The ‘wicked problem’ of change management in healthcare organisations Australian Institute of Health Innovation Associate Professor David Greenfield 18

The ‘wicked problem’ of change management

in healthcare organisationsAustralian Institute of Health Innovation

Associate Professor David Greenfield

18 March 2014

http://www.isqua.org/home

Australian Institute of Health Innovation’s mission

Our mission is to enhance local, institutional and international health system decision-making through evidence; and use systems sciences and translational approaches to provide innovative, evidence-based solutions to specified health care delivery problems.

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The Centre for Clinical Governance Research

The Centre for Clinical Governance Research undertakes strategic research, evaluations and research-based projects of national and international standing with a core interest to investigate health sector issues of policy, culture, systems, governance and leadership.http://

www.aihi.unsw.edu.au/ccgr


What is a ‘wicked problem’?

What is a ‘super wicked problem’?

What is a ‘social mess’?



A wicked problem is a problem …

that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognise.

whose solution requires a great number of people to change their mindsets and behaviour.


The solution depends on how the problem is framed and vice-versa i.e., the problem definition depends on the solution.

Stakeholders have radically different world views and different frames for understanding the problem.

The constraints that the problem is subject to and the resources needed to solve it change over time.

The problem is never solved definitively.



Ten characteristics (Rittel and Webber, 1973)

1. There is no definitive formulation of a wicked problem.

2. Wicked problems have no stopping rule.3. Solutions to wicked problems are not true-or-false,

but good or bad.4. There is no immediate and no ultimate test of a

solution to a wicked problem.5. Every solution to a wicked problem is a "one-shot

operation"; because there is no opportunity to learn by trial and error, every attempt counts significantly.



6. Wicked problems do not have an enumerable (or an exhaustively describable) set of potential solutions, nor is there a well-described set of permissible operations that may be incorporated into the plan.

7. Every wicked problem is essentially unique.8. Every wicked problem can be considered to be a symptom

of another problem.9. The existence of a discrepancy representing a wicked

problem can be explained in numerous ways. The choice of explanation determines the nature of the problem's resolution.

10. Planner has no right to be wrong i.e., planners are liable for the consequences of the actions they generate.



What is a ‘super wicked problem’?

Super wicked problems have the following additional characteristics:

• Time is running out.• No central authority.• Those seeking to solve the problem are also

causing it.• Policies discount the future irrationally.

Levin, K., Cashore, B., Bernstein, S. and Auld, G. (2012) “Overcoming the tragedy of super wicked problems: constraining our future selves to ameliorate global climate change” Policy Sciences, 2012, 45:2, 123-152.


Complex problems as messes:

"Every problem interacts with other problems and is therefore part of a set of interrelated problems, a system of problems …. I choose to call such a system a mess.“ (Ackoff, XX)

‘Social messes’:• Consequences difficult to imagine;• Considerable uncertainty, ambiguity;• Great resistance to change; and,• Problem solver(s) out of contact with the problems and potential solutions. (Horn, 2001)



Another way of describing the issue is as a ‘social mess’ (Horn, 2001):

1. No unique “correct” view of the problem.2. Different views of the problem and contradictory

solutions.3. Most problems are connected to other problems.4. Data are often uncertain or missing.5. Multiple value conflicts.



Another way of describing the issue is as a ‘social mess’ (Horn, 2001):

6. Ideological and cultural constraints.7. Political constraints.8. Economic constraints.9. Often a-logical or illogical or multi-valued

thinking.10.Numerous possible intervention points.



Why is change management in healthcare organisations a ‘wicked

problem’?



problem’?

Change can be a wicked problem because

it is implemented primarily to improve

things, but can be exceedingly difficult to

complete successfully.



problem’?

Studies indicate that 70% or more of

organisational changes either fail to achieve

the desired results, fail altogether or make

things worse (Warrick, 2009;14).



problem’?

The messy organisational environment often leads to unforeseen issues and requires unplanned ‘emergent strategies’ (Stewart and O’Donnell, 2007; 240).

There appears to be a lack of understanding of how to successfully manage change, especially among top management (Warrick, 2009; 14).


Why is change management in healthcare

organisations a ‘wicked problem’?

Need a balance of involvment between executives, managers and frontline staff (Brunoro-Kadash and Kadash, 2013; McWilliams and Manochin, 2012; Saul et al, 2014; Stewart and O’Donnell, 2007).

Executives often desire to spend little time to attend to changes (Turner, 2013).


What are the change management approaches and their underlying

assumptions?


Kurt Lewin is credited with being a pioneer who investigated organisational change management.

• Change through learning• Forces: stability and change• Focus: team/ group level routines and

mindsets• Choice: engagement or resistance• Model: unfreezing – change - refreezing

Change management models


Complexity theory and organisations:

• Rethink hierarchy and control• Learn the art of managing and changing

contexts• Encourage experimentation, divergent

views• Self-organising processes of teams• Small changes to create large effects

(Burnes, 2004)



Lean and Six Sigma -

Two techniques which employ multidisciplinary teams to organise thinking about process improvement, formalise change strategies, actualise initiatives and measure progress.



Lean healthcare

Attitude of continuous improvement Value creation Unity of purpose Respect for front-line workers Visual tracking Flexible regimentation

(Toussaint and Berry, 2013)



Six Sigma

Define the problem within a process. Measure the defects. Analyse causes. Improve the process performance to

remove the causes. Control the process to make sure defects

do not recur.(Liberatore, 2013)



Cautionary note

• Evidence base lacking compared to the enthusiasm for it.

Significant gaps in the Lean and Six Sigma health care quality improvement literature and very weak evidence that either improve health care quality.

(Vest and Gamm, 2009; Holden, 2011; DelliFraine et al 2010, 2013; Liberatore, 2013

)




• Plan, do, study, act (PDSA). • Deming’s plan, do, measure, improve,

total quality management (TQM).• Realistic Evaluation (RE).• Releasing time to care (RTM). • Transforming care at the bedside (TCAB).

(Brunoro-Kadash & Kadash, 2013; 221)


What is your paradoxical role as a change manager ?


The paradoxical role of “change manager”

• Engage colleagues with the problem without making them feel that they have created or contributed to the problem (Baathe and Norback, 2013; 490-491; Saul et al, 2014; 22).

• Deal with the facts and emotions, i.e. social aspects (Stewart and O’Donnell, 2007; 241).



• Need a new mental model, but such models are ingrained (Anderson and McDaniel, 2000; 84).

• Scope and definition: balance the big-small (Stewart and O’Donnell, 2007; 239).

• Static and complex adaptive system perspective (Anderson and McDaniel, 2000; 86-87).



• Define problems, plan and implement change processes.

• Support the old while advocating for the new.

• Be precise about system problems, but flexible in your approach.

• Focus on structure, processes and outcomes.


What are the common dilemmas relating to change management?


Recognise common dilemmas

• Who’s right to lead change?

Education and/or positional attainment are inadequate criteria to equip future clinical leaders to take on the responsibilities to lead change (Gilbert et al, 2012; 237).



• Must adopt new mental models of health care organisations however mental models may be well ingrained or subconscious and thus difficult to change (Anderson and McDaniel, 2000; 84)

• Difficulty of how to measure or rate organisations when assessing the effectiveness of a change across various sites (Gerst, 2013; 206-207)



• The right balance of who to involve (Brunoro-Kadash and Kadash, 2001; 283).

• “Command and control thinking” (Gerst, 2013; 205-206).

• Cause is often confused with effect, leading to counterproductive actions (Gerst, 2013; 205-206).



• The ripple effect - altering one component can produce significant changes in another (Brunoro-Kadash and Kadash, 2013; 228).

• How to effectively allow for emergent, unforeseen issues (Stewart and O’Donnell, 2007; 239).


• How to create the best kind of training or preparation for the new system (Stewart and O’Donnell, 2007; 245-246).

• Social aspects must be managed: recognise that staff performance and feelings towards the management or their job may be altered by organisational changes (Stewart and O’Donnell, 2007; 245-246).



Strategies to maximise effective change management outcomes


Change management strategies

Five guiding principles:

• Clarity of purpose;• Alignment of effort;• Credibility of leadership;• Integrity of the organisation; and,• Accountability for performance.

(Saul, Best and Noel, 2014)


Change strategies which may assist in facilitating change within organisations:

• Engagement• Distributed leadership• Change champions• Accountability• Emergent issues• Culture



ENGAGEMENT• Engage staff at all levels (Brunoro-Kadash and Kadash, 2013;

McWilliams and Manochin, 2013; Saul et al, 2014).

• Barriers may need to be removed (Baathe and Norback, 2013; 491).

• Build trust (Baathe and Norback, 2013; 490-492).

• Improve organisational literacy (Baathe and Norback, 2013; 490-492).

• Employees may need to be informed that organisational development is part of their job (Baathe and Norback, 2013; 492).

• Professional practice and job satisfaction (Brunoro-Kadash and Kadash, 2013; 221).



DISTRIBUTED LEADERSHIP

• Enable distributed and/or localised leadership; provide balance to top down planning (Stewart and O’Donnell, 2007; 239).

• Incorporate the knowledge and experience of workers at different levels of the organisation (Anderson and McDaniel, 2000; 89).

• Remove the disconnect between frontline, managers and executive staff (Baathe and Norback, 2013; 491).



DISTRIBUTED LEADERSHIP• Facilitate better relationships between

staff (Baathe and Norback, 2013; Millward and Bryan, 2005; Stewart and O’Donnell, 2007).

• Effective leaders use a variety of leadership strategies: coercive, authoritative, affiliative, democratic, pacesetting and coaching, depending on the situation. Each of these styles derives from emotional intelligence. (Greenfield, 2007, 2009; Goleman, 2000; 78-80).



CHANGE CHAMPIONS• The creation of a new role, the ‘change

champion’ (Warrick, 2009; 14-15).

• Improved communication and information sharing during changes (Steward and O’Donnell, 2007; 240).

• Implementing leadership development programs (Gilbert et al, 2012; 236).



ACCOUNTABILITY

• Accountability in decision making and implementation (Brunoro-Kadash and Kadash, 2013; 228).

• Support can be increased through communication with staff (Caldwell, 2008; 132)

• Collective accountability for outcomes (Saul, Best and Noel, 2014).

• Facilitating the self-organisation process and harnessing structure according to need (Millward and Bryan, 2005; XIX).



EMERGENT ISSUES• Allow for emergent issues during the

changeover (Stewart and O’Donnell, 2007; 241).

• Problems are fluid, changeable and defined by the relationships between members (Anderson and McDaniel, 2000; 85-86).

• But need to keep the change goals clearly in sight.



CULTURE• Encourage a culture accepting of change

(Caldwell, et al, 2008; 132).

• Improvisational - structure balanced with flexibility - behaviour which enables innovation and creativity at all levels (Anderson and McDaniel, 2000; 89).



CULTURE• The culture of the organisation will affect

the success of implemented changes (Millward and Bryan, 2005; XVII).

• Encourage a learning environment (Anderson and McDaniel, 2000; 89; Stewart and O’Donnell, 2007; 240).

• Allow for real time learning (Anderson and McDaniel, 2000; 89).



“Consequences of a designated change in the health care system will not be possible to predict completely and that it is not possible to find a solution before trying it out. This lead to the growing understanding that the improvement of healthcare is an iterative process with no set solutions to be figured out before involving in the process.”

(Lindgren, Baathe and Dullve, 2012; 19)

Conclusion


Conclusion

“Change is a continuous process of improvement. It is the messy business of trying things out, running pilots, conducting informal field experiments and otherwise actively testing ideas to see how they work in the real world.”

(Gerst, 2013; 206)


Contact details

Associate Professor David Greenfield

Senior Research FellowCentre for Clinical Governance ResearchAustralian Institute of Health InnovationFaculty of MedicineUniversity of New South Wales

Email: [email protected]

mailto:[email protected]


References

Ackoff, R. (1974). Redesigning the Future. New York, Wiley.Anderson, R. and R. McDaniel (2000). "Managing health care organizations: where

professionalism mees complexity science." Health Care Management Review 25(1): 83-92.

Baathe, F. and L. Norback (2013). "Engaging physicians in orgnaisational improvement work." Journal of Health Organisation and Management 27(4): 479-497.

Brunoro-Kadash, C. and N. Kadash (2013). "Time to care: a patient-centered quality improvement strategy." Leadership in Health Services 26 (3): 220-231.

Burnes, B. (2004). "Kurt Lewin and complexity theories: back to the future?" Journal of Change Managemetn 4(4): 309-325.

Caldwell, D., J. Chatman, C. O'Reilly, M. Ormiston and M. Lapiz (2008). "Implementing strategis change in a health care system: the importance of leadership and change readiness." Health Care Management Review 33(2): 124-133.

DelliFraine, J. L., J. R. I. Langabeer and I. M. Nembhard (2010). "Assessing the Evidence of Six Sigma and Lean in the Health Care Industry." Quality Management in Healthcare 19(3): 211-225 210.1097/QMH.1090b1013e3181eb1140e.

DelliFraine, J. L., Z. Wang, D. McCaughey, J. R. I. Langabeer and C. O. Erwin (2013). "The Use of Six Sigma in Health Care Management: Are We Using It to Its Full Potential?" Quality Management in Healthcare 22(3): 210-223 210.1097/QMH.1090b1013e31829a31838e.


References

Gerst, R. (2013). "Deming's systems thinking and quality of healthcare services: a case study." Leadership in Health Services 26( 3): 204 - 219.

Gilbert, A., P. Hockey, R. Vaithianathan, N. Curzen and P. Lees (2012). "Perceptions of junior doctors in the NHS about their training: results of a regional questionnaire." BMJ Quality & Safety.

Goleman, D. (2000). "Leadership that gets results." Harvard Business Review March-April: 78-90.

Greenfield, D. (2007). "The enactment of dynamic leadership." Leadership in Health Services 20(3): 159-168.

Greenfield, D., J. Braithwaite, M. Pawsey, B. Johnston and M. Robinson (2009). "Distributed leadership to mobilise capacity for accreditation research." Journal of Health Organisation and Management 23(2): 255-267.

Holden, R. J. (2011). "Lean Thinking in Emergency Departments: A Critical Review." Annals of Emergency Medicine 57(3): 265-278.

Horn, R. (2001). Knowledge mapping for complex social messes. Foundations in the Knowledge Economy, Stanford University.

Levin, K., B. Cashore, S. Bernstein and G. Auld (2012). "Overcoming the tragedy of super wicked problems: constraining our future selves to ameliorate global climate change." Policy Sciences 45(2): 123-152.

Liberatore, M. (2013). "Six Sigma in healthcare delivery." International Journal of Health Care Quality Assurance 26(7): 601-626.


References

Lindgren, Å., F. Bååthe and L. Dellve (2013). "Why risk professional fulfilment: a grounded theory of physician engagement in healthcare development." The International Journal of Health Planning and Management 28(2): e138-e157.

McWilliams, C. and M. Manochin (2013). "Engaging junior doctors: evidence from "open spaces" in England." Journal of Health Organisation and Management 27(4): 520-526.

Millward, L. and K. Bryan (2005). "Clinical leadership in health care: a position statement." Leadership in Health Services 18(2): xiii-xxv.

Rittel, H. and M. Webber (1973). "Dilemmas in a general theory of planning." Policy Sciences 4: 155-169.

Saul, J., A. Best and K. Noel (2014). "Implementing leadership in healthcare: guiding principles and a new mindset." Essays.

Stewart, J. and M. O'Donnell (2007). "Implementing change in a public agency: leadership, learning and organisational resilience." International Journal of Public Sector Management 20(3): 239-251.

Toussaint, J. and L. Berry (2013). "The promise of lean in health care." Mayo Clinic Proceedings 88(1): 74-82.

Vest, J. and L. Gamm (2009). "A critical review of the research literature on Six Sigma, Lean and StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare." Implementation Science 4: 35.

Warrick, D. (2009). "Developing organisational change champions: a high payff investment!" OD Practitioner 41(1): 14-19.


Documents

The ‘wicked problem’ of change management in healthcare organisations Australian Institute of Health Innovation Associate Professor David Greenfield 18