Changing how we think about change: How healthcare leaders can create a progressive culture


Mark Graban

President, Constancy, Inc
Author, Lean Hospitals & Lean Blog


Too often, I hear healthcare leaders complain that staff or other managers are “resistant to change.”

A phrase like this points the finger of blame, usually unfairly. Assigning blame isn’t the best way to improve healthcare safety and quality of care, and it’s clear that labeling people isn’t the best strategy for effecting change in an organization either. When a point of view is dismissed as general resistance, an opportunity is missed to understand the real, underlying issues.

Lean thinking and modern change management approaches point us down a better, more productive path toward change and improvement. Healthcare is experiencing massive change that requires leaders to be responsive and adaptive when faced with new constraints, demands, and challenges, such as the shift from fee-for-service to value-based reimbursement.

Rethinking resistance

“Resistance to change” shows up at all levels of an organization. And whether it’s resistance to new management practices or to new technology, it can be a frustrating barrier to overcome. For example, in a recent Cardinal Health survey, more than one-third of hospital service line leaders cited difficulty securing buy-in as a barrier to implementing new automated inventory management solutions.
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In most cases, the so-called resistance has an underlying cause, and Lean teaches us to seek out the root cause of resistance and ask “why?” When we approach “resistance” as a problem to solve, rather than demanding that people get on board, we can make real progress.

It starts with an effort to understand what’s behind the resistance. We can ask questions such as:

  • Does the person disagree with the change for a valid reason?
  • What do they know about the situation that the person proposing the change doesn’t know?
  • Does the resistor have input that would tweak the change to make it even better?
  • Do they have an alternative solution that should be considered?
  • Should that person have been given more input earlier in the process?
  • Is it possible that the resistor doesn’t understand the change, putting the impetus on the leader to better explain what will actually change and why?

When asking these questions, it’s important to embrace a Lean leadership style, one in which leaders aren’t top-down, command-and-control decision makers but, rather, collaborative coaches.

Talking about change

It’s ironic when leaders and change agents complain about a lack of buy-in when they’re not putting enough effort into selling their ideas to others.

It’s only natural that employees might get defensive when their leaders push change on them without getting their input. Without seeking employees’ opinions, even proven best practices like electronic medical records, hourly rounding, and automated inventory management systems may pose legitimate challenges.

Better change leadership includes working with people earlier in the process to:

  • Gain agreement that there is a problem to be solved
  • Gain agreement that the problem can be solved (or made better)
  • Gain agreement that we can solve the problem here
  • Gain agreement that a potential solution is worth testing

For example, instead of forcing a solution like daily team huddles, can you first get agreement that something needs to change? If people say, “There’s no problem here,” then you have little chance to get agreement on any solution, no matter how valid. A good strategy might be to help a team brainstorm opportunities for improvement. For instance, the group could develop a list of communication challenges within a team that cause delays in patient care or discharges. Once a team agrees there’s a problem to be solved, they’re more likely to ask for help and participate in the improvement process, which includes being more willing to talk about solutions.

Getting past “good enough”

Many change initiatives get derailed when employees agree that there is a problem, but they believe it’s unsolvable or that “the way it’s always been” is “the way it has to be.” Staff know they face common barriers to change, such as running out of supplies, difficulty getting into locked automated cabinets, and items expiring because they were overstocked or not rotated properly. The team might think those situations are normal and that’s just the way it’s always going to be.

A leader needs to help people understand that the situation can be made better and that improvement is possible. Using case studies or examples from other organizations can help build confidence that things can be improved.

If the team is not confident that they can successfully implement something, like an enterprise wide automated inventory management system, then leaders should build up their teams’ confidence by starting first with smaller improvements that solve smaller problems in an effort to prove the value of a larger solution.

Starting small is a classic strategy for “Kaizen” – the Japanese strategy of making collective, continuous incremental improvements – and it’s one reason that many teams often start with “5S”(a method for waste reduction through workplace organization ) as an initial Lean strategy because it’s relatively simple and can make a surprisingly big impact.

Make the change

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Once there is agreement that there’s a problem, that it’s a solvable problem, and that we can likely solve it, then it’s time to talk about possible solutions – or “countermeasures,” as we tend to say in the Lean approach. Getting input and discussing different possible approaches takes time, but it builds the necessary buy-in that makes change more likely to succeed and to be sustained.

Lean thinking encourages hypotheses, experimentation, and learning by doing, instead of "knowing the right answer" or solution. Organizations need to be flexible and adjust as they pilot and implement a change instead of just marching forward with a pre-determined solution, even if that solution is a best practice.

Following the " Plan Do Study Adjust" (PDSA) model, and engaging staff and managers in all phases of this process, is a more effective change strategy than what organizations often do out of habit: "Plan Do" or just "Do Do Do." Each proposed change should be a hypothesis that predicts, "If we do this, then we will get that result."

Once we form a hypothesis that a new solution or technology will be helpful, such as a KanBan system or radio frequency identification (RFID) tracking for key supplies, start small and enact the change in one department or area. Too many organizations struggle with change because they attempt to roll out a new process or technology everywhere, all at once. When we do this, any hiccups are magnified, which can lead to another form of resistance: "See, we tried that, and it didn't work."

Make it stick

Successful change involves engaging employees in defining the problem, understanding its causes, and choosing a countermeasure to test. The employee engagement continues as we work with them to “study” and evaluate the impact of the change. Did we get the results we predicted? Were there any side effects or other surprises? Does our data and subjective analysis conclude that we should adopt, adapt, or abandon what we’ve tried? 

When we start with a pilot, we minimize our risk of failure. Hardly anything ever goes perfectly, even with a good understanding of a problem and a reasonable improvement hypothesis being in place. When we “Plan and Do” on a small scale, we can learn from our early attempts, and then “Study and Adjust” accordingly.

Despite best efforts, others may still be reluctant to embrace change. But over the past 12 years in healthcare, I’ve observed that following these strategies can help create more buy-in. This leads to faster and more successful improvements. We eventually reach the point where we stop talking about resistance and focus instead on the problems we just haven’t solved yet. That’s the spirit of Lean and continuous improvement in a nutshell.

Disclaimer: This content is sponsored by Cardinal Health. Mark Graban received compensation from Cardinal Health for participating in this educational program.