How to Get Health Care Employees Onboard with Change

Organizational transformation is notoriously difficult. Twenty years ago, John Kotter pegged the failure rate at 70% and the needle hasn’t moved much since. Major change also takes a long time to implement — between five and seven years on average — and the performance improvements that are achieved rarely last.

In healthcare, change is even harder than in most industries. Clinical and administrative staff often view their work as a vocation as much as a profession, and they are historically suspicious of senior administrators and resistant to strategic agendas. While a desperate need for change and organizational performance improvement may be obvious to the top team, staff can view that premise as fundamentally flawed. They’ve lived through tumultuous times before and the status quo has always returned.

In 2011, when I came to Centura Health in Colorado as President of its largest operating group (Mountains and North Denver Operating Group or MNDOG) and CEO of its flagship health organization, Saint Anthony Hospital, I saw a clear mandate for change. The organization had a strong community tradition and over 4,500 talented employees. Yet, a variety of financial and operational problems impeded success and we lacked a clear strategic path toward building the kind of coordinated care delivery system healthcare desperately needs. I put my immediate energies toward building an exceptionally strong executive team. Together we developed an agenda for change and put it into action.

Within a few years, we had dramatically turned around the organization’s finances, performance measures, and market share. Things were looking up on all fronts except one. Our employees weren’t along for the ride.

This is the story of what we did to turn that around by involving our people in our organizational change process in a much deeper and more meaningful way. Doing so, we stumbled across a formula for accelerating organizational objectives while managing even higher levels of performance and engagement.

Rounding and listening

“I have hope that you are actually listening to associates now.”

Out of more than 500 responses, that was the one that hit me hardest. We performed pulse surveys quarterly after every town hall meeting at Saint Anthony Hospital. The questions were developed by Press Ganey, the healthcare survey company, and were related to employee engagement. We also had open questions in our surveys to give people an opportunity to express their concerns related to leadership, operations, compensation, and staffing. The feedback could be tough at times. Though we’d achieved significant organizational change and performance improvement in a very complex and challenging industry and market, it was clear that our employees didn’t feel included on the journey or excited about our accomplishments. The disconnect between how they felt about our organization and how the organization was actually performing was perplexing.

To dig into the details, I engaged in a hospital tradition and began rounding. I talked with clinical, administrative, and operational staff where they worked and asked them to tell me more.

I learned that people didn’t feel connected to our vision or the changes we were working to make. Our goal was to become the destination healthcare provider in our market while achieving national standards for best practices, care quality and satisfaction, and becoming recognized as a health leader in the communities we serve. Most of our employees’ concerns were far more basic. They were worried about working conditions, managerial support, staffing levels, and so forth, and they believed that leadership was just talking out of its hat because we had failed to address their long-term concerns.

Listening and taking notes, I knew I could solve almost everything and still not fix the bigger problem of connection and engagement. There was a lack of trust in us and alignment with our agenda. Years of experiences with administrators saying one thing and doing another had made people cynical. Hearts and minds would need to be changed in a fundamental way.

So I did what CEOs often do when they confront a maze they might get lost in – I called for help and asked an executive advisor and organizational change expert for guidance. I’d worked with organizational change consultant Phil Harkins at a number of different health systems before, including Centura, and he understood our situation acutely. He proposed that we try something new.

Unlocking the power of purpose through teams

We’d already collaborated to develop the cohesion of my top executive team by clarifying each executive’s individual purpose and connecting that to the shared purpose of the group. For example, my chief strategist and one of our hospital CEOs were both passionate leaders who cared deeply about improving our system but they were always on opposite sides of key organizational and strategic issues. By getting them to dig deep and talk about their own personal motivations, it became obvious that they actually shared the same overall vision. This helped them to identify what they each wanted to do to contribute to our larger agenda and helped us define their distinct roles and responsibilities more clearly. That sort of work had a remarkable effect on bringing leadership together, helping us to communicate with each other more openly and candidly, and making it faster and easier for us to innovate and execute.

We decided to expand that approach to the entire organization.

But how do you make something like that happen at scale? Purpose is not a canned or artificial HR program. Discovering it is deeply personal and almost therapeutic. You can’t fake it or force it. Through Phil’s research and our experience, we knew that it was best engendered within the close environment of a cohesive team. When close peers face high stakes, real problems and interpersonal challenges, the work of discovering and sharing purpose seems to galvanize their sense of team almost magically. We decided to implement a similar process among other teams, and then cascade that throughout the organization.

We started by identifying the “passionate champions” of the organization, meaning people who are particularly committed to healthcare, problem solving, and each other. Then we selected 50 of these people and divided them into four model teams.

Next, we set these teams to work on defined areas of organizational need – Quality, Clinical Operations, Administrative Operations, and Associate Engagement.

Each of these teams went through the same team development program as my senior leadership team. We helped team members identify their individual purpose and connect that to the organization’s overall purpose. For example, one front-line nurse was incredibly dedicated to patient satisfaction. Joining the Quality team gave her a way to bring her personal perspective on best approaches to patient care to that group and helped her to see how directly her individual efforts could contribute to our larger goal.

Next, we gave these teams the freedom to identify organizational problems in their area of concern. The Clinical Operations team focused on “throughput” bottlenecks in order to improve how efficiently patients could be moved through the system from intake to discharge. This efficiency is a key driver of operational costs but also a leading indicator of patient satisfaction and quality since prompt discharge means clinical best practices are being applied and quality outcomes achieved. Our Clinical Operations team was composed of nine people who represented every area of the hospital that touched throughput, from the ER to the wards to pharmacy and administration. Whereas before they might have seen their roles as siloed from one another, now they worked collaboratively to solve bottleneck issues across the system.

Sometimes this work surfaced tensions so it was important to facilitate and coach people through their conflicting points of view. Team members who were initially at odds were always able to reach a collaborative solution because they had spent time getting to know each other and they understood that everyone shared the same priorities around improving patient care. The vulnerability and openness the team-building process established made it easier to get aligned.

Once each team had figured out a solution to whatever problem they identified, we recused some of the members and replaced them with other “passionate champions” closer to the field. This new group became the implementation team charged with executing on the strategy. The original team members who remained were responsible for bringing new team members through the team-building process. The team members who were recused were assigned to new teams where they also helped lead and develop team cohesion in those new groups. Many people were reluctant to leave the teams they’d helped build. Team members had grown close and wanted to stick together. But by dispersing them to other teams, we created a process of leaders teaching leaders that cascaded throughout the organization, with increasing numbers of people aligned around a shared purpose and focused on solving meaningful challenges.

Our focus on meaningful problems was critical. Many “team-building” exercises are theoretical and the stakes are low. Our approach engaged people on developing tangible solutions that would contribute to our vision. It reinforced alignment, helped build our capabilities and led to actual improvements in organizational performance.

In the end, it felt as though we had 50 new leaders helping to run the organization.

Picking up speed and measuring progress

Not everyone was touched by the work right away, but the network effect was powerful. I was amazed by the level of commitment and passion that grew throughout the organization.  We moved faster and made more significant progress because we combined the power of purpose with project work that was designed to improve organizational performance.

We made sure to track and measure progress and status frequently. We measured each team’s performance and development at regular intervals through Phil’s Team Effectiveness Assessment (TEA) instrument, a 360 system that tracks, reinforces and bolsters team norms and best practices. We also measured operational metrics like quality, safety, satisfaction and financial scores to gauge our progress compared to national standards of excellence. And we continued to take the temperature of the organization by conducting surveys on employee engagement and culture.

Measuring in three areas helped us to avoid letting personal experiences or perspectives cloud our judgement of how well we were doing as an organization. We also kept rounding and conducting listening forums and town halls to make sure we surfaced and were aware of every concern.

The rich understanding that we developed enabled us to employ very crisp and targeted responses to problems and concerns that were tied to our strategic priorities. For example, we changed our leadership when it did not reinforce or align with our vision and new approach. We also altered our staffing approach and increased compensation in select areas to improve performance.

Leading in a new way

For the top executive group, the work of being a leader also transformed. The approach we put in place forced us to listen and learn how to support people rather than dictate or direct them. We became actively engaged in collaborating with our people as they worked to solve the problems of the organization. Sometimes we were coaches, sometimes mentors, sometimes facilitators. In this way, we modeled a new type of leadership, closer to the kind of servant leadership approach I’ve always admired.

In breaking out of our own administrative silo, however, we were also very visible and open to scrutiny. We knew that cynicism in employee ranks was long-standing and any time we fell short we would be reinforcing old perspectives. So we articulated our promises clearly – even writing them down in memos – and we matched those to outcomes that people could observe and track, thereby linking what we said with what we did. Within our leadership group, we also defined new behaviors that would support our new approach to leadership and I took it on myself to continue to observe and coach our team to stay on track.

Through this experience, I came to understand why traditional change agendas often fail to really move the needle. When change is imposed, active and passive resistance assures that it will never be a complete success because resentments never fully dissipate and engagement is lacking.

There’s a better way. We shifted from a top down approach to a transformational one by involving as many people as possible as early as possible. We managed this by creating a cultural practice in which teams defined their purpose and objectives, and leaders taught others how to grow and lead.

Some CEOs might worry that ceding a change agenda to multiple teams throughout an organization is a recipe for confusion, misalignment and a slower pace of change. But when people are aligned around shared purpose and engaged in real problem solving within a strong team environment, they achieve overall goals and change objectives much faster and more effectively. Not only does this bring leadership and engagement to a new level, but organizational culture is also stronger and more dynamic as a result. Sustaining change is a lot easier when those conditions are in place.