How to Implement Change in Practice

Abstract

Learn what it takes to overcome the status quo and implement change because stagnation can jeopardize the future of your practice.

Introduction

Do changes introduced in your practice go nowhere, bogged down by negativism, distractions, disinterest, or even active resistance? Are new ideas smothered by a culture of complacency and inertia? It is worth your while to find out what it takes to overcome the status quo and implement change, because stagnation can jeopardize the future of your practice. The ability to change is crucial to the success of any organization and has never been more important than it is in today's changing oncology practice environment.

The Essential Underpinnings of Change

Certain elements must be in place in an organization for change to take hold: an agreed-on direction for the practice, a functional and effective leadership structure, and a culture that promotes and rewards change.

Shared Vision

Any idea for change should fit into an established direction regarding where the practice is headed. If your practice has not yet engaged in strategic planning, including developing a vision statement, start there. (see “Strategic Planning: Why it Makes a Difference and How to Do It,” an earlier article in the Strategies for Career Success series.)¹ The very process of articulating a vision and a strategic direction for the practice encourages input from all of the practice decision makers and allows divergent perspectives to be aired and addressed in order to reach consensus. The resulting vision should be communicated to everyone in the practice and continually reinforced to foster a culture that is ready for the changes needed to move toward the vision.

Effective Leadership

In addition to a shared vision, effective leadership is needed for change to be successful. “The key to transformational change or any change is to have leadership that is able to understand it, support it, explain it, and move the organization to commit to it. That is 95% of the success of any change,” says Nick A. Fabrizio, PhD, a practice management consultant with the Medical Group Management Association (Englewood, CO).

Radiation oncologist David Fryefield, MD, medical director at Willamette Valley Cancer Institute (Eugene, OR), agrees, describing a leader as “someone who is willing to say ‘yes, I'm going to do what is necessary to lead,’ which includes knowing how to build consensus, what to communicate, and what decisions to make independently. It's a daunting task.”

On the flip side of the requirement for a leader is the need for followers. “Among physicians, follower is a word that suggests a certain weakness, but we shouldn't look at it that way,” says Fryefield. “If everyone tries to be a leader, the organization isn't going to go anywhere. The role of followers is really a position of strength, involving elements of trust—letting go of a certain amount of control.” An appropriate leadership structure, including a leader and physicians who are committed to the vision and willing to support it, is key to transformative change. All of the physicians in the practice need to be team players, including taking responsibility for the entire practice and being willing to recognize the leader's authority.

Organizational Culture Supporting Change

Although full schedules, distracting events, fear of change, and apathy are obstacles to change, the real enemy of change is complacency. “Having the will to change is critical,” says consultant Fabrizio. “Do [the practice leaders] have the willpower to push change through? If not, stop right there.”

Even groups that seek change may be complacent and not committed to follow through. That was the situation encountered by a practice administrator we'll call Joyce Mills, who was recruited to “fix problems” in an eight-physician oncology practice in the Midwest. She noted that “the single biggest obstacle to change in the practice was that both the physicians and the staff were comfortable with not changing.” A practice that is ready for change has a culture that looks for ways to improve and promotes and supports ways to enhance quality, patient care, and efficiency.

Creating a Readiness to Change

In shifting from a culture that is satisfied with the status quo to one that is ready to change, the “fire in the belly” needed to bring about change has to start at the top. The physicians are central. Because they set the tone for the practice, the practice will not be ready to change until they are ready.

If the physicians in your practice seem mired in inertia, providing information is one way to increase the group's desire to change. “Data is incredibly powerful, especially for physicians,” says Fryefield. “Measure everything you can think of, and use that data to help drive change.”

When she was brought into the practice as a change agent, Mills found the physicians “believed that all the needed changes were at the staff level.” The practice's referral base was one of the areas in which she provided information to cultivate a readiness to change. She gathered data from the practice's referring doctors about the oncologists they referred to. Physicians in her practice had believed, in the absence of data, that their referral base sent patients exclusively to their practice. But the facts proved otherwise. After seeing the data about their referring doctors, the oncologists realized that they needed to do some face-to-face marketing, Mills says.

“Asking your patients and referring physicians what they think of you can also identify needed changes,” Fryefield notes. “That defines pretty clearly—sometimes painfully clearly—what you need to change.” You can gather information by inviting patients to focus groups as well as by using ongoing surveys. Fryefield suggests monthly patient surveys rather than occasional ones.

Benchmarking data that compare your practice's performance on key practice indicators to those of other oncology practices also provides information that can encourage a readiness for change.^2,3

Dealing With Resisters

Once you suggest a change, identify those who are for and against it. “Find out who will be on board and support the initiative, who are the naysayers, and also who will say they support it but in fact will undermine it,” says Fabrizio. Mills agrees and advises approaching them immediately.

Resistance to change is normal and should be expected, according to Ana-Elena Jensen, PhD, a practice enhancement facilitator with TransforMED (Leawood, KS), a subsidiary of the American Academy of Family Physicians. “Resistance to change usually comes from fear, on one of three levels—what will happen to me in my world, how will my relations to my colleagues change, or how will our practice and our patients be affected,” she explains.

Fryefield also says fear of change often underlies resistance. “You really have to be sensitive to the effects of change on the people who will be affected,” he comments. “People are good at their job and know what to expect. If you give them a situation where they don't know what to expect, they do become afraid, but they don't express it that way. Instead, they say it's not a good idea or we can't do that.”

In some cases, the naysayers may not be open about it. “You have to actively listen,” Mills says. “Sometime you hear them say yes, but their body language is saying something else.” If you suspect someone is a resister, Jensen suggests sitting down with that person to talk about their concerns, rather than have their opposition be a hidden distraction. “Find out why they are resisting and what they would recommend,” she says. “They may have very valid reasons that can lead to innovations in the practice.”

One way to address fears is to show individuals how the change is going to help them do their jobs more effectively or how it supports the direction of the practice. Another tactic is to initiate the change on a trial basis. Let everyone know that after a set period of time, such as 3 months, the pros and cons of the change will be assessed.

But some individuals may continue to resist change despite efforts to win them over. Their pessimism and low morale can have a toxic effect on the changes being implemented.⁴ “If people who are not on the bus are retained, that's bad,” says Fabrizio. “Individuals who are going to undermine the program have got to go.”

Implementing Change

Communicate

Frequent and effective communication is especially important during change, because so much is going on. “Communicate at strategic, operational, and individual levels,” Jensen says.

When launching a transformative change, Jensen suggests developing a plan for who needs to know, when they need to know, and in what manner. “Communicate the who, what, where, why, and how of the change. Start with the overview—the strategic reasons for the change. Communicate the vision of what's going to happen, how individuals will be involved, what is expected from them and their team, and why it is important to the practice and the patients. In the absence of communication, people will fill the vacuum with inaccurate information and often start talking with each other and creating assumptions that are not true.”

Jensen emphasizes that providing the opportunity for the staff members to give their perspective is highly important. “In staff meetings, solicit concerns, questions, clarifications, and suggestions. Then, take them into account.”

Use every medium at your disposal to tell people about the change. Meet with people one on one as well as in groups. Use e-mail, the practice intranet, and break-room bulletin boards. “You can't say something once and think that everybody gets it,” says Fryefield. “If you've said it 15 times, say it 16 times.”

Foster a Team Culture

In managing a change process, the participation of those who will have to change is essential. Consciously work on developing a team culture, in which everyone works toward a common goal. The vision of the practice and the objectives of specific changes should be clearly articulated. Developing and nurturing a team culture is an ongoing process that is founded on a climate of trust and mutual respect.

Set clear expectations. Individuals should know what is expected of them, should understand the roles of others, and should have a sense of shared accountability. Empower individuals to work toward the goal in their own job, in addition to contributing ideas for the team as a whole. Invite team members to indicate areas in which they would like to take initiative. “They need to see the vision for the future and what they can contribute,” Jensen says.

Identify and Empower Champions

All changes need visible champions who are committed to the goal and can lead others. “The practice leaders may know of individuals with natural leadership skills among the staff, people who will do a great job of convincing their peers,” Jensen says. She suggests creating a change team around a certain process and having individuals lead their peers in that effort. “Empower them with your support, and give them tools and resources needed to do the job.”

Provide Feedback and Positive Reinforcement

Individuals want to know how they are doing and whether their efforts have made a difference. Just as you used data initially to foster change readiness, continue to use it to document progress and reinforce new behaviors. For some change activities, daily or weekly reports of results might be called for, whereas for others, such as a report of the number of medical records converted to a new system or average patient waiting times, a monthly report might be appropriate.

External data also provide credible feedback that helps sustain change. Find out what your patients and referring physicians think about the changes you are making and give that information to both physicians and staff.

Take the lead in encouraging others and praising individuals who do well. Acknowledge people's efforts in the change process and thank individuals for their contributions to the success of the practice. Celebrate milestones and successes to foster team cohesion and sustain change efforts. As Fryefield points out, “successful change comes when everyone thinks the change is their idea.”

Additional Resources

• Collins JC: Good to Great: Why Some Companies Make the Leap … and Others Don't. New York: HarperCollins Publishers, 2001

• Nelson B: 1001 Ways to Reward Employees. New York: Workman Publishing, 2005

• Silversin J, Kornacki MJ: Leading Physicians Through Change: How to Achieve and Sustain Results. Tampa, FL, American College of Physician Executives, 2000

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

Author Contributions

Conception and design: Dean Gesme, Marian Wiseman

Administrative support: Marian Wiseman

Provision of study materials or patients: Dean Gesme, Marian Wiseman

Collection and assembly of data: Marian Wiseman

Manuscript writing: Marian Wiseman

Final approval of manuscript: Dean Gesme, Marian Wiseman