Tag Archives: Change Tools

Org Change is Missing in Health Care Tech

If you are an Organizational Change Management (OCM) professional you must read this.  If it doesn’t make you angry then you need to read it again.

Robert M. Wachter, professor of medicine at the University of California, San Francisco, and the author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” wrote an op-ed that appeared on Sunday, March 22, 2015, in the New York Times under the headline “Why Health Care Tech Is Still So Bad.”

As Org Change professionals, we are collectively pressured to provide hard data to prove the value of OCM.  We see project teams rigorously measured and rewarded for meeting scope, budget and schedule without any regard for actual adoption or business impact.  We deal with senior leaders who believe that they will realize 100% of a projected benefit on the day a project is completed.  We know that this is crazy, but can’t seem to do anything about it.

My recommendation: Download this article from the NY Times.  Circulate it among your sponsors.  Talk with them about it.  This is what OCM is all about.

Here is the unedited text of the op-ed:

 LAST year, I saw an ad recruiting physicians to a Phoenix-area hospital. It promoted state-of-the-art operating rooms, dazzling radiology equipment and a lovely suburban location. But only one line was printed in bold: “No E.M.R.”

In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point.

That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows.

If the only negative effect of health care computerization were grumpy doctors, we could muddle through. But there’s more. A friend of mine, a physician in his late 60s, recently described a visit to his primary care doctor. “I had seen him a few years ago and I liked him,” he told me. “But this time was different.” A computer had entered the exam room. “He asks me a question, and as soon as I begin to answer, his head is down in his laptop. Tap-tap-tap-tap-tap. He looks up at me to ask another question. As soon as I speak, again it’s tap-tap-tap-tap.”

 “What did you do?” I asked.  “I found another doctor.”

Even in preventing medical mistakes — a central rationale for computerization — technology has let us down. A recent study of more than one million medication errors reported to a national database between 2003 and 2010 found that 6 percent were related to the computerized prescribing system.

At my own hospital, in 2013 we gave a teenager a 39-fold overdose of a common antibiotic. The initial glitch was innocent enough: A doctor failed to recognize that a screen was set on “milligrams per kilogram” rather than just “milligrams.” But the jaw-dropping part of the error involved alerts that were ignored by both physician and pharmacist. The error caused a grand mal seizure that sent the boy to the I.C.U. and nearly killed him.

How could they do such a thing? It’s because providers receive tens of thousands of such alerts each month, a vast majority of them false alarms. In one month, the electronic monitors in our five intensive care units, which track things like heart rate and oxygen level, produced more than 2.5 million alerts. It’s little wonder that health care providers have grown numb to them.

The unanticipated consequences of health information technology are of particular interest today. In the past five years about $30 billion of federal incentive payments have succeeded in rapidly raising the adoption rate of electronic health records. This computerization of health care has been like a car whose spinning tires have finally gained purchase. We were so accustomed to staying still that we were utterly unprepared for that first lurch forward.

Whopping errors and maddening changes in work flow have even led some physicians to argue that we should exhume our three-ring binders and return to a world of pen and paper.

This argument is utterly unpersuasive. Health care, our most information-intensive industry, is plagued by demonstrably spotty quality, millions of errors and backbreaking costs. We will never make fundamental improvements in our system without the thoughtful use of technology. Even today, despite the problems, the evidence shows that care is better and safer with computers than without them.

Moreover, the digitization of health care promises, eventually, to be transformative. Patients who today sit in hospital beds will one day receive telemedicine-enabled care in their homes and workplaces. Big-data techniques will guide the treatment of individual patients, as well as the best ways to organize our systems of care. (Of course, we need to keep such data out of the hands of hackers, a problem that we have clearly not yet licked.) New apps will make it easier for patients to choose the best hospitals and doctors for specific problems — and even help them decide whether they need to see a doctor at all.

Some improvements will come with refinement of the software. Today’s health care technology has that Version 1.0 feel, and it is sure to get better.

But it’s more than the code that needs to improve. In the 1990s, Erik Brynjolfsson, a management professor at M.I.T., described “the productivity paradox” of information technology, the lag between the adoption of technology and the realization of productivity gains. Unleashing the power of computerization depends on two keys, like a safe-deposit box: the technology itself, but also changes in the work force and culture.

In health care, changes in the way we organize our work will most likely be the key to improvement. This means training students and physicians to focus on the patient despite the demands of the computers. It means creating new ways to build teamwork once doctors and nurses are no longer yoked to the nurse’s station by a single paper record. It means federal policies that promote the seamless sharing of data between different systems in different settings.

We also need far better collaboration between academic researchers and software developers to weed out bugs and reimagine how our work can be accomplished in a digital environment.

I interviewed Boeing’s top cockpit designers, who wouldn’t dream of green-lighting a new plane until they had spent thousands of hours watching pilots in simulators and on test flights. This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.

Our iPhones and their digital brethren have made computerization look easy, which makes our experience with health care technology doubly disappointing. An important step is admitting that there is a problem, toning down the hype, and welcoming thoughtful criticism, rather than branding critics as Luddites.

In my research, I found humility in a surprising place: the headquarters of I.B.M.’s Watson team, the people who built the computer that trounced the “Jeopardy!” champions. I asked the lead engineer of Watson’s health team, Eric Brown, what the equivalent of the “Jeopardy!” victory would be in medicine. I expected him to describe some kind of holographic physician, like the doctor on “Star Trek Voyager,” with Watson serving as the cognitive engine. His answer, however, reflected his deep respect for the unique challenges of health care. “It’ll be when we have a technology that physicians suddenly can’t live without,” he said.

And that was it. Just an essential tool. Nothing more, and nothing less.

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Creating a Shared Need: The Threat vs. Opportunity Matrix

Not long after any initiative’s core team has been assembled, it is essential to get that team aligned and to get them thinking about the potential effects of their initiative.  A “best practice” is to have the team collectively work through this tool to find ways to frame the need for change as a threat and opportunity over both the short and long term, for all stakeholders. 

What is it?

Most readers will be familiar with SWOT Analysis.  The concept with the Threat vs. Opportunity Matrix is to put yourself in the shoes of the stakeholders being impacted by your initiative and imagine their perspective.  Framing the need for change as a short-term threat can serve as the proverbial 2×4 to the side of the head that gets attention and creates urgency.  But long-term organizational effort is sustained by opportunity not crisis, so it is necessary to frame the need for change as opportunity as well.   A frequently overlooked benefit of this tool is that it gets the team thinking about potential resistance to the initiative early in the process.

Why do it?

The purpose for using this tool is threefold (See Figure 1)

  1. To enable the team to articulate the need for the change in terms that will resonate with the stakeholders being impacted.
  2. To anticipate the pushback the team may get from those affected by the change, and to begin an adoption risk mitigation plan
  3. To build alignment and consensus among the team leading the initiative
Threat vs Opportunity Matrix

Figure 1 – Threat vs Opportunity Matrix

How do it?

There is no right or wrong way to do this.  The value is in the conversation that the team has and the list that is generated.   It can be done with sticky-notes on a flipchart, on a whiteboard, or at a table with a scribe on a computer.

Before using this tool, pre-work should include a list of stakeholders and the project charter.  It can also be valuable, though not essential, to pull a cross-functional team together to participate in this exercise.  

1.   Working individually, CAP team members list the reasons for the change initiative.

a.       List both the threats of not changing and the opportunities created if the change is successful

b.      Additionally, try to anticipate the resistance by considering the potential pushback from skeptical stakeholders, i.e. the threat if we DO change and/or the opportunity if we don’t change.  This is a first look at potential resistance to the initiative.

2.     Team members then share their perceptions and then debate and discuss similarities and differences.

3.     Team members then collate and sort the reasons into short vs. long-term.

4.    The team should review their list of stakeholders and try to ensure that they have identified reasons that will resonate with all key constituent groups (e.g., manufacturing, marketing, engineering, sales, etc.).

Tips:
  1. Most reasons for an initiative can be articulated as both a threat and an opportunity.  For example; failure to change will result in job losses, vs. successful change will lead to job growth.  It is useful to retain both versions early in the process.  The team may decide later to portray the need for change one way instead of the other to maximize its effectiveness.
  2. Some teams may struggle articulating the need for change, or to do it for all stakeholders, early in the project.  Therefore, it may be useful to begin this discussion and then revisit it once the vision has been articulated.  It may also drive additional conversations with the project sponsor to clarify the need from the leadership perspective.  Effective teams treat this as a living document and both update it and refer back to it regularly – the team’s understanding of the stakeholder’s perspective will (and should!) evolve over time
  3. A “Best Practice” is to use this tool together with 3-Ds matrix
When do it?

This tool should be used early on in the project, even during the team chartering process.  Though subject to modification throughout the project, this initial statement of need is essential to moving forward with a clear sense of why this change initiative is essential to do at this point in time.