Change Management: Is the Juice Worth the Squeeze?

Change in the US healthcare system is likely coming on a scale not experienced for generations. (see Feb 12, 2013  and Feb 15, 2013)   It is useful to pause and reflect upon the responsibilities leaders in our field have to help anticipate and manage the process of change.  In particular, under what circumstances does a leader deliberately take a group of people – physician practice, clinic, hospital, delivery system, teaching program – through a deliberate and orchestrated change management process?  One critical question: Is the juice worth the squeeze?

There are a number of theoretical academic management models of change management.¹    One model was developed and popularized by William Bridges who publishes widely in this area, both in traditional print media and on-line.  The following figure is adapted from Bridges’ work:

Bridges’ schema of change management has distinct Kübler-Rossian overtones (see “Curve A” above).  In this model, organizations go through a mourning process for the old world order, before the new can be embraced.  During the “Endings” period people are encouraged to let go of the old ways – often ways that met with success in the past .  The “Transition Zone” is a zone of discomfort.  Some people may leave the organization; others will marshal their creativity to find ways to succeed in the new era.   In “New Beginnings” some will display new behaviors, developed to meet the demands of the new playbook, and ultimately become role models for others.

The impact of the change is felt in “Curve B”.  During the process, the overall level of anxiety increases, peaks and ultimately returns to baseline as the change becomes the new normal.  Directly related to the waxing and waning of group anxiety, organizational performance will actually decrease, before rebounding – this is the critical point – to a level of performance higher than where it started ("Curve  C").  The organization must endure the expected rise in anxiety (the squeeze) in order to enjoy the ongoing benefit of enhanced performance (the juice).

We have plenty of examples of looming changes in healthcare and education – shift from volume to value payments, curricular innovations, group physician visits, team based care, competency-based rather than time-based education to name only a few.  Here are a few questions to ask prior to embarking on a deliberate change process.  If none of these conditions exist, you may want to pause and reflect carefully before launching a major change initiative:

• Does my organization have a commitment to a particular strategy, and are current behaviors incompatible with this strategy?  (e.g., we think the our future success depends on innovations in training providers to thrive in a new delivery system – department chairs are focused on building research programs).

• Is the organizational behavior that needs to change damaging the organization? (e.g. inattention to known regulatory requirements).

• Is the anticipated improvement in performance significant?  If you presented to results of the process to an objective observer, would they be impressed or lulled to sleep?

• Is the anticipated improvement, once obtained, sustainable, or just a one-time event (e.g. a single year improvement in productivity)?

• Is the organization sufficiently stable to weather the transition?  Is it already engaged in too many disruptions and transitions?

In an unstable environment, leaders have responsibility to instill as much discipline around change as possible.  To paraphrase the Serenity Prayer:

"God grant me the serenity 
to accept the things we do not need to change; 
 courage to change the things we must;  
and wisdom to know the difference."

¹    McDeavitt JT, Wade KE, Smith RE, Worsowicz G. "Understanding Change Management" Am J Phys Med Rehabil. 4(2) pp 141-43, 2012.