Nimble management

Introduction
Healthcare, like other sectors, has evolved to service a societal need. With a high number of players, interlocking systems and regulations, it is sensitive to the forces of people, process, and technology. The proposed reform will drive hospitals (also referred to as healthcare organization or provider in this essay) to be more competitive, bring down costs, and provide better outcomes. These are possible through transformational initiatives, none of which may be easy or intuitive. This essay highlights an alternate view of value and the factors that are crucial to succeed in instituting change.
Defining and locating value
Every organization exists because of a customer need it serves. A hospital helps a citizen to remain and stay healthy, and in the process creates and delivers value to the patient. Value may be defined as a product of quality of care, price paid for care and image of the hospital. Perception of value varies depending on type of care and other available choices e.g. patients seeking cardiac care may be fine spending high dollar amount as opposed to those seeking cure for common flu. Every interaction the patient has with the provider erodes or adds to patient loyalty. Value is greater than the sum of all services rendered to the patient. While it is convenient to work with an internal definition of value, a patient centric view is likely to fetch favorable results. A strong commitment to customer value increases organization’s competitive advantage, market share, and profitability. Drawing out a value stream is a key activity in the process of discovering this strategic measure of success.
Building blocks of a value stream
A value stream is a traditional six-sigma tool that allows us to analyze and align the sense of value within and beyond the enterprise. Admit-Discharge-Transfer-FollowUp (for in-patient) and Appointment-Diagnosis-Treatment-FollowUp (for outpatient) are typical value streams in health delivery. A business process is a set of activities that builds the value stream. An activity is a task or business function that has a hand-off either to another activity or to an end customer and has some measure of value. Activities may be of three types
• Those that create value
• Those that do not create value but cannot be dropped immediately
• Those that do not create value and are considered for elimination
While in the process of detailing the value stream, it is tempting to start reductionist, cost cutting changes mid way through the exercise. On the other hand, organizations need not go overboard with minutiae and must learn to prioritize the processes to balance the effort and gain. Surveys show that one of every five Medicare beneficiaries discharged from the hospital undergo readmission within 30 days, and half of non-surgical patients are readmitted to the hospital without having been seen by a doctor in an outpatient follow-up. There is opportunity in extending the scope of the value stream beyond the traditional enterprise boundaries. Providers, for example, can offer great value through post-discharge medication management. Creation of value stream forms a foundation for integrated health delivery. Such new models of business require innovative teams and leadership to succeed.
Team and Leadership
Most organizations are set up to operate in functional silos. During projects, resources from different departments combine to form a virtual team (matrix based). This is a winning formula so long as people are rational, share common motives and prioritize project goals in favor of departmental interests. However, in practice, managers struggle to get stakeholders aligned, provide contextual leadership, and retain a well performing team. One of the ways to have a focused team is to have it assigned to relevant business processes. The importance of team-based collaboration in healthcare is a difficult yet important agenda to pursue. Typically, the CxO owns the value stream and the dedicated senior management oversee each business process. Reformulation of the organization personnel along lines of business process often creates dramatic shifts in power. In general, people resist such initiatives making change management an important part of any innovation. The diagram below shows the connections between value stream, business process, activity, and organizational hierarchy.

A strategic transformation without strong leadership seldom has a chance to succeed. An empowered workforce that shares the strategic vision with its senior management creates an environment where change can thrive.
Socio technical aspect of change
Projects may fail for a number of reasons including lack of change management, resistance of stakeholders (including end user) and incorrect definition of value. Projects seldom fail for technical reasons as they do due to poor expectation and change management. Organizations need to recognize the interdependency between social and technical subsystems during periods of change. The technical subsystem consists of tools and techniques used to deliver favorable outcomes using given inputs. The social subsystem comprises of the people, knowledge, attitudes, needs, and chain of command affecting the workforce.
Psychological barriers
Altering knowledge and attitude is an effective and sustainable way to transform human behavior. Typical barriers in warming up to change include:
• Differences of opinion - people impacted by change often question its concept and are pessimistic about benefits arising from it
• Not participating in change - not acknowledging initiatives and not familiarizing with contents of the initiative
• Inertia of past practice has no motivation to adopt innovation
• Lack of preparation, lack of confidence and fear of job loss - during change, it is common for people to lose jobs. Paradoxically, it creates new jobs too. Employees who find it difficult keeping pace with change drop out and create skill gaps filled through lateral recruitment.
• External barriers – limited time, resource constraint, conflict between patient preferences and organization culture.
Illustrating the impact of barriers on change, a survey of over 800 participants at an annual electronic medical record (EMR) trade fair in the US in 2007 found that 19% of respondents reported that they had or were in the process of de-installing an EMR system.
Group dynamics
Diffusion of change across professions or groups depends on prevalent belief system and shared work experience. Lack of explicit tasks, lack of local leadership, and influence of professional socialization; all are factors that slow down change. Physicians train to be fiercely independent and exercise high levels of autonomy. Practice of medicine by its very nature is fluid with few formalized control mechanisms. Integrated inter-professional education is only starting to gain recognition in healthcare. Organizations realize collaboration and inter-professional relationship are critical success factors in patient care. Targeted workplace based training will prove to be vital for providers to manage group dynamics, keeping in mind that interventions aimed at one group could impact other professional groups.
The Brain factor
Any disruption in routine is potential change and is intimidating for most parts. Physiologically, the prefrontal cortex of the brain handles multiple threads of logic. However, its processing capacity is limited producing fatigue and possible anger upon reaching the threshold. Activity in the pre-frontal cortex burns a lot of metabolically expensive blood glucose. In contrast, the basal ganglia use blood sugar more economically and have higher processing capacity. This part of the brain stores the hardwired memories and habits and allows us to do the task mechanically. The interplay between the two parts of the brain gives us an insight into workforce resistance towards change. Traditional change management does not sufficiently address psychology and/or physiology. Reward-rebuke approach, unless applied system-wide, yields predictably low results. Surveys suggest that primary driver in workplace is neither money nor promotion, but a personal interest in the job, a conducive environment and fulfilling inter-professional relationship with colleagues.
When the prefrontal cortex perceives a well-meaning initiative as a threat, it soon becomes exhausted and just as quickly gets the individual to resist. One way to get past the brain defense is to help people to assimilate change contextually; get them to see the big picture and connect the dots. Brains scans show a tremendous amount of activity during moments of insights with the brain busy building complex connections. Good change management needs a lot of patience. Leaders have to resist their urge to be prescriptive. When the front line employees do not have the time window to make these connections on their own, they view change adversely. Addressing the physiological impulses constructively can be soothing to the prefrontal cortex.
Conclusion
“And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. ” – Niccolo Machiavelli