QUESTION

1) Explain the internal and external drivers: rationale and purposes of the change intervention.

2) Consider the change perspective/s that you think might be driving the people initiating the change. Think carefully about the assumptions you think the initiators hold about change and its nature.

3) By applying the theories in change strategy:

a. Describe the change strategy that was adopted

b. Demonstrate the approaches (theories and models) adopted for change strategy development and implementation

c. the strategic planning tools used as well as how they were modified or abandoned to suit organisational requirements.

4) Evaluate limitations of the change intervention, and propose alternative change perspectives and strategy development and implementation approaches/tools, and justify your selection of the given.

SOLUTION

About RAH

(Royal Adelaide Hospital Annual Report 2003-2004)

Royal Adelaide Hospital (RAH) is one of the largest teaching hospitals of Australia which has been serving since 1840. It provides tertiary healthcare services for South Australia and secondary healthcare services for Adelaide. With 680 beds, it is one of the largest in the region. It provides medical services in the fields like Neurology & Neurosurgery, Oral and maxillofacial surgery, Thoracic medicine and Cardiovascular surgery.

The hospital offers basic training positions in internal medicine, surgery and general practice, as well as advanced training in a range of specialty areas. The staffs are also actively involved in cutting edge research, making it a centre of research excellence as well. As mentioned in the latest annual report, its mission is to maintain and improve health of the people by providing high quality health services, promoting the healthy practices in the communities and encouraging teaching and research values. The values set by the hospitals are its commitment to Quality, Service, Value and Innovation. The hospital values its staff and always engages everyone in any kind of strategic decision making. Thus continuous improvement is imperative at RAH.

The proposal- “Rationale of the change”

The hospital discovered various safety issues in the usage of medicines. These issues were never addressed until year 2002. There was no dedicated department to address the issues of safe medication usage. During its history of around 150 years, nobody ever thought that any education or training needs to be imparted for safe medication.

Once the issues were recognized, it was proposed to form a multi-disciplinary team of individuals from all departments who will work in this area in future. The group was named as “The Medication Quality and Safety Working Group” and its basic philosophy was to improve medical safety from disciplines of Pharmacy, Nursing and Medicine. The team included practitioners from the fields of Pharmacy, Nursing staff, doctors, management and administrative workers as well. This group reported to the Hospital’s Drug Committee and Clinical Practice Unit.

Present case deals with the change management dealt with the implementation of suggestions given by the group. The group gave suggestions on the safe usage of intravenous potassium chloride (KCl). The project aims were to:

• raise awareness about the risks associated with the inappropriate KCl administration
• determine loopholes in current handling of KCl in various processes and take steps to plug them

• Change strategy

  (Lewin’s 3 stage model 2012)

  In order to implement the suggestions, a change management strategy was adopted. The strategy was based on Lewin’s 3-step change model. So, the philosophy was- Unfreeze, Change and then Re-freeze. Following were the steps undertaken.

  Determining team composition

  (Dyer 1984)

  As per the proposal, the team consisted of multiple departments. The leading department was ‘Pharmacy Department’ which had the knowledge of the core issue in hand. The leading department was assisted by ward-based nursing staff. The objective set by the group was to ensure that proposed safety standards should be followed by every personnel belonging to any department. The underlying philosophy was that each individual should take up ownership of implementing the change. The team was advised to take up co-ordinated efforts to share the knowledge across all departments and communicate the changes to be undertaken across the organization. It was ensured that at least one person from each of the departments, be it a functional department or an administrative department, should represent in the group.

  Defining roles and responsibilities

  (Bridges 1991)

  The major task was to define the responsibilities of the group members and thus guiding them to carry their jobs in more focussed manner. In the absence of set responsibilities, this proposal would have doomed to fail as these responsibilities were apart from the current responsibilities of the staff and thus require additional efforts.

  Since this was a new initiative, even the management was not very clear about the implementation plan. The initial responsibility given to the group was to collect and analyse the medication incident data. There were internal as well as external sources of data which were related to cases of unsafe medication usage. In fact, a number of safety standards were successfully implemented in US and UK. The team thus collected the data from these cases. Apart from that, a number of related incidents that happened in Australian hospitals were also analysed.

  Unfreeze- “Reviewing existing policies and processes”

  (Kotter 1997)

  In order to understand the need for the change in processes followed for KCl usage, current practices were reviewed. The storage procedures and policies were analysed and tested for international safety standards. Various experiments were done to find out the right storage place and the expiry date for stored KCl. It was found out that KCl ampoules were stored at the same place where other chemicals like sodium chloride were stored. Since both materials were used for purpose of medicinal preparation, the nurse ward unknowingly stored them together. The untrained staff would use KCl without dilution as they did it with sodium chloride. The KCl in concentrated form was not a safe medical agent. Hence, it was proposed that KCl will be stored in locked cupboards with proper labels mentioning the procedure to dilute it before use.

  No pre-mixed infusions were used till now when it came to the usage of KCl. A feasibility study was thus conducted by Pharmacy Department to find out the alternative pre-mixed infusions. A cost benefit analysis was also undertaken. A preliminary study indicated that a small range of infusions were available with just about the same cost as prevalent. Steps were then taken to introduce them in the procedures.

  The need for changing the current processes and taking up new alternatives was communicated by the group to all departments. One group representative from the respective department was made to understand the importance of above safety procedures by supporting case studies and collected data. Presentations were handed over to the representatives so that they can present to their teams and clarified the doubts if any. So communication was the key to drive the change management in this case.

  Change- “Undertaking a pilot project”

  (Mourier 2001)

  Once every department was aware of the changes that were to be introduced in the hospital and every one was convinced about the need for such changes, the group decided to implement the changes in the form of a pilot project.

  A medical ward was selected for this pilot project for two months. The two actions that were to be performed were:

  1. Implement new storage procedures
  2. Order and use pre-mix infusions as an alternative to dilution of KCl along with its use

  A member of Pharmacy department took educational sessions of multiple groups of medical and nursing staff. These sessions communicated the logic behind the changed processes. The existing KCl units were ordered in grams but the pre-mix infusions came with metrics in terms of millimoles. A conversion chart was thus prepared so that right quantity of infusions were ordered and used. Trainings were given on the storage procedures and handling of KCl. The existing medication charts were also modified to include the pre-mix infusions in medications. The staffs were trained to prepare the infusions and use them properly. A checklist was also provided to every staff member to ensure that they don’t accidently ignore any step because of subjective bias of previous procedures. Wall charts and pockets cards were also prepared to assist the staff.

  Challenges faced

  Lots of challenges were faced. Educating a huge staff was a complex task. There were people of different levels of understanding. Hence, the presentations and other tools had to be as simple as possible and in appropriate language. The next challenge was to get approval of medical staff to implement the usage of alternative pre-mix infusions. With proper standardization tools like charts, this was made possible. Training of nursing staff regarding the dosage was also a daunting task as they lacked the knowledge. Labelling and storage of pre-mix infusions and existing KCl storage was to be done by administrative staff. Proper distinctive labels with colour coding were done to make the differentiation. The existing sodium chloride bottles were also labelled to distinguish them. Changes were done in the medical reporting structure to include the safety precautions taken during KCl usage. Proper training for reporting was also needed and so sessions were conducted in this regard.

  Overcoming challenges and moving ahead

  (Axelrod 2000)

  As mentioned above, educational tools in form of charts, pocket cards and presentations were used to educate the staff. While getting approval from the medical staff for using pre-mix infusions, it was agreed that proper dose of KCl as well as infusions will be separately specified on case to case basis in order to avoid any sort of confusion. The conversion charts from grams to millimoles were available with every staff personnel and also were pasted at different locations. Standard medical reports were issued with inclusion of KCl safety procedures undertaken. It served dual purpose of reporting as well as making the staff memorize the whole process.

  The pilot project was successful and the changes were taken in positive manner by the ward. Following this success, the changes were implemented in other wards as well. The task was difficult given the huge size of hospitals. But the strategy continued to remain the same and communication was the key. Each ward was assigned to one group member who ensured that the things went ahead in right directions. Any feedback, complaints and clarifications were dealt with professional approach.

  Refreeze- “Setting standards”

  (Kotter 1997)

  Once every ward started following the changed procedures, the change management went into its last and final phase. The objective set in this phase was to make the safety procedures as a habit and not an enforced act. Periodical review of the wards included the checks on the safety procedures especially adopted for KCl usage. Following an exhaustive approach, the changes were implemented even in the surgical wards. Trainings were conducted from time to time where feedback was taken from the staff regarding the difficulties in implementation of the processes. With the advent of information technology, automated reporting standardized the whole process. Although pre-mix infusions could not replace the KCl, but still the staff was trained to use them in emergency situations. Technologies such as electronic prescribing with decision support and bar coding of drugs prior to administration to the patient helped to reduce the risks of KCl usage and thus safety standards got imbibed in the culture of hospital.

   

  
  Conclusion

  As seen from the case study, change management in big organizations can become a daunting task. It is more difficult for an organization such as RAH, which has long history of more than 150 years. Main reason behind this is that there are set policies and procedures that are being followed for so many years that no one questions them. It is very difficult to even find out the loopholes in them and so the need for change in itself a big thing. The present case shows that how even a minor change, as redefining the safety standards for KCl usage, can affect the image of the organization. It is thus very important for every organization to critically review their procedures and processes to tune with the changing times. Once they start making such reviews frequently, they will definitely find out some areas of improvement. The key drivers in initiating the change will be the fact that their competitors have improved over the time and hence they should also be moving forward. Once the need for change is appreciated by the organization, it should communicate the same to every level. It is important to communicate the message to even a small department as, the change will affect or may affect each and every personnel. Communicating in a way that everyone knows the importance of change is crucial as everyone may not have the same understanding level. The message should be simple enough for everyone to digest. Presentation plays an important role here, as in this case the organization used wall charts, pocket cards etc.

  Once everyone appreciates the need, then the organization should prepare to unlearn its old processes. This is very difficult stage but proper training along with commitment to improve help to overcome any inertia. A change leader plays an important role here, as played by the Pharmacy Department in RAH, by setting definite goals to be achieved in order to implement the change. Once the objectives are in place, it is easy to define the change strategy and its operational aspects.

  Change strategy is where the ground realities are understood. In this case, the strategy adopted could not have been confined to just communicating the suggestions to every department. Given the size of the organization, it is imperative to test the changes to be implemented. Like in this case, a pilot project was run for two months in one ward, similarly for any big organization pilot runs for any changes should be done. The results from pilot tests give confidence to change initiators as well as provide support to their philosophy to convince everyone. It must be noted that pilot run should cover each and every operational aspect so that it highlights the difficulties in implementation. Any concerns arising out of pilot run should be dealt with before going for implementation in whole organization. (Kanter 1983)

  A pilot run helps in determining the operational strategy for implementing the change throughout the organization. To make it simple, the philosophy should be to consider it as a series of pilot runs at different departments, like it is done by RAH in multiple wards. It is an integrated approach and thus every department should be involved. Any concerns arising at this stage should be resolved at the earliest. Proper milestones must be set to monitor the progress from time to time. It must be ensured that every single personnel follow the changed policies or processes.  (Mourier 2001)

  The final step of a successful change management plan is to imbibe the change in the culture of the organization. The change should be made as a standard in whole organization and people should follow it without being reminded about it. Periodical trainings and making the change as a part of daily routine helps in making the change as a thing given for granted.

  Hence, it can be said that a simple three staged process of change management i.e. Unfreeze-Change-Freeze, is the basic foundation but implementing them can be a big task. It must however be noticed that commitment and communication are the two key factors that drive a successful change management strategy. (Kotter 1997)

   

  
  Excerpts from the interview with Ms K Read (Nursing Director)

  Following are excerpts from an interview with the Nursing Director of RAH, who was present when the project was being implemented in the different departments.

  1. What made the hospital think about reviewing the safety standards followed especially for KCl usage?

  RAH has always strived towards continuous improvement. We do review our policies and procedures time and again to ensure that we incorporate the latest medical developments. Particularly saying about KCl, we have been reading number of cases and mishaps arising out of ignorance of medical staff about its proper usage in various hospitals in Australia. Being a pioneer teaching hospital in Australia, we thought of reviewing our safety procedures regarding KCl usage and implement any improvements here to set an example for other small hospitals in the region. We never faced any mishap due to KCl at our hospital, so it was a proactive step.

  2. How difficult it was to group together representatives from various departments under “The Medication Quality and Safety Working Group”?

  It was a difficult task given the size of organization and the work load on each individual. The hospital was asking for extra efforts on their part and additional responsibilities with no tangible reward. Since a cross-departmental team was to be prepared, it was a task indeed to manage the cross-departmental conflicts as well as cultural issues. Managing time for everyone was a challenge. Pharmacy department was the leader and it was assisted mainly by the nursing staff. Everyone was not having the same level of understanding of this issue, so it was a big challenge to communicate to them in a simple manner in which they can digest it. The Pharmacy department worked really hard to make presentations and charts to communicate their idea to every member of the group. Any clarifications sought were handled very carefully. It was a big task to bring them together, but once it was done we knew the rest of the things would become simple to implement.

  
  

  3. How did the idea of pilot run come into picture?

  We knew that it was very difficult to implement the safety procedures at one go. It is understood that no one will change just by accepting the need for change. We need to see the project in operation to highlight the issues beforehand. Even small issues like ordering pre-mix infusions in terms of millimoles were to be seen as critical to implement. We therefore decided to test the changes in one ward first. The results were positive and it gave us the confidence to move ahead and implement it organization-wide.

  4. What new challenges you faced post pilot project while implementing the changes at organizational level?

  We needed to convince the senior management about the changes to be introduced. Presentations were made to the board and cost-benefit analysis was done for the whole project. We prepared a milestone based implementation plan and got approval from the management. The challenge was to meet those milestones. We adopted an integrated approach by implementing the changes in every ward in parallel. It was difficult enough to educate every member and monitor them while working with KCl. We incorporated clauses of KCl safety in the draft medical reports so that proper reporting and monitoring could be performed. As the time went on, we could see the changes in the working styles of the ward staffs and they were taking them in a positive way.

  5. Any limitations which you think you are facing till date?

  We could not replace the KCl wholly. It was because we were not able to make everyone realize that pre-mix infusions are effective in every case. However, the staffs were trained enough to order and use pre-mix infusions in emergency situations and hence improving the overall safety standards.

  6. Will you call the change implementation strategy a success?

  Definitely, it is a huge success as it has enhanced the reputation of our hospital as being proactive in bringing new safety standards. The way it was implemented has set a precedent for new changes in other fields as well.  “The Medication Quality and Safety Working Group” is continuously working to bring about new changes in other areas as well.

   

  
  REFERENCES

  Donald L. Kirkpatrick, How To Manage Change Effectively, (San Francisco, 1985)

  John P. Kotter and Dan S. Cohen, The Heart Of Change, (Boston, 2002)

  John P. Kotter, Leading change, Harvard Publications (1997)

  “Journal of Organizational Change Management”, Emerald (2011), accessed March 25, 2012

  Pierre Mourier, “Conquering Organizational Change: How to Succeed Where Most Companies Fail”, Project Management Institute (2001), accessed March 25, 2012

  Richard H. Axelrod, Terms Of Engagement: Changing The Way We Change Organizations, (San Francisco, California, 2000)

  Rosabeth Moss Kanter, The Change Masters, (New York, 1983)

  Stewart J. Black and Gregersen B. Hal, Leading Strategic Change, (New Jersey, 2002)

  William Bridges, Managing Transitions: Making The Most Of Change, (Massachusetts, 1991)

  William G. Dyer, Strategies For Managing Change, (Massachusetts, 1984)

  Lewin’s 3 stage model, accessed March 25, 2012, http://www.lmcuk.com/management-tool/lewins-3-stage-model

  Royal Adelaide Hospital Annual Report 2003-2004, accessed March 25, 2012, http://www.rah.sa.gov.au/aboutrah/annual_report.php

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