THE QUALITY CO$T CONNECTIONS

Implementing changes, overcoming resistance

Being specific with direction is paramount

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Every day it seems there is another process change that caregivers are asked to make. These changes may come as the result of an improvement project or root cause analysis or may be needed to meet accreditation standards. Whatever the reason, it is often challenging to get people to permanently adopt new processes or behaviors. By understanding the factors that inhibit change you'll be better able to deal with resistance.

There are many reasons people oppose changing the way they've always done things. It could be due to a lack of direction, lack of skills, or lack of pressure to change. The known way of doing things often feels better to people than the new way that has been proposed. When developing improvement strategies, it's safe to presume some people might not make the changes. This resistance should be anticipated and dealt with during implementation.

Resistance to change can arise simply because the expectations are unclear. For example, the directive "improve communication among caregivers" contains no information on the new behaviors that are expected. Does it mean: more talk or less talk, more handwritten notes or less, better listening, more face-to-face dialogue or less? When planning change, start with clear objectives and how you'll measure them. Without specificity, people often lack agreement on what changes are needed. What appears to be resistance may simply be a misunderstanding or a disagreement about the expectations.

Change sometimes fails because people are not provided with the skills needed to implement the change. Perhaps the new caregiver communication initiative requires that staff use the S-BAR model for passing along information. Schemes such as this will fail if they are introduced simply as a form that is distributed and staff members are told essentially, "get on with it." Instead, there should be formal training, allowing people to practice communication skills using the model before it is a daily habit.

Successful implementation also requires pressure of some kind. It might be recognition for correct behavior change and/or reprimand for incorrect behavior change. Ideally, the pressure will come from a message from management that they want the change and are determined to see it implemented.

Sometimes people resist a new process because of the danger that, in making the change, present levels of performance might decrease. It is true that introduction of an additional process step or a new way of doing things often results in a short-term decrease in staff performance while new skills are being learned or while errors in introducing the change are eliminated. It is important to convey to those being asked to change that these problems will be short-lived and no one will be reprimanded for decreased performance during the implementation period.

Diagnose the resistance

When you run into resistance to a process change, get the people affected by the change involved in diagnosing the cause. Do this by asking, "What are the major problems you are encountering that we could solve if we worked together?" This question leads to an increased awareness of what is wrong and naturally leads to potential solutions. The discussions that occur surrounding this question often unfreeze the people concerned, and they begin to talk about issues that may not have been brought to the forefront before. Just talking about the issue causes people to gain new perspectives. They may sometimes come to perceive that they themselves are the prime cause of the improvement failures.

Usually when people understand why they have been resisting a change, their resistance decreases or, at least, becomes more rationally based. Not following the required steps of a process is often a symptom of something else — perhaps unwillingness to give up the old way of doing things or perhaps the new process is unworkable. Uncovering these reasons and discussing them with the people involved can help get at the real cause of the problem.

Overcoming resistance to change works best when it is tackled by the group affected by the change. One person, such as the manager or quality director, has little influence without the wholehearted cooperation of the others. The best way of obtaining such cooperation is to engage staff members in developing the improvement actions so they have ownership of the process changes and the results. If you can, separate the process change ideas from the improvement project. Try to make them the property of the group expected to adopt the changes.

The success of any process improvement or change initiative depends on the extent to which employees view it as legitimate and likely to be beneficial. All improvements have associated benefits but some of these benefits may not personally affect staff members. For instance, complying with Joint Commission standards has value for the organization. This value may not be readily apparent to the people being asked to implement changes required by the standards. Some process changes, such as externally imposed mandates, require a certain degree of trust on the part of staff. In some situations it may not be possible to obtain group buy-in for a change. In these circumstances, managers must create pressure — by holding people accountable — to ensure that required tasks or behaviors are adopted.

When faced with a failed improvement project, it can seem that staff members have irrational motives for not implementing the desired changes. Or perhaps it's just that people commonly reject anything that management wants to introduce. Yet there are often very logical reasons why people don't embrace the new behaviors. Use the check list in figure 1 to evaluate why a desired process change was not successful. Once the cause of failure is understood, alternative change strategies can be developed.