providers identify and treat older adults with depression required a lot of different expertise. We needed funders to help align policies around evidence-based approaches, agency directors willing to “unfreeze” policies that limit innovation, including collaborative approaches to care, and supervisors to support care managers who are learning about new techniques for depression screening and behavioral interventions. Simply sending providers to training would not have been enough to bring about organizational change. |
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TIP#3: Clarify how the future will be different from the past and how you can make that future a reality Jennifer DeCubellis Project: Multifaceted effort to improve outcomes for Medicaid beneficiaries Approach: We worked with programs to ensure they understood that we have a foot in each canoe—one fee-for-service and the other performance-based contracting—and that our canoes were rapidly moving apart. If we stood still and did nothing, we inevitability would sink, so we needed a strategy to keep afloat while transitioning our “goods” to the other canoe. Basically, we painted the crisis. Then, we painted the opportunity: we could get ahead of health reform and begin building the business case and infrastructure for value-based purchasing so that when payers were ready, we were as well. We spent several retreat sessions identifying items that we struggled with today in fee-for-service that we could improve in the new model. These sessions served to get everyone excited about the opportunity, ensure alignment, and define leaders for each action area. |
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TIP #4: Make sure as many others as possible understand and accept the vision and strategy Kyle Allen, M.D. Project: Reducing the incidence of treatment-induced dementia in hospitalized patients Approach: We provided frequent updates and reviews of the delirium protocol to all clinical departments and administration. We also developed letters that were signed by the CEO, chief operating officer, the chief medical officer, and the chief nursing officer about the importance of preventing delirium and how best to manage this condition if it did occur. |
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TIP #5: Remove as many barriers as possible so that those who want to make the vision a reality can do so Jennifer Porth Project: Implementing a care coordination model for older adults Approach: One of the greatest barriers we’ve found to successful transitions from the hospital to home or other health care setting was lack of time. Patients needed it for transitioning, adjusting, learning, and simply living. And so did our transitional care team. We encouraged them to take the time they needed to build a relationship with the patient—one that would help foster the patient’s self-management skills. It was amazing to watch how the patients would open up and be willing to work through life's many challenges and barriers when they were given the time and opportunity to do so. |
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TIP #6 Create some visible, unambiguous successes as soon as possible Randi Berkowitz, M.D. Approach: At Commonwealth Care Alliance we have begun conferences with primary care teams and our skilled nursing facility (SNF) partners to discuss difficult cases. We recently reviewed the case of a woman who had been evicted from her apartment after starting a fire with a cigarette and was subsequently admitted to one of our SNF partners. The team learned that the patient was being supported by multiple waiver programs and there were "too many cooks" trying to organize her care. That conference helped identify early on in the SNF stay who was the appropriate contact person, what supports and challenges the patient would likely have on discharge, and understand the key principles of medical decision making surrounding the decision to continue to live at home. This not only helped nursing home staff understand better what community resources there are to manage complex patients at home, it also created some enthusiasm for the conferences themselves. |
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TIP #7 Press harder and faster after the first success Jennifer DeCubellis Project: Multifaceted effort to improve outcomes for Medicaid beneficiaries Approach: We realized early successes in year one, and began to see trends of staff not attending update meetings, tasks getting bumped further down the line, and some old behaviors creeping back in. We realized we needed to celebrate our success and acknowledge the victories and the work that went into them. That was quickly followed by our need to start a new “wave” of energy. We brought in some new leadership roles, we shook up groups that were starting to stalemate by redefining membership, refocusing tasks, and changing meeting structures, and spent some time painting the vision again for our journey–[pointing out] we weren’t there yet. At the end of each year we look to reinvestments for the upcoming year and drive these initiatives with frequent milestones and report-ins to keep us moving along. Balancing the celebrations with the constant forward motion has taken strong project management tools and persistent leadership across sectors. Having defined leaders in each sector has been critical to keep the “crisis of the day” from derailing us. |
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TIP #8 Reinforce new ways of behaving until they are strong enough to replace old traditions Lee Greer, M.D. Project: Enhancing services for heart failure patients in rural communities Approach: Change takes time. Do not declare mission accomplished too early and falsely believe the process is hardwired. We continue to share our results and routinely provide updates on our new health care delivery model. Over time, this led to acceptance of the model and is now embraced for other disease states. |