As you’ve gleaned from the title of this blog post, today we are focusing our conversation on CHANGE; with a particular emphasis on its implications in healthcare.

However, before we get deep in the weeds, it’s important that we acknowledge the elephant in the room; CHANGE is HARD

I suspect that most of you reading this post, have a basic understanding of the physiology behind emotions. And this understanding is important, because CHANGE is EMOTIONAL. We can thank your tiny central organ friend called the amgydala for contributing to making CHANGE so difficult. Reacting to sensory inputs, producing neurotransmitters and influencing our emotional and physiological responses, our amygdala adjusts to lived experiences to amplify our reactions. What we’ve learned throughout our lifetimes this far, is that CHANGE is EMOTIONAL, CHANGE is HARD, all because it forces us outside of our comfort zone, and places us in a vulnerable situation. 

When presenting the content of this blog post to our Staff and Resident’s of the Ottawa Hospital DEM, we did a poll on which emotions stood out to the audience members when they first heard the word CHANGE. The results were quite striking: 

% Response
Negative Emotions

[Fear, Worry, Anger, Doubt, Apprehension, Exasperation, Anxiety, Confusion, Uncertainty]

 

80%

Positive Emotions

[Excitement, Challenged, Curious, Elation, Joy, Eager]

 

20%

The innate reaction of the large majority attending this presentation in person was to associate a negative emotion to the simple word: CHANGE

Our innate fear and reticence to change, is something that is founded and supported by recent research published by the American Psychological Association as part of their Stress in America Coping with change campaign. This research demonstrated that more than 50% of respondents reported chronic stress stemming from an organization change at work. This statistic is staggering, and supports the general principles in medicine, of burnout and chronic stress, due to constant organizational change. 

That is why today, our Grand Rounds has focused on the concept of CHANGE, and has a single objective; to CHANGE your notion of CHANGE.

“Let us change your perception of CHANGE”

 

Importance of Change in Healthcare

 

CHANGE is all around us. If you reflected back on your last week, you likely have made some changes in your life recently. Things like welcome a new family member, or perhaps something smaller like changing the brand of milk that you use. 

CHANGE is present at an INDIVIDUAL level in the little things that we do differently day-to-day. At an ORGANIZATIONAL level it can be seen in recent re-masking policies at hospitals across the country. Even at a SOCIETAL level change is happening – cancel culture being a prime example from recent years. 

CHANGE in HEALTHCARE has never been more prominent than in the last decade; especially as new and emerging adversities provide catalyst for change. And we’re not just talking about the COVID-19 pandemic. 

The above  headlines from the last 6 months, highlight challenges such as rural ED closures, nursing and family physician shortages as well as unprecedented wait times. These challenges will force emergency departments across the country to adapt to the needs of our patients and the system. Because although CHANGE is DIFFICULTI think it is important to remember that CHANGE  is ADAPTATION. Think of it as a CONSTANT. CHANGE is the only thing that is constant in our current system. And EVOLUTION or ADAPTATION of our healthcare system is integral to it’s survival. 

“EVOLUTION or ADAPTATION of our healthcare system is integral to it’s survival”

CHANGE is essential in the current climate of our healthcare system. However, not all change yields POSITIVE outcomes. Which is why as frontline healthcare providers and leaders, we need to get involved, to influence change to the best of our abilities. Our ability to INFLUENCE change is paramount, because we took an oath. We took an oath, to serve, protect, prevent and treat our patients both medically, socially and psychologically. We are our patients voice, to ensure their safety in our crumbling healthcare system.

“Patient Safety is a Top Priority: 3/10 of Canadians feel Patient Safety is suffering”

Data from the Canadian Patient Safety Institute demonstrates that 3/10 of Canadians feel Patient Safety has gotten worse nationally over the last 5 years. This concern is echo’d in the recently published CMA findings post-pandemic of more than 4000 preventable deaths in 2021 alone, the fact that cancer screening remains 35% below the pre-pandemic average and that more than 90% of in-person chronic disease visits were missed between April 2091 and April 2020. 

The above is why Organizational Healthcare Reform is Essential. CHANGE is essential not only for our patients, but also for us. Because our system is crumbling, and we can’t hope to continue longevity in an emergency medicine career, if things don’t evolve. It is our responsibility to ensure that we, our colleagues and our patients are prioritized in the ever constant wheel of change barreling through our healthcare system. 

“At the heart of every vision, every aspiration, is a crisis”

 

Organizational Change

 

To be able to influence change, it is imperative to have an understanding of (1) the system in which we work, (2) organizational change theory and (3) the barriers that hinder change. 

 

What system do we work in? 

 

SYSTEMS THEORY is a foundational concept in organization development and change. It was described in the 1940s by biologist Ludwig von Bertalanffy. It focuses on characterizing systems as being open and fluid, and being composed of several interconnected subsystems. A single movement at one subsystem influences the others; much like the concept of a gear system or chain-reactions. In healthcare we could use the example of a lack of long term care facilities causing barriers to discharge for inpatients and resulting failed discharges, leads to bed pressure and overcapacity issues that transpire to impact ED bed availability and wait times. 

“One subsystem has a domino effect on all other subsystems”

Systems theory adequately represents the inter-connected nature of our healthcare system, but it fails to acknowledge the CONTEXT in which our system operates. The context in which our system operates is imperative to understand, as it conveys the complexities and unpredictability of the healthcare system. 

CYNEFIN FRAMEWORK provides the context in which a system operates; either simple, complicated, complex and/or chaotic. An organizational system, can at any time exist within one of these realms, and can also TRANSITION between them. Each particular system requires a specific type of leader to ensure it’s optimal operation. 

Simple Context: This type of system is characterized by stability and clear CAUSE-AND-EFFECT relationships. The processes within the system are linear, which allow easy sensing, categorizing and response patterns that respond best in a command & control setting. It is far too simple to explain our healthcare system, but can help explain certain processes within the healthcare system such as cancer screening programs. 

Complicated Context: Houses a degree of uncertainty and nuance which relies on EXPERT opinion. For example, the concept of risk stratifying chest pain based on experience and expertise and analysis of RF, TnT and ECG values. Leaders operating within this system will often look to “best practices” to outline the next steps. Innovation only occurs in the absence of large risks. 

Complex Context: Contains UNKNOWN UNKNOWNS. Meaning that implementing a change requires manipulation of a set of variables. However, manipulation of these variables leads to the discovery of unintended effects on alternative aspects of the system. These types of systems requiring change management through QI PDSA framework. This tends to describe our healthcare system on a given day. 

Chaotic Context: Describes a system in which their is a lack of control at many levels. The system is in a FORCED-TO-ACT scenario, where change experimentation is not possible. Leadership is required to follow a TOP-TO-BOTTOM leadership hierarchy. This describes our healthcare system in times of acute crisis; for example during a code orange and it’s resulting Incident Management System (IMS). 

The above theories, help to understand the complexities of our healthcare system. Not only does it operationally follows systems theory, being composed of many inter-related subsystems within a larger overarching system. But it operates within a COMPLICATED context, and occasionally even CHAOTIC context. Which emphasizes further the lack of predictability and ability to control for all variables. Because their are so many unknown variables that are hidden and impacted by any change made within the system. This highlights why change is difficult, but also why innovation is essential. 

 

What is organizational change theory? 

 

Over 100s of years, different entities have attempted to study change within various organizations to best describe the necessary steps and/or considerations that need to be made to effect change. Understanding these organizational change theories is imperative not only for leaders but also change-makers, because they provide a blueprint of stakeholders and barriers to change. 

ADKAR: Organizational change theory which highlights that organizational change is intricately linked to personal individual change. It focuses on the diagnosis of employees on their “readiness for change”. It requires goal-oriented modelling and motivation of individuals employees as the cornerstone of change at an organizational level. 

Lewin’s Theory: Highlights a tangible 3-step process for change to occur. 

      • Unfreeze: Information gathering stage. The goal is to focus on understanding the barriers to change and the stakeholders involved in a particular behaviour that seeks to be modified. It is imperative to identify a common driving force or goal that appeals to those who will be affected by change. 
      • Change: Change is implemented through a series of modifications of behaviours, but also feelings and thoughts. 
      • Refreeze: Anchoring of the change as the new “status quo” or a new habit. 

Kotters: 8-step change model theory, which focuses on unifying a vision for change, and engaging and enabling change through employees. 

These organizational change theory’s exemplify the need for leaders to motivate and engage employees, and to use a systematic approach at breaking down barriers to be able to implement sustainable change.

 

What are the barriers to change? 

 

It is not enough to simply understand the system, and the steps required for change. It is imperative to also understand the barriers to engagement of the humans who are affected by change. Understanding barriers to change that influence both EMPLOYEES and their EMPLOYERS is necessary to innovate solutions and prevent failed change initiatives. 

EMPLOYER PITFALLS: 

    • Lack of Clarity: We operate within a system with intrinsic complexities. The complexity of our system makes it easy to fall into the trap of wanting to try and fix everything all at once. The adage of “Less is More” highlights an easy strategy to maintain employee engagement. A complex problem should be broken-down into small problems, to be fixed one at a time. If the goal is too broad, the clarity of what is to be accomplished gets lost, and people will engage less.

“Less is More” 

      • Lack of Commitment: Commitment does not solely depend on motivation. It also requires that clear tangible outcomes be identified, so that employees may act on them to achieve a predetermined end result. A leader needs to identify SMART goals and objectives that are measurable to be able to leverage employee commitment. 

“Be SMART” 

      • Lack of Collaboration: Collaborative action is sometimes difficult to garner in healthcare because we often work in sillo from our physician peers. But highlighting exemplary collaborative action and promoting peers to help with the problem at hand, are just two ways that leaders can increase team collaboration. 

“The greatest leaders, PROMOTE their peers” 

      • Lack of Accountability: Stakeholder engagement is imperative, as people are more likely to be committed and accountable for their actions, if the idea was there’s to begin with. 

“Engage Stakeholders Early”

EMPLOYEE PITFALLS: 

Personal resistance to organizational change often stems from a lack of motivation. This motivation in the workplace environment is linked to the pillars of job satisfaction:

    • autonomy;
    • mastery;
    • and purpose. 

Our fear to change in the emergency department are often related to our fear of losing autonomy and purpose.

    • Loss of purpose: Burnout and moral injury can often obscure our purpose. As emergency medicine physicians, we want to be able to provide safe high quality care to all our patients. If a proposed change does not align with this purpose, it is easy to become disillusioned and not have intrinsic motivation to see things through. Embracing a growth mindset, where a purpose can change over time can help ensure intrinsic motivation is never fully lost. 
    • Loss of autonomy: An ED physicians autonomy exists within a paradox. Often we are highly limited by both internal and external constraints within the emergency department; lack of human resources, emposed shifts we need to work, and long wait times. Given the already limited flexibility and autonomy we have on shift, a change that further assaults this will garner negative reactions. 

Although prioritization of autonomy and purpose should be considered when imposing new changes. It is important to remember that change is never intended to be a direct assault on either of these. At times for the “greater good”, or the “bigger picture” we will need to sacrifice some of our autonomy or purpose temporarily to allow a change to occur that will overall benefit patient care and department well-being. Once a change is fully completed, our sense of purpose and autonomy is regained. 

 

Wellness & Change

 

65% of change initiatives require a significant behavioural change from employees. Employees require the bandwidth to be able to accomplish change in parallel to their day-to-day operational demands. For ED physicians balancing new initiatives with out innate shift responsibilities often appears impossible. This is because our tanks are empty; fatigue and burnout are real. 

A study by Rodrick Lim et al., demonstrated that 86% of ED physicians pre-pandemic met 1-criteria for burnout. While Mercuri et al., identified a burnout-rate of 60% during the height of the pandemic for ED physicians across the country.  

With such high burnout rates, even the smallest change will appears to be impossible. Preventing burnout has never been more important, as a recent systematic review by Salyers et al., identified a constant negative relationship between provider burnout and patient safety, quality care and patient satisfaction. Emphasizing that if we are suffering our patients are also. 

“When we suffer, our patients suffer”

Preventing burnout is NOT the topic of todays blog, but I encourage you to click on some of the resources below: 

Although burnout is not the sole centerpiece of this blogpost, you can’t talk about change without acknowledging burnout. Because if your battery is on empty, you won’t have the energy required to enact change. Their are three concepts I personally have found useful to ensure that I not only prevent burnout, but also am poised at the ready for the inevitable changes to come. 

“Never Operate at 100%”

A mentor of mine taught me this concept, wherein your energy and capacity for more is dictated by the energy left in a battery. In general, you should always operate at about 60%. This allows you to rev things up in the event of acute crisis or change without fully depleting your battery. In comparison, if you always operate at 100%, you have no energy left to dedicate to anything else. 

“You CAN’T control everything”

Part of staying well in medicine means being able to identify what you can and cannot control. And accepting that some things are outside of your control, and as such should not bring you any stress. It is important to identify things that you CAN’T change, and come to peace with them, so  that you have more bandwidth to be involved in things you can CONTROL and can CHANGE.

“We are in this together” 

“There is strength in numbers”, and in healthcare we are never alone. We all have colleagues, but also allies in our allied healthcare providers both locally, provincially and nationally. 

 

Conclusion

“CHANGE is EMOTIONAL”

CHANGE is emotional, but it is an unavoidable life process that we deal with daily in our everyday lives. This also translates to an organization’s life. In HEALTHCARE the concept of ORGANIZATIONAL CHANGE is essential, to maintain both patient and personnel medical and psychological safety and well-being, because we know that the Status QUO is not working. A better system can only occur if we change.

“CHANGE can be MASTERED”

CHANGE is a process that we can master. It often feels like we don’t have control over change, and in certain circumstances, to a certain degree we don’t. But mastering our ability to identify things we can and cannot control is an important part of arming ourselves to avoid burnout through periods of change. We don’t need to become that 50% statistic of people suffering from chronic stress from organizational change. And remember, we are in this together. There is power in numbers; learning and leaning on your colleagues makes change that much easier.

“CHANGE is LOGICAL”

CHANGE is a logical process, that should focus on changing smaller aspects of a larger problem, for which tangible actions and accountability are possible. Because the barriers in change are dependent on engagement of the employees, something that is the responsibility of both YOU and your employer.

References