East-West synthesis drives change model

Sessions are heart of customer service improvement

The unique fusion of a process for major change created at the Harvard School of Business and a Japanese business culture model where change is driven by department managers and staff rather than by top leadership has helped power a successful customer service initiative at the University of Texas M.D. Anderson Cancer Center in Houston.

The eight-stage process of creating major change, developed by John T. Kotter,1 is set out as follows:

1. establishing a sense of urgency;

2. creating the guiding coalition;

3. developing a vision and a strategy;

4. communicating the change vision;

5. empowering broad-based action;

6. generating short-term wins;

7. consolidating gains and producing more change;

8. anchoring new approaches in the culture.

"This was the coat rack on which we hung other elements of the initiative," says Duke Rohe, a systems improvement specialist in the office of performance improvement.

A key Japanese tool for change, Kaizen sessions, helped get the staff used to change, he continues. "They are little 15-minute crafted meetings, requiring all the staff to do the same thing," he says. "Perhaps a little assignment is given — to come back to the next session with at least one small idea on an idea card that will make them or the department better."

The whole staff has to participate, says Rohe, noting that for effective change to take place, "everyone has to change. It’s like [developing] a muscle; you start easy, but you get stronger." (The interrelationship of Kotter’s model, the Kaizen sessions, and the structure of the customer initiative process are shown in the diagram here.)

The initiative was born about three years ago, and was undertaken by the Institute for Healthcare Excellence (IHE), which was created to work in conjunction with M.D. Anderson’s office for performance improvement to pilot new programs and new ideas. Working through the vehicle of the IHE, M.D. Anderson and Paula Descant, MAO, education specialist, spearheaded the effort.

"We set up the initiative to improve quality institution-wide and developed a program that was a combination of learnings and models that Paula and I have absorbed through school and through practical experience," Rohe says. "I come from the process side; if you don’t change your process to support great service, you fail the customer [the patient] time and again."

"We looked at several key factors," says Descant, who developed six modules of basic customer service needs. "The better service we give our customers more efficiently, the happier your customers and employees will be."

The initiative targeted three main pilot areas: the pharmacy, the information line, and the diagnostic center. "We ended up changing people — or the people changed themselves," Rohe explains. "We gave them the tools, and staff behaviors changed; they become the improvement finders, instead of the top leaders, which is more often the norm."

This structure, again, is more typical of Japanese culture, Descant observes.

Achieving change

The change process began with Rohe and Descant "selling" the customer service initiative to department management. "Everyone thinks they need customer service," Descant says. "Our department is known for this."

"What they don’t understand is that to make deep-seated change, you can’t do it with just classes," Rohe adds.

According to Rohe and Descant, one of their goals is for the department staff to walk away from the program with something practical they can apply in the real world.

"We offer them the tools to get them to change the culture to be customer-friendly — then we offer the classes," Rohe explains. "It’s the talk about culture that gets them." No punches are pulled as the initiative is explained. "We let them know we are going to change the process side, and that requires teams to support the service they are going to deliver," he says.

"That means a commitment of six months, during which we will be taking people off the floor," Descant adds.

To that end, a change readiness form is completed electronically, which "lets them know what it will feel like being short of staff," Rohe says.

Accordingly, Rohe and Descant required that no other change take place during the initiative.

"We knew that in the next summer, the pharmacy would have to open a new satellite facility," Rohe recalls. "They weren’t sure what they wanted to do. They thought about it and came back and said, [The change process] will be the thing to help kick it off,’" he adds.

"You first have to get the managers to see why they have to change," Descant says, explaining why it is important to establish a sense of urgency. "We use a balanced scorecard; Duke goes through and asks about turnover, productivity, attendance, customer service, finance, and so forth."

"If they don’t see a need for change, they don’t need to do this," adds Rohe. "At change readiness, we encourage them to talk to a manager who has already gone through this; we don’t want them folding in midstream."

Most departments did not have a standing mission statement, Rohe and Descant found.

"If they didn’t, we helped them create one," Rohe says. "We had the managers do it because they are the drivers and sponsors of what we are about."

In creating the guiding coalition, the key question asked was, "Who are your stakeholders?" They could be staff, departments downstream, or the patients. As originally conceived, the coalition would include an advisory board as well as a customer service board. In this case, however, since the advisory board is built on a top-down structure, only customer service boards were formed.

The customer service board "can be anyone the staff feels is important to their department," says Descant. "In the information line, we have ex-patients on their board."

"You feel honored to be on this," Rohe adds.

This process is driven by the staff. "We treat staff like stakeholders," he explains. "We let them know what they are about to go through, because not all of them will buy in."

One reflection of just how important buy-in is, is the change master position. "Since we need buy-in from the staff, we ask people to interview for this position," Descant says. "We require each department to have two change masters."

Prior to calling for volunteers, a change master from a previous team is brought in to share his or her experience. Then staff are given two days to read about the position before going through an interview process.

"This is serious stuff," Rohe emphasizes. "It is a two-year requirement with no additional pay — you just obtain more skills.’"

Rohe, Descant, and the managers all interview the candidates, based on a predetermined set of criteria. "We are looking for people who can be quick on their feet, who have facilitation skills and presentation skills, and who are team builders, because they will be presenting the customer service modules," Descant explains.

Once the two are selected, they are given a mini-orientation to bring them up to the same level of knowledge as the managers.

The next stage, the customer service board meeting, includes the two change masters, the board, and the managers. "The outcome from there is to look at the managers’ mission and to begin crafting the vision," Rohe adds. "Appreciative inquiry is used; we examine the gap between where we are and where we want to be."

In the two-day session, the participants are given a sense of the overall process of how Rohe and Descant work with teams and with customer service modules.

"On the second day we break them off," says Rohe. "The change masters and Paula work on running teams, as well as on doing customer service modules. I take the managers into a session called run the bus, change the bus.’ This covers how they will change themselves and the staff."

"It’s really developing a strategy," Descant explains. "It gets them on the same page. It is also the first step in empowerment; that change master gets to say his or her piece."

Next, an individual team is selected by the change masters and management, also using a set of specific criteria, Rohe says. "The first team’s goal is to turn the vision into a real vision statement for the department." He says the ideal team size is six members, but teams have been formed with as few as three members.

The team runs with this assignment for five weeks, then approves a vision statement. Ultimately, the customer service board approves the statement, "but everyone has their fingerprints on it," Rohe notes.

In addition to approving the vision, the board also approves the next project. The idea is to generate short-term wins. "Over the two-year process, a department probably will run 10 teams," he explains. "You have a five-week project, identify the change, then implement it. This way, you get immediate impact," Rohe points out.

"It is the customer service board’s responsibility to make sure the short-term wins are continued and produce more change," Descant adds.

These changes are accomplished either through Kaizens or through the customer service training modules, she says. "One team did a new telephone process. When it got done, we did a module on this new process; now it’s anchored in the culture."

"The very first team in the outpatient pharmacy revamped the existing flow process for dispensing outpatient drugs," Rohe recalls. "The second personalized the vision statement for their department and developed customer service scripts; a third team took the new customer service skills we learned and a new process and built new performance evaluations around those skills — they re-crafted the evaluation form. At last count, we have had over 30 Kaizens implemented. The staff catalogs and celebrates them."

Perhaps most gratifying, the customer service initiative has become contagious. "As often as not, the departments now approach us," he says.


1. Kotter JT. Leading Change. Cambridge, MA: Harvard School of Business; 1996.

Need More Information?

For more information, contact:

• Duke Rohe, Systems Improvement Specialist, M.D. Anderson Cancer Center, Houston. Tele-phone: (713) 745-4433. E-mail: drohe@pdq.net.