Launching and Leading Change Initiatives in Health Care Organizations: Managing Successful Projects

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Copyright © 2014 by David A. Shore. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Shore, David A., author.

Launching and leading change initiatives in health care organizations: managing successful projects / David A. Shore.—First edition.

David A. Shore.—First edition.

p.; cm.

Includes bibliographical references and index.

ISBN 978-1-118-09914-8 (cloth)—ISBN 978-1-118-41892-5 (pdf)—ISBN 978-1-118-41598-6 (epub)

I. Title.

[DNLM: 1. Health Services Administration. 2. Organizational Innovation. 3. Planning Techniques. 4. Program Development. W 84.1]

RA971

362.1068—dc23

2013047962

List of Figures and Tables

Figures

Figure 2.1: Project Accuracy/Quality Matrix

Figure 2.2: The Knowledge Curve

Figure 2.3: Risk Probability and Impact Matrix

Figure 4.1: Strategic Planning and Initiatives

Figure 5.1: Initial Project Evaluation Criteria

Figure 5.2: Prioritization PICK Chart

Figure 5.3: Project Portfolio Bubble Chart

Figure 6.1: Four Domains of Trust Building

Figure 7.1: Core Project Stakeholders

Figure 8.1: Gung Ho Onboarding Continuum

Tables

Table 2.1: Project Resolution History

Table 7.1: Project Sponsor Classification

To my parents, Ruth and Milton Shore, who embody every positive quality described in this book

Preface

ANY ORGANIZATION primarily does two things. It conducts its regular business. It also changes that business from time to time. In other words, its activities consist of operations and innovation. Leaders must always strike a balance between the two. Nevertheless, when an organization's environment is changing rapidly, it must innovate a lot. That is the situation health care organizations find themselves in today. If you are in health care, as the saying goes, you are seeing change.

How do organizations innovate? They launch initiatives. Change events. Projects. The vocabulary differs from one organization to another. Health care professionals will have no difficulty knowing what I am talking about, whatever the terminology. Something is changing pretty much all the time. Whatever it is, there's a team working on it.

As part of my work—beginning at the Harvard School of Public Health and continuing in other contexts—I developed a program on launching and managing projects. My colleagues and I have taught this program in numerous health care systems and in countries around the world. I have also taught seminars to professional associations, to conference groups, and in other settings. Every time we conduct the program, I make a point of asking the attendees to list some of the initiatives and projects they are involved in, and the list always astonishes me. One participant was trying to speed up turnaround time at his hospital's lab. Another was hoping to improve linen-loss management. A third was involved in creating a new Pain Management Center. Another was working on replacing the organization's financial system. The initiatives are big, small, and every size in between. They are long term and short term. They are in various stages of completion. Most of all, they are numerous. When I ask participants how many projects they themselves are involved in, the answers typically range from six to twelve.

It is not surprising that projects have proliferated so widely in health care, given that the sector is evolving so quickly. New technologies appear regularly. Cost pressures are intensifying. All of health care's many stakeholders—patients, clinicians, administrators, payers, regulators, and so on—want to see improvements. The recent reform law in the United States, the Patient Protection and Affordable Care Act, popularly known as Obamacare, has already begun to affect health care organizations. For example, the act calls for more accountable care organizations (ACOs) and provides incentives for their creation. As a result, hospital systems, physician practices, and insurance networks all around the country are launching projects to turn themselves into ACOs. Like any change initiative, the movement toward ACOs can be thought of as an uncertain, risk-bearing experiment. Organizations have options in regard to their participation in the ACO program, however, with the classic option offering less risk and less potential reward, and the premier option offering more of both. This trade-off between risk and reward applies to many projects, not just ACOs.

It is essential for every stakeholder that well-conceived projects accomplish their objectives. Any change initiative's goal, after all, is to improve things, and health care badly needs improvement. Unfortunately, the failure rate of health care projects is high. Some projects crash and burn. Others peter out and are abandoned. Still others linger on indefinitely, never quite achieving their goals but never quite dying, either. I will offer some statistics about failure rates later in the book, but for the moment consult your own experience. Of all the projects you have been involved in, how many failed? How many are in trouble right now? Few of the leaders I speak with in the sector can answer none to either question.

Projects fail, of course, for many reasons. But my research and experience suggest one underlying malady that has infected nearly every dead or dying project: a poor launch. Whatever the specifics of an ailing project's diagnosis, the trouble was almost always built in from the beginning.

In noting the importance of a project's inception, I find that I have considerable support among the world's great thinkers. Success depends upon previous preparation, said Confucius; Without such preparation there is sure to be failure. Plato put it only slightly differently: The beginning is the most important part of the work. An African proverb says, If you want to know the end, look to the beginning. It has even been noted that Barack Obama, in implementing health care reform, would do well to heed the advice of the only other U.S. president to hail from the state of Illinois. Give me six hours to chop down a tree, said Abraham Lincoln, and I will spend the first four sharpening the axe.

Stephen R. Covey, the best-selling author of such books as The 7 Habits of Highly Effective People, elaborated on Lincoln's notion with a homely anecdote. A man walks to work and sees another man sawing a tree. On his way home from work, the same man is still sawing the same tree. The first man asks, Have you thought of sharpening your saw? The sawyer replies, I don't have time to sharpen my saw. I am too busy sawing this tree.¹

Where change initiatives are concerned, sharpening the saw—or the axe—is the difference that makes the difference.

To be sure, there are plenty of people in the business world who would discount the importance of spending so much time getting ready. Ready, fire, aim has become a mantra for many action-oriented managers—or, as Nike says, Just Do It.² That may work in an Internet-based business such as Facebook, where product engineers can put something up on the website to see if it has the desired effect, and then make a change if it doesn't. But the approach doesn't work in health care. Too much is at stake. Errors are too costly, in lives as well as in resources. Besides, the evidence for the importance of good first-mile preparation is overwhelming. If I were to add an aphorism of my own, it might be this: Initiatives don't end poorly—they begin poorly. Or maybe this: With projects, the end depends on the beginning. Certainly the importance of a good launch resonates with the people in health care organizations who are actually involved in projects. One group of program participants, who happened to be in Illinois, presented me with a framed copy of Lincoln's quote about sharpening the axe. That, they said, was the single most important idea they took away from our several days together.

Who Should Read This Book

Anyone who leads or manages a health care initiative will benefit from this book. The book will also greatly benefit those who serve on project implementation teams. I say that with some assurance because so many of my students, executive education program participants, and clients have told me that they find the ideas and methodologies helpful. These students and professionals come from diverse roles in health care. They are physicians, nurses, and therapists. They are managers and administrators. Many are senior executives.

The people in this last group, senior leaders, have a special responsibility for starting projects right. If they don't provide the necessary support, it will be hard for even the best-intentioned project manager to achieve the hoped-for results. This is a lesson any of us could learn from W. Edwards Deming, the famous apostle of manufacturing quality, who died in 1993 at the age of ninety-three.

In the mid-1980s, Toyota was making serious dents in the market share of Detroit's Big Three—General Motors, Ford, and Chrysler. The Japanese company's chief advantage lay in its exceptional manufacturing quality. Toyotas didn't break down as often as other cars. They lasted longer. Their fit and finish, to use the auto industry's term, was far better. Deming had tried to interest U.S. automakers in his ideas about quality decades earlier, but had received a chilly reception. He ended up spending much of his working life in Japan, teaching quality principles to Toyota and other Japanese manufacturers.

Donald Petersen, who was chief executive of Ford from 1985 to 1989, watched an NBC special on Deming one night. As the story goes, he called his head of quality (who had never heard of Deming) and said, We have to get this guy in here. Deming agreed to come on one condition: that Ford's top thirty leaders participate in his first seminar.³

With all the leaders gathered, Deming began his presentation. About halfway through, Petersen's secretary came in and handed him a note. Petersen left the meeting. Deming promptly took a chair and sat down. People in the audience assumed he must be tired—after all, he was already an elderly man. But fatigue wasn't the issue. Deming said to the group, If Mr. Petersen has something more important than quality to attend to, don't you think we should wait for him? After that, nobody left the room. Senior leaders in health care would do well to translate this lesson to the context of change management in health care.

Health care projects depend on astute management of change. But more than anything else, they depend on leaders who pay attention, who understand the importance of starting right, and who know how to launch projects that succeed. That is why I am hopeful that senior leaders of every sort of health care organization will read this book and take its lessons to heart. If leaders can increase the percentage of successful projects, patients and practitioners everywhere will be better off. So will the organizations that depend on these projects for innovation. As will the leaders themselves, for they will be accomplishing their goals rather than running down perpetual blind alleys.

Part 1 of this book lays the groundwork for my method. It looks at health care through the lens of change initiatives and thus managing change. It examines the fundamentals of these initiatives and outlines the criteria for success and failure. It explores what an organization must put in place if its projects are to get off the ground during that essential first mile.

Part 2 focuses on selecting the right projects, which is one of the two most important tasks of the first mile. Most health care organizations have scores of projects under way at the same time. It's a sort of spray-and-pray approach: if we try enough initiatives, maybe some will work out. I argue for a far more systematic method of selecting and supporting projects. It is not that I expect every one to succeed; the world is too uncertain for that. But I do want every project to be scrutinized, and then supported if it passes scrutiny. The chapters in this part offer a set of tools with which organizations can assess, approve, and set priorities for their portfolio of projects—and then review the projects as they proceed to see how well they are doing.

Part 3 dives into the other essential task of the first mile: choosing the right people. At many organizations, the same twenty or thirty or forty people always seem to wind up on project teams. They are the people leaders think of in connection with change. They are the ones who say, Yes, sure, I can do that, rather than Sorry, I'm too busy. The result is that this group of well-meaning, overworked individuals can't possibly devote the time required by all of their