A receptionist, a medical assistant, a nurse, and a doctor work as a team at a community health center that is part of an integrated health system in Colorado. Their clinic director, Helen, who has just returned from a major conference, tells them with great excitement, “I’ve just signed us up to be one of the champions of a new model that could improve our care of patients with hepatitis C!” With some trepidation, but also a willingness to try given that they like and trust Helen, the team agrees to pilot the initiative, “Connect for Health, Colorado.”
Over the next several months, the team is asked to attend several meetings and perform new tasks, many of which do not seem to directly benefit their patients. Because the system isn’t set up for these tasks, they add complexity to the workflow and at least an hour or two to their already long workday. When Helen asks the team about joining a second initiative that builds on the first, the team unanimously votes “no.” What went wrong?
This scenario is ubiquitous in health care today. Well-intended change, especially at the outset, can make life more difficult for the people who are engaged in it, and often the result is a failure of the initiative to sustain or scale. Improvement initiatives abound, and yet we don’t see much real improvement or organizational transformation. Some changes, like implementation of electronic health records (EHRs), have brought healthcare professionals to a point of near revolt. High levels of burnout have been reported across the healthcare workforce, and some clinicians are leaving the medical profession, in part because they are losing hope that real change is possible. The Institute for Healthcare Improvement (IHI) grouped “failed change efforts” into three areas: failure of ideas, failure of will, and failure of execution.1
Ideas fail when they do not effectively diagnose the problem or generate a set of solutions that would work. Most failures of ideas arise from not having the right people engaged to correctly identify the problem or to create the right portfolio of solutions—that is, those who are most affected by the problem, like patients. Effective codesign and innovation strategies can assure that the right problem is tackled and that a set of realistic solutions can be tested.
Failures of will occur when everyone, from leadership to front-line staff, lacks the motivation and agency to effectively engage in the process of developing or implementing the solutions. People don’t support change when they haven’t been invited to provide input about what might work for them. Often, they work around the change if such pathways are possible.
A failure of execution occurs when new solutions are not implemented in a way that works. In our experience, most failures of execution arise from not anticipating how the change will affect the human beings involved or from not building systems in which the change becomes the new, sustainable norm.
Failures and solutions in these three areas are interrelated and, depending on whether the change is simple and incremental, complex, or transformational, one might combine a set of change strategies that best address the type of change and the context.
In this chapter, we will primarily focus on change management strategies to create changes that address failure of will and failure of execution. We will introduce three frameworks that have been used by people across industries to create more effective change: one that focuses on improving will (Switch2), one that explores the psychology of change3 with an emphasis on sustaining the will to change and shift culture, and one that is useful in supporting the execution of complex change (Kotter’s eight-step change model4). In this chapter, we will apply these frameworks to real-world examples of large-scale transformations at Cambridge Health Alliance and in 100 Million Healthier Lives. The chapter will conclude with reflection regarding the responsibilities of change leaders.