CHAPTER 18

Implementation and Planning: Supporting Organizational Change

Effective communication is critical to positive patient experience. We are becoming more aware of the power of effective communication as a pathway for creating more meaningful connections, expressing empathy, and improving experiences, safety, and quality outcomes. However, believing in the value of communication is only the beginning. Healthcare leaders must develop and implement a thoughtful strategic plan when instituting a communication skills program that will effect change across an organization.

Chapter 17 explained the train-the-trainer process for developing internal trainers, a valuable tool to successfully implement communication skills programs. If you want to change the culture of an institution, there are additional processes that can help make your initiative a success. You can use this general framework as a guide:

1.   Identify the problem or question.

2.   Gather data.

3.   Generate provisional solutions.

4.   Plan, act, and adapt.

Notably, this framework is meant to be a social process characterized by coalition building and consultation. In this chapter, we explore the choices and processes at “Sample Hospital,” a fictional example drawn from our years of experience across the country.

Identify the Problem or Question

Ms. Conner serves as the Director of Patient Experience at Sample Hospital. As she examines patient experience survey reports, she notices that clinician communication remains consistently low, despite a recent push to create awareness of the importance of patient-centered care. Over the past year, patient experience score reports have been administered to each clinician; those with lower scores have been told that they must improve. While some claim to recognize the importance of patient experience, no one seems motivated to change. Some individuals have disputed the findings with statements like “the surveys are invalid,” “my patients really like me,” “we don’t have time,” and “it’s not my job to make patients happy.”

Ms. Conner needs to take action to raise patient experience. For the remainder of this case study, we are going to follow two possible pathways. As we notice the similarities and differences between the paths, we can consider how they might reflect or guide us in our own organizational change efforts.

Pathway A
Eager to see improvement, Ms. Conner decides to develop a communication skills program for clinicians. She believes that patients at Sample Hospital deserve to feel respected, understood, and cared for. She wonders: How can we develop a program that makes a real impact? How can we engage clinicians and inspire them to express more empathy? What will it take to truly inspire change at Sample Hospital? Armed with her spreadsheets of patient experience scores and patient complaints, she gathers information about leading communication skills programs to present to her management team.

Pathway B
Ms. Conner understands that there is a connection between patient experience and the communication skills of clinicians. She also knows that clinicians have a deep sense of pride in their work and that being told they need communication skills training carries the implication that they are doing it “wrong”—a message known to generate great resistance. She also believes that best practices and evidence is only one-half of the equation—truly engaging with clinicians to understand their experiences and concerns is key. Over the next month, she speaks with formal and informal leaders in her institution, hoping to be able to form a small task group to explore the following question: “What support or skills do clinicians need to make patient encounters as efficient and effective as possible?”

As we explore both pathways, you may recognize that Pathway A represents a more traditional attempt to instigate change. One risk of this option is that Ms. Conner will seize on a solution too quickly and miss critical opportunities to engage key stakeholders. In fact, this approach was one that Ms. Gray took in Chapter 17, resulting in a lost opportunity. As discussed in previous chapters, we encourage leaders to engage others through “dialogue” rather than “monologue.” Parallel to using the ART (Ask, Respond, Tell) cycle when communicating with patients (see Chapter 5), when leaders invest in assessing and sharing understanding (as seen in Pathway B), they increase the likelihood that the plan will be accepted and that changes may occur.

As you identify the problem or question related to changing the communication skills environment, you may want to consider the five classic W questions: who, what, when, where, and why. For example: Who is most impacted by the problem? What are you trying to change? When do you need to address this problem? Where is the issue more concerning (e.g., department, specialty, clinic, etc.)? Why should you address this problem? Exploring questions like these may also be helpful across the phases of any major management effort.

Gather Data—Including Numbers, Experiences, Stories, and Observations

Pathway A
Ms. Conner has very high-quality data about both her institution and how it compares to other health systems across the country. She makes a very strong case for the link between clinicians’ interpersonal skills and outcomes such as patient experience, safety, malpractice risk, readmission rates, and quality of care indicators (e.g., adherence to treatments and chronic disease management). She has projected the costs of a systemwide training program against expected savings over 10 years.

Pathway B
Ms. Conner starts her task group meetings with a report comparing local patient experience and outcomes to national trends. “These numbers bring our awareness to something we need to pay attention to. They also suggest great potential for us to improve. What do we need to understand further about the experience of our clinicians and our particular health system so we can do our best to communicate our desire for this project to be in partnership with our clinicians? If we can’t understand where they are coming from, we can’t offer something of value to them.”

The group proposes a series of “Taking the Pulse” lunches in all the clinical and service areas. The 45-minute format includes a 2-minute speech from the Chief of Service, a story of outstanding service by a clinician in that unit, and a focused discussion answering the question, “What is the most challenging aspect of your clinical communication with patients, and how can we support your work to meet that challenge more effectively?”

While the idea of gathering data will certainly involve patient experience survey reports, we recommend delving more deeply into a diverse range of “data.” These data may include personal stories and experiences from patients, families, and clinicians. Observations of interactions across multiple contexts provide valuable insight. Data should also include other metrics such as quality and safety reports, staff engagement scores, malpractice claims, patient complaints, and more.

In Pathway A, Ms. Conner’s data set is limited to quantitative or fact-based data, used in support of a course of action that she already feels committed to. Her case is reasonable and rational. But it rests on a foundation that has not been created to include other voices or perspectives—most notably, those who will be most affected by a proposed training. She also misses the chance to find the links between what she cares most about and what her clinicians are experiencing.

The team in Pathway B offers another approach to data collection as they conduct the lunches over a two- to three-month period. They discover that clinicians are anxious about increasing expectations for patient contact (i.e., through secure electronic messaging) and about conversations with patients seeking opioids. The sessions also highlight a sense of change fatigue among the group following the adoption of a new electronic health record system, a safety campaign emphasizing the importance of handwashing, the implementation of nurse-physician bedside rounding, and the hiring of a new hospital president and CEO. The quantitative data collected in Pathway A are crucially informative. The ideas shared in Pathway B are proposed as added resources for developing a more robust understanding of the problem. Additionally, collecting stories and gathering ideas will engage a broader constituency of stakeholders. People are much more likely to accept and support change when they feel that their voices were heard in the early stages of that change.

Generate Provisional Solutions

Pathway A

Ms. Conner’s commitment to her patient experience role creates a sense of urgency to drive change, and she plans to launch a communication skills program as soon as possible. She develops a catchy title and description for the program and creates a PowerPoint presentation using fundamentals she learned while attending a recent conference. She decides to offer a 90-minute workshop session for clinicians, who can sign up to attend during lunch breaks (this is all the time she hopes for from busy clinicians).

Ms. Conner creates a flyer and starts visiting department meetings to build awareness about the importance of communication and the impact on patient experience, while announcing the upcoming opportunity. She sends e-mail blasts to all clinicians with dates and registration information. The first two workshops are well attended, mostly by younger clinicians and those who are known as top performers. The next several workshops have very low attendance, and Ms. Conner is discouraged. She wonders: Why don’t these clinicians care about patient experience? Can’t they take just 90 minutes of their day to learn about communication? What can I do to engage them?

Pathway B
Ms. Conner’s task force reviews all the numbers and experiences shared during the lunches and decides that a tailored communication skills course using a facilitator training program model is the best approach. Aware of the degree of change fatigue, the task force approaches the leadership team with their findings and with several critical requests. One is for support in acknowledging and thanking staff for their efforts to date. The other is for a strong mandate and the financial support for the proposed communication skills initiative. The task force requests that several delegates of the leadership team be supported to do a site visit at a comparable institution that completed a communication skills training program the year before. There is general agreement as to the direction everyone wants to take, but there is also a desire to feel as fully informed and prepared as possible before the project is widely announced.

Now might be a good time to reflect on similar changes that might be occurring in your own organization’s culture. We all know that the landscape of healthcare is rapidly changing, and healthcare clinicians are increasingly given no choice but to adapt. These changes are often disruptive, frustrating, and stressful. As in the case of Sample Hospital, there may be multiple initiatives under way. A communication skills program can feel like yet another time-consuming task, with the risk of being perceived as one more “flavor of the month.” When launching a successful program, you must first assess the local culture. What are the past or current program initiatives? What was the impact of the programs? What is the current level of morale among clinicians and staff?

In her eagerness to implement a program, Pathway A Ms. Conner inadvertently overlooked several factors within the local culture that might impact the level of interest and engagement among her target participants. Again we see the risks that Ms. Conner takes, singlehandedly owning such a huge amount of the responsibility and drive for the project. But support from C-suite leaders is critical. While these leaders need not engage in the intricate details or logistics of the program delivery, it is critical that they buy in to the concept. This will likely make—or break—the program.

Invested leaders will reflect on and respond to the local culture, especially within the context of a targeted population (e.g., physicians, nurses). Like Ms. Conner did in Pathway B, you can consider strategies for most effectively addressing the current needs of the organization by forming a group of leaders to contribute thoughtfully to the process.

This book outlines a set of useful and meaningful skills to help change the ways that clinicians communicate with patients, families, and their teams. Sometimes, you will need to generate temporary solutions that are customized both to the needs of your organization and to the individuals who co-create a local culture. As you decide on options and next steps, you may again want to consider the five W questions: Who should be involved in a change effort? What would a program or solution look like (e.g., workshops, coaching, videos)? When would the effort begin and end? Where should the effort start (e.g., inpatient versus outpatient; nurses versus physicians versus entire team; specialty versus department)? Why are you committed to the proposed effort?

Plan, Act, and Adapt

Pathway A

Following her disappointment with the initial response to her enthusiastic plan for a hospital-wide communication skills course, Ms. Conner takes a different tack. She recognizes the need to adapt after the failed launch of the 90-minute lunch sessions. In an effort to respond, Ms. Conner further explores how healthcare systems have successfully implemented communication skills programs. She invites a guest facilitator to lead a pilot session and recruits allies who represent the population of targeted learners to attend the pilot version of a revised program. These allies make a point of actively recruiting several people who were doubters. The pilot participants are given time to reflect on how the proposed program will translate to their larger setting.

Three months after the pilot program, Ms. Conner takes a delegation including her CEO and Chief of Staff to another large hospital within the Sample system where participants share the story of the process, including the rewards and setbacks. The new hospital is invited to consider its readiness to embark on its own communication skills enhancement program.

Encouraged by the experience of their peers, Ms. Conner moves things more quickly this time. A train-the-trainer program, modeled after the revised pilot program, is up and running at the new hospital location within three months. The process of bringing the enhanced communication skills training to all five of the system’s hospitals takes two and a half years. Although this is longer than the executive team’s goal of 18 months, the adaptation is ultimately considered successful. Patient experience scores significantly increase and, unexpectedly, absenteeism decreases slightly for the first time in years. Several of the original pilot groups contact Ms. Conner’s office about training in advanced communication skills around end of life care.

Pathway B
The leadership team is comfortable and highly committed to a train-the-trainer program. A launch is planned in six months. As part of the launch, the leadership conducts a “thanks for your commitment to excellence” campaign to appreciate all staff for their participation in the change initiative over the preceding two years. The thank you includes a message to clinicians that foreshadows a “clinician-led” professional development initiative to improve clinician effectiveness during the clinical encounter and to support compassionate care during difficult conversations.

There is also a smaller project developed to help educate patients about “how to talk with your team,” including pathways and processes to divert all but the most relevant electronic messages away from the clinicians. 80 percent of the local site leaders who formed part of the original task group have signed up to be trainers.

The framework outlined in this chapter can help guide your thinking as you contemplate and prepare for action. As described in the case of Sample Hospital, Pathway B represents a smoother approach. However, we often embark on a change effort with too little preparation, as seen in Pathway A. The key lesson here is not that Ms. Conner failed in Pathway A. Instead, we can reflect on how Ms. Conner successfully adapted and redirected along the way. The next section provides practical considerations to guide you in your planning. Your actions, and the subsequent success or failure of your plans, will be directly influenced by the level of thoughtful and strategic preparation.

Practical Considerations

The next section includes some final practical details to consider as you drive your initiative. We intend these suggestions to be contingent upon continuous assessment and adaptation as you embark on any change effort.

•   Engage Leaders: Successful change efforts are highly dependent on the extent to which key leaders embrace the program. Executive leaders (e.g., CEO, CNO, and CMO) must approve funding and time allocations. We recommend that leaders enroll as participants in one of the initial workshop offerings to provide feedback and authentically endorse the effort.

•   Identify a Project Management Team: An effective project management team will likely involve both executive/senior leaders and operational project managers. The roles and responsibilities of each team member should be identified clearly. Senior leaders will likely serve as thought leaders or steering committee members. Project managers will oversee the operational tasks of program development and delivery such as messaging about the program, recruiting participants, scheduling, registration, preparing materials, and more.

•   Seek Wise Counsel: Planning a successful program requires support from a variety of sources. As we plan the content and delivery method, we will need to enlist individuals who have the knowledge and skills necessary to guide the curriculum and to engage learners. Although a train-the-trainer program is a highly effective way to develop a cadre of internal expertise (see Chapter 17), that approach is not for everyone. We might instead identify one or two champions who can develop or offer the necessary expertise. Many systems invite visiting communication experts to provide a more immediate solution.

•   Tailor the Message: Consider approaches to best reach and motivate the target audience (the clinicians who will engage in the new program). Your organization may have internal marketing or communication staff members who can lend support as you craft announcements and prepare materials. Promotional assets may include e-mail invitations, short in-person presentations at department meetings, print materials, a webpage, and more. Make sure to get formal endorsements from key leadership and respected colleagues. Creating a campaign to announce and promote the initiative is an often overlooked, yet crucial, part of planning.

Conclusion

In this chapter we offered four elements to consider as we embark on organizational change processes: (1) identify the problem or question, (2) gather data, (3) generate provisional solutions, and (4) plan, act, and adapt. Our case examples were meant to highlight the importance of taking an actively social and inclusive approach whenever possible.

There is a saying in science: “All models are bad, but some are more useful than others.” The most important mindset for change is to pay close attention to what arises in us, our colleagues, and our organization as we experience the work of supporting communication skills training. From our experience will emerge the guidance for what to continue doing, what to consider changing, and what to stop.

It is important to acknowledge that nothing is ever as neat and tidy as a change-management model might have one believe. Having this process proceed with many bumps and missteps isn’t necessarily a failure of planning or strategy—it’s the very nature of the business.