Leading Through Rapid Change Management

Approaching Catastrophic Change

Pharmacy leaders are routinely faced with issues of change management. ¹ Incremental change is most often driven by a changing practice guideline while major change is most often indicated with updates in automation, staffing models, or service lines. Many change management theories revolve around incremental change with a deliberate step-by-step process. ² For example, Kurt Lewin, one of the early pioneers of change management modeling, describes his Theory of Planned Change in 3 steps: (1) unfreezing—identifying a need to change status quo; (2) change; and (3) refreezing—reinforcing the new process. ³ Increasingly pharmacy leaders are being faced with circumstances requiring rapid change. The authors of the American Society of Health-System Pharmacists (ASHP) research and Education Foundation’s Pharmacy Forecast 2020 even devoted a section on “black swan” events, the concept of an unlikely event that has massive consequences. ⁴ The COVID-19 pandemic is the latest example of a black swan event that stimulated rapid change management across the pharmacy community.

Lewin’s model provides a framework for addressing rapid change. Lewin’s first step, unfreezing, can be reframed as unlearning a long-established process rendered both ineffective and irrelevant due to a black swan event. Rapid situational assessment, open communication with all stakeholders, and creative thinking is required when faced with such an event. Creative thinking requires the leader to break away from the status quo and be open to novel approaches to address an unstable or rapidly changing situation. Open communication and empowering staff to offer ideas are essential to developing novel solutions and obtaining stakeholder buy-in simultaneously. Because of the rapid change required for dealing with a black swan event, failure is to be expected. Frequent reassessment and readjustment of a change will help frame failure as a learning tool and keep stakeholders engaged. Some recent examples of rapid change management are described below.

Increasing Revenue and Decreasing Spend

Rapid change often involves finding ways to produce new revenue streams or decrease overall spend. Pharmacy leaders have been successful in doing just that in creating new services such as in-house specialty pharmacy. When ASHP wrote their resource guide for specialty pharmacy in 2015, they “anticipated that by 2020 specialty pharmaceuticals will represent 50% of all US drug expenditures for only 2% to 4% of the population.” ⁵ Specialty pharmacy draws the attention of providers, pharmacy, payers, and patients for a number of reasons. Implementing this service often results in higher adherence rates, an easier to manage reimbursement system, and an overall increase in patient satisfaction. Such a build allows for dispensing of specialty medication in house, improved patient care management, as well as increased revenue. ⁶

The shift away from the traditional fee-for-service model to value-based reimbursement embodies a significant transformation in healthcare. Pharmacy leaders need to adapt rapidly to this shift as pharmacists play a pivotal role in achieving best medication use and adherence outcomes. Leaders should disperse pharmacists throughout their practice (ie, ambulatory, transitions of care, retail, etc.) to provide an array of services including monitoring, counseling, and medication therapy management to enhance quality of care. Moreover, pharmacists can coordinate patient care, preventing future hospital admissions and improving overall outcomes. ⁷

Another example of a rapidly growing landscape is the infusion space, prompting pharmacy leaders to carve out ways to provide these services in the most cost-effective way to their patients. For many, this means opening infusion centers for outpatients to gain reimbursement from commercial payers for high cost infusions. Such treatment centers are an ideal location for a wide variety of infusion services ranging from antibiotic therapy to oncology treatment plans. There are numerous benefits to provision of these services including but not limited to expedited care transitions from the hospital to an outpatient setting, which is a considerable patient satisfier. ⁸

Restructuring Models and Ensuring Safety

Rapid change forces pharmacy leaders to rethink staffing models to promote physical distancing and address quarantining of staff. When assessing the pharmacy practice model for potential restructuring, leaders should consider redesigning staffing hours to allow sufficient overlap in coverage based on patient census. Use of objective data such as pharmacist workload from orders verified or consults is helpful in determining staffing ratios. Additionally, it is prudent to have contingency plans for situations where staff is short to ensure responsibilities are redistributed appropriately. In emergency situations, pharmacy residents and leaders should also be utilized to expand coverage or allow for primary role reassignment. ⁹ Moreover, it is important to evaluate what duties and responsibilities may need to be temporarily halted. For example, reduction in in-person rounding was reported to be a common staffing change to mitigate pandemic pressures. ¹⁰

To best accommodate staff safety, pharmacy leaders must create novel workflows. First, rapid change can affect the way workspace is utilized, which can be challenging when it is already limited. To communicate such alterations, leaders should use technology to maintain consistent and easy-to-access updates. There are now several virtual platforms readily available for communication and holding of team huddles, departmental meetings, and educational sessions. Next, leaders should consider leveraging remote IT clinical system access to augment staffing models. One such site described a 2-week rotation in staffing model amid the pandemic, alternating between on-site and off-site. ¹¹ The off-site staff completed tasks such as order verification and consults, while on-site staff were responsible for emergency response and product checking. In cases of decreased census, leaders should attempt reducing staff to correlate with current patient volume to further reduce financial burden.

While a phased approach has been suggested to ensure essential resources remain accessible to staff in the context of the pandemic, these strategies are applicable to other scenarios requiring rapid change management. This is particularly important when anticipating new or recurrent surges in patient census. Regardless of which approach is used for addressing the need for rapid staffing modification, technology and creativity are valuable assets.

Promoting Well-Being and Resilience

Pharmacy leaders have the duty to disseminate information regularly and recurrently on managing stress, reducing burnout, and identifying available professional mental health assistance. Such communication should include effective, convenient, accessible, affordable, and confidential resources. ¹² They should also incorporate treatment approaches used to address burnout among health care professionals including meditation, breath work, relaxation techniques, mindfulness training, and cognitive-behavioral therapy. ² Leaders should also foster spiritual resilience through distribution of positive messaging that emphasizes appreciation for personnel’s dedication and altruism. Disseminating strategies for focusing on success and gratitude, as opposed to failure and anxiety, will help in embodying happiness amidst uncertainty. Furthermore, providing guidance as to how to recognize what is and what is not under an individual’s control allows for balance between expectation and reality. ¹³

Leaders also have the responsibility to encourage others in openly discussing vulnerability and the importance of protecting one’s psychological resilience. ¹ Healthcare professionals are notorious for not seeking assistance when they are experiencing burnout due to discretion concerns and the associated stigma. ¹⁴ Individuals who are repeatedly “occupied” or “inaccessible” during these discussions should be given separate consideration as avoidance behavior is a key indicator of significant distress. Therefore, leaders must be cognizant of staff who are easily and overly distressed to provide them personalized support. If an individual’s suffering is severe and/or unwavering, he or she should be referred for professional mental health support. ¹⁵

Though evidence shows that having a supportive leader protects your mental health, leaders are human as well. Accordingly, leaders with seniority should keep a pulse on how individuals with less experience are managing by checking in with them more frequently. ⁵ Assessing concerns, fears, and stress points is useful to inform leaders and provide insight on specific areas requiring attention. Development and implementation of plans for cross training and rotating roles among administration will assist in preventing leader burnout. Leaders should prioritize reflection on and learning from the incredible experiences to create a grateful rather than traumatic narrative. ¹⁶ This practice will provide greater appreciation, stronger relationships, increased compassion, new opportunities, and enhanced development. ¹²