organizational and process reengineering: approaches for health care transformation

Health Care Management / Process Improvement

“Jean Ann captures the keys to total success based on her unique and valuable insights along with her strategic and holistic perspectives to total health care transformation.”—Imelda K. Butler, Managing Director of Century Management and Co-founder of the Odyssey Consulting Institute, Dublin, Ireland

“... an invaluable tool for health care executives as they address the pain points of moving from fee for service to fee for value.”—Michael W. Davis, Principal, Mountain Summits Advisors LLC, Denver, Colorado, USA

“...a refreshingly practical road map with real solutions that any health care organization should find beneficial.”—Ivo Nelson, Chief Executive Officer and Chairman, Next Wave Health, Houston, Texas, USA

“...emphasizes the coupling of health systems engineering and process improvement tools and techniques with effective change management to achieve successful cultural transformation and high performing and innovative health care organizations.”—Barry T. Ross, LFHIMSS, DSHS, University of Pittsburgh, Pennsylvania, USA

“I highly recommend that anyone who is a leader read Dr. Larson’s insights regarding the importance of process improvement and culture in change management and quality improvement.”—Gene Michalski, President and Chief Executive Officer, Beaumont Health, Royal Oak, Michigan, USA

“Jean Ann cleverly aligns the best tools and techniques together that drive reliable, sustainable change to our modern health care organizations.”—Rudy Santacroce, PE, Vice President, Operational Excellence, RTKL and Associates, Dallas, Texas, USA

“Jean Ann’s education as an engineer coupled with her vast experience as a senior leader in large health care organizations confirm her as the expert to document this practical approach on how to implement change in your health care organization.” —Elizabeth Jeffries, RN, CSP, CPAE, Executive Coach, Keynote Speaker, and Author of The Heart of Leadership: How to Inspire, Encourage and Motivate People to Follow You

“This book is the only resource you will need to charge forward with courage and confidence to move your organization to unbridled success.”—Val Gokenbach, DM, RN, MBA, Robert Wood Johnson Foundation, Detroit, Michigan, USA

ISBN: 978-1-4822-2514-3

9 781482 225143

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Organizational andProcess Reengineering

Approaches forHealth Care Transformation

Dr. Jean Ann LarsonFACHE, FHIMSS, DSHS

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“Dr. Jean Ann Larson has captured the critical criteria essential to create and sustain total organizational transformation by integrating the two strategic pillars of process and people. Jean Ann is a master and thought leader in organizational transformation based on her many years of practical knowl-edge and experience of transitioning organizations as an internal and exter-nal change catalyst. In Organizational and Process Reengineering, Jean Ann captures the keys to total success based on her unique and valuable insights along with her strategic and holistic perspectives to total health care transformation.”

—Imelda K. ButlerManaging Director of Century Management and

Cofounder of the Odyssey Consulting Institute, Dublin, Ireland

“This book reminds me of a few organizations I’ve consulted with where administrators only paid lip service to being for change. Their main objec-tive was to protect their job by keeping groups happy regardless of the cost. The groups could be the medical staff, the nurses or big donors. Too often I have presented significant savings opportunities or have seen other consul-tants do so and have the recommendations accepted but never implemented. I often have felt like the person who throws a rock in a pond making a big splash but then only seeing the circles widen and vanish. We need execu-tives who are leaders and not simply managers. Dr. Larson’s book addresses how organizations can make sure that they have the winning ingredients for change.”

—John L. Templin, Jr., LFHIMSS, FACHE, FAAHC, DSHS President, Templin Management Associates, Inc.,

Greenfield Center, New York

“It’s been said, ‘Education that doesn’t change behavior is a waste.’ I believe the same goes with process and organizational change. Jean Ann Larson is one of the few professionals I know who can convert research and experi-ence around large scale change and methodically make it understandable to those needing to apply it.”

—Duke RoheQuality Improvement Education Consultant,

MD Anderson Cancer Center, Houston, Texas

“Dr. Jean Ann Larson has developed an invaluable technique that integrates process reengineering and change management functions derived from her years of experience in the health care provider industry. This novel tech-nique will assist health care organizations to successfully transcend the implementation of new clinical and financial processes that will be required to address fee for value business models. This book will become an invalu-able tool for health care executives as they address the pain points of mov-ing from fee for service to fee for value.”

—Michael W. Davis Principal, Mountain Summits Advisors LLC,

Denver, Colorado

“Health systems are some of the most complex organizations in business. While most health care transformation books are conceptual rehashing of the same problems that have plagued this industry for decades, Dr. Larson’s book offers a refreshingly practical road map with real solutions that any health care organization should find beneficial.”

—Ivo Nelson CEO and Chairman, Next Wave Health,

Founder of Healthlink, Inc. and Encore, and board member of several health care-related businesses

“Dr. Larson has taken an all-inclusive approach that underscores the integra-tion necessary to provide high quality health care. She has taken 25 years of extensive experience in the health care field and provided practical solutions to a rapidly changing landscape. Dr. Larson’s approach transcends borders and is a must-read for those who consider themselves change agents in the health care industry.”

—Rudy Gheysen, BA, Dip.PM, CMM III PE, OCC President, Senior Consultant, Asymmetric Consulting,

Ontario, Canada

“Modern health care organizations find themselves in a tremendously pre-carious and challenging position to continually do more with less with-out compromising quality and patient satisfaction. Solutions to process change are oftentimes complex and far from easy. Dr. Larson has created a brilliant approach to organizational transformation through her unique

combination of approaches to process improvement coupled with her vast experience in the industry. This book is the only resource you will need to charge forward with courage and confidence to move your organization to unbridled success.”

—Val Gokenbach, DM RN MBA RWJF Leading Leaders

Formerly CNO of Beaumont Health Systems, Detroit, Michigan

“US health care is beyond simply picking the ‘low hanging fruit’ of siloed process improvement initiatives. True transformational change is a product of highly effective communication, collaboration, trust and a clear vision of the desired future state. Jean Ann cleverly aligns the best tools and tech-niques together that drive reliable, sustainable change to our modern health care organizations.”

—Rudy Santacroce, PE Vice President, Operational Excellence,

RTKL and Associates, Dallas, Texas

“My students are taught that designing and introducing the best processes and systems in the world are doomed to fail without championing organi-zational transformation that requires the understanding, appreciation, and buy-in for change by stakeholders. Therefore, I commend Jean Ann Larson for developing this book that emphasizes the coupling of health systems engineering and process improvement tools and techniques with effective change management to achieve successful cultural transformation and high performing and innovative health care organizations.”

—Barry T. Ross, LFHIMSS, DSHS Life Member-IIE

Adjunct Faculty, Health Policy and Management Department,Graduate School of Public Health and Field Faculty,

Department of Industrial Engineering, University of Pittsburgh, Pennsylvania

“If any industry is in need of transformation, it’s health care. And the perfect professional to lead this charge is Dr. Jean Ann Larson. Jean Ann’s educa-tion as an engineer, coupled with her vast experience as a senior leader in large health care organizations, confirms her as the expert to document this practical approach on how to implement change in your health care organization. Organizational and Process Reengineering: Approaches to

Health Care Transformation is an exciting read, full of hope and how-to’s for leaders who really want to take themselves and their organizations to the next level.”

—Elizabeth Jeffries, RN, CSP, CPAEExecutive Coach, Keynote Speaker,

Author of The Heart of Leadership: How to Inspire,Encourage and Motivate People to Follow You

“Transformational leaders have a true desire to seed the organization with smaller wins that will energize the journey of change. Organizational and Process Reengineering: Approaches to Health Care Transformation helped my leaders determine the most advantageous way to delve into our challenging areas. New proven tactics to age-old problems without rocket science!”

—Bennetta B. Raby Health Care Executive and Transformational Consultant

“I highly recommend that anyone who is a leader read Dr. Larson’s insights regarding the importance of process improvement and culture in change management and quality improvement. Her command of both process and structure to support outcomes is superb. In addition, she possesses vast knowledge and understanding of human behavior and its relationship to process improvement required to achieve performance excellence.”

—Gene Michalski President and Chief Executive Officer,

Beaumont Health, Royal Oak, Michigan

CRC PressTaylor & Francis Group6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

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This book is lovingly dedicated to my Mom and Dad, Eloise and Verl S. Larson, who have always believed in me and encouraged

me; and to my partner and husband, Robert I. Jaramillo, who is one of my biggest supporters; and to our daughters, Danielle

and Natalie, who continue to inspire me. I am blessed.

xi

Contents

Preface ....................................................................................................... xv

Acknowledgments ..................................................................................xix

Author ......................................................................................................xxi

1 Introduction and Intent of This Book .........................................1Why Use Reengineering and Process Redesign and Why Now? ...............2How I Am Defining Reengineering and Process Redesign .......................3Health Care Environment Today ................................................................4

2 Setting the Stage for Reengineering and Process Design ...........5How Continuous Improvement Differs from Process Redesign or Reengineering .........................................................................................5Why Do Organizational Reengineering and Process Redesign? ...............8How Do You Select Projects for Reengineering? .......................................8

Potential Financial Implications and Return on Investment (ROI) ........9When Not to Do Process Redesign ..........................................................10Who Are the Key Players and Why? .........................................................10What Are the Key Prerequisites for Process Redesign? ...........................11Of Special Note to Senior Leaders ...........................................................14Identifying Core Strategic Business Processes .........................................16Is Your Process Really a Core Process? ....................................................18

3 Change Readiness for Leaders: Are You Ready to Lead Change? .........................................................................21Overview of the Eight Factors of the Change Readiness Index ..............22

Eight Factors of the Change Readiness Assessment ............................23Are You Flexible When Change Happens? ..............................................25

Flexible Leadership ...............................................................................26Flexible Teams .......................................................................................26

xii ◾ Contents

Do You Have a Sense of Adventure? .......................................................27Adventurous Leadership .......................................................................27Adventurous Teams ...............................................................................28

Are You Confident to Lead Change? ........................................................28Confident Leadership ............................................................................29

How Optimistic Are You? .........................................................................29Optimistic Leadership ...........................................................................30Optimistic Teams ..................................................................................30

How Passionate Are You about What You Do? .......................................31Passionate Leadership ...........................................................................31Passionate Teams ..................................................................................32

How Resourceful Are You? .......................................................................32Resourceful Leadership .........................................................................33

Are You Tolerant of Ambiguity? ...............................................................33Leading through Ambiguity ..................................................................34

How Resilient Are You? ............................................................................34Resilient Leadership and Teams............................................................35

Conclusion and Opportunities to Learn More .........................................35

4 Organizational Change ..............................................................37What Is Culture? ........................................................................................39Role of Senior Leaders as Leaders of Organizational Change .................39What Does the Research Say? ...................................................................41Reengineering/Process Redesign Lends Itself to Being Led from the Top .............................................................................................41Kotter and Cohen’s Organizational Change Readiness Assessment ........42How Does the Organization Decide That This Is the Way to Go? .........42Is the Organization on Board? ..................................................................43Establishing and Leading Reengineering in Your Organization ..............44

5 Overview of the Methods and Tools ..........................................47Why Does the Organization Need to Change and Why Are We Targeting This Process? .............................................................................50What Are the Issues and What Is It That We Must Achieve? ..................52How Might We Create and Implement the Ideal Process? ......................55

6 Roles and Responsibilities .........................................................57Role of the Organization’s Senior Leaders ...............................................57Orienting Senior Leaders ..........................................................................58

Introductions and Icebreakers ..............................................................58

Contents ◾ xiii

Team Building .......................................................................................59Purpose of the Change Initiative ..........................................................60Do’s and Don’ts for Senior Leaders ......................................................60Current State Overview .........................................................................61Goals and Targets .................................................................................61Methodology Overview ........................................................................62Organization ..........................................................................................62Next Steps ..............................................................................................63

Role of the Facilitator ................................................................................63Choosing and Orienting Facilitators .....................................................64Challenges to Their Success ..................................................................67Orienting and Training Facilitators .......................................................68

Role of the Team Leaders .........................................................................71Orienting Team Leaders ........................................................................73Challenges to the Team Leaders’ Success .............................................73

Role of the Team Members .......................................................................75Choosing and Orienting Team Members .............................................80

Role of Other Support Professionals ........................................................83Identifying the Metrics for Success ...........................................................84

7 Methodology for Reengineering and Process Redesign Teams ....85Conduct a Concerns Analysis ...................................................................87Identify Goals and Objectives of the Ideal Redesigned Process .............91Establish Process Metrics ..........................................................................93Develop the Ideal Process Flowchart .......................................................95Check the Ideal Process ..........................................................................100Value-Added/Non-Value-Added Flowcharting .......................................102Perform Force Field Analysis ..................................................................106Develop the Implementation Work Plan ................................................ 113Employ Project Management Techniques .............................................. 114

How to Keep the Team on Track ....................................................... 116Ten Ingredients for a Successful Team ...............................................121Best Practices Checklist for Project Managers and Team Facilitators ....121Best Practices for Meeting Management.............................................122

8 Role of Technology and Innovation .........................................123Use of Redesign Principles .....................................................................124Use of Value-Added/Non-Value-Added Flowcharting to Assess If and How Technology Can Help .............................................................127

xiv ◾ Contents

Use of Force Field Analysis .................................................................... 131Review of Information-Based Activities .................................................132

9 Critical Success Factors ............................................................135Critical Success Factors for Reengineering and Process Redesign ........140

Senior Leadership Must Lead the Effort .............................................140Status Quo Cannot Be Acceptable ..................................................... 141Senior Leadership and Team Members Must Fully Engage in the Reengineering Initiative ........................................................... 141Resistance Should Be Expected .......................................................... 142Medical Staff Must Be Involved ..........................................................144Team Leaders Must Be Strong and Respected ................................... 145Team Members Must Come from All Parts and All Levels of the Organization ............................................................................. 145Mindsets and Approaches Must Change from Function to Process .....146Change Must Be Orchestrated and Led .............................................. 147

Key Success Factors and Conclusion ...................................................... 153Communication Must Be a Priority .................................................... 153Major Process Redesign Is Not a Quick Fix ....................................... 155Organizations Must Change, Too ....................................................... 155Use of Project Management Principles and Techniques Is Important ... 156

References ................................................................................................159

xv

Preface

With the most recent health care reforms included in the Affordable Care Act (ACA) and the American Recovery and Reinvestment Act (ARRA), health care systems are faced with the need to fundamentally change how they deliver care. And this must be done in a way that significantly brings down the costs of providing health care while making sure patients and communities receive the best possible care. There are many theories about how to do this, and many approaches to addressing this challenge. Some approaches help shift our think-ing from acute episodic care—when patients are sick or injured—to figuring out more holistic and proactive ways to keep us and our communities healthy, minimizing the need to use traditional health care services. This book mines the gap between the two ends of the continuum and helps us get from old reimbursement and payment models to fixed payments and population health models, thus helping our organization’s services thrive while we have the time to rethink how we care for ourselves, our patients, and our communities.

This transition may be painful, as are most major shifts, with both winners (us, patients, caregivers) and losers (those who have made millions of dol-lars in the current system). Those heated debates lie outside the scope of this book. However, the approach described here will help us work with our teams at all levels of the organization to fundamentally reduce costs and improve quality and outcomes. The methods and tools are actually quite simple—if only they were easy. The biggest challenges are to change our thinking, trans-form our organizations, and make the transition to a new way of leading and managing the health of our organizations, communities, and our nation.

The biggest challenges are to change our thinking, transform our organi-zations, and make the transition to a new way of leading and managing the health of our organizations, communities, and our nation.

xvi ◾ Preface

Who Is This Book Written for?

This book is for senior leaders of health care systems and process improve-ment professionals who are looking for ways to lead and implement funda-mental change in organizations and our health care delivery systems and care processes. They can appreciate that much debate will continue on the national and state levels. However, they desire to do something now, and they want an approach that they can use to begin transitioning their pro-cesses from where they are today to where they need to be to thrive in the new environment. As opposed to being frozen by uncertainty and fear and feeling they are victims, they want to take proactive steps to make their organizations successful and allow them to continue to exist for the patients and communities they serve. The good news is that this approach can be facilitated internally with innovative ideas coming from the physicians, nurses, other caregivers, and leaders who currently manage the processes and the organization. Thus, the approach encourages leaders who know that their organizations can be different and who want to reconnect with their original reasons and motivations for pursuing a career in health care.

What Is Unique about This Book?

There are many books written on process improvement methods. Other books are available that discuss leadership’s role in organizational transfor-mation and change. My experience as a health care leader and executive convinces me that these disciplines lead to organizational transformation and are only effective in the long run when they are melded to provide an inte-grated approach. The intent of this book is to provide a road map as well as the tools and approaches that will help health care leaders combine process improvement and organizational transformation approaches to guide them and their organizations to dramatically improved ways of providing care and serving their communities. The book includes templates, tools, checklists, agendas, and even an approach to strengthening leaders’ abilities to process, react to, and manage the change that they themselves will be experiencing while they are leading their own teams and organizations. This approach has been developed over twenty years and reflects my deep experience and research and educational pursuits in industrial engineering, leadership, and organization change. I realized as a young(er) process engineer working in health care that no matter how good the process improvement tools and

Preface ◾ xvii

methods were—be they Plan–Do–Study–Act (PDSA), Lean, or a variation thereof—they were not sufficient. I found that we needed approaches where senior leaders could lead and where the organization’s culture could be honored for new behaviors to emerge and allow lasting real change. In fact, today those who are effective in using these methods are led by leaders who get the fact that they have to lead their organizational change initiatives.

This book reflects my learning and experience as a senior health care executive, a leadership and organization change researcher, and now as an executive consultant. I hope you find it helpful. And I would love to hear from you and have you share your successes and what you learn along the journey. Only through continuing the dialogue and our experiences can we continue to improve health care for ourselves and our loved ones.

Dr. Jean Ann Larson

xix

Acknowledgments

Writing a book is a large endeavor as anyone who has written one knows. This book itself is just a capstone representing years of practice, study, and work with amazing colleagues from whom I have learned a lot. As you will see in the work referenced in this book, I truly stand on the shoulders of many giant thought leaders who have gone before me and shared their learn-ing so generously. First of all, I am thankful to the leaders and organizations who have allowed me to try and experience these concepts in the real world. I appreciate their faith and trust in letting me work with their very best people. One of these organizations includes Beaumont Health System in Michigan, where much of this work was conceived and refined. I particularly want to thank former CEOs Ken Matzick and Gene Michalski for encouraging me and trusting me with this work under their leadership. Also, I offer thanks to all the other leaders and team members who proved to me that by working together using these methods, we could improve processes, improve patient care, and help people learn and grow while making organizations better places to work. Other health care organizations where I have more recently used this approach include Children’s Medical Center of Dallas and CHRISTUS Health.

I also want to thank Kris Mednansky, my editor at CRC Press, who con-vinced me that this book would be more than just a second edition of the book I wrote in the mid-1990s. Her insights and patience are greatly appreci-ated. As she put it, “You’re a much different professional now, so you’ll bring much more to it and write a very different and relevant book.” Thanks for not letting me give up on this project. Also, thanks to the many professional colleagues who encouraged me (you know who you are) and convinced me that this book will benefit the health care industry and add value. My copy editor, Diane Montgomery, did more than improve the grammar. She helped me clarify my writing and, most important, was enthusiastic about the topic and encouraged my efforts even in the dark days of writing.

xx ◾ Acknowledgments

I also offer love and gratitude to my husband and partner, Robert I. Jaramillo, who helped all along the process, constantly encouraging me while critiquing difficult sections and helping make them clearer. With his attention to detail and knowledge of publishing, he helped me pull the man-uscript and figures together, improving the book every time he touched it.

I am humbled.

xxi

Author

Dr. Jean Ann Larson has led organizational, professional, and business transformations for more than twenty-five years. She has served as an inter-nal process engineer and consultant; a change agent; vice president of clini-cal quality and safety; and chief learning officer, founding an award-winning and respected corporate university. She also served as a senior executive of two large health care organizations where she led the functions of organi-zational effectiveness, process improvement, executive development, talent management, team building, employee engagement, accreditation, care man-agement, quality and patient safety, as well as leading several clinical areas.

She is a past president of the Society for Health Systems of the Institute for Industrial Engineers and past vice chair of the Healthcare Information and Management Systems Society. She also holds various certifications in process improvement, consulting, executive coaching, and several diagnostic assessments.

Dr. Larson earned a bachelor’s degree in industrial engineering, an inter-national MBA, and a doctorate in organizational change from Pepperdine University, with an emphasis on personal, professional, and organizational transformation and change. She has written, edited, and published books and many articles on process redesign, process improvement, leadership, organization change, and organization transition. She is the editor and one of the many chapter authors of Management Engineering: A Guide to Best Practices for Industrial Engineering in Health Care (CRC Press, 2014).

Jean Ann is a frequent presenter at national and international conferences on change management, leadership, transformation, cultural change, process improvement and redesign, and learning and organization development. Her passion is helping leaders, teams, and individual practitioners make lasting improvements in their processes, working relationships, and organizations.

xxii ◾ Author

She firmly believes that the best ideas for improvement come from those who are closest to the work.

She is founder and managing partner of her own consulting firm, Jean Ann Larson & Associates, where she works with clients to help them dra-matically improve their ability to deliver results, improve their organizations, and execute their most challenging goals.

1

Chapter 1

Introduction and Intent of This Book

In the introduction of an earlier edition of this book in the late 1990s, I noted health care was changing so quickly that incremental improvement approaches would not always be adequate or appropriate. I stated that the changes the public and consumers needed from health care could not be delivered using continuous improvement approaches and tech-niques alone. This is even truer today. To meet the demands of changing demographics— older, heavier, less healthy patients—the changing envi-ronment with reduced revenues, rapidly evolving technologies, and more regulations, it is critical to learn strategies and methods for construct-ing different, new, and vastly improved care delivery approaches and processes.

As a senior leader or internal team facilitator of an organization, the process of taking teams from a blank sheet of paper to a radically reengi-neered process that meets the goals and objectives that you, your execu-tive team, and your board have set to meet new external constraints and challenges— along with hitting your ambitious stretch targets—can seem like the most daunting part of the change process. The steps, tools, and techniques outlined in this book can be used independently or in conjunction with each other to help a team move from that blank sheet of paper to a newly and radically redesigned process. The biggest chal-lenge in reengineering organizations and process is often the transition we need to make in our own thinking. Thus, the reengineering approach described in this book uses principles of organizational, team, and

2 ◾ Approaches for Health Care Transformation

human dynamics while being rooted in process improvement and engi-neering. Not only do organizations benefit from the new processes, but the initiatives also result in transformed teams and increased capacity in leaders and employees.

The approach and mindset outlined in this book is simple to learn and use. It allows and even requires that all stakeholders come to the table. It does not require expensive certifications, engineering degrees, or the use of complicated processes or tools. It does not replace current improve-ment methods such as Plan–Do–Study–Act (PDSA), Lean, or Six Sigma, but instead provides an organizational-based framework that helps leverage those efforts when applied appropriately. The approach should be leader led, which is preferable, or it can be part of an organizational-wide change initiative. Those at the grassroots level can use the facilitation methods to initiate fundamental changes within their own spans of control and scopes of service.

Why Use Reengineering and Process Redesign and Why Now?

As a process improvement professional and senior leader working in health care for almost thirty years, I maintain that process improve-ment is timeless and can never stop. Even if our current financial and regulatory environment did not demand it, continuous improvement is vital to staying on top of the constant incremental and game-changing shifts that occur in health care. These changes happen due to develop-ments, such as advances in medicine, science, and technology, which ultimately improve the health of individual patients and the health of the community.

The good news is that the American Recovery and Reinvestment Act (ARRA) of 2009 and the Affordable Care Act (ACA) make continuous improvement and reengineering a necessity—not just a nice-to-do activity. All processes can be improved. Many should be thrown out or reengineered. We also need to design new processes for providing better care where those processes do not yet exist.

Health care needs to improve a lot, not just a little. In a 2014 poll of nearly 150 CEOs and other senior leaders, a survey found that 69% noted the need to increase process efficiency, 51% intended to reduce costs with suppliers, and 45% planned to reduce redundant procedures in care

Introduction and Intent of This Book ◾ 3

(Gamble, 2014). These statistics do not fully take into account continued hospital consolidations and a substantial delay in capital expenditures. Health care no longer has the luxury of doing the annual budgeting dance where everyone tightens their belts to eke out a 5%–10% reduction in expenses. The days of shifting costs around in a constant shell game in health care are over. Studies show that health care needs to reduce costs by 40% during the next five to ten years (Dunn, 2014a). Simple process improvement will not get us there.

The only real long-term sustainable way to take costs out of provid-ing health care while improving quality and safety is by focusing on processes, people, technology, and the ways these intersect to make up our care systems. We also need to consider the context and environment, including the organizational culture, leadership, structure, legal, regula-tory, and financial state of affairs, and the community being served. We must knock down the silos and take a holistic approach to change and reengineering.

Leaders of health care providers note that there is a “Triple Aim,” a frame-work developed by the Institute for Healthcare Improvement that calls for simultaneously improving the individual experience of care, improving the health of populations, and reducing the per capita cost. Though this is an enormous challenge, the reengineering approach as described in this book can help meet that Triple Aim. It will help organizations transform their culture, using collaborative efforts while employing systems engineering principles successfully long used in other industries.

How I Am Defining Reengineering and Process Redesign

Reengineering involves redesigning the entire business process and related subcore processes and systems. It includes organizational redesign and restructuring as well. Process redesign is redesigning a defined part of the

The days of shifting costs around in a constant shell game are over. The only real long-term sustainable way to take costs out of providing health care while improving quality and safety is by focusing on processes, people, technology, and the ways these intersect to make up our care systems.


care or delivery process. It is a fundamental transformation of the organi-zation. Reengineering and process redesign approaches are different than continuous improvement, though some of the tools and techniques may seem similar. This approach does not replace continuous improvement, nor is it superior. It is a different methodology used for a different purpose. It is used when there is no current system or process to improve or when a cur-rent process needs more than improvement—it needs to be fundamentally redesigned. It is what we need for our health care systems when we need to rethink how we deliver care and transform the organization.

Health Care Environment Today

As mentioned earlier, recent challenges caused by the ARRA and ACA make dramatically improved processes a minimum requirement, not a luxury. As revenues shrink and bond ratings for health care organizations fall, access to capital for replacements for aging facilities and technology continues to decrease. We need new processes and approaches that help our organiza-tions reduce costs while increasing capacity so we can continue to serve our patients and communities despite health care’s evolution into models that include fixed and capitated payments across the board, accountable care organizations (ACOs), and per member/per month fees. In many markets, this is already the new reality. Some organizations have already figured out how to survive and perhaps thrive in this environment.

Reengineering involves redesigning the entire business process and related subcore processes and systems. It includes organizational redesign and restructuring as well.

5

Chapter 2

Setting the Stage for Reengineering and Process Design

This chapter addresses the best way to set the stage in your organization for process redesign and reengineering. Some of the approach is similar to what a continuous improvement practitioner might employ, whether using Define, Measure, Analyze, Improve, and Control (DMAIC); Lean; PDSA; Six Sigma; or some other performance improvement methodology. However, what is unique about this approach is crucial, even if the difference is only in emphasis. One of the first things I recommend is that you explore whether or not your team should utilize a quality improvement approach or a process redesign approach. Both approaches have their value but only when they are used appropriately.

How Continuous Improvement Differs from Process Redesign or Reengineering

Perhaps you find that traditional process improvement methods do not yield the game-changing results you need in your organization. The first question to explore is whether or not your core processes are sound or unsound, or if parts of those processes are nonexistent or chaotic. If you are dealing with a sound process, you should employ continuous improvement methods. Using reengineering or process redesign in this instance would be unnecessarily


disruptive—if done correctly and true to definition, it could potentially do needless harm to a sound process. However, if the process in question is unsound, obsolete, or has not yet been developed, reengineering, along with process redesign tools and techniques, is appropriate. It is pointless to incrementally improve an unsound or obsolete process. And it is impos-sible to improve a process that does not yet exist. Throughout this book, the basic difference, sound process versus unsound or nonexistent process, will determine which approach you should use. When you are considering a reengineering initiative, as a senior leader you need to ask yourself if you are ready for an organization-wide transformation.

So what are the indicators that you may want to consider reengineering or process redesign to increase the magnitude and speed of desired results? The first might be that you have tried to incrementally improve the process— maybe more than once—and you find that is not enough and does not pro-duce the results you need. Next, you may consider using process redesign when the fundamental rules of how the work is done are suddenly changed. For example, have there been markedly new federal or state regulatory requirements that will profoundly influence how the work gets done? Or are you implementing a game-changing medical or information technology (IT) advancement? These issues may lead to reason three, which is when you know you have to create a brand new process—due to new technology or because your organization has a new service line, market, or group of cus-tomers. Additionally, if you need to get the team and stakeholders to think creatively, give up their tight grip on “the way we’ve always done it,” and get on board with the needs and details of a new way of doing things, process redesign may be the approach to use. Once the goals and objectives of the new processes are determined and agreed upon by the stakeholders, sponsors, and redesign team, the possibilities of how to accomplish those are endless.

In conclusion, it is always good to consider reengineering and process redesign when you need to redesign or improve major, critical core business processes. Redesigning your core processes will not only influence much of the rest of your business, but it will also provide many other opportunities for continuous improvement in other processes along the way. In Table 2.1

When you are considering a reengineering initiative, as a senior leader you need to ask yourself if you are ready for an organization-wide transformation.

Setting the Stage for Reengineering and Process Design ◾ 7

Table 2.1 Process Improvement versus Reengineering

Use Process Improvement?Use Reengineering or

Process Redesign?

Assumption • Process is sound• Process is stable and can

easily be documented

• Process is not sound or is obsolete

• Process not stable

Style Analytic Synthetic

Essence Process exists and performs OK e.g., your current process is working but it just needs to be improved a bit

Process does not exist or is very chaotic:• New process to support a

new service line• New type of customer or

patient requires a new process

Approach Incremental improvement will give you the results you need

Incremental improvement is not sufficient

Level Fundamental assumptions about how the work is done remain the same (micro)

Fundamental assumptions about how the work is done have changed (macro)• New regulations• New clinical technology• New medical science finding

Change Limited Holistic

Goal Enhancement Stretch

Discipline Industrial engineering Research and development—innovations

Domain Need to improve a few processes that are not core business processes

There is a need to develop or redesign major core processes affecting a large proportion of your organization

Executive role

Need an executive champion (support)

Need top-down buy-in of senior clinical and administrative leaders for the change to happen (leadership)

Extent Widespread Concentrated on strategic initiatives

IT role Incidental Fundamental


you will see a summary of when it is best to use process improvement tech-niques versus a reengineering approach.

Why Do Organizational Reengineering and Process Redesign?

With all the improvement methodologies available, why reengineer health care processes? This book illustrates that this approach can help you inte-grate and apply other methodologies when appropriate. It is particularly helpful when you need to fundamentally overhaul processes or create com-pletely new ones. As mentioned earlier, I do not recommend this approach when other continuous improvement methodologies will meet your needs. However, when you need to completely change and reengineer how you serve your patients, communities, and customers—when a complete redo of processes needs to happen, or when you need to create or invent new processes—this approach will get all the right people at the table. It also facilitates everyone working together to identify and agree upon the appro-priate overarching goals before any project charters or specific objectives are written. My experience has been that it is preferable and more lasting for the reengineering approach to start at the top of the organization with the CEO and executive council. The entire organization needs to be behind this organizational transformation. However, it is possible for leaders of individ-ual service lines or core processes to also use the methodology to achieve game-changing shifts in how care is delivered, albeit with limitations in scope. This process redesign approach provides a simple methodology that may be quickly learned and facilitated to help a team reengineer and redesign even the most complex processes or those processes that do not yet exist.

How Do You Select Projects for Reengineering?

Perhaps in your organization you are grappling with your patient direct admit process. Or is your goal to improve your revenue cycle or care management processes? You may realize that to survive when fee-for-service payment models go away, you are going to have to fundamentally transform your culture and reengineer your care processes. No doubt you have already tried different continuous improvement processes such as PDSA, DMAIC, Lean, Six Sigma, Change Acceleration, or a consultant’s redux of any of these. As


mentioned earlier, I am not devaluing any of these approaches. I have relied on many of them for various projects throughout my career. However, there comes a time when you need a more substantial approach. One might argue that given the current health care challenges we face, that time is now. Later, traditional tools, like PDSA or Lean, and even more sophisticated tools, such as Six Sigma, can be brought in and employed if and when appropriate.

Champy and Greenspun (2010) suggest that to find reengineering oppor-tunities, you should

◾ Focus on areas of risk. ◾ Focus on high-cost areas. ◾ Focus on the work of the physician. (And I would add the nurse.) ◾ Focus on the patient. ◾ Focus on areas where you can succeed. (I note that you should select areas where failing is not an option—if it is too easy, it is probably just incremental change.)

Champy and Greenspun (2010) provide general guidelines. I suggest you explore those processes and initiatives that must be successful for your orga-nization to realize its mission, vision, and strategy, and maybe even to sur-vive. Think about the following potential impacts and implications of doing reengineering. Which ones might be appropriate for your organization?

Potential Financial Implications and Return on Investment (ROI)

1. Reduced waste and process steps cause costs to decrease, improve safety by reducing the potential for errors, and improve patient satisfac-tion and employee engagement by reducing and eliminating the parts of the processes that frustrate and delay both patients and caregivers.

2. Increased capacity, by improving throughput of patients, increases the productivity of people as well as assets and facilities.

3. The ROI can be calculated by assessing reduced expenses (e.g., labor, supplies, or overtime [OT]) and improved revenues, or by reduced fines in today’s markets when we do not meet the patients’ expectations.

You may realize that in order to survive when fee-for-service payment models go away, you are going to have to fundamentally transform your culture and reengineer your care processes.


When Not to Do Process Redesign

We have talked about when to consider reengineering and process redesign, but it cannot be emphasized enough that the approach or methodology is not a panacea and it should only be used when appropriate. In short, you should not do process redesign if

◾ You are not intentionally trying to transform your organization. ◾ You have a viable current process, which if improved, would be adequate for the results you are seeking.

◾ Your current process improvement methodologies are working. ◾ You do not want the disruption from the significant change that process redesign can cause.

◾ You only have a few processes to improve. ◾ You have reviewed Table 2.1 (Process Improvement vs. Process Reengineering) and concluded that it is not needed.

Who Are the Key Players and Why?

Organizational reengineering requires that senior leaders lead the major organizational change initiative that this approach of reengineering and redesign entails. The board of directors should also understand the potential risks and impact. The effort may be one of the organization’s biggest challenges, and before success is achieved, there will be trying times.

Additional key players include physicians, nurses, clinicians, and others close to and responsible for the process or service line. You need their subject matter expertise, their commitment to make patient care better, and their courage to own the newly designed processes. In addition, each core process will need skilled facilitators, service line leaders, and the appropri-ate support staff resources such as financial, planning, IT, marketing, and PR professionals. Your reengineering effort needs to include this diverse group of experts since you are changing people, processes, technology, and the very work environment, which includes culture, organization structure, and

You should not do process redesign if you are not intentionally trying to transform your organization.


reporting relationships. The organization and its people will be transitioning in every way imaginable.

What Are the Key Prerequisites for Process Redesign?

One key requirement is the right mind-set. As senior leaders of the organi-zation, you need to be willing to make fundamental changes to the ways in which your organization cares for patients. It is not about tweaking a few things or making incremental changes. Reengineering is for the benefit of your customers or patients—not for your organization’s convenience. As leaders, you will have to demonstrate some humility and admit that you may not have all the answers or be benefiting patients and customers at all times. In fact, you may find that large parts of your organization are very diffi-cult for your patients to navigate. Because of the complexity of health care organizations, in the past you may have solved one or two problems and created eight to ten more. Even though you may be an industry expert or highly trained professional, you still have to accept the need to listen to the customer—what Lean calls the “voice of the customer” or VOC. If you do not believe this, your newly redesigned process will be temporary, not meet the organization or process goals, and may even ultimately fail, meaning that

Your reengineering effort needs to include this diverse group of experts since you are changing people, processes, technology, and the very work environment, which includes culture, organization structure, and report-ing relationships. The organization and its people will be transitioning in every way imaginable.

Reengineering is for the benefit of your customers or patients—not for your organization’s convenience.

Even though you may be an industry expert or highly trained professional, you still have to accept the need to listen to the customer—what Lean calls the “voice of the customer” or VOC.


it may be worse than the process it was supposed to replace—not to men-tion the financial loss from the costs you have incurred from investing time and resources to do the redesign.

You have to have the courage and stomach for fundamental game-changing transformation. Often, ideal processes initially seem to be a threat to stake-holders across the board. Some will perceive that the new process will take away their power and influence while others will gain from them. Your val-ues have to evolve from protecting your own specialty or turf to helping the organization as a whole become more productive. Jobs often become more multidisciplinary and may seem more complex to the organization. However, if it simplifies the processes for the patient or customer, it is well worth it. In addition, the traditional organizational hierarchy will need to become more process and team oriented as the organization becomes more focused on results and outcomes versus functions.

To make organization-wide reengineering and process redesign a suc-cess, managers will have to grow their skills beyond being supervisors and instead learn to coach their employees. For many managers and leaders, this is a new skillset. They may never have had a leader in their own past who was able to coach them. They may also see their employees’ success as a threat. They need to view their employees’ success in the process reengi-neering initiative as if it were their own success. Rewarding managers for coaching can send a powerful message that coaching is valued.

Creativity and problem-solving become as important as complying with standard operating procedures. Though the intent is not to diminish the importance of both clinical and legal compliance, it should not be the sole measure of success. Leaders, managers, and employees must learn to problem-solve, understand root cause analysis, and know how to apply creativ-ity and innovation in new situations. They have to be open to trying new approaches and methods.

When measuring the need for or the impact of reengineering or process redesign efforts, you will need to find ways to go beyond just the typical financial measures. To fully gauge how well the process is improving the patient’s experience and outcomes, you want to hone in on key operational measures. There may be only a few measures you can select using your existing data; however, even one or two indicators can be very compelling. As you begin to redesign processes, you will observe that real costs do get taken out of your organization. Operational changes and improvements lead financial measures, so the changes you implement will ultimately show up as stronger financial health of the organization.


You must tip your organization on its side and adjust its focus from tra-ditional functions to processes—as your customer and patients experience them. In particular, you should be aware of the gaps between the functions that are often unseen by those within the organization but are very visible and frustrating to customers and patients. Those gaps are the parts of their encounters with your organizations that not only frustrate them but also may be risky in some ways if not even potentially dangerous. Think of all the places where either the information, the patient, or both change hands.

Figure 2.1 illustrates the transformations that you must undergo if you want to move from a traditional hierarchical organization to one that embraces the need to fundamentally reengineer core business and care processes.

You must tip your organization on its side and adjust its focus from tradi-tional functions to processes—as your customer and patients experience them.

From To

Jobs

Structure

Axis

Manager

Executive

Priority

Measures

Focus

Values

Multidimensional

Team

Process

Coach

Leader

Result

Operational

Customer

Productive

Narrow

Hierarchy

Function

Supervisor

Bookkeeper

Activity

Financial

Manager

Protective

Figure 2.1 Reengineering transition. (Courtesy of the First Consulting Group.)


Of Special Note to Senior Leaders

Most of us manage and lead the way that we were led. However, if your organization is highly dependent on command-and-control styles of leader-ship, and you are not ready to change this, I suggest that you not read any further. Your frontline employees and those closest to the customers and patients will be your biggest source of intelligence and the font of many great redesign ideas. In this new type of culture, leaders must let go of con-trolling, micromanaging types of behavior and focus on the results and out-comes. They must allow employees to voice their opinion and challenge the usual ways of getting things done. Instead of managers complaining about new younger generations and how they challenge the way things are done, they should encourage these behaviors as long as the dialogue remains con-structive and helpful. (This conversation can be facilitated by a skilled facili-tator, if preferred.) Ultimately, as the senior leader, you will need to make the decision about what is right for the company and what new changes will help implement the new processes while meeting the overall goals of the redesigned processes and the organization. So, you will have the ultimate say, but if employees get tired of speaking up and making suggestions, or if they perceive this is not allowed, you will never get the input from them later when you want it.

Transitioning from a command-and-control micromanagement style of leadership to a more participative coaching approach is not easy. You may wish to employ an executive coach for yourself or others on the senior leader-ship team to help facilitate the transition. You do not want your senior team to be the major obstacle to organizational reengineering success. Another prerequisite is a true belief that those closest to the process and the customer have knowledge beyond that of the top leaders. This belief is often missing in hierarchical command-and-control organizations. This can be tough for many leaders who want to jump into the weeds or, worse yet, second-guess every reengineering team decision and micromanage every effort. As leaders, we have to truly let go of controlling our team and trust the process. If we set the

Your frontline employees and those closest to the customers and patients will be your biggest source of intelligence and the font of many great redesign ideas. In this new type of culture, leaders must let go of con-trolling, micromanaging types of behavior and focus on the results and outcomes.


overall organizational and process objectives, and the new processes realis-tically meet those objectives, our teams are accomplishing their objectives. Again, since it can be a tough transition to let go of this control, you may wish to consider an executive coach to assist you and your team.

Leaders need to more than buy-in to the process redesign approach; they need to sell it. By selling it, they need to engage their colleagues and employees at all levels, particularly those closest to the core processes and delivery of care. Even Kotter and Cohen (2002) changed their communica-tion step from communicating with employees to engaging employees in order to successfully implement change. This is a subtle but vital difference. Leaders need to be rewarded for engaging their teams and for doing process redesign or reengineering—realizing that if they keep doing what they are currently doing, the organization and the patients will ultimately lose. In the short term, individual leaders may win the political contest while losing the overall battle in that the organization becomes less successful or even fails when other organizations are able to steal market share.

Team leaders with the courage and the ability to support their teams are critical to success, as are facilitators who know how to guide the process and keep it moving without dictating or taking it away from the partici-pants. The organization will provide many naysayers and challenges to the teams who are reengineering how care is provided. Team facilitators, along with the leaders, will need to fully embrace both process improvement and organizational development methods to fully engage the participants while maintaining the trust and respect of leaders and peers at all levels of the organization. Some of the key attributes of a successful leader of organiza-tional reengineering and process redesign are

◾ The ability to listen to employees and seriously consider their ideas ◾ The ability to let go of control and not micromanage ◾ The ability to accept that the people who do the work have a unique level of knowledge, are closest to the process, know it better than senior leaders, and are best able to redesign it

As leaders, we have to truly let go of controlling our team and trust the process. If we set the overall organizational and process objectives, and the new processes realistically meet those objectives, our teams are accomplishing their objectives.


◾ The ability to accept that patients and customers have unique and valu-able perspectives

◾ The ability to “sell” difficult new actions and behaviors, and engage all employees

◾ The ability and willingness to assign skilled competent facilitators to the reengineering teams and allow them to do the necessary work, even if it temporarily takes them away from doing their regular assign-ments or roles (The really good facilitators are usually fought over in an organization.)

Identifying Core Strategic Business Processes

The next important task is for the organization to determine the core busi-ness processes or clinical services that need to be the focus of the process redesign efforts. The process of determining and identifying the core pro-cesses that your organization will focus on is a top-down approach with grassroots participation. What does this mean? The leaders identify the core processes and then determine the overall goals. Later as we undergo the reengineering process, we will identify more specific objectives and metrics for each of the targeted core processes.

If an organization has already identified centers of excellence or clini-cal service lines, this will make it an easier task. There are several ways to identify your major lines of services: by volume, by revenue, by capital investment, by community need, or in most cases, through some combi-nation of these. For a hospital, overall clinical service lines might include obstetrics, cardiology, surgery, and pediatrics. In the case of specialized hospitals, clinics, or physician practices, the core processes would be developed on the basis of the major type of customer or patient served. The main thing is to try to step outside of your own perspective and think how patients or customers might view you and experience your services.

Once you have a fairly long list—and it will get long quickly—the next step is to prioritize your service lines and core business processes. This

The main thing is to try to step outside of your own perspective and think how patients or customers might view you and experience your services.


expansion of the list happens because once you have made reengineering your key change initiative, everyone would want to be a part of it, or at least use the approach to solve their key challenges. I suggest you use a modified Pareto analysis to pare the list down to the top five or six service or business lines that either serve 80% of the patients, provide most of the organization’s margin, or will be influenced by the changing reimbursement methods. The good news is that if you use a rational approach, you cannot go wrong. Even if one of your favorite services is not selected initially, improvements to the major service lines will have a significant impact on the other smaller service lines.

Another way to add value to the prioritization process is to find some appropriate benchmarks to help you identify where it seems you have the biggest opportunities for improvement and growth. The areas where you can improve the most, though challenging at first, can provide the biggest ROI financially and politically—if leadership is ready to tackle the 800-pound gorilla, then they must be serious about this initiative. Another service line may become part of your top five or six by virtue of it being a very competi-tive one or where you have had problems in the past. For example, many organizations select obstetrics because it is often a family’s first experience with a health care system. If this experience makes a good impression with new families, they may continue to use your health care facility for future services. Additionally, today’s new payment models offer us opportunities to go boldly where we have not gone before. For example, those opportunities include creating an Accountable Care Organization (ACO), ensuring that care management processes within providers and within health plans truly help us reduce readmissions, proactively attend to patient populations, and help patients deal with chronic health issues before costs increase and patient outcomes are not what they need to be.

If your organization grapples with prioritizing major initiatives, you may use internal or external consultants to ensure that you are being rigorous in your approach to prioritizing and selecting the core business processes; otherwise, your efforts will be diluted and unsustainable. You want to avoid politicizing the prioritization process as much as possible. Also, you may consider run-ning your core processes and major initiatives through an organization-wide

You want to avoid politicizing the prioritization process as much as possible.


enterprise project management office and senior executive–led steering com-mittee to make sure that the correct initiatives are selected and supported.

The final concern is that you select those service lines where process redesign can provide the organization the most bang for the buck in ROI: improved patient outcomes and satisfaction, competitive advantage, and abil-ity to compete in the marketplace. As mentioned earlier, this is an approach to use when you find that taking a cautious or incremental approach has not gotten you to goal in the past. So go ahead and target that new process you need to develop or the current one that is costing your organization the most in terms of not only costs but also in patient quality and patient satisfaction.

Is Your Process Really a Core Process?

Organizationally and strategically, you must define what your core processes are. You may already have value stream maps of some of them. However, just because you have developed a flowchart for a process, it does not mean it is a core process. You must ask questions such as, Who are our customers? Whom do we serve? What business do we want to be in? What is our spe-cialty or niche? What do we want to be known for? How do our customers and patients experience us? What are their biggest frustrations?

To help the senior leader determine if he or she is focusing the organiza-tion on the right processes, I offer the checklist provided in Table 2.2.

There will be a tendency to want to make every process or service line part of a core process and your reengineering efforts. I suggest that orga-nizations select five to eight core processes that encompass 75%–80% of patients by volume or revenue. For nonclinical areas, select the process that drives 80% of your business or activities. You want to focus the orga-nization on areas where concentrated reengineering efforts can yield big results so that leaders, facilitators, and other key resources are not spread too thin.

There will be a tendency to want to make every process or service line part of a core process and your reengineering efforts. You want to focus the organization on areas where concentrated reengineering efforts can yield big results so that leaders, facilitators, and other key resources are not spread too thin.


Table 2.2 Core Process Checklist

Yes/NoIs the Targeted Process Really a Core Business Process

That Should Be Reengineered?

Do a significant number of patients and customers experience this process?

Is it a significant source of revenue?

Is it an integral part of our mission, key strategy, or major initiative?

Is this process as is putting us at risk owing to falling revenues?

Is this process as is putting us at risk owing to community concerns?

Is this process as is putting us at risk owing to changing regulations?

Is this process as is putting us at risk owing to patient satisfaction concerns?

Is this process as is putting us at risk owing to patient safety concerns?

Is this process as is putting us at risk owing to a large number of complaints?

21

Chapter 3

Change Readiness for Leaders: Are You Ready to Lead Change?

Everyone thinks of changing the world,but no one thinks of changing himself.

Leo Tolstoy

There is a great need for a change in mindset for reengineering or process reengineering efforts to be effective. In particular, this is true for senior leaders. When expecting an organization to make fundamental change, how leaders approach the situation is critical. Everyone will watch how those guiding the reengineering efforts behave and work together—or do not! Senior leaders need to let go of control and trust the team to meet the agreed upon organizational and process objectives. When dealing with change, leaders need to understand and appreciate their own and their col-leagues’ strengths and vulnerabilities.

In my work with reengineering and other organizational change initia-tives, it is apparent that we each perceive and react to change differently. And there is no one way or one right way. I developed a Change Readiness Index to help leaders and members of teams gain awareness about their own reactions to change, allowing them to identify strengths and potential areas of vulnerability. This change readiness assessment helps individu-als, leaders, and teams identify vulnerabilities and blind spots while also identifying strengths you can employ as you experience, react to, and


even lead change. The change readiness assessment helps each individual understand their unique change profile, as well as the unique profiles of their colleagues and team members. This awareness allows the team to draw upon complementary strengths to more effectively lead change in the organization.

As you read the following overview of the eight factors of the Change Readiness Index, ask yourself the following questions and reflect upon them:

1. How do you perceive change? 2. How do you react to change? 3. How do you and your team experience change, advocate executive

team development, and focus on the goals? 4. What are the implications for the organization? 5. How can you approach change differently in order to be effective?

Overview of the Eight Factors of the Change Readiness Index

We all perceive and respond to change differently, and we each have dif-ferent strengths we can leverage in how we approach change. I developed the Change Readiness Index to help us understand how we, as individuals and teams, experience and react to change differently, and how we can leverage our strengths and capabilities to help us more effectively cham-pion change in our organizations. These differences have a significant impact on leadership styles and affect how we influence others. As lead-ers of organizations and teams, one of our most important roles is leading change.

The eight factors of change readiness I have identified help us take a closer look at how we are affected by change and allow us to more coura-geously forge the path ahead. Each of the following sections in this chapter explain the eight factors, why each is important, and the various pros and cons of scoring too high or too low in each area. At the end of this chapter, you will have a better understanding of your change readiness profile and how to leverage your unique traits.

In addition to the earlier reflection questions, I encourage you to com-plete the reflection questions at the end of each section. To begin, think about how you perceive change and react to it. And think about the times

Change Readiness for Leaders ◾ 23

you have reacted differently than your colleagues when a significant change occurred.

◾ How do you believe you feel about change compared with your col-leagues? Family members?

◾ Are you more open to change in your life than others are? ◾ Is your openness to change different in your professional life versus your personal life?

◾ Why or why not?

Eight Factors of the Change Readiness Assessment

The Change Readiness Index is designed to assess the eight factors of change readiness. When dealing with change, each of us will show vary-ing degrees of intensity in each factor. Ideally, we would exhibit at least a moderate level of each. As we will see, it is not necessarily good to score extremely high, nor is it bad to score really low. In fact, it is helpful to have individuals on teams with different strengths and traits as they then can help the team deal with change in diverse ways.

The eight factors are:

◾ Flexibility ◾ Adventurousness ◾ Confidence ◾ Optimism ◾ Passion ◾ Resourcefulness ◾ Tolerance for ambiguity ◾ Resilience

The index allows each of us to assess from a holistic perspective where we are vulnerable to the downside of change and transition, while highlighting strengths and resiliencies that can be harnessed to help us learn and grow.

In fact, it is helpful to have individuals on teams with different strengths and traits as they then can help the team deal with change in diverse ways (see Figure 3.1).


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If at the end of this chapter you want to learn more about how you person-ally experience and react to change, a separate customized change readiness assessment and profile report is available. As you go through the sections in this chapter, you will notice that there are special considerations for those in a leadership position or operating as part of a team in any organization. It is critical for leaders to stay engaged and positive while implementing change initiatives. It is equally important for leaders to be able to coach others to embrace and adapt to change. Keeping this in mind, take a moment to reflect on recent changes and transitions in your organization. What factors made these changes seem positive or negative for you or your team?

Section Reflection Questions

◾ List your negative reactions to a recent professional or personal change. ◾ List your positive reactions to a recent professional or personal change. ◾ What makes a change seem positive? Negative? Why? ◾ Why do you think it is important to become more effective in how we perceive and react to change around us?

Are You Flexible When Change Happens?

The first change readiness factor is flexibility. Flexible people have goals and dreams like everyone else, but they are not overly invested in exactly how they turn out. When something does not work out, they will say, “If plan A doesn’t work, let’s go to plan B.” If you are very flexible, you are not wed-ded to specific outcomes. You are able to generally take things in stride. If the situation changes, your expectations shift right along with it. However, being perceived as highly flexible may indicate, or project to others, that you lack commitment or the ability to stick with a difficult task over time. If you are moderately flexible, it means that at times you are flexible and able to make changes or adjustments as required by changing circumstances. There will also be other times where you take a more rigid stance and stand firm. This may be because you do not understand the need to change, or it may conflict with your values or way of doing things.

If you are not flexible at all, you can be very set in your ways and do not like it when goals or expectations change. It may even take you more time than others to process and understand the changes going on around you. Ideally, you want to be flexible enough to be able to change your


perspective when appropriate, while not being so inflexible that you refuse to do anything different.

Flexible Leadership

Both extremes of flexibility are magnified in a leadership capacity. It could be perceived that leaders who are too flexible do not fully understand the issues at hand, or can be easily swayed. If too inflexible, it could also come across as if the leader does not appreciate the impact on his team’s work life dur-ing change or transition periods. There may be times where you need to be extremely flexible, taking time to listen to opinions with careful patience. For a leader especially, there will be other times when change is coming quickly, where you will need to make a top-down decision, requiring less flexibility.

Flexible Teams

When working as part of a team, it is important to stay focused on your goals and objectives, while remaining flexible and open to possible change. You may come into a team with your own perceptions of how to solve a problem, but it is important to realize there are other perceptions in the group, and multiple ways of solving problems. Be careful not to jump too quickly to a solution before hearing everyone out. Team members who are too inflexible often risk checking out when their ideas are not chosen, which can be extremely harmful to the team. On the opposite end of the scale, you must also be wary of being perceived as too flexible, or the rest of your team may wonder if you are truly engaged.


◾ How might you be perceived by others if you are seen as too flexible? ◾ How might you be perceived by others if you are seen as inflexible? ◾ How would you rate your flexibility level on a scale of 1–10 with 10 being the highest?

Ideally, you want to be flexible enough to be able to change your per-spective when appropriate, while not being so inflexible that you refuse to do anything different.


Do You Have a Sense of Adventure?

Two ingredients capture the adventurous spirit: the inclination to take risks and the desire to pursue the unknown—to walk the path less taken. Adventurous people love a challenge.

Being highly adventurous indicates that you may frequently ask, “Why not?” when it comes to taking risks or exploring new options. You are often the ideas person and innovator on the team. However, if you are perceived to be too adventurous, it may indicate that you have a tendency toward recklessness. Others may fear that you enjoy risk for risk’s sake, and that you seek out new experiences just for the thrill of it.

A moderate sense of adventure indicates that you usually perform well during organizational shake-ups, since change always involves both risk and the unknown. You are seen as being proactive—a person who can initiate and create change. Having a low sense of adventure indicates you are risk averse and do not like to try new things. You may be suspicious of anyone suggesting a new way of doing things, or suggesting that you personally try something new.

Adventurous Leadership

Successful leaders often exhibit a healthy sense of adventure, no matter how challenging or difficult the task at hand is. However, a leader should not be too adventurous, where the “adventure” could be perceived as thought-less frolic by your team. Leaders who score high in the Adventure and Confidence index must learn to be vulnerable with their team, and take a back seat in areas where they think they know the most. Recognize that others on your team may have more creative ideas, and do not let your sense of adventure stop you from taking others’ opinions into account.

Two ingredients capture the adventurous spirit: the inclination to take risks and the desire to pursue the unknown—to walk the path less taken.

Recognize that others on your team may have more creative ideas, and do not let your sense of adventure stop you from taking others’ opinions into account.


Adventurous Teams

It is best to enter into any team environment with a “we can do this” atti-tude. Team members with a healthy sense of adventure are easily able to learn through the process of doing and adapt more easily to change. Team members with a good sense of adventure can be infectious to others, just as those with a low sense of adventure can negatively influence the team. In the face of change, make a commitment with your team to figure things out for the greater good, and let those who score higher on the Adventure index motivate those who score lower in the face of change.


◾ How might you be perceived by others if you are seen as too adventurous?

◾ How might you be perceived by others if you are seen as not adventur-ous at all?

◾ Do you feel that you are more or less adventuresome than your work colleagues? Family members or friends?

◾ How would you rate your sense of adventure level on a scale of 1–10 with 10 being the highest?

Are You Confident to Lead Change?

If optimism is the view that a situation will work out, confidence is the belief in your own ability to handle it. There are two types of confidence. Situational confidence is the belief that, “I know I can swim across this channel, learn this program, or write this report.” Self-confidence is the belief that, “I can handle whatever comes down the pike.” The Change Readiness Index measures self-confidence.

A high level of confidence indicates you are an individual with a strong sense of self-esteem. You believe that you can make any situation work for you. However, if your confidence is too high, you may be perceived as someone who thinks they know everything and who is not open to feedback. A moderate level indicates that you have a good level of self- confidence without being overconfident. You can handle most situations that come along; however, there are times when your confidence may be lack-ing, or waver. This could be when you are in unfamiliar territory or facing


situations that are similar to ones you have had trouble with in your past. A low level of confidence indicates that you may be lacking in self-esteem and have a lot of self-doubt in your abilities. The only impact of change you can envision is one that brings bad news and more difficulties into your personal and professional life.

Confident Leadership

A leader must be confident that he can lead his team from point A to point B. Change can cause fears to arise in your team, and if the leader is not perceived as confident, this almost immediately affects the rest of the team. Exude confidence in yourself and your team’s abilities, and inspire those around you to embrace transition and uncertainty.


◾ How would you be perceived if you were too confident? ◾ How would you be perceived if you were not confident enough? ◾ What is the difference between self-confidence and self-esteem? ◾ How would you rate your confidence level on a scale of 1–10 with 10 being the highest?

How Optimistic Are You?

Is the glass half empty or half full? Optimism is highly correlated with change readiness, since the optimist recognizes opportunities and possibili-ties, while the pessimist observes only problems and obstacles. Being highly optimistic indicates that you believe things always work out, and you find encouragement and hope in every situation. However, if you are seen as too

Exude confidence in yourself and your team’s abilities, and inspire those around you to embrace transition and uncertainty.

Being highly optimistic indicates that you believe things always work out, and you find encouragement and hope in every situation.


optimistic, your team may wonder if you lack critical-thinking skills. You want to avoid being considered someone who is blindly optimistic about every situation by your colleagues.

Being moderately optimistic indicates you are optimistic in general. Being less optimistic indicates that you are the one who can easily see the possibilities of a bad outcome in any situation. You may be perceived as overly cautious, fearful, and negative. You could risk overlooking valuable opportunities.

Optimistic Leadership

An optimistic leader is able to take negative events in stride and create posi-tive outcomes. Whether you choose to be optimistic or pessimistic, the real-ity is that the situation must be dealt with. Choosing to be optimistic allows you to see new opportunities, despite what may otherwise be perceived as a setback or negative event. Be wary of blind optimism, where you are perceived to ignore the realities that need to be addressed in order to move forward. It is important for a leader to be realistic about the situation, but optimistic that the team can solve it together.

Optimistic Teams

In a similar fashion, team members who are too optimistic often leave prob-lems to work themselves out, while those who are too pessimistic are quick to believe that obstacles cannot be overcome. Team members who are too optimistic may have unrealistic expectations for the time and effort required to complete a project, while those who are too pessimistic will have diffi-culty getting a project off the ground or attempting to solve a problem.


◾ How would you be perceived if you were too optimistic? ◾ How would you be perceived if you were too pessimistic? ◾ Where do you think you fall? Are you more optimistic or more pessimistic?

◾ What might be the value of having a team that included both optimists and pessimists?

◾ How would you rate your confidence level of optimism on a scale of 1–10 with 10 being the highest?


How Passionate Are You about What You Do?

Passion is the fuel that energizes all the other traits. If you have passion, nothing seems impossible. On the other hand, if you do not have passion, change can seem exhausting. Passion is your level of personal dynamism. It shows up in your level of intensity and determination. Your passion helps propel you forward and get things done. To make a new procedure work, to overcome the myriad of problems that any plan for change may produce, you must have passion, enthusiasm, and drive.

A high level of passion can help you move through the most challenging and difficult changes, even when others doubt it can be done. However, if you are highly passionate, you may come across as somewhat pushy, bull-headed, and stubborn. You may also be at risk of burning out, and at times, you may not be able to see and deal with obstacles. Having a moderate level of passion indicates that you do have passion toward certain aspects of your life, and when you are interested or fully engaged in things you love, you will show energy, drive, and determination. However, when you are not interested in the situation at hand, you may not exert the same level of energy and enthusiasm. If you lack passion, you may come across as lacking in drive, energy, or the ability to get difficult tasks done. You may give up too easily when more perseverance would help you be more effective.

Passionate Leadership

Passion indicates your level of energy and commitment to seeing some-thing through. Passion is the fuel that propels you, your business, and your team forward in the face of long days, long nights, and inevitable setbacks. Change can be exhausting, and the ability to persevere requires a passionate leader.

Passion is the fuel that energizes all the other traits. If you have passion, nothing seems impossible.

Passion is the fuel that propels you, your business, and your team for-ward in the face of long days, long nights, and inevitable setbacks.


Passionate Teams

In any organization, there will be ugly meetings and frustrating projects. A team must be able to feed off of each other’s passion to achieve a goal. The level of commitment within a team can be determined by the level of pas-sion for a particular project. Passion helps us to persevere.


◾ How would you be perceived if you were too passionate? ◾ How would you be perceived if you were too passive? ◾ Where do you think you fall? Are you more or less passionate than your colleagues, family members, or friends?

◾ How would you rate your general level of passion on a scale of 1–10 with 10 being the highest?

How Resourceful Are You?

Resourceful people are effective at making the most of any situation and uti-lizing whatever resources are available to develop plans and contingencies. They see more than one way to achieve a goal, and they are able to look in less obvious places to find help. They have a talent for creating new ways to solve old problems.

If you are highly resourceful, you always find an answer or solution, even when others have given up or tell you that everything has already been tried before and will not work. However, if you are too resourceful, you might have a tendency to overlook obvious solutions and create more work than is necessary. Being moderately resourceful indicates that you can be resourceful at finding solutions to problems that arise. There may also be times when you may get stuck and decide to give up or stick with the status quo. You may not want to invest your time and energy into finding a solu-tion or better way of doing things. If you are less resourceful, you may find that when you encounter obstacles, you get stuck, dig in your heels, and go back to the old way. You have a difficult time finding solutions and methods to address new or challenging situations.

Resourceful people have a talent for creating new ways to solve old problems.


Resourceful Leadership

For those of us in a leadership role, it is critical to realize that you cannot do everything yourself. The team you lead is your best resource for creativity, and a critical factor for success is relying on their support. Resourcefulness forces you to have a big picture perspective of a problem; however, it is important not to miss the obvious solutions, overcomplicate problems, or take the “long way around.” Be wary of not being resourceful enough, or you may only see one way of doing things and remain stuck in old habits or methods.


◾ How would you be perceived if you were too resourceful? ◾ How would you be perceived if you were less resourceful than others? ◾ Where do you think you fall? Are you more resourceful? Less resourceful? ◾ What might be the value of having a team that included team members who were highly resourceful as well as those with less ability to be resourceful?

◾ How would you rate your resourcefulness on a scale of 1–10 with 10 being the highest?

Are You Tolerant of Ambiguity?

The one certainty surrounding change is that it causes a lot of uncertainty. No matter how carefully you plan it, there is always an element of indefi-niteness or ambiguity. Without a healthy tolerance for ambiguity, change is not only uncomfortable, it is downright scary.

A high tolerance for ambiguity means that, although not everything is defined or under your control, it does not threaten or frighten you. If you have too much tolerance for ambiguity, it can also get you in trouble. You may have difficulty finishing tasks and making decisions because you feel that you do not have all the details. You may also have difficulty pinning people and situations down if you are too comfortable with fuzzy situations. A mod-erate ability to tolerate uncertainty or ambiguity means that you tolerate ambi-guity fairly well, but at times may feel uncomfortable when a situation arises and you do not know what is coming next or what the impact will be. You

Without a healthy tolerance for ambiguity, change is not only uncomfort-able, it is downright scary.


will either try to gather more details to clear things up, or work through it as best you can. If you have a low tolerance for ambiguity, you may tend to feel that any kind of change, new direction, or idea seems threatening and scary. You may feel out of control and uncomfortable with the fact that you feel you do not know what is going to happen next and how it will affect you.

Leading through Ambiguity

A leader must accept that with change comes a certain level of ambiguity. New initiatives require patience and the ability to instill confidence in your team when things are unclear. It is important to do a self-assessment of your tolerance of ambiguity and recognize that your team may not be as comfort-able as you may be. Uncertain times require added patience, especially when fears in the team arise. Team members must also remain calm and patient with their leader as they provide further detail pertaining to big picture ideas.


◾ How might others perceive you if you are too tolerant of ambiguity or not tolerant enough?

◾ How tolerant of ambiguity do you feel you are? Are you more or less so than your colleagues or friends?

◾ How would you rate your tolerance for ambiguity on a scale of 1–10 with 10 being highest?

◾ What might be the value of having a team that included team members who were highly tolerant of ambiguity as well as those with less toler-ance for ambiguity?

How Resilient Are You?

Resilience is that quality that allows some people to be knocked down by life and come back stronger than ever. It is your ability to cope with stress and adversity. If you are resilient, you are more able to bounce back from the setbacks you experience in your life. Resilient people take delays, obsta-cles, and setbacks in stride, and are able to rebound from adversity quickly with a minimum of trauma. Failure or mistakes do not throw resilient peo-ple. They do not dwell on them and get depressed, but bounce back quickly and move on. If you are resilient, you are more able to bounce back from the setbacks you experience in your life.


If you have a high level of resilience, life’s trials and difficulties do not keep you down for long. You are able to move through them and on to bet-ter things. However, if you are perceived to be too resilient, people may see you as aloof and unconcerned. In some ways, if you are not influenced by your life’s setbacks, you may be less likely to learn from them.

Being moderately resilient generally means you do not let the trials and difficulties of life keep you down for long. However, there are times when you may feel hit particularly hard when something does not turn out the way you had hoped, and it may take you longer to recover. If you are less resilient, you may feel particularly frustrated when something does not turn out the way you had hoped. You may be prone to negative thinking that can cause the adverse outcome to have a stronger and longer impact upon you.

Resilient Leadership and Teams

Whether you are in a leadership role or part of a team, you need to be indi-vidually resilient and help the organization itself become resilient. Remind others, “We got through that tough situation in the past, and we can handle this current situation.”


◾ How would you be perceived if you were too resilient? ◾ How would you be perceived if you were less resilient than others? ◾ Are you more resilient or less resilient than those around you? ◾ Where do you think you fall in resilience on a scale of 1–10 with 10 being the highest?

Conclusion and Opportunities to Learn More

Ideally, we would be strong and balanced in all eight of these traits. However, this is not the case for most of us. As you have moved through each of the change readiness factors, you have most likely found that you

Resilient people take delays, obstacles, and setbacks in stride, and are able to rebound from adversity quickly with a minimum of trauma.


score higher or lower in different areas. Your goal should be to be aware of any traits where you score very high or very low, and be mindful of the caveats offered. Being aware of them helps you take advantage of those traits that can help you deal more effectively with change while minimizing those traits that do not serve you as well.

An effective strategy for team success is to seek out other perspectives from colleagues who score differently on each of the factors than you do. To help you further your learning, I offer an online self-assessment and profile report that covers each of the eight change readiness factors. If you are inter-ested in taking the assessment, please e-mail me at [email protected] with “Change Readiness” in the subject title. I encourage teams to take the assess-ment and share their results, in order to leverage each member’s strengths while helping minimize vulnerabilities. You can take the assessment as an individual, or better yet, take it with your leadership team. You can compare your various strengths and vulnerabilities when it comes to how you handle and lead change. Having a group profile will also give you an opportunity to leverage your strengths, as well as your team’s strengths, as you imple-ment organizational transformation and change.


◾ What surprises you? ◾ What are your strengths? ◾ How might others perceive your reactions to change? ◾ How can you build on your strengths? ◾ Who can you partner with? ◾ How might working with others with different change readiness trait profiles help you be more effective when dealing with change?

Most likely, we have both strengths and weaknesses in our ability to handle change.

An effective strategy for team success is to seek out other perspectives from colleagues who score differently on each of the factors than you do.

37

Chapter 4

Organizational Change

I realized early in my career that no matter how well I used any of the tools and skills I had learned as an industrial engineer or through my MBA program, the most important ingredient for success was being part of an organization that had a healthy continuous improvement–based culture. Our best process improvement tools—PDSA, Lean, Six Sigma, process redesign, or reengineering—will not be successful without a culture of change and improvement behind them. In Chapter 3, we discussed how individuals and teams may experience, perceive, and react to change. Well, what about orga-nizations? And what if the organization is not ready? What are your options? Run away quickly? Find champions or early adopters?

At the risk of being obvious, organizations are made up of many individ-uals who experience change differently. And whether the culture is good or bad, all are in it together. Organizational change needs to take into account the people, processes, and culture. How do you do that? The methodology I describe in this book combines best practices and techniques from process improvement, Lean, and organizational development and change. The very act of using this collaborative approach will help many employees begin behaving and perceiving their roles and contribution to the organization in new ways. But it is not enough. There is a critical piece missing. From Figure 4.1, you can see the need to bring together people, processes, and culture in order to effect change. And it is the senior leaders who are the

Our best process improvement tools will not be successful without a cul-ture of change and improvement behind them.


change leaders. Figure 4.1 illustrates how leading change ought to encom-pass culture, people, and processes, and be enabled by technology.

Culture also includes components of leadership, organizational structure, history, the political system, and the communities in which the organization resides. With all these moving parts, we can see why transforming organiza-tions can be so challenging. Figure 4.2 illustrates how change occurs within a broader, more holistic context.

Process

Culture People

Technology

Changemanagement

Figure 4.1 Leading change encompasses people, process, and culture.

Public policy

Community

Organizational culture

Organizational structure

Technology

People Process

Chan

ge

Figure 4.2 Change from the inside out.

Organizational Change ◾ 39

What Is Culture?

If culture is so important to transforming our organizations, just what is it? There are as many definitions of culture as there are books written about it. Academics alone have 164 definitions the last time I looked. I prefer the definition offered by John Kenagy, MD, founder of Kenagy & Associates. According to Dr. Kenagy, culture is made up of four components: mindsets, methods, strategies, and structures (Dunn, 2014b). I like this definition because it gives us concrete things in our organizations that we can identify and change as necessary. And the reengineering methodology I describe helps effect all four of these parts of culture.

To begin, senior leaders have to get very clear on strategy. The process to get leaders there helps move mindsets. Additionally, the facilitation tech-niques teach team members at all levels of the organization to behave in new ways, which in turn influences mindsets and how individuals see their ability to solve problems and create the future.

Any reengineering initiative must be focused on a key organizational or business strategy. The approach described in this book offers new methodologies of addressing challenges, and it provides the tools for professionals inside of the organization to reengineer care methodologies and other business processes. These new processes and methods require a new structure that fits the new organization. So, form does really follow function, which is a much more effective method than running into an organization, restructuring it, and hoping everything falls together and gets better—wishful thinking at best. So again, when you think about culture, think of mindset, methods, strategies, and structure.

Role of Senior Leaders as Leaders of Organizational Change

The missing piece in many unsuccessful change initiatives is the leader-ship ability and commitment of senior leaders. The role of senior leaders in a reengineering initiative cannot be overemphasized. Reengineering is a culture change and an organization-wide effort. It will be only as success-ful as the leaders are in effecting cultural and organizational change. Two key competencies of senior leaders include leading change and developing people. This methodology helps them do both. First, leaders need to define the strategic vision and the why and how reengineering efforts will help get


the organization where it needs to go. Leaders need to define the culture and organizational change the organization is moving toward. Reengineering is one of several ways that can be used to shift the organization forward. It helps develop people’s individual capabilities and their ability to work together while redesigning strategic business processes.

If the senior leaders are not on board or are openly feuding about the need for reengineering, changing the culture, or disagreeing about other issues, it will send mixed signals and employees will be hesitant to get on board—and rightfully so. I maintain that reengineering needs more than executive champions; it needs organizational leadership. The methodology I employ and describe in this book samples from the best of well-known pro-cess improvement methodologies, as well as some of the leading thinking in organizational behavior and development. As such, it requires that leaders get strongly behind it. Why?

In many organizations, leaders unfortunately take a top–down, con-trolling approach, which does not allow the best ideas and employees to flourish. This approach requires that employees be encouraged to be creative, capable, and complete. If top leaders do not buy into these beliefs and question their employees’ abilities to create redesigned processes and help the organization move forward, they should not be doing this type of work, let alone be leading a complex organization. The minute the leaders start second-guessing solutions and micromanaging the imple-mentation is the day that the organization will remain stuck in the status quo. Reengineering in this environment will only lead to cynicism and frustration.

If the senior leaders are not on board or are openly feuding about the need for reengineering, changing the culture, or disagreeing about other issues, it will send mixed signals and employees will be hesitant to get on board—and rightfully so.

Reengineering is a culture change and an organization-wide effort. It will be only as successful as the leaders are in effecting cultural and organi-zational change.


What Does the Research Say?

Research says that leaders must be able to spot talent and then let the talent do its job. This is easy to buy into, but difficult to execute. Change is coming from more directions and at a faster rate every day. The only way our orga-nizations will be able to compete is to include and encourage our best and brightest to help move our organizations forward. The good news is that leaders can engage their employees in change initiatives by being open about the challenges faced as well as their faith in their employees to help them innovate and redesign processes. I recall one of my mentors, the CEO of a 350-bed hospital at the time, addressing an all-leader meeting to share the tenuous position that the organization was in shortly after the financial crash of 2008. He was open about the challenges we faced and why. However, he also emphasized how much faith he had in all of us as leaders to get the organization through the very difficult times. Everyone appreciated both his candor and his faith in the team. Underlying the ability to engage employees is the ability to be authentic and transparent with employees, despite how vulnerable it may make us feel as senior leaders. We all know that hard deci-sions have to be made, but whatever happens is easier to accept if we feel we are working with people of integrity and transparency. Protecting our employees with half-truths does not help them or give them the necessary information to make the decisions they need to make. Reengineering, like other large-scale change efforts, requires transparency, integrity, and faith in the team’s ability to overcome the organization’s challenges.

Reengineering/Process Redesign Lends Itself to Being Led from the Top

The reengineering approach lends itself to being led from the top—key management decisions and strategy are made by the senior leaders, while allowing employees at all levels to contribute to and be part of the changes the organization is going through. Often leaders resort to control and micromanagement because they have not articulated a strategy and overall direction. Then, they get frustrated because people “don’t do what they are supposed to.” Reengineering and process redesign expects the opposite. Leaders lead, and employees innovate and execute. Leaders make sure that the newly designed processes meet the strategic direction and goals of the


organization. There are also key checkpoints along the methodology time line where senior leaders are required to provide their input and agreement with the team’s progress and approach. The input is sought at the higher goals and objectives level, not at the tactical how-to stage also known as the “in-the-weeds” level.

Kotter and Cohen’s Organizational Change Readiness Assessment

I recommend that senior leaders individually, and as part of the senior execu-tive team, reflect upon how each perceives and reacts to change (see Chapter 3). In addition to your own and your team’s change readiness assessment, you may consider using an organizational change readiness assessment. I recommend Dan S. Cohen’s (2005) assessment based upon Kotter’s earlier work in Cohen’s book, The Heart of Change Field Guide. He identifies four basic elements of change readiness and the guiding principles behind them:

1. Take the temperature. You cannot start real change without a realistic picture of the internal climate of the organization.

2. Identify the hurdles. Cultural barriers to change should be identified and addressed early in the change process. Some of these hurdles may resolve later, but cultural challenges often come back to bite you harder later on.

3. Talk to the people in the trenches. In fact, the reengineering and process redesign methodology will help you stay in touch and involve them. The people closest to the process and the customers often know more than senior leaders about the real issues, problems, and potential solu-tions because they live and breathe them every day.

4. Be prepared for pushback. Resistance is a natural response and is inevi-table. People react to and process change differently, and they are moti-vated by many different things. We all experience transitions differently, and we require our own amount of time to do this.

How Does the Organization Decide That This Is the Way to Go?

In addition to the organizational, team, and individual change readiness assess-ments, and the determination that past process improvement efforts will not


suffice, there are other earlier questions that you and the senior leadership team can explore and discuss. Does your organization have any of these symptoms?

◾ High costs relative to where they need to be, or a major drop in rev-enue and/or margin shrinkage

◾ Serious customer complaints ◾ Unacceptable safety events ◾ A realization that radically new processes are needed

If you recognize some of these challenges as those your organization is facing, you can ask further questions around organizational readiness, toler-ance for change, and reengineering.

Is the Organization on Board?

Once you have determined that the senior leaders are committed and they have established a prioritized strategic approach, you can begin conversa-tions to find if the organization is really on board. This is Cohen’s (2005) “take the temperature” principle.

◾ Is there pain? Are you faced with revenue shrinkage, costs increas-ing, customer satisfaction going down, patient safety events increasing, employee turnover increasing, etc.? Do frontline managers and employ-ees feel this pain? You may not think so at first, but once you talk with them, you will find that they are very aware of these challenges.

◾ Is that pain measurable? How much are any of these factors costing the organization? Make sure that you translate everything back to dollars since that is a common currency in most organizations.

◾ Can these problems not be solved incrementally? Maybe you have been working on these issues for some time, but you are not getting the results that you need. Have your employees been working on the prob-lems for weeks, months, maybe even years with only limited success?

◾ Is there discipline and are there measurable outcomes that will focus the organization on the highest priority processes? Do you have a pri-oritized strategic plan, and do you know the key processes you need to work on to help you execute your strategy and reach your goals?

◾ Is the executive team willing to work together? Can they cast aside their differences and natural competitiveness to help the organization succeed? Are frontline managers able and willing to work collaboratively?


◾ Are all leaders able to work together? Do they know how? Do they need help coaching or facilitation to help with this?

◾ Do the leaders have a shared compelling vision for where they want to go? And do they really buy into it?

If you are uncertain about any of these issues, you can use simple online surveys and questionnaires with your executive team to help them under-stand where they are collectively and where they need to go.

Establishing and Leading Reengineering in Your Organization

Please note that this approach is flexible and integrates with the culture of the organization as it makes sense and assumes that the leaders have decided this is the approach they need to take. It does not bolt someone else’s proven technique onto your culture. Though it may have worked elsewhere, there were many variables that contributed to its past success in other places such as culture, senior leadership, and employee engagement. These and other factors often have a much bigger impact on success than the slickness of the tools and methodology.

The business world is in love with fads and buzzwords. Leaders get hooked on concepts and programs that may not be the best fit for their organizations (and consultants do not turn down the work). Think total quality management, International Standards Organization, theory of con-straints, Lean Management, Balanced Scorecard, Work Out, self-directed teams, business units, and matrixed organizations. These are all great prac-tices, but not right for every organization (Haneberg, 2005).

To further the cause of why you should use reengineering versus what you have always done, senior management must sell the need for change throughout the organization. Why is your organization doing reengineering? What are the drivers? If it is financially driven, what are the specific issues, and what is it costing you? It is not enough to say, “We’re doing reengineer-ing because of ARRA or the ACA.” The reason must be translated down through your organization, and even better, to specific service lines. If the organization is threatened by a big loss in market share or even bankruptcy, you should not be afraid to let employees know. Others in the organization cannot provide ideas and solutions if they are unaware of the problem or the gravity of the problem.


You should only consider reengineering or process redesign for your orga-nization when you know that incremental improvements are not enough. Perhaps you keep solving the same process issues over and over and are still not getting the results you need to meet your customers’ and patients’ needs. Your challenge as an organizational leader is to make sure that your peers, senior leaders, and team leaders recognize the need for a major change in the organization. You will need to paint the picture through data, patient, employee, and physician experiences. This is not something an individual leader or facilitator can do alone. Senior physician and administrative leaders must be actively involved. It is not enough for senior leaders to strongly sup-port the process redesign efforts. They must walk, talk, and breathe process redesign, and believe this method will elicit the change required to make the organization better. It is key that you engage the employees in your efforts—not just communicate to them what they need to do.

Up front, and before core processes or teams are identified, hospital and medical administration must agree on the impetus for change and a quanti-fied prioritized plan for what the core processes are and in what order they will be redesigned. For some organizations, the impetus or threat is dramati-cally reduced revenues or even bankruptcy. For others, it may be the many changes and unknowns associated with health care reform.

Senior leadership must begin engaging employees around the need for change and the aggressive targets and time frames, while also helping the organization understand why the status quo is no longer adequate or accept-able. This aggressive approach needs to be sold to all stakeholders, including employees, physicians, board members, and even community members. In many organizations, this can be very difficult, particularly if the organization has historically been financially successful or if they have survived and thrived through previous downturns. It makes it too easy to assume, “This too shall pass.” At this point, a strong steering committee should be formed to lead and communicate the need for change. This communication needs to occur in as many venues as possible: board meetings, daily rounds, department meetings, leader meetings, etc. Podcasts, videos, blogs, and newsletters can help dissem-inate information and provide continuous updates on progress and challenges. In spite of all this, my experience has been that it is normal to expect resis-tance and even denial. This will be discussed later in the section on critical success factors. As one anonymous writer once noted, “Everyone is in favor of progress, it is just changing that they don’t like.”

Since reengineering is a major organization initiative, it must be started and led by the senior leadership team. Leaders need to make sure they are


not purposely or inadvertently working at cross purposes. Some process improvement can be done in local or isolated areas of an organization, with or without the blessing or knowledge of senior leaders, or with just one senior leader champion. Reengineering will surely fail if a significant senior leader opposes it either openly or passively. Thus, having the leadership team working together and knowing what needs to be done is vital.

47

Chapter 5

Overview of the Methods and Tools

Before providing a detailed description of each tool and step in the facilita-tion methodology, this chapter explains the methodology and how the tools fit together. You may even want to read this chapter first to get a brief over-view of the methodology. You will note that each step builds on the results and outcomes from the prior step. This assumes that your organization and your leadership team has reached the difficult realization that redesigning core processes is required to survive or thrive, and has made the major deci-sion to do it. Specifically, the senior leadership team has determined that reengineering how you deliver care is your organization’s major strategic objective, and fully understands the strategic and cultural change implica-tions of this objective. Senior leaders have selected the few key initiatives, which are assigned to facilitators and team leaders, and have defined the scope of the initiative without being prohibitive. Nothing can be off-limits. The management team appreciates the order and magnitude of change that this endeavor will unleash within the organization and is ready to actively manage this change.

It is important to note that determining the need for redesigning core processes and communicating the necessary profound changes to the work-force is the role of the senior leaders. The purpose of the communication is not to inform but to engage all the stakeholders, including all employ-ees at all levels. It cannot be delegated to the facilitators or team leaders. And though they will undoubtedly reinforce the messages and the need for change, everyone on the team should have a general knowledge about the


process redesign initiative before the first team meeting. Facilitators have key roles and will have plenty to do without also handling the major leadership roles of senior management. Without senior management’s active engage-ment in their leadership roles, no matter how great a facilitator’s skills are, the teams will fail. In fact, it is not too extreme to note that the essential component for successfully reengineering your core business processes is the leadership team. The preferred scenario and best way to be successful at process redesign is for senior leaders to provide leadership, while facilitators provide the facilitation and process redesign tools for their assigned teams. Senior leaders need to provide as much support and air cover as possible for facilitators, team leaders, and team members. And frankly, if there are senior leaders who do not support the initiative, even if their behavior is short of outright sabotage, they should probably be reassigned, where they cannot harm the initiative, or let go. Even one leader not on board can have a nega-tive effect on overall success.

To illustrate, let’s assume your hospital has a shrinking bottom line, or is quickly losing market share, or has serious quality concerns. Your organi-zation has decided to embark on reengineering in an approach that looks something like this:

1. The organization identifies the targeted core or key processes that must be redesigned in order to address profitability, market share, or quality issues.

2. The organization undertakes a brief current state assessment to deter-mine how bad the current situation is. This current state assessment is expressed in terms of metrics or pain points. It is not an exhaus-tive review and analysis of the current processes. This may already be evident in what motivated the organization to take the first step, or this step may help the organization further focus its process redesign efforts. Examples include an analysis of service line profitability by payer, or analysis of market share by service. At this point, the organization may also want to determine what key customer groups think of it in order to better understand why it is losing market share or profitability. For example, if physician groups are no longer referring to the institution and patients are going elsewhere, the organization must ask why. If the hospital lost a major managed care insurance contract to another competitor, it should investigate the reasons why this occurred. Or the organization may need to work with other organizations to develop processes that will enable it to become part of an accountable care

Overview of the Methods and Tools ◾ 49

organization. In this way, key issues and key processes that need to be addressed will rise to the surface.

3. Next, the organization envisions the future, exploring the ideal process for the situation from the perspective of the customer—whether that customer is a physician, patient, community member, or someone else. For health care organizations, usually the patient is ultimately the key customer. Eventually, each core process or service team will go through visioning to develop an ideal state. How this is done is described in more detail in later chapters.

4. The organization begins to explore how to get from today’s current state to the ideal scenario through core process redesign and value-added/non-value-added flowcharting. How senior leaders can help the organization through this and how the facilitators can help process redesign teams are described later in this book.

5. Next, using force field analysis, teams develop project plans for imple-mentation of the new vision and redesigned processes.

6. Finally and on an ongoing basis, senior management monitors where the organization focuses and makes any necessary course corrections to ensure the new processes meet the overall objectives and are able to meet the appropriate metrics. Use of continuous improvement tech-niques can then help keep processes effective and efficient over time. This is the point where classical continuous improvement tools and techniques, such as PDSA, Lean, and Six Sigma methodologies, will come into play to help your organization keep moving forward.

Describing the approach makes it sounds simple—which it is. But it is not easy. Also, it becomes an iterative approach. Keep in mind that working on five or more core processes further raises the level of complexity. However, that ultimately leads to orders of magnitude of change. If you are responsi-ble for facilitating or managing one of the reengineering initiatives, or if you are one of the senior leaders responsible for the overall organizational trans-formation, the next chapter will explain the unique roles that each plays.

Figure 5.1 shows a diagram of the approach and the associated tools. Some of the tools may look familiar if you have been part of a process improvement or problem-solving team. Though there are a few new

Describing the approach makes it sounds simple—which it is. But it is not easy.


approaches and tools since there is an integration of process improvement techniques with organizational development and change principles, many of them are familiar tools applied in a new way. The next sections will address the questions from the conceptual model in Figure 5.1.

Why Does the Organization Need to Change and Why Are We Targeting This Process?

Senior leaders must first be collectively convinced that serious fundamen-tal change is required. If this is not the case, this reengineering approach should not be employed. However, if leaders are in agreement, the next task is to make the case and sell the need for change and engage employees in reengineering and redesigning core processes. Senior leaders should engage employees by helping them understand the environment and drivers that are requiring the big changes. Without being alarmists, leaders need to be completely transparent about the seriousness and need for change. Is there risk of loan defaults or bankruptcy? Are there competitive threats? Are the

Senior leaders should engage employees by helping them understand the environment and drivers that are requiring the big changes.

Methodology Process

Why?

What?

Why not?

Who, how,when?

Selling the need OrientationSetting the

ground rules

Brainstormingconcerns

Settingobjectives

Establishing themetrics

Flowchartingthe idealprocess

Checking theprocess

Identifyingobstacles

Developingalternatives

Developing theimplementation

plan

Projectmanagement

Figure 5.1 Conceptual model of the reengineering methodology.


organization’s costs higher than most of the competition’s? Is the organiza-tion losing market share? Or is it a combination of factors? To communicate effectively, leaders must meet with employees as much as possible, tell the story, and paint the picture. Employees need time to process the informa-tion. They need to grasp the situation and begin to envision ways they can be part of the solution and forward momentum. A particularly effective means of engaging employees, if you have the luxury of time, resources, and money to employ it, is to use learning maps that tell the organization’s story and describe the present situation. The maps can be used to facilitate directed dialogues and discussions with small groups of employees.

Another consideration beyond why the organization needs to transform is selling “why” the specific selected processes and initiatives are selected. Why has this team, this group of individuals, been selected to redesign this pro-cess? Why should they spend time away from their day-to-day assignments to work on this initiative? What exactly is the process they are focused on, and why has it been targeted? What is the scope? From the moment the team is brought together, senior management must answer the many ques-tions that team members will have. Some team members may be cynical or even fearful at first. They may not be aware of the situation that is causing the organization to consider reengineering, or they may not appreciate the severity of the challenge.

In the initial orientation meeting, team members must be provided an overview of the methodology and their role in the process redesign. For some who may not have had much experience with process improvement, it may seem intimidating. The team should appreciate that the scope of the ini-tiative is nothing short of significant, radical change. The approach is not just another business fad or new incremental approach. It is assumed that the organization is beyond the traditional annual 5%–10% cut across the board. Both the teams and senior leaders must be open to fundamental change.

The orientation should also include a discussion of the various steps that will be used to redesign the process: concerns identification and analysis; objectives development; process metrics development; ideal process flow-charting, or alternatively, value-added/non-value-added flowcharting; force field analysis; and implementation plan development. Roles will need to be

A particularly effective means of engaging employees, if you have the luxury of time, resources, and money to employ it, is to use learning maps that tell the organization’s story and describe the present situation.


clarified, and ground rules should be established. In later chapters, there will be further discussion of the need for ground rules for the team. Some exam-ples of ground rules include the following:

◾ We will reengineer the process from the patient’s perspective, not for our convenience or the convenience of our traditional departments.

◾ We will function collaboratively. ◾ Positive contributions are expected of everyone throughout the process. ◾ The status quo, or the “way we have always done things,” is not an option. ◾ We have some serious financial and other targets that we must meet. For example, we must cut our costs in half. We must improve patient satis-faction up to the 95th percentile. The group’s charge is to creatively find ways to redesign the process to operationalize those targets or goals.

◾ The objectives and process metrics will help us decide between alterna-tives and be the measure of our success. Above all, decisions will not be based on power, politics, or organizational influence.

What Are the Issues and What Is It That We Must Achieve?

The team must understand the scope of the process under review and then identify major concerns with that process. These concerns will then be turned into the objectives of the ideal process with the help of the facilita-tor. Specific goals and objectives will be defined for the ideal process. These are not to be constraints or specifications but should help describe how the new ideal process will look. Where possible, the objectives should be very specific and then stated quantitatively as process metrics that will ultimately help the team decide between alternatives and measure success. For exam-ple, for an objective of faster process time for patients in the emergency room, the process metric might be the actual time interval from the decision to admit the patient until the actual admission time. This way, teams can measure the current time, have a stretch goal for the new redesigned pro-cess to meet, and then measure success against that metric.

The team needs to envision the new process as creatively as possible. Instead of the usual clichés, “It won’t work here,” and “It can’t be done any other way,” the team needs to constantly ask, “Why not?” This is done by flowcharting a brief ideal process that meets the objectives of the process and adheres to common reengineering principles listed below. (If it is not brief, it is probably not ideal.)


Some principles to keep in mind when you are redesigning processes include the following:

◾ Organize around outcomes, not tasks. In other words, focus on the pur-pose of the process, e.g., healing patients, providing therapies, register-ing patients, getting an X-ray film, or diagnosis.

◾ Be flexible in anticipation of future needs. Make sure that the rede-signed process is not limiting or that it does not lock you into propri-etary technologies or obsolete organizational structures.

◾ Put the decision point where the work is performed. In a hospital set-ting, this means making sure that when a patient needs care, it can be decided upon and provided at the bedside.

◾ Build control into the process. This can be done by first designing a logical process, minimizing hand-offs, and putting the decision point as close to where the work is done as possible.

◾ Do not be limited by current logistical constraints. Treat dispersed resources as though they are local. Teams often limit their creativity when designing the new process due to current logistical constraints on patient flow, information flow, or materials flow. Team members need to imagine that those day-to-day constraints are momentarily suspended. The facilitators should ask questions such as, “What if you didn’t have to wait for the patient information or the necessary supplies?” “What if all supplies and equipment were available exactly when and where you needed them?” “What if the patient did not have to be moved around to receive diagnoses and treatments?”

◾ Build or enhance strategic links with external entities. This principle can be particularly powerful. Once a team looks beyond the present boundaries of the process and begins to envision partnerships between other stakeholders, such as admitting physicians, patients, and families before the patient arrives—and even after they leave—incredible break-throughs can occur. When one client team was redesigning their patient care process for total hip and knee replacement patients, they found that by partnering with referring physicians’ offices and providing man-datory courses for elective patients’ families to prepare them financially and emotionally, as well as making sure that the proper equipment was ready and waiting in the home upon discharge, the average lengths of stay were reduced significantly. And patient and family satisfaction increased dramatically. Now this approach is fairly standard in most health care organizations.


◾ Capture information once and at the source. This redesign principle is still particularly poignant for the health care industry. Even with elec-tronic medical records, patients are typically asked the same questions numerous times. Team members must suspend current reality and imagine that the newly redesigned process will allow patients to answer questions once and then the associated information would be displayed in a way that caregivers across the continuum have faith in its validity and are able to see it as it becomes relevant.

If your team is still unable to develop an ideal process, or if the ideal pro-cess they have identified still does not meet these redesign principles or the objectives of that ideal process, you will need to employ other techniques such as value-added/non-value-added flowcharting to further inspire the team to reengineer the process.

Using a force field analysis approach, the team also identifies all the cur-rent realities (obstacles) of why the ideal process and its various steps would not work. Force field analysis comes from Dr. Kurt Lewin’s (1939) work in the organization change and behavior field (see Figure 5.2). It is a technique that graphically illustrates the forces that work toward a successful solution

Present stateor

desired state

Driving forces(positive forces for change)

Restraining forces(obstacles to change)

Figure 5.2 Kurt Lewin’s force field analysis.


and the obstacles that work against the solution. The team can then make sure and leverage the supporting forces while minimizing or eliminating the obstacles to success. To avoid having an impossibly long list only the major items with major impact and the highest probability of occurrence are listed and further analyzed (Hammer and Champy, 1994).

How Might We Create and Implement the Ideal Process?

The team must ultimately creatively identify alternative ways to eliminate or offset the obstacles to the ideal process. The top alternatives—those that best meet the goals and objectives for the ideal process—become the tasks on the first draft of the implementation plan. Using project manage-ment techniques, these tasks are further detailed or divided into smaller tasks that are then assigned to team members, prioritized, ordered logically and sequentially as appropriate, and given due dates with time frames for completion.

Later chapters will describe in more detail the approach, methodology, and tools in a step-by-step fashion, using specific examples to help illustrate how the tools build upon each other and how they are applied.

57

Chapter 6

Roles and Responsibilities

Since reengineering will influence the entire organizational culture, it is critical that senior leaders lead the effort and that other key players do their part to support the initiative. Thus, it is very important to be clear about the expected roles and responsibilities for senior leaders, team leaders, facilita-tors, team members, and support staff. Even though many of the partici-pants will be experienced in process improvement, problem-solving, and other types of multidisciplinary meetings, it is important that each indi-vidual understands their role in a process reengineering and redesign team. Individuals should also know what is expected of them, as well as the vari-ous do’s and don’ts that will allow the teams to function productively and be successful in meeting their objectives.

Role of the Organization’s Senior Leaders

The original edition of this book was geared toward individuals charged with facilitating process redesign in their organizations because that was my role at the time. I learned firsthand that a grassroots effort intended to affect the entire organization is difficult to start, let alone maintain. Also, I saw firsthand what happened to our reengineering efforts when the top leader was promoted and moved on. The executive who replaced him had little interest in reengineering, and the effort quickly died—even though we had booked $40 million in real cost savings in less than a year. The new leader felt the need to disassociate himself from his predecessor and make his own mark. So in this edition, I cannot emphasize enough the importance


of the senior leaders. This is not a situation where leaders only need to be supportive. For real organizational reengineering and process redesign to be successful, it is crucial that senior leaders step up and lead the effort. If they choose to strictly dabble in the efforts, I recommend that the organiza-tion use only continuous improvement methods and approach change in an incremental fashion.

Also having been a senior health care executive in several operations and staff roles, I have learned how easily senior leaders can both support and derail efforts. It is not enough for only one senior leader to champion the initiative; the entire senior executive team needs to be on board. With orga-nizational reengineering and process redesign, ALL processes and services will be affected. More importantly, solutions and new redesigned processes will overlap and be dependent on each other. If the efforts are successful, organizational culture will be affected and new behaviors will be appar-ent to customers, patients, and the community. If one or two senior team members are not on board, reassignment of their duties and roles should be considered so that their lack of support does not derail the initiative.

Orienting Senior Leaders

When engaging in organizational reengineering, it is vital that senior lead-ers be aligned around and fully engaged with the overall goals and efforts. Leaders need to fully understand, support, and sell the initiative to direct reports and peers. An initial orientation workshop can help the executive team get a good start. There are a few critical agenda items that will help everyone begin on the same page.

Introductions and Icebreakers

It may seem odd to have existing leadership teams start out with introduc-tions and icebreakers. However, I find that even very long-tenured teams may not really know each other. Introductions can also serve as an ice-breaker. There are many ways to achieve good initial group interaction.

When engaging in organizational reengineering, it is important that senior leaders be aligned around and fully engaged with the overall goals and efforts.

Roles and Responsibilities ◾ 59

Online resources and books can provide creative ideas to use. Below is a short list of quick starts for the first orientation session, other orientation ses-sions, and team meetings:

◾ A good news check-in: Ask everyone to quickly share what is the best thing that has happened to them in the past week, month, quarter, etc. If this is the first meeting, I use a longer time period. However, for weekly meetings, I use a quick round-robin check in. The good news can either pertain to professional or personal news. The only constraint is that each response should be succinct and no more than twenty to thirty seconds.

◾ Two truths and a lie: Have each person write down three facts about themselves—two that are true and one that is a lie. Going around the table each person shares their three “facts.” The group has to decide which one is the lie.

◾ Ask each person to share a life-changing event for them personally. ◾ Ask each person to share their birth order along with pros and cons. ◾ Ask each person to share a favorite vacation, a favorite birthday, a favorite book, etc. (Of course, they also have to quickly share why it is a favorite.)

The value in having team members know each other better is to start to build professional trust. Since reengineering requires significant organiza-tional change, there will be rough times. The more the senior leaders are aligned, trust each other, and support the effort with a united approach, the better the organization will move through the challenging times.

Team Building

Senior executive teams are like many other teams. They are really collections of people rather than “teams” in the real sense of the word. I advise you to take advantage of the initial orientation to begin building and strengthening the executive team. There are several approaches to do this. I often use a workshop I call “Leading from Within.” It involves a team assessment of communication styles, motivators, and emotional intelligence quotient (EQ), which helps with self-awareness, peer awareness, and more important, practical ways to work more effectively as individuals and as a team. Other

Senior executive teams are often really collections of people rather than “teams.”


approaches I have used include Patrick Lencioni’s (2002) work from his book, The Five Dysfunctions of a Team. The change readiness assessment discussed in Chapter 3 also can be used by the entire team to better understand the team’s profile and tolerance for change, allowing them to build on their strengths as change leaders while mitigating any vulnerabilities.

Purpose of the Change Initiative

There must be a compelling story and overview as to why your organiza-tion needs such a radical approach. In other words, everyone needs to see and understand the burning platform. How bad is bad? Why? How might we respond? Why would not doing what we have always done get us there? The CEO must be as transparent as possible. He or she should not assume that the executives understand the challenge, let alone buy into it and commit to addressing it. Share the numbers graphically and in tables. Paint a clear picture. Be clear on trends and what is different now. Share compelling stories from customers, patients, physicians, and employees. There is an old saw that says, “Facts tell, stories sell.” Make sure senior leaders understand why they need to address the issues before them. Leaders cannot delegate them to their direct reports or to external consultants. Though some of the work can be performed by their direct reports and even external consultants, the senior leaders need to own the challenges and the changes required to meet the challenge.

Do’s and Don’ts for Senior Leaders

Senior leaders play a key role in any organizational change initiative, and a reengineering initiative is no different. Leaders need to understand that employees will be watching them, so they need to be both confident and competent. They need to drive change and engage employees around this effort. Table 6.1 lists some do’s and don’ts I recommend. Please note: the don’ts are just as important as the do’s.

Leaders need to understand that employees will be watching them, so they need to be both confident and competent.

There must be a compelling story and reason why your organization needs a radical approach such as reengineering.


Current State Overview

Senior leaders need an overview of the current situation to truly understand the impetus for change. They need to be able to “paint a picture” of the chal-lenge and share compelling stories to help employees understand how they can help and what their role is. Though the situation and magnitude of the change required may seem frightening at first, it is less frightening than the unknown or the scenarios we conjure up when we have little to no information. Also, involv-ing employees gives them a way “to do something” and address the challenges the organization faces. This is particularly important for clinicians. They are accustomed to solving problems and do not like to feel helpless.

Goals and Targets

There should be measurable goals and targets for the reengineering initia-tive, and then they should be translated to the team and project level. In fact, there should not be an initiative or team unless it is specifically focused on attaining a significant part of the overarching goal. All goals and objec-tives should have metrics associated with them. You should consider both

There should not be an initiative or team unless it is specifically focused on attaining a significant part of the overarching goal.

Table 6.1 Do’s and Don’ts for Leaders of Reengineering Initiatives

Do’s for Senior Leaders of Reengineering Initiatives

Don’ts for Senior Leaders of Reengineering Initiatives

Understand the current situation, the future challenge, and the urgency for the change

Don’t be afraid to say you don’t know

Provide direction, stretch goals, and objectives

Don’t micromanage the teams—They need to design the “how”

Challenge the teams to be creative Don’t let the teams give up too soon

Be patient—with yourself and your employees

Don’t expect everyone to be on board right away—You have had more time to discuss and process the challenges before the organization

Provide the resources when they are needed

Don’t think you will get an ROI on the initiative in the first few days or weeks


process and outcomes metrics. Additionally, you ought to include financial, quality, employee engagement, patient satisfaction, and patient safety mea-sures. Where possible, use already established measures. Recognize that you will probably not have all of the metrics available that you would like, and the metrics you do have access to will not be perfect. Some example goals and associated metrics are listed in Table 6.2.

Methodology Overview

During orientation, senior leaders should also get an overview of the meth-odology in order to demystify it, help everyone appreciate the approach, and learn how the teams will be guided. Often organizations give out stretch goals and incredibly difficult challenges with vague directives such as, “Use Process Improvement or Lean,” without helping leaders or employees know how to get from where they are to where the organization needs to go. This may be one reason that as organizations we often spend an inordinate amount of time documenting and reviewing the current processes. It seems easier because we know the current state, but we do not have a clue how to come up with the new ways of doing things.

Organization

In the orientation to senior leaders, you need to make sure they understand how the reengineering initiative is organized. For example, which leaders

Table 6.2 Sample Goals and Metrics

Sample Goals Sample Metrics

Best in class employee engagement Increase overall Gallup score from 3.2 to 3.8 in one year

Provide the highest patient satisfaction in the marketplace

Patient satisfaction scores are at the 90th percentile for all inpatients

Reduce the cost of a total hip replacement to no more than 90% what Medicare reimburses for this type of patient

Average cost per case for a hip replace-ment is less than or equal to 90% of the Medicare reimbursement amount

Cut the length of stay (LOS) in half for uncomplicated total joint replacements

Goal metric is 0.5 LOS

Reduce patient complaints about billing Monthly complaints about billing are less than 10


are responsible for the different core processes? It is important to clearly delineate how decisions will be made, how conflicts will be handled, and what resources will be available to the leaders.

Next Steps

The next steps discussion should include an overview of the first few steps, the time frames, and how to get started. What should teams do first? Second? And so forth. When do they check in? Figure 6.1 illustrates an example of an orientation agenda for senior leaders.

Role of the Facilitator

A critical success factor for deploying reengineering is to have a team of highly skilled facilitators. These facilitators must be knowledgeable about the methodology and the tools, as well as how to facilitate teams to draw out their best ideas and help them accomplish challenging objectives. They should understand the organizational culture and be held in respect by leaders and employees alike.

Senior leadership team orientation—high-level agenda items

Introductions123

4

5

6

7

9

8

Ice breaker/team buildingDiscussion

• Purpose of the initiative• Challenges we face

Do’s and don’ts• Role playing

Current state overview• High-level overview

Goals of the overall initiative• Subgoals• Metrics targets

Methodology overviewOrganization of the initiative

• Leaders• Resources

• Deliverables• Due dates

Next steps

Figure 6.1 Sample orientation agenda for senior leaders.


Choosing and Orienting Facilitators

A key ingredient in the successful deployment of systemic organizational reengineering is the selection and training of the team of highly motivated and skilled team facilitators. Some organizations choose to employ external facilitators, at least up front, if not through the entire process. I recommend that these individuals ultimately be internal facilitators. There are several benefits to this approach. First, as an organization, you train and deploy a cadre of committed professionals who can help the reengineering initia-tive succeed over the long term. This approach can supercharge your talent management efforts and help you vet and train your future leaders. In fact, it might become a crucial strategy to have your high potential leaders’ par-ticipation. It will help develop them and allow them to shine by giving them visibility on a key organizational challenge. Done well, the value of these individuals will be greatly enhanced, and they will be seen as proactive change enablers throughout the organization. It will signal to the rest of the organization how important the reengineering efforts are because you are putting your best and brightest people on the reengineering effort and rede-sign teams. Through each team meeting, both their visibility and credibility will increase. On the other hand, it will quickly become apparent if any of the selected facilitators are not suited for or interested in this assignment.

When looking within your organization for facilitators, there are some key attributes to look for. Ideal facilitators exhibit process orientation, a holistic or big-picture perspective—they are systems thinkers, creative, and restless about the status quo. They demonstrate enthusiasm, optimism, persistence, tact, and the ability to work as part of a team. And they exhibit well-developed com-munication skills. They are also not concerned about taking all the credit for the efforts of the teams. This may be a tough list of qualifications for any one

A key ingredient in the successful deployment of systemic organizational reengineering is the selection and training of the team of highly moti-vated and skilled team facilitators.

The most important criteria include the individual’s ability to ask good questions and get the team to open up to each other and to alternative perspectives.


individual to fill. However, two or three facilitators serving together on a team may be able to complement each other and collectively meet the criteria.

In my experience, the most important criteria include the individual’s ability to ask good questions and get the team to open up to each other and to alternative perspectives. In asking good questions, the facilitator must be curious about processes, and the why of how people and processes work together. He or she must be unafraid and persistent in questioning and possess a willingness to respectfully challenge and to follow up with yet another question. The facilitator must also encourage questions from the team, making sure they understand that there is no such thing as a bad question. Another key criteria is self-confidence and confidence in the reengineering initiative, and the ability of the teams to come up with inno-vative solutions and approaches. In my own experience, when I have been accused of asking so-called gratuitous questions, these situations have been when some of the greatest breakthroughs happened. Through the questions, the facilitators must be able to help the team fundamentally question their own processes and assumptions, reflect upon those processes and assump-tions, toss them out whenever and wherever necessary, and ultimately for-mulate recommendations to reengineer care delivery for the benefit of the patients and those who pay for that care.

Having strong self-confidence and faith in the process redesign effort, the tools, and techniques are also key criteria to look for in a facilitator. They must be skilled in the use of the process redesign tools and techniques, and be able to improvise while using the tools to make sure that the overall goals are not forfeited in order to slavishly follow the methodology or use the tools. Being able to think on one’s feet is critical. Often, this comes through experi-ence. While tools and techniques can be taught, faith in the need for change and the belief in the wisdom of the approach cannot. Facilitators will often feel they are the only ones who see the need for change and the only ones who recognize that the team can make it happen. They must have within them the ability to rekindle the energy and confidence in their fellow team members to move forward and not give up. Facilitators will have to be com-fortable in presenting data that is uncomfortable to the team and in being a messenger of bad news. They must believe in what they are doing to move the team forward when individual team members, and perhaps even leaders, are mired in symptoms of deep denial or change fatigue.

Facilitating a process redesign project can seem quite challenging, even for a veteran process improvement facilitator. Though there is a process and methodology as described in this book, it is not as straightforward


or prescriptive as the classic PDSA Shewhart cycle where a process is improved. Nor does it include as many tools as the Lean or Six Sigma meth-odologies. With reengineering or process redesign, the process is not accept-able or sufficient as is, so it must be essentially thrown out. The facilitator and the team basically start from scratch. It is difficult to know the solution or what the new, improved/redesigned process will look like before the team has created it. For leaders who like to be in control and want to man-age (or even micromanage) the fine details, this can be a challenge. Also, most teams are accustomed to analyzing reams of data about the current process. However, with process redesign, this is not only not required but is also a waste of time. And though teams might want a clear understanding of the downsides of the current process to make sure they are not designed into the new process, it is not necessary to dwell upon them and inadver-tently cause the team to become loyal to the old ways of doing things.

Another challenge is that most facilitators and team leaders are used to serving as internal consultants or decision makers who excel at providing recommendations and solutions for the organization. A reengineering or process redesign facilitator is first and foremost not a solution provider. And though many team members and team leaders may wish to see the facilitator in this role, it is important to convince the team members that they will be the ultimate solution providers and implementation experts. The facilitator’s role is to guide the team through the methodology of reengineering or rede-signing the process. The facilitator must be comfortable with the fact that he or she is not a current (old) process expert and may know very little, if anything, about it. If nothing else, this lack of knowledge about the current (old) processes helps the facilitator remain an objective third party, willing to ask questions to challenge the team to dig deeper into their resources and skills in order to employ higher levels of creativity. The facilitator’s job is to help the team transcend the old process in order to create a fundamentally new process, allowing patients and customers to be served more effectively and efficiently than they might have imagined was possible.

A reengineering or process redesign facilitator is first and foremost not a solution provider. Although many team members and team leaders may wish to see the facilitator in this role, it is important to convince the team members that they themselves will be the ultimate solution providers and implementation experts.


Some facilitators may be concerned about not being the clinical pro-cess expert. In fact, when it comes to understanding new and unfamiliar processes, too much familiarity and commitment to the old process might inhibit their ability to challenge and get to the root causes of issues. So, hav-ing facilitators who are outsiders to the process can actually be an asset to the team. To do this, they must be good listeners and good communicators. They must be able to deal with team conflicts and conflict between indi-viduals. I suggest if there is no hearty discussion and disagreement in the meetings, then either nothing productive is happening or no one is really communicating about the key issues and concerns. Easy agreement may be a sign that the team is just scratching the surface and avoiding the real issues. That said, the facilitator must be able to direct any contention or con-flict toward a common productive end and proposed solution.

The facilitator must keep the team focused and on track. A facilitator must ensure that everyone is heard and listened to in a collegial manner, and that no single person or group has the opportunity to promote a one-sided or limited agenda. The facilitator must also make sure that the group pro-cess and the engineering methodology is followed so that ultimately what results from the team’s efforts is a truly reengineered process that meets the process and organization’s objectives. It is the facilitator’s role to guide the team through concerns identification and analysis, process objectives devel-opment, process metrics development, ideal process or value-added/non-value-added flowcharting, force field analysis, and implementation work plan development. Each of these steps of the methodology will be described in more detail in later chapters.

Challenges to Their Success

Time is a major challenge. Assuming that the facilitators, team leaders, and members are selected internally, they will already have significant day-to-day responsibilities. Staff members whose workload may be easier to defer or offload should be assigned to each of the teams to provide support and expertise to the teams. These staff individuals might come from depart-ments such as management engineering, management systems, management

A facilitator must ensure that everyone is heard and listened to in a col-legial manner, and that no single person or group has the opportunity to promote a one-sided or limited agenda.


development, finance, information technology, human resources, customer service, marketing, planning, research, or similar departments found corpo-rately or in larger organizations. It is helpful and preferred that they have some facilitation experience. If they do not, they may be teamed up with others who have more facilitation experience and skills.

In hierarchical organizations, as most health care organizations con-tinue to be, there may be a bias for selecting facilitators at a certain level. This assignment could be a good one for your high potential leaders. I caution against using level in the organizational hierarchy to determine if an individual is capable of facilitating. I have seen very effective facilita-tors come from all levels of the organization. I have also seen instances where senior leaders were not as effective due to the position and title they held. Team members did not feel free to speak up, and the leaders themselves felt that they should have all the answers. It is preferable to have senior leaders serve as steering committee members or team leaders, not as facilitators.

Though some of the criteria for facilitators may seem subjective and may be difficult to assess without sophisticated assessment instruments, organi-zational leaders, administrators, and managers of individual potential facilita-tors can help judge whether they would be qualified for the role of process redesign facilitators. Any initial areas of weakness can be offset by assigning two to three facilitators per team with various strengths to facilitate together. Eventually, the facilitators learn from each other, and all the facilitators become stronger with a broader range of skills benefiting the individuals and the organization. Table 6.3 shows criteria and attributes to look for when selecting effective process redesign and reengineering facilitators.

Orienting and Training Facilitators

With limited time for training in most organizations, and the reality that people learn best by doing, it is important to provide the critical information and skills to get the facilitators started and on their way. Assuming the lead-ers have selected good facilitators with a variety of facilitation experiences, they mainly need to understand what is different with facilitating reengineer-ing and process redesign. Since reengineering is organization-wide and will involve substantial change from the status quo, it is important that the facili-tators appreciate the magnitude of the undertaking and that they understand why reengineering or process redesign is being used versus other improve-ment methodologies.


Financial, regulatory, and new care challenges need to be explained and mapped to the current reality, helping the facilitators understand the risk of doing nothing or even the risk of continuing with the status quo. Critical metrics, key performance indicators, and targets need to be provided as well as any team-specific targets. The facilitators or the team leaders cannot “sell” the need for reengineering if they themselves do not believe that it is neces-sary or that it cannot be done.

Table 6.3 Criteria and Attributes for Reengineering Facilitators

Criteria and Attributes Yes/No

Well respected in the industry ✓

Process improvement team facilitation and meeting management skills

✓

Process orientation ✓

A holistic or big picture perspective ✓

Creativity ✓

Restlessness and dissatisfaction with the status quo ✓

Enthusiasm ✓

Optimism ✓

Persistence ✓

Tact ✓

The ability to work as part of a team ✓

Very well-developed communication skills ✓

Humility—or not overly interested in taking all the credit ✓

Ability to ask persistent and probing questions ✓

Willingness to challenge the team and the status quo ✓

Ability to get each team member’s participation ✓

Understanding of the reengineering and process redesign methodology

✓

Self-confidence and self-assurance ✓

Confidence in the group process and the team’s ability to find and implement creative solutions

✓


The governance and organizational structure of the reengineering effort also needs to be clearly illustrated—first to the senior leaders and the chosen facilita-tors, and then to all the organization. Who will be making the decisions? Who will arbitrate any differences of opinion? How will the reengineering effort be organized, and how will it integrate with the overall organizational structure? How are the teams selected, and how are the associated targets for each team set? It is helpful for the potential facilitators to know who they will be part-nered with, as well as each potential facilitator’s strengths. Team leaders and the associated resources need to be identified for each team. Roles for all the key players in the effort must be clearly delineated, e.g., senior leaders, team leaders, team facilitators, and team members. In particular, it is important for the facilita-tors to know what is not their responsibility, as well as the assigned scope of responsibility for themselves and their teams. I have found that when teams hit rough spots, facilitators try to do too much and compensate when others are not stepping up to do what needs to be done. The accountability for the results of the reengineering and process redesign must stay with the team and not get delegated to the facilitators or support people.

A major part of the facilitator’s orientation session includes an overview of the reengineering and process redesign methodology and explanation of their part in rolling it out. Specific tools and the use of the tools should be explained, including how those will help the teams redesign their processers. It is helpful to provide both a hard-copy training manual and electronic versions of what is expected of the facilitators and the teams, along with the associated time frames and deliverables. Facilitators should also be given copies of tools, templates, explanations, and examples so they can create and recreate the tools they will need as they are facilitating their team’s activities. Explanations about how, when, and where each tool is used can be particularly helpful. Facilitators should also feel empowered to use the tools as they see fit. The main objective is not to get through the tools and methods, but to do what is necessary to accomplish the objectives and hit the targets. Not every tool may be necessary or appro-priate, and some may require improvisation to meet the team’s needs.

Managing and facilitating change should also be covered along with a read-ing list of practical articles, books, and ideas—particularly to provide facilita-tors an idea of what to expect, and some tried and true methods for when the team gets stuck. Great resources to provide to the facilitators include The Team Handbook (Scholtes et al., 2003) and The Team Memory Jogger (Joiner Associates Inc., 1995). Facilitators and team leaders should fully appreciate that resistance is to be expected and that everyone accepts change differently, and in his or her


own time. If time is available, I recommend a two-hour workshop on change readiness where the team goes through a process and a self-assessment to better understand how they personally deal with change, and identify their strengths and weakness around change. The team members can then compare change readiness profiles and leverage each other’s strengths so that when the going gets rough, they can help each other deal with the inevitable transitions that will be required. This workshop will also help team leaders to recognize, com-municate, and manage the change. (See Chapter 3 for more information on the change readiness workshop and assessment.)

Lastly, the facilitators should be provided with time frames, next steps, key deliverables, and milestones. Immediate next steps might include team leader orientation meetings, team training sessions, and report-out sched-ules. In summary, the facilitator orientation training should include the topics illustrated in Figure 6.2.

Refer to Table 6.3 to help you select the best facilitators. No one person will fit the profile completely; however, by pairing strong complementary individuals, you will have good facilitation expertise for the teams.

Role of the Team Leaders

Process team leaders are important to successful reengineering and process redesign. These leaders are essentially process owners. They need to be own-ers of the current processes and committed to redesigning the new processes

Facilitators’ orientation—high-level agenda items

Overview of the challenge and reason for the organizational reengineering initiative1

2

3

4

5

6

78

Financial and operational measure and targets—overall and by team

Each team’s focus and organizational overview, including

Next steps and key deliverablesChange readiness assessment and deliverables

Review of change management principles and challenges

An introduction to the tools and methods

Reengineering approach overview including the philosophy and how it compares to otherprocess improvement techniques

• Background• Leadership• Other staf f resources assigned to and available to the team leaders and facilitators

Figure 6.2 Sample orientation agenda for facilitators.


to meet the agreed-on process redesign goals and objectives. As opposed to being passive observers of the process redesign, team leaders need to do what it takes to remove obstacles and create opportunities for the process redesign to happen successfully—both in team meetings and outside of the meetings. In short, a process team leader must meet the qualifications listed in Table 6.4.

Realistically, it is rare to find all of these qualities in one person. It makes sense to assign more than one team leader to each team. In a typical clini-cal service line, the team might have a physician leader, a nursing leader, and even an administrative leader. These three leaders can work in parallel to help reinforce the strengths, organizational connections, and relation-ships that each brings to the table. They can also help ensure that their traditional respective constituencies are represented, listened to, and kept

As opposed to being passive observers of the process redesign, team leaders need to do what it takes to remove obstacles and create oppor-tunities for the process redesign to happen successfully—both in team meetings and outside of the meetings.

Table 6.4 Attributes and Qualifications of an Effective Team Leader

ATT An Effective Core Process Team Leader Must:

1 Manage one of the functions or major pieces of the process being redesigned.

2 Have the respect of their peers.

3 Have a stomach (and heart!) for reengineering. It can be a wild ride.

4 Be comfortable with change.

5 Be able to let go of control and trust the team and the process.

6 Be tolerant of ambiguity.

7 Be calm (or seemingly so) in adversity.

8 See that process redesign gets done.

9 Obtain resources and support for the team.

10 Run interference with the organizational bureaucracy.

11 Gain cooperation from the appropriate functional managers.

12 Motivate, inspire, and advise the team.

13 Shield the team from unproductive criticism.


informed so they can all support the change and help implement the team’s recommendations.

The next question is how to get these selected individuals to lead the team collaboratively. When they focus on common, aggressive, and chal-lenging stretch goals—which they are collectively accountable for—this will help bring them together. One idea is to put the service line leaders on a common incentive system where they succeed or they fail as a team. For any one of them to get their raise or bonus, the team has to hit the targets that they are assigned for the process redesign efforts.

Orienting Team Leaders

Team leaders should be formally appointed by the senior leadership team and provided with an overview of the importance of and expectations for the role. Team leader orientation meetings should be scheduled with each team’s leaders and facilitators. In these orientation sessions, the senior lead-ership team should kick off the reengineering initiative. A possible agenda for these sessions is shown in Figure 6.3.

In summary, the team leaders must know that they are ultimately respon-sible for meeting the financial and other targets given to their teams, and for ensuring that recommendations are made and brought to the senior leaders or steering committee within a set timetable. Leaders and their teams are responsible for implementing the recommendations within the time frame the team says is doable. For example, at the end of three months, they might be required to provide a prioritized implementation work plan including assign-ments, deliverables, implementation dates, associated cost savings, and real-ized benefits. Though it might seem like an aggressive time frame compared with some continuous improvement initiatives, with reengineering you prob-ably do not have the luxury of more time for various reasons. The urgency also quickly gets the team focused on making and implementing the neces-sary changes before they have a chance to lose momentum or focus.

Challenges to the Team Leaders’ Success

Team leaders will not succeed if they do not think they have a common goal. In reaching this goal, they need to appreciate each other’s different styles, strengths, and relationships with individuals in the organization. They need to collaborate with each other and be able to reach out across the larger organization to secure the resources and support that will help the


team achieve its objectives. Team leaders need to get comfortable running interference for the team. They also need to learn to effectively juggle their day-to-day priorities and the priorities they have as leaders. Team leaders now represent a reengineering team for a core process redesign, not a func-tional area. They need to appreciate that they lead a team that may cross broader boundaries than those that report directly to them.

Team leaders’ orientation—high-level agenda items

12

3

4

5

6

7

8

9

10

Introductions and ice breakersOverview and purpose of the initiative

The need for organizational change. Present the impetus for change, the targets, thecompetitive threats, and other factual information.

Business and service line pro�tability and loss. Share with each set of team leaders themagnitude of their potential opportunity for major improvements in �nancial quality orsatisfaction outcomes to help illustrate the need for care delivery process redesign.

The results of external comparative analysis. Based on external comparisons orbenchmarks, this information helps team leaders understand that there is signi�cant potentialfor improvement. And though each organization is unique and it may seem legitimate toquestion the validity of the comparative data, if both the internal measures and externalmeasures show large opportunities, the team should be able to �nd signi�cant improvementsthrough process redesign.

As part of the handouts or takeaways from the orientation session, each team leader shouldreceive a summarized high-level report of potential opportunities. Basically each team leadershould receive a report—both electronically and in a binder—outlining the data from items 2and 3 above.

Team leaders should also understand that senior leadership’s role is to provide direction andassistance in overcoming organizational obstacles—on a regular or as needed basis—and toprovide any necessary additional resources to implement the team’s recommendation to meettheir target.

The stretch targets. Each team leader should have clear visibility to the organization-widetarget as well as their own team’s targets.

Resources available to help with the process redesign. For each team, identify the facilitators,cost accountants or �nance resource, the data analysis, or other staf f support available to theteam.

Time frames and required deliverables. It is important that each team understand that they areresponsible for providing an itemized list of recommendations, with individual assignments anddue dates, in the form of a prioritized implementation plan with the associated improvements.

A brief overview of the tools and approach. This overview may be the abridged version of thefour-hour training session provided to all facilitators. The team leader should also have accessto any eLearning modules as well as electronic tools, templates, resources, and examples.

Next steps. Explain what the team leaders’ immediate next steps are. Their top three prioritiesare to review the information provided at the meeting, identify the appropriate team members,and invite them to be on the team and schedule the �rst few team meetings.

We will discuss orientation of the selected team members in a later section.

Figure 6.3 Sample orientation agenda for team leaders.


Role of the Team Members

The team members will be responsible for participating in and ultimately doing the process redesign. It is their duty to bring their knowledge of the process and expertise to bear in the redesign of the targeted pro-cesses. Most important, they must feel free to share their knowledge and be allowed to do so. It is important that each team member understands that each individual, as a member of the team, is responsible for the process redesign and for implementing recommendations. This means they must be involved in developing the recommendations and defend-ing those recommendations against naysayers. They are also responsible for the successful implementation of the recommendations and associated changes. I have seen team members try to lob a couple of token recom-mendations over the wall to the team leaders and senior management without really engaging in the process. However, team members need to grasp the awareness and understand that they are ultimately responsible for making it all work. As the senior leadership team and steering com-mittee begins to respond, “Go for it. Do what you have to do to make it so,” the teams will begin to understand the organization is behind them and they have to implement the recommendations and make change happen.

The team must be truly multidisciplinary for the recommendations and changes to be successful and sustainable. In spite of the teams being set up this way, there are often factions who believe they uniquely know what the problems are and think that meetings to discuss the problems and solutions are unnecessary. (Though one has to wonder if they were experts in the process changes, why had they not implemented them sooner?) The good news is that several of the tools in the methodology, such as concerns analy-sis and the objectives development exercise, help foster respect among the team members, or at least a better appreciation for the challenges that other team members may be facing in different parts of the process.

Most successful teams include both management and frontline employ-ees. The frontline employees are closer to the process than management, but managers often have the ability to clear obstacles and immediately

The team members will be responsible for participating in and ultimately doing the process redesign. It is their duty to bring their knowledge of the process and expertise to bear in the redesign of the targeted processes.


implement good ideas. Often there are concerns that employees will not speak their minds as openly with managers on the same team. However, I find that employees are not intimidated to share their thoughts in front of managers. For customer service–related issues, there is no one closer to the customer or the patient than the employee or caregiver. This is appar-ent to most good managers. If a manager inadvertently or consciously shuts down the others on the team, the facilitators and other team leaders should address this behavior outside of the meeting as soon as possible, before the next team meeting.

The team is partly responsible for managing the change. I say partly responsible because along with the team leaders, senior leaders, or steering committee members, who bear ultimate responsibility, team members must manage some of the change by helping manage or minimize some of the gos-sip. At the very least, they must be careful of what they share with colleagues outside the team. They must realize that many potential ideas will be dis-cussed, analyzed, and explored without ever becoming a recommendation by the team. Therefore, it is important not to get colleagues and employees over-wrought about recommendations that will never become real or implemented.

Each team should also understand that they are responsible for redesign-ing their processes to achieve substantial targeted goals. For example, their goal may be to reduce costs by several million dollars or by a large percent-age in a year. They may have a target to increase customer satisfaction or employee engagement by double digits. The aggressiveness of the target helps make clear that incremental improvements are not adequate. Against these aggressive targets, each team is expected to prepare a prioritized work plan or list of recommendations with an approximate value of dollars saved, increased market share, improved patient satisfaction, improved employee engagement, and other types of potential values and benefits. Each work plan should also include a rough communication plan. Professionals from departments such as internal communications or public relations (PR) can consult with the team and help the team flesh out the details. This communi-cation plan should not be overlooked, nor should it be too narrow in scope. All stakeholders need to be included in the communication plan. While some recommendations may include only a handful of employees, others may need to be communicated to the entire organization or even the community.

In most instances, and wherever possible, I recommend face-to-face communications. Even if written or e-mailed material is provided, it should not replace face-to-face meetings. As much as possible, employees should get information from their supervisors or line leaders. At one organization I


worked with, the PR team prepared information packets and talking points so that managers would be prepared to accurately share vital information. Senior leaders also made themselves available to answer questions if nec-essary. And, as much as possible, use existing channels to get information out, e.g., Town Halls, leader meetings, department meetings, blogs, internal videos, etc. Do not be afraid to overcommunicate both repeatedly and in a cascading fashion. Make sure that communications that cascade from the top of the organization, across, and down to all levels remain accurate and appropriate.

When communicating, team leaders and members should remember the following checklist:

◾ Be specific. ◾ Provide context. ◾ Express a goal—why are we doing what we are doing and why are we talking about it?

◾ Emphasize the actual process change and the associated benefits. How will individuals be affected, and why will it be better, and for whom?

◾ Keep a strategic frame of mind. What is the big picture? ◾ Recognize there are multiple perspectives, and the more they are acknowledged and heard, the better the transition and implementation.

◾ Credit the team’s efforts and successes, not just those of individuals. ◾ Exercise caution when and if assessing blame. If done at all, it should be in private. Preferably mistakes should be learned from, not punished.

◾ Provide a sense of timing.

On the other hand, team leaders and members should make sure to never:

◾ Oversimplify or talk down to people. ◾ Apply process or functional language to people. Speak so people can understand the changes. Do not cover up what needs to be done with buzz words or jargon.

◾ Omit the customer or patient from the discussion. ◾ Assume mutual understanding of terminology or situations.

In Figure 6.4, you will find a template for a communication plan for reen-gineering teams.


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In research I conducted with health care leaders, one highly experienced health care executive noted that it is difficult to get employees on board. He remarked that executives can be too impatient and not appreciate that while they have been discussing a situation and approach for days, if not weeks, employees need time to understand and process the new situation. They are unlikely to instantly get it. We have to give people time to assimilate the need for change and the approach toward addressing it. It is also essential to allow a give-and-take discussion instead of talking at people in a one-way fashion. A mentor of mine once observed, “People don’t learn (or get it) until they hear the sound of their own voice,” in a discussion. You can never safely assume that your presentations, no matter how brilliantly prepared or executed, have hit their mark and that the employees understand your intent or your message. It is important to let employees probe, question, and share their concerns. Some leaders are afraid of these “unscripted situa-tions.” However, if employees go quiet and listen “respectfully,” you have no idea what they are thinking, if they understand, and if they are committed to the initiative. One client used interactive technologies to “poll” employees during communication sessions to gauge reactions and get questions and concerns out into the open where they could be discussed. It is much better to address the issues when they first come up rather than letting them fester and develop lives of their own. As Mark Twain once said, “A lie can travel half way around the world while the truth is putting on its shoes.”

Each recommendation must have an implementation plan associated with it—especially if it encompasses major change and affects much of the organization, which will be the case with many recommendations. Since the teams have to develop recommendations in a short time period, they have to be able to meet frequently and regularly, understanding that the reengineer-ing initiative takes precedence over their day-to-day activities. This can be challenging, frustrating, and exhausting. Though proactive activities such as reengineering or process redesign do not seem to have the pull on our time as do the urgent tasks, reengineering is critical to the long-term success of the organization. The senior leaders, team leaders, and facilitators will need to keep the team focused on this imperative. Once a team loses momentum, it can seem like twice as much work to get back on track. There should be

Though proactive activities such as reengineering or process redesign do not seem to have the pull on our time as do the urgent tasks, reengineer-ing is critical to the long-term success of the organization.


a conscious effort to defer or reassign day-to-day responsibilities whenever possible while doing process redesign. Obviously, patients and customers still need to be tended to; however, other administrative tasks can be put on hold. If the teams become high-performing teams and are able to make significant recommendations that will help them meet their targets in a short time frame, everyone will be better served. Quick-hit recommendations that are identified should be implemented as quickly as possible since they will help move the team and organization closer to the targets while improving care processes and reducing costs. Quick hits also show rapid results and serve as encouragement to the teams and to the broader organization.

Choosing and Orienting Team Members

So what does an ideal team member look like? Team members must be open, honest, and willing to share their knowledge and experience. They should be willing and able to assist in additional data gathering and interpre-tation as questions about the process or recommendations come up. They ought to be comfortable with identifying opportunities for improvement and able to help the team formulate recommendations. Team members will be assigned the implementation of many of these recommendations along with the team leaders. Lastly, they will need to learn to have courage and deal with ambiguity as opportunities are discussed. They will soon realize that some of the recommendations being considered and discussed will have a direct impact on their day-to-day workflow and process. This is an area that the facilitators and leaders will have to constantly be aware of and help the team get through.

Parts of the team leaders’ orientation must be shared with all team mem-bers at the first meeting of the team to serve as an overview and introduc-tion to the initiate. All team members must understand the reasons for and why the organization requires fundamental change as opposed to incre-mental change. It is important to give them an overview of reengineering, process redesign, and the scope of the changes that are expected. In addi-tion, there should be a list of basic ground rules to ensure that meetings are productive and working relationships remain productive. Ground rules might cover these topics:

◾ Assignments and accountability ◾ Attendance ◾ Breaks


◾ Confidentiality ◾ Conversational rules ◾ Handling conflict ◾ Interruptions ◾ Meeting time and place ◾ Participation ◾ Promptness ◾ Rotation of responsibilities

Although teams may have heard the leaders present an overview of the initiative, or read blogs or seen videos about it, it is important that they hear the information together as a team. This way, they can discuss how it affects their core process and what it will mean to them.

Separate from general meeting ground rules, process redesign rules must be shared with the teams. Team members must understand that the review of the process must be from the patient or the customer’s perspec-tive, not that of departments, management, or employees. This can be difficult since we often feel we know what is best for the patient or cus-tomer. Later tools and discussion will help drive this thought for the team and keep them focused on it. Despite fear or misgivings about past experi-ences with organizational change or process improvement, team members are expected to make a positive contribution to the team’s efforts. Team meetings are not gripe sessions, nor are they a chance for the person who shouts the loudest to promote his or her own agenda. Teamwork and col-laboration are essential. This can be a challenge. Though many health care professionals would state they are team players, in reality, they have been trained and educated to be highly autonomous professionals. The focus on challenging targets is designed to help give the team meetings a sense of urgency and encourage even the most intransigent individualist to bond with his or her fellow team members. Once we realize that we cannot solve a particular challenge alone, we become more likely to reach out to others for collaboration and new ideas—but not until then. It also explains why I start with a concerns analysis before setting objectives and moving onto the more appreciative approach of designing the ideal new process.

It is critical that team members understand the status quo is not an option. This is also a challenge since most people choose to live believ-ing or pretending that change is not inevitable and can be avoided. Perhaps even more interesting is that many of the team members have not only bought into the status quo, but they also benefit from it, and may have even


helped create it. It is part of their routine, and gives them a sense of control and competence. Figure 6.5 depicts how humans react to change and why it can be so difficult to deal with any change whether we perceive that change to be good or bad. Senior leaders and facilitators must beware. In an effort to avoid change, team members or team leaders can end up being true sabo-teurs, all the while coming up with their own “solutions” or workarounds outside of team meetings, and at the eleventh hour. This can be very

It is critical that team members understand the status quo is not an option. This is also a challenge since most people choose to live believing or pre-tending that change is not inevitable and can be avoided.

Status quo = expectations

met

Change = disruptions in expectations

Competence

Comfort

Control

Confidence

Figure 6.5 What does change represent to people?


disruptive and slow down the progress of the team. If this behavior occurs, it needs to be addressed quickly and unequivocally.

When you look at the model in Figure 6.5, it becomes apparent why change for us or anyone else is something we naturally want to resist. In our status quo lives, we know what the expectations are. We feel competent, in control, comfortable, and confident. However, when a good event (birth of a child, new marriage, or new job) or a bad event (death in the family, loss of a job, or relationship problems) causes change in our lives, we are not clear about what is expected of us or what the new rules are. We are suddenly out of our comfort zone, less confident, and feel less competent. The new situation may make us feel a bit out of control.

Role of Other Support Professionals

Each team should work closely with a cost accountant or financial analyst to supply them with comparative cost data and to keep track of the value or costs of the team’s various recommendations. Their reports can help identify and prioritize where the greatest opportunities lie. They can also assist with targets and assess the short-term and long-term impact of the team’s recom-mendations on the organization as a whole. Depending on the sophistication of the organization’s financial reporting system, they may be able to cost out the entire patient or customer experience and assist with “what-if” analyses, which can help when the team needs to phase in or select between initiatives.

Most important, they are able to objectively track the team’s efforts, such as savings and overall benefits for the steering committee or senior leadership team. With financial experts working with all the teams, the senior leaders can trust the numbers behind the recommendations coming from the teams. These experts can also help the team understand the limitations of the data, while still ensuring that it will be used for decision making. The last thing you want is for a team to fall into the trap of arguing about the data or its applica-bility to their case. Some organizations try to have the team leaders or facili-tators do all the tracking, but with everything else these individuals have on their plates, the financial analysis role becomes an even more important one.

Strategic planners can help teams understand the details of the strategy and how it intersects with the market data. They can also help keep the team realistic when it comes to addressing the market strategy and constraints due to current and future building and technology capital projects. Quality assur-ance professionals have the pulse of the appropriate quality outcomes from


the patient and customer perspectives, and can help identify and track how the patient or customer’s quality or experience will be or needs to be influ-enced by the team’s recommendations. They can also help the team identify the critical, industry standard quality indicators and measures.

Identifying the Metrics for Success

Teams should be given very aggressive financial targets for which they are expected to provide sufficient recommendations within a short time frame, such as ninety days. Paralysis by analysis cannot be allowed since it often results in a “proof” against the need to change. Here is where external data or information can be helpful. If truly advanced benchmarking partners can be found, aggressive opportunities for financial and clinical process redesign can be identified and quantified as targets for each of the teams. On the other hand, if your organization is rapidly losing market share or profitabil-ity, the aggressive opportunities targets can be quantified on a team-by-team basis as the amount of net income or market share that must be regained or realized within a short time frame to remain a viable organization.

It is important to understand that the recommendations must be creative and aggressive enough to meet the very challenging targets. If we only need an improvement of 5%–10%, we should use other more traditional and less disruptive process improvement methods. If the initial recommendations brought forward by the team do not come near to the targets, leaders should direct the team to employ more of the process redesign techniques. Change is difficult. The organization is investing a lot of resources to realize substantial gains, so it is important to set the targets high and not to settle for mediocrity.

Besides having goal-oriented aggressive facilitators and team leaders, how can you as a senior leader ensure that the teams do not go veering off course or give up too soon? First, make sure that the targets are not strictly financial. The teams need more holistic measures for the processes they are redesign-ing. Those measures should include customer and patient satisfaction, and quality measures. And they should be a mix of process and outcome mea-sures. As much as possible, the nonfinancial measures should also be quan-tified. For example, one objective for the emergency department’s process redesign could be to expedite patients through the process. The measure for this objective might be patient turnaround time. A stretch target would be to cut that turnaround time in half. The objectives setting process and the estab-lishment of process metrics will be discussed in detail in a later chapter.

85

Chapter 7

Methodology for Reengineering and Process Redesign Teams

Much has been written on reengineering and process redesign but little on how to actually make it happen in health care. In Champy and Greenspun’s (2010) book, Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery, they cite examples of reengineering cases within sev-eral organizations. The stories the authors tell are inspirational and speak as much to the talent and passion of an individual leader as to the reengineer-ing approach. In McNulty and Ferlie’s (2002) book, Reengineering Health Care: The Complexities of Organizational Transformation, they also provide excellent case studies while presenting process reengineering as nothing short of a planned organizational transformation. The question is, if this is a transformational approach that can move health care delivery forward, how do we get started and what is a proven approach? What can a senior leader or change leader do to begin reengineering in his or her organization? This book, and specifically this chapter, offers a methodology to help you reen-gineer and transform your organization by using a simple approach and set of tools and methods—many of which may be somewhat familiar as they are similar to those used in other process improvement methodologies and organization development approaches.

The overall process is illustrated in Figure 7.1. It shows a high-level over-view of all the steps in the methodology. Later in this chapter, each step is described and illustrated using an orthopedics team’s work as an example.


First, you want to make sure you know which process you are going to reengineer. If you have read this far, you have probably identified those core business processes you need to redesign in order to achieve success. As such, you have selected core processes that are important to achieving your orga-nization’s most challenging goals and the strategic initiatives that will enable you and your organization to deliver on your unique value. Your primary goal as a senior executive in charge of the overall effort is to create the envi-ronment to help your teams get through the reengineering approach of rede-signing how your organization cares for patients and serves the community. This effort does not conclude until the recommendations are implemented. For those of you who are team facilitators, you are the guides who will help the teams achieve their goal. It is important that the team leaders, facilitators, and team members (to a lesser extent) understand each of the tools and steps in the process, as well as how those tools and steps fit together to help guide the team through a significant redesign of core processes.

The case studies and examples in this chapter and throughout the book are based on the experiences of actual clients. This book presents them as generic illustrations with no client-identifying information. They have been simplified and aggregated where necessary to clarify the use of a tool or the approach.

Prerequisites

Check the ideal process

Identify goals/objectivesof ideal process

4

1 2 3

5 6

7 8 9

0

Conduct processconcerns analysis Establish process metrics

Value-added/non-value-added flowchart for

ideal process

Develop the ideal processflowchart

Perform force fieldanalysis

Develop implementationplan

Use project managementtechniques to implement

ideal process

Figure 7.1 Reengineering roadmap overview.

Methodology for Reengineering and Process Redesign Teams ◾ 87

Conduct a Concerns Analysis

The first step—once the team has completed their orientation and introduc-tions and has a good understanding of their role, the why, the goals, and tar-gets of the team—is to identify all the concerns and issues surrounding the current process. Refer to step 1 in Figure 7.2. Make sure the team members are first clear on what the targeted core process is, what it includes, and what it does not include to set some boundaries and help the team focus. I usually suggest that the team initially identify a high-level starting point and a high-level end point in the process. Later, these may be refined. Examples of a high-level process starting point may be as follows: the client has a need; the patient arrives at the clinic; or a patient calls about their bill. Process end-ing points may include the following: a solution is provided to the client; the patient is discharged or leaves the clinic; or the patient pays the bill.

To help the team relate what may seem to them to be somewhat abstract financial and customer service targets to the realities of day-to-day patient care, the facilitators must challenge the team members to identify from their own insider’s knowledge where some of the major opportunities for improvements in the care or business process may be. And even though team members may understand the idiosyncrasies of the “as-is” process and may have even helped create it, they need to view it from the perspective of a patient, family, client, or customer.

Using brainstorming techniques in a round-robin fashion, team members identify their major concerns with the current process. In my experience, the team will identify a wealth of opportunities once they get started. In fact, this allows everyone to vent for a bit and mutually come to terms with

Conduct processconcerns analysisPrerequisites

01 2 3

Identify goals/objectives ofideal process

Establish processmetrics

• Select and define key core processes• Select/appoint the team• Orient the leaders, facilitators, and team members• Team building• Establish ground rules

• Brainstorm concerns with the current situation• Review, revise, edit, and group concerns• Begin to convert concerns into potential goals and objectives of the new process

• Convert key concerns into objectives or attributes of ideal process• Make sure that goals and objectives are as specific and measureable as possible

• Based on the goals, objectives, and attributes of the ideal process identified in step 2, establish metrics for the ideal process (both process and outcome metrics)• Select key high- level metrics

Figure 7.2 Reengineering roadmap—setting the stage for process redesign.


the fact that there are many opportunities to dramatically improve the cur-rent process. Concerns and opportunities are written on a flip chart so they are all visible to the team. Facilitators should remind the team that having a large number of concerns on the list is not necessarily a bad thing. Where valid concerns can be identified, more significant opportunities for improve-ment can also be found. Also, for the next step in the methodology, a robust and comprehensive set of concerns helps identify all the critical objectives and criteria for the ideal process that will be developed.

At the same time, the facilitators must ensure that this discussion does not deteriorate into a gripe session. To accomplish this, the facilitator must deviate from traditional brainstorming and immediately question and probe when negative comments are made. Asking simple questions such as the fol-lowing can help further define the concern and get closer to the root cause of the issue:

◾ Why do you say that? What do you mean? ◾ Could you be more specific about what this issue is or why it is a problem?

◾ Could you help me understand why you think this happens this way?

The key point is to keep everyone focused on the process issues and to not assign blame and turn the session into a finger-pointing match.

For example, let’s assume that a team member says something like, “My major concern with the current process is that bed management, or fill in the name of some other department, does not do their job.” To defuse a potentially volatile shouting match and disruptive blaming behavior, the facilitator can ask

◾ What do you mean by this? (An answer might be that the team is not notified when a bed is ready.)

◾ Could you be more specific? (They don’t tell us when the bed is ready.) ◾ What specifically do you feel that bed management is not doing? (They are not noting in the computer in a timely manner that a bed is available.)

The point of the concerns analysis step is to keep the team focused on the opportunities for improvement of the process and to not point fingers or blame individuals for the process shortfalls.


◾ What do you feel is their role versus your role in this process? (They should quickly and consistently keep us updated about which beds are open or soon-to-be open.)

◾ Is there anything you could do to help them provide you the informa-tion in a timely manner? (Perhaps I could contact them via phone when I need a bed stat. I could also specify more thoroughly what type of bed the patient needs and why.)

Ultimately, you may find that the real concern is different than the one originally stated. Indeed, the problem could be that the emergency depart-ment is not notified when beds are ready for new admissions. Alternatively, the concern could turn out to be that notification occurs but the appropriate bed is not identified. The value of this questioning process, which to some team members can seem frustrating at first, is that the real issues get put on the table so they can be addressed versus just addressing the initial symp-toms of those problems.

The following list illustrates examples of concerns that might be identified during a concerns analysis for an orthopedics service line:

1. The current scheduling system is time-consuming and not up-to-date. 2. The current schedule is not accurate. 3. Communications between the departments are compromised because

of problems with the schedule. 4. Patients are not informed when therapy or treatments will occur. 5. Communication with pre-op and recovery nurses is inadequate. (The

facilitators will need to probe this one more with the team.) 6. Therapy assignments are inconsistent. Different staff members care for

patients throughout their stay, leading to the patients’ perception that care is fragmented.

7. Orthopedics staffing is inadequate. This is often everyone’s first and foremost concern before they realize that streamlined, logical, well-working processes usually do not require as much staff.

8. Distribution of workload or work assignments does not seem to be equitable.

9. Transporters are underutilized. 10. There are too many traction requests on the night shift when less staff

is available. 11. Patient prioritization for therapy needs to be more specific to the indi-

vidual patient’s needs and situation. For example, two patients may


both be post-op, day two, and on the same clinical pathway. However, clinically, they may have different priorities because of their unique clinical situation. One may have missed a therapy session because of pain, one may be having more challenges with mobility, and one may have a particular comorbidity that requires special treatment, and so on.

12. Preoperative education needs to work more directly with continuing care so that patients and families can be better prepared for discharge.

13. Inconsistent information is provided to the patient by different disci-plines, leading to confusion and a diminished trust in all the caregivers’ abilities.

14. Dietary and pharmacy instructions are inconsistent. 15. Too much time is required to put up and take down traction. 16. Equipment needs to be updated. 17. Space is inadequate in occupational therapy, physical therapy, etc. 18. Staff is not trained properly in the use of equipment. 19. There are delays in service provided to patients. 20. The appropriate clinical pathway is not always feasible for the patient

because of pain or medication. 21. The pathway does not correspond with the patient’s preference or life-

style, e.g., baths versus showers. 22. Patients are moved from the unit to the therapy and ancillary areas too

frequently. 23. Nursing homes and rehabilitation centers do not always accept patients

on the weekends. 24. There is a delay in getting the required equipment or appliances in

patient’s homes before or just-in-time when they are discharged to home.

25. No consistent yet personalized mechanism exists for contacting physi-cians in the event of an emergency.

26. Separate databases lead to inconsistencies, redundancies, and confusion.

Needless to say, any of these concerns can spark many additional ques-tions to understand what the underlying issues are. However, a properly facilitated concerns analysis will get most, if not all the issues, out on the table. It also helps the team members understand the many challenges faced by their colleagues and the other departments. And, although this step in the process will lead to the development of the objectives for the team and the process, we purposely leave the issues at this level to help ensure that the team does not leap immediately and prematurely into finding solutions or


solving problems at the lowest level. The sample list illustrates how tempting this can be. The team must come to realize that because the concerns are at best symptoms, applying quick fixes will not get the team to a new ideal redesigned process. In fact, you may find that multiple efforts to resolve these same concerns have been repeating themselves for months, and even years, without really getting to the root cause or crux of the issue, never leading to an improved process or outcome for the patient.

Now a note about why I start with this step. Most process improvement methodologies and organizational development approaches start with goals and objectives. Developing goals and objectives follows the list of concerns with the current process because of some lessons learned on my part. By first focusing on what is wrong with the process, the team gets a good over-view of the current process and the fact that it is not adequate to deliver the results the organization and its customers or patients require. Second, and perhaps sadly, it is easier for us as humans to complain and identify things we do not like. Instead of overcoming that tendency, I use it to benefit and provide momentum to the team. Since we will use the concerns list to make sure that we have all the appropriate objectives, this list will help us ensure that we have not forgotten anything. It can be very challenging to come up with a comprehensive list of objectives for a brand new process or a pro-cess that does not exist. Lastly, we will eventually employ some appreciative inquiry techniques as we design the ideal process. So before doing that, this step ensures that we are not glossing over issues that need to be addressed.

Identify Goals and Objectives of the Ideal Redesigned Process

The next step in the methodology is to use the list of concerns to establish the objectives of the ideal or redesigned process. This step not only focuses the team and ensures that the team has common goals, but it also further ensures that the team is not left with a list of problems from the current process that must be solved, which would lead to improving the existing process instead of serving as a basis for setting process redesign objectives. Refer to step 2 in Figure 7.2.

The team evaluates each concern to assess if it can be flipped or con-verted into a clear specific objective, either by itself or combined with another concern. In some cases, the team may need to sort out and/or combine concerns into similar categories using a simple affinity diagram.


However, there is a fine line between the need to group the concerns and ending up with a watered-down or less descriptive list. The power of this approach is that though many people find it difficult to develop a com-prehensive list of process objectives for a process that has not yet been designed, they are quite capable of listing concerns or problems with the current process. Furthermore, if all the concerns are carefully identi-fied, listed, and described, the team starts out with a list of specifically what they do not want the new process to look like. They are therefore more likely to develop a comprehensive list of the objectives of the new process. In addition, it further reinforces the need for significant change. I have often referred back to the list of concerns with the current pro-cess when the team begins to falter or get nostalgic about the old/current process.

If we go back to our previous bed management example and recall the team’s concern that the emergency department is not notified when beds are ready for new admissions, one simple team objective for the ideal process might be that the emergency department is made aware of available beds for new admits as soon as the bed is ready. Using our hypothetical orthopedics process redesign team and their list of concerns, ideal process objectives might be to have

1. Real-time, flexible patient scheduling with coordination among all disci-plines and departments, including physicians.

2. Enhanced multidisciplinary teamwork, including physicians, preopera-tive services (pre-op), and postoperative services (post-op).

3. Adequate staffing seven days per week and twenty four hours a day (7 × 24) for all disciplines to meet patient activity and requirements.

4. Adequate space. 5. Equipment that is updated and appropriate to the patient. 6. Enough equipment to minimize delays. 7. Consistent pre-op, post-op, and discharge information (from all sources

for the patient and family) to prepare the patient. 8. Staff and patients are educated and informed about procedures with up-

to-date information on an on-going basis. 9. Streamlined and nonredundant information. 10. Minimal delays in service to the patient. 11. Service provided in a location appropriate for the patient (i.e., at the

bedside or on the unit if necessary). 12. Appropriate use of traction equipment including the trapeze.


13. Convenient, timely, and easy-to-access (i.e., provide close available park-ing) pre-op education and testing processes.

14. Nonstop transport. 15. Adequate and appropriate pain control throughout the process.

In the examples of concerns and objectives listed above, concerns #1 and #2 become objective #1, as illustrated in the previous two lists. You will note from these examples that often the team may find that some concerns are redundant or may be combined into one objective. Or a concern may remain just a concern and cannot or should not be turned into an objective for the purpose of reengineering or process redesign. Also note that some objectives will seem extremely simple while others will seem almost impos-sible. However, as the team works together, more of the objectives will be amenable to being turned into a reality once the team’s creative juices get flowing. In addition, the team begins to realize that the objectives of the ideal process benefit patients, customers, and caregivers alike.

Establish Process Metrics

The team has now made good progress by establishing some common goals and objectives. However, if they are truly going to put the old process aside and invent a truly new redesigned process, they must make sure that they obtain the dramatic results they are aiming for. The new ideal process must meet as many of the objectives that the team has agreed to and listed. It is therefore important to make as many of the objectives as possible measur-able, so that there is a way to determine if the process truly is ideal or if it is only a slightly improved version of the status quo. The team should review the list of objectives, understanding that it is alright if some of them are somewhat soft. They should look for as many as possible that can be mea-sured. Even for the softer measures, they should be able to clearly describe what success will look like when they meet the objective. Refer to step 3 in Figure 7.2.

Continuing the bed management example where the objective was that the emergency department be made aware of available beds for new admits

As the team works together, more of the objectives will be amenable to being turned into reality once the team’s creative juices get flowing.


as soon as the bed is ready, a process measure or metric might be the amount of time between when the bed is available and when the emergency department is notified that it is available. It is important that these measures are simple to understand and easy to monitor, so that later the team does not have to debate or guess whether they have really met their objectives based on how the results were measured. If possible, the team should use measures that are already available and tracked continuously in existing sys-tems or processes. This provides an accurate baseline measurement, and the team has access to reliable measures that can be tracked continuously with-out expending additional resources. It also cuts down on the need to add resources to track metrics, which is costly, non-value-added, unsustainable, and should be a huge “no-no.”

If the necessary measures are not currently available, for example, if the time between when the bed is available and when the emergency depart-ment is notified is not already being tracked, the team must assess whether measuring this specific time interval is important enough in determining if objectives are being met. An alternative would be to broaden the measure to the interval between bed availability and next assignment to that bed—if this statistic is readily available and extractable from the current patient informa-tion system or electronic medical record. If necessary, the team may even have to broaden the measure further to, for example, the interval between when it is determined that the patient needs to be admitted to when that patient is actually admitted, again assuming these data are available. Usually, broader measures are not only more readily available, they are also often closer to what the patient, family, or customer perceives, and these measures—along with any improvements—can be easily observed, making the measures even more relevant. In addition, when a team is truly engaged in process redesign or reengineering, it is highly likely that the process will be so radi-cally different that the broad measures will be precise enough to document the process changes. If you are cutting the total process sequence and dura-tion in half or even quartering it, as is easily the case in a reengineering or process redesign effort, even the broadest measures will be able to document and track the efficacy of the redesigned ideal process.

If possible, the team should use measures that are already available and tracked continuously in existing systems or processes.


Objectives of the sample orthopedics work redesign team might require the following process metrics:

1. Number of current patient delays (e.g., longer than ten minutes) per month

2. Number of conflicts (e.g., when the patient is not available for a test or treatment)

3. Number of understaffed situations 4. Staff productivity and utilization by day of the week and time of day 5. Number of patient or family complaints 6. Patient satisfaction survey scores 7. Actual patient outcomes versus expected patient outcomes

Most of the metrics above are quantitative. I recommend quantitative measures, process, and outcomes, as well as qualitative or descriptive mea-sures. Once the team has established goals and objectives and ensured that the objectives can ultimately be used to measure the success of the process redesign, it is time to actually develop a new ideal process that can and will meet the objectives.

Develop the Ideal Process Flowchart

As a senior leader of an organization or internal team facilitator, the actual process of taking teams from a blank sheet of paper to a radi-cally redesigned process that meets the idealistic-sounding goals and objectives—along with hitting some ambitious stretch targets—that your organization, you, and the teams have set, can seem to be the most daunting part of the change process. However, these steps, tools, and techniques can be used independently or in conjunction with each other to help get a team from that blank sheet of paper to a newly and radi-cally redesigned process. The approach uses principles of organizational and team dynamics, and is rooted in process improvement and industrial engineering, so that not only do organizations benefit from the new pro-cesses, but they also come out of the exercise with higher-functioning teams and increased capacity in leaders and employees. Refer to step 4 in Figure 7.3.


To level the playing field, encourage the teams to start from scratch as much as possible. Putting knowledge and experience aside is difficult, as many of us have experienced how hard it is to “unlearn” something. I have the team start with a blank sheet of flip chart or a white board. First we review the objectives, and then I ask the team to envision in their minds what the ideal process would look like. One way to challenge them is to ask how they would want it to work if it were them or a loved one going through the process. Using concepts from an organizational development approach called Appreciative Inquiry developed by David Cooperrider and Diana Whitney (2005) at Case Western Reserve University, we ask the team to imagine the best possible process for this core process. The theory and this author’s experience indicate that an affirmative approach to change, such as an appreciative inquiry, generates more ideas about what is pos-sible and helps reduce resistance to change. As noted by Albert Einstein, “Imagination is more important than knowledge.” The traditional approach to problem-solving is to look for a problem, do a diagnosis, and find a solu-tion. The primary focus is on what is wrong or broken. Since we look for problems, we emphasize and amplify them. However, if we focus on what is possible and positive, it is energizing and helps fuel our creativity and ability to find innovative solutions and approaches.

Using one 8½-by-11 inch sheet of paper for each major step in the pro-cess, the team begins to brainstorm the steps of the ideal process. The sheet can then be taped to the wall with the understanding that the step place-ment and even the step itself will evolve and change. If you can get them,

Develop ideal processflowchart

Check the idealprocess

Value-added/non-value-added flowchartfor ideal process

4 • Ask questions to help team members envision the process as it could ideally be

5 6• Is the process really ideal?• Does it incorporate redesign principles?• Will it be able to meet the goals, objectives, and metrics of the ideal process?

• Label/identify each step in the ideal process as value- added or non-value- added• Are there ways to minimize or eliminate non-value- added tasks?• Are there additional ways to make these tasks less of a burden to your customers?

Figure 7.3 Reengineering roadmap—developing the ideal process.


large sticky notes are perfect. As the steps are described and put up on the wall, alternately and concurrently use visioning to describe how the process could or should look. Challenge any assumptions or existing or unwritten rules about the step or the process. The caveat is that it is often the unwrit-ten rules that are the strongest. They usually come about based on long-standing assumptions, such as, “We always thought that was the way the lab wanted us to do this process.” In this approach, major steps are added, deleted, rewritten, and reorganized to document what the ideal process might be. I call this “ideal process flowcharting.” Figure 7.4 shows the docu-mentation of an ideal process developed by an orthopedics service line.

The example flowchart looks neat and tidy, but it can be a challeng-ing and messy process to get to this point. Also, it cannot be emphasized enough that it is not the goal of this step to document the existing process. The facilitators will need to keep challenging and reminding the team that they are not documenting the current process as they may have done in the past process improvement projects. Meticulously debating and document-ing a process that is going to go away or be changed markedly is simply not value-added or a good use of the team’s time. However, old habits die hard. And this step in the methodology can be very uncomfortable for individuals who need more structure and are less comfortable with or less tolerant of ambiguity. Here is where taking the change readiness assessment described earlier and doing a debriefing as a team can help team members appreciate their change readiness profile as compared with those of their teammates. Another thing I suggest to help those who need more structure is to keep a road map of the methodology prominently displayed on the wall so that though participants may feel lost at times, they realize there is a plan and they are headed in the right direction to reengineer the process and get the results they seek.

In addition to using vision-based redesign and the rule-breaking pro-cess, the facilitators can challenge the group to think about new technol-ogy or current technology used in a new way that might make the process more ideal. Here is where taking an appreciative approach can help the team. Continue asking them, “How do we want the new process to look and perform?” “Are there technologies that might help us?” Specifically, the team identifies and reviews information and potential technology-based activities in the ideal process. Are there new technologies or new uses of current technology that can improve performance, make the process more efficient, or even eliminate steps? Examples may include technology to help in the transportation of critical supplies, such as pneumatic tube systems or


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conveyor boxes; robotics; and information systems to track patients, employ-ees, equipment, or supplies. Often, major breakthroughs can occur at this point.

If necessary, research and site visits can be arranged to get an idea about how specific technologies might work in the ideal process or to investi-gate how other organizations use technology to reengineer their processes. Research should not be limited to health care and should cover any and all instances where other organizations handled somewhat similar processes with either creative new technology or where they used old technology in creative new ways. Leaders, facilitators, and team members should also appreciate that within their very organization, other groups or departments may be using technologies that may benefit, at least temporarily, the new redesigned process. In my past experience with broad multidisciplinary teams, individuals are usually aware of other similar processes or technolo-gies that may at least spark some additional ideas for the current team. Solutions can be as simple as using or repurposing old technologies, such as phone systems or e-mail systems, in innovative ways, or as complex as implementing new types of imaging or mobile systems throughout the organization.

Representatives from the information services department and other technology areas, such as biomedical engineering, can provide options and alternatives to the team. However, these individuals must be forward-thinking, can-do problem solvers who see the potential solutions as oppor-tunities rather than just more potential work for themselves. Serving as naysayers will not provide value to the team. Unfortunately, technical people can sometimes thwart the creative juices of the team by negatively getting into infinite levels of detail in the new technology and all the obstacles to implementation before the team has decided the technology is worth the effort. This can cause the team to prematurely abandon creative alternatives before they can be reviewed. First, the team needs to determine whether the proposed or considered technological solution will actually help solve the problem or provide the breakthrough to allow the new process to support the objectives of the new process.

At this point, potential breakthrough technologies are identified for the process, and it is here that the facilitator and team leaders document any technology benefits and criteria. Benefits documentation ultimately helps justify (or not) the investment in the technology. Technology should not be purchased just for its own sake or because some other organization uses it. If the technology does not radically improve the process by significantly


eliminating process steps and non-value-added activities, or by cutting total process time, it is probably not worth the effort. The team also needs to keep track of what the purpose of the technology is and what problems it is supposed to solve. Here, documenting the technology cri-teria can be helpful. As the documentation begins to describe what the technology must do, the beginnings of a request for information criteria emerge. As the team understands how the technology can enable the redesign process, they begin to get a sense of the relative priorities of the individual criteria. Further system and technology criteria may also be developed or further refined during the force field analysis step described later in this chapter.

Too many times in health care organizations, we implement technology that seems to have great promise but does not address the key issues it was intended to address, or it takes so long to implement that we either forgot what the issue was or the issue no longer exists in its current form. This step allows the team to determine if there are technological solutions that can help enable a better designed promise and deliver the intended results as opposed to bringing in a new technology that has seemed to have worked somewhere and appears to solve a problem we may have. Instead of bolting it onto our organization, we configure and implement the technology in an integrated fashion within the culture, people, and processes it is intended to serve.

Once the team has a draft ideal process flow, they must ensure that they have truly envisioned how the process should be. The team needs to ask

◾ Is our newly created process really ideal? ◾ Does the process in its draft form meet the goals and objectives of the ideal process?

◾ If not, what changes should be made? ◾ Do some rules need to be broken to make it happen? ◾ How are we limiting ourselves to current practices and assumptions? ◾ What assumptions do we need to evaluate further? ◾ Do innovative processes and technology need to be further researched?

Check the Ideal Process

Before declaring victory and assuming that we are now working with the most ideal process possible, the team needs to rigorously assess it against


these criteria and sound redesign principles. At an overall level, the team needs to ask

◾ Does it meet the objectives? ◾ Is it optimized? ◾ Will it help us achieve our process and organizational metrics?

Next, the team should review the draft ideal process against process rede-sign principles. Does the ideal process adhere to sound redesign principles? Specifically:

◾ Has the team organized the process around outcomes, not tasks, func-tions, or departments? The team needs to make sure that they have not inadvertently built in and asked for processes or steps just because, for example, “That is what the accounting department has always asked us to do.”

◾ Is the process flexible in anticipation of future needs so that the new process does not immediately become tomorrow’s dinosaur? Can the process quickly and easily be adapted to meet changing customer and financial requirements without sacrificing quality?

◾ Has the team put the decision points where the work is performed? Hopefully, every time a customer or patient asks a simple question, the person they ask should be able to answer the question, assist them, and resolve any issues.

◾ Has the team built logical control into the process itself? The process should not require multiple checkers to ensure that it is performed cor-rectly and effectively.

◾ Have human factors been considered in the design? ◾ Has the team treated dispersed resources as though they were local even if they are not? There may be methods and technologies that either make the resources local or make them appear local from the caregiver’s and customer’s perspective. This is a necessary and helpful perspective to hold when developing the ideal situation or process.

◾ Does the ideal process build or enhance strategic links with external entities? Has the team looked far enough into the front and back of the process to ideally redesign it? Some of the most innovative redesign solutions can be realized by working with customers and suppliers long before and long after they are no longer inside our organization. Within the hypothetical orthopedics team, the team members learned that the


earlier they could begin working with patients and their families before elective surgery to educate them and prepare them for what types of equipment and post-surgery home care would be required, the more the length of stay and cost per case could be reduced. The team also found that the more closely and collegially they could deal with nurs-ing homes and home care agencies for earlier, after-hours, and weekend placements of patients, the more they could expedite patient care and discharges.

◾ In the ideal process, is information captured once and at the source? The team must avoid having vital information captured redundantly by several caregivers along the process and scribbled onto scraps of paper for later recording into the electronic medical record or on a flow sheet.

If the answer to any of these questions is “no,” the team must go back and adjust the newly redesigned process in such a way that the answer becomes “yes.”

Value-Added/Non-Value-Added Flowcharting

The next step for reengineering and redesigning processes is value-added/non-value-added flowcharting. This technique is especially helpful when the redesigned process still seems overly complex (which is often the case), and when the team is not quite able to break away from the current process model to get to an ideal state. This flowcharting technique can be used in most situations where processes need to be improved. It is similar to value stream mapping but is a bit simpler and more straightforward. Its advantage is that it quickly and graphically illustrates where the potential opportuni-ties for major improvements may lie. It particularly lends itself to process redesign and reengineering since it can lead to a further evaluation of all the old assumptions and may ultimately lead to some additional, very signifi-cant breakthrough solutions. It is also appealing for clinicians and caregivers since it mainly seeks to eliminate or address the non-value-added activi-ties, which are often the source of considerable frustration for caregivers, patients, and customers. Refer to step 6 in Figure 7.3.

In fact, a simplified version of this approach is more than suitable for the task and can easily be understood by all team members. First, the process to be redesigned or an overly complex ideal process is clearly identified by the team members. Team members are then educated about what value-added


process steps are versus what non-value-added process steps are. In short, value-added process steps are steps the customer is willing to pay for or engage in with your organization. Value-added process steps are defined as being valuable only from the perspective of the customer, not that of the team’s leaders or members.

Non-value-added steps are process steps that the customer or patient is not willing to pay for. They fall into two categories. First are those steps that are of no value to anyone, such as redundant tasks, delays, and wasted time or resources. These are the steps that probably delay and/or irritate custom-ers, patients, families, caregivers, and employees alike. These should be eliminated from the process as completely as possible. The second group are steps that may be necessary or even required by regulators, legal, and other entities, but do not provide direct value to the customer. Examples include documentation, record keeping, maintaining a database, preparing test equipment, and similar activities. These tasks should be made as transparent or invisible and as painless to the customer as possible.

Once the team members understand the concepts of value-added tasks versus non-value-added tasks, it is time to start flowcharting. This is done by using a flip chart, markers, and masking tape. The facilitator begins by dividing a flip chart page into two columns—the left-hand column for non-value-added activities and the right-hand column for value-added activities. Each step in the current process or ideal process is placed in the appropriate column until the entire process is documented.

Figure 7.5 shows how value-added/non-value-added flowcharting works, using a simple example of getting a flu shot from the patient’s perspective. Even in this simple example, it is evident that very little of the process is value-added from the patient’s or customer’s perspective. In fact, this method of flowcharting can be very humbling and perhaps a little threatening to team members and team leaders when they see that very little process time and resources are actually spent on activities that are the reason your patient or customer is engaging with you. However, it should be noted that in all industries for all processes that have not been fundamentally redesigned and reengineered, value-added processes represent on average less than 10% of the total process, and in many cases less than 5%. This means that we have many opportunities for a significant redesign of our processes in health care.

Value-added process steps are defined as being valuable only from a cus-tomer perspective, not that of the team’s leaders or members.


Going back to our flowchart, we begin to critically assess the non-value-added steps. First, we identify those non-value-added tasks that are com-pletely wasteful, redundant, or causing delays. These should be targeted for elimination. This may not be as easy as it sounds because these are often where the customer intersects our bureaucratic organizational structures. In our simple flu shot example, certain types of information are requested of the patient more than once. Some may argue that this redundancy occurs to ensure quality of care. The real reason could be that the different pro-cess players have independent policies and procedures in their departments that require them to ask repetitive questions. Or they do not trust that either the process or the customer will provide accurate information. Or they do not trust their colleagues in other disciplines to obtain accurate, adequate information. One way or another, these steps must be eliminated from the process, if for no other reason than to stop annoying the customer, who, after the second or third time of being asked the same questions, begins to wonder if the caregivers know what they are doing clinically or if we ever communicate among ourselves.

The next step is to identify the non-value-added process steps that the customer is not willing to pay for but that are necessary for running our business, process, or service. An example might be keeping records of patients’ histories and allergies. These tasks cannot and should not be eliminated; however, their impact on the process should be minimized. For example, we should keep these records as clear, simple, and as accessible as possible so that all caregivers have access to them in a timely manner and that the patient is not continually burdened with repeating the same infor-mation for us several times. Verifying information is one thing and can actu-ally reassure patients, whereas constantly reconstructing or repeating this

Getting a flu shot

Non-value-added activity1. Patient arrives2. Patient waits3. Patient signs in4. Patient waits5. Patient shown to room6. Patient questioned7. Patient rolls up sleeve

Value-added activity

8. Patient gets flu shot

Figure 7.5 Value-added/non-value-added flowcharting example.


vital information can cause the patient to wonder if the right hand knows what the left is doing. We also want to ensure that everyone is seeing the same version of the information at the same time. Patients’ situations and customer issues can change rapidly and significantly at any time.

Next, the value-added process steps should be critically reviewed to make sure that they are truly necessary, and if so, as effective and efficient as possible. For example, a patient may seek an antibiotic for an ailment and view getting the antibiotic as a value-added step in the process. However, that does not mean that the medication is necessary or appropriate for the patient’s condition. This type of questioning may be escalated to a clinical quality group along with the data showing it is a common occurrence and needs to be reviewed clinically and systematically.

Technology can often improve value-added process steps. A simple clini-cal example of this is laparoscopic surgery versus traditional open surgeries. Though both methods accomplish what the patient is paying for, the newer method, where indicated, allows the patient to heal and return to normal routines more quickly. Value-added processes can also benefit from technol-ogy when it allows the value-added steps to be performed more quickly or when it allows the customer to be part of the process. Examples include Accu-Chek for monitoring blood sugar levels and pulse oximetry monitors for patient self-monitoring of blood oxygen levels.

The ultimate goal of this type of value-added/non-value-added flowchart-ing is to end up with an ideal process where the wasteful, redundant tasks are eliminated; the necessary non-value-added tasks are minimized, stream-lined, and made as transparent as possible; and the value-added steps are performed as efficiently as possible. With either this technique or the ideal process flowcharting described earlier, the next question forming in the team’s collective mind is, “So how do we actually get to this ideal process?” Given that the newly redesigned process is radically different from the cur-rent process, the gap between the current and the new process can seem quite challenging. The next section on force field analysis provides some insight.

Given that the newly redesigned process is radically different from the current process, the gap between the current and the new process can seem quite challenging.


Perform Force Field Analysis

Force field analysis is a technique traditionally used by quality improve-ment teams during improvement implementation planning (see Figure 7.6). It comes from the social sciences and is a concept first described by Kurt Lewin, PhD (1939). A renowned social psychologist, Lewin developed a force field analysis model that describes any current level of performance or being as “a state of equilibrium between the driving forces that encour-age upward or forward movement and the restraining forces that discour-age it.” Essentially, this means that a current equilibrium exists because the forces acting for change are balanced by the forces acting against change. The driving forces are (usually) positive, reasonable, logical, conscious, and economic. The restraining forces are (usually) negative, emotional, illogical, unconscious, and social/psychological. Both sets of forces are very real and need to be taken into account when dealing with change, managing change, or reacting to change (see Figure 7.7).

As used in the process redesign methodology, force field analysis graphi-cally depicts the forces that support the ideal process steps or implementa-tion activity, and the forces that work against successful implementation of those steps or the new process. This technique helps identify up front what current parts of the environment, situation, or process will effectively work to enable the redesign process, and most important, what major obstacles will have to be overcome or addressed to enable successful implementation. In its traditional use, the facilitator challenges the team to brainstorm all the many factors that may surface to thwart or delay implementation. This step

7 8 9

Perform force fieldanalysis

Develop theimplementation plan

Use project managementtechniques to implementideal process

• See force field analysis worksheet, Figure 7.8

• Based on column 2 from worksheet in Figure 7.8, identify ways to minimize obstacles to the ideal process• Leverage any ideal process enablers

• Communicate with colleagues, with leaders, with stakeholders• Keep the implementation team on track• Celebrate short-term and long term wins• Measure and adjust. Measure and celebrate success

Figure 7.6 Reengineering roadmap—implementing the ideal process.


forms a key bridge between the ideal process and the actual implementation plan for that ideal process. It represents much work and thought, but only by having the team do this part of its work can successful implementation be accomplished.

When first using this technique with redesign teams, I realized after two hours of listing potential obstacles that we needed a way to separate the wheat from the chaff, so to speak. There seemed to be no end in sight to all the various obstacles to the ideal process. The team often got caught up in the lengthy discussions of relatively trivial issues while skirting the discus-sion of some of the very big ones. What we needed was a quick, straightfor-ward way of employing some sort of Pareto analysis. We basically needed to identify the 20% of the obstacles that were most likely to cause 80% of our problems in execution or implementation.

Thus, as you can see in Figure 7.8 (force field analysis worksheet), the traditional force field analysis format has been modified. The new format focuses primarily on major obstacles rather than enablers. I have done this because I have found that process redesign leads to such major fundamental change that, unlike continuous improvement, the change enablers during and after implementation may initially not be identifiable. The process can change so much that only the system-wide enablers such as organizational environment or leadership will remain. Furthermore, many of the enablers of the process may still be in the future (e.g., implementation of new technology).

Driving forces(positive forces for change)

Restraining forces(obstacles to change)

Present stateor

desired state

Figure 7.7 Kurt Lewin’s force field analysis.


If we look at Tables 7.1a through 7.1e, the first column guides the team to identify all the obstacles of implementing the ideal process. To prevent the team from getting lost in a lengthy list, the two right-hand columns help provide a relative weight and priority for each obstacle. This addition to the matrix drives home the point that we are most interested in the major obsta-cles rather than an exhaustive, all-encompassing list of factors that might thwart implementation. You will note that we do a force field analysis on each of the tasks comprising the ideal process. At the end, we will also take a look at a force field analysis of the process in its entirety. At that point, we will factor in system-wide enablers so that we can make sure that we lever-age them.

Please note that each table illustrates one step in the ideal process flow, e.g., Table 7.1a is step 8, Table 7.1b is step 9, Table 7.1c is step 10, Table 7.1d is steps 11 and 12, and Table 7.1e is step 13.

In the third column of Tables 7.1a through 7.1e, we query the team to dis-cuss the relative probability or likelihood that an obstacle might occur and actually negatively influence implementation. Since at this point we are still envisioning the future, exact probability analysis would not be appropriate and may cause “paralysis by analysis” through endless debate and conjec-ture. However, within the team, there will be a collective awareness of what may or may not happen. Therefore, relatively rough probabilities of occur-rence are defined as high, medium, and low.

Force field analysis worksheet

Ideal process step or task

Obstacles Ways to minimize the obstacle Probability ofoccurrence

Impact ofoccurrence

Figure 7.8 Force field analysis worksheet template.


Table 7.1a Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 1)

Task 8—Care Plan Communicated to All Disciplines

ObstaclesWays to Minimize

the ObstaclesProbability of Occurrence Impact

Don’t receive all orders

• New order sheet• Physical Therapy (PT)

checks for Occupational Therapy (OT)

• PT but not OT• Online access to

Operating Room (OR)• Check surgery schedule• U.S. hand-carry order• Tube order• Locate OT/PT in unit

M but decreasing

Orders not written Check surgery schedule L

Orders not timely Order entry online ? (Only anecdotal evidence)

Table 7.1b Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 2)

Task 9—Provide Comprehensive Care



Staffing limitations • Fill open positions• Address coverage• Use pathways to predict

staffing needs• Use history analytics to

predict staffing needs

H H

Patient not available Communicate to therapy H H

Family not available Schedule families H M

Physician not available H L–M

Chart not available M–H H

(Continued)


In column 4 of Tables 7.1a through 7.1e, the team is asked to evaluate what the impact would be on the process or the patient if the obstacle were to occur. The team then needs to determine whether the impact is high, medium, or low. Before alternatives or solutions to minimize all the obsta-cles are laboriously developed, we apply relative weights to the obstacles. All of the obstacles that rate a high probability of occurrence and a potentially high impact on the process or patient are further analyzed, and alternatives

Table 7.1b (Continued) Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 2)

Task 9—Provide Comprehensive Care



Patient refuses Preadmission teaching (PAT) H first, L H

Patient not cognitive L H

Patient noncompliant PAT class L H

Patient/family do not speak English

Schedule interpreter L H

PCA pump not available (or meds)

• Have own in unit• Provide epidural• Have patient on OR

schedule, request PCA

M H

Mealtime conflicts • Flexible schedule. Early or late tray

• Do therapy after breakfast• Global schedule provided

M–H L

New procedure is unknown to staff

L L

New type of equipment Call sales representative L

Equipment not available Repair existing equipment M

Availability of therapist • Report between nursing and therapist (use pathway plan)

• Constant staff on unit• Identify window of

opportunity to predict number of therapists needed

L


and solutions are identified and noted in column 2. Some of these alterna-tives will ultimately become part of the team’s implementation plan. Low-probability, low-impact items are usually not further evaluated. For those that have either a medium probability or medium potential impact, team consensus or further analysis of the data can determine whether alternatives and solutions to the obstacles should be developed. The examples in Tables 7.1a through 7.1e show how modified force field analysis would look for several steps in the redesign process from our orthopedics example that we discussed earlier. Note that we completed a list of obstacles by task and then determined the probability and impact. We determine the probability and impact before we brainstorm the ways to minimize the obstacles. Why? We want to spend more time on those items with a higher probability of occur-rence or with a bigger negative impact if they do occur.

Table 7.1c Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 3)

Task 10—Patient Progresses Automatically to Care Pathway without Continuing Care



Patient complications See below L–M H

Variances/exceptions • Analyze which ones can be addressed. How? When?

• Who would address?• Accountability, e.g.,

physician• Process complication

L–M H

What is timely? Education? L–M ?

What is cost-effective? Education? L–M ?

What is appropriate? Education? L–M ?

Patient may progress ahead of schedule

e.g., OT protocols L L–M

Pathway may conflict with patient’s lifestyle

L H

Communication barriers

Patient class M H

Family resources unavailable

Patient classes M H


To identify the ways in which the high-priority, high-impact obstacles could be eliminated or at least minimized, the team should use brainstorm-ing techniques. Often the team will identify short-term and long-term solu-tions to an obstacle. They may feel inspired to implement the short-term solution even as they continue to work on implementation of the long-term solution. This is fine as long as the team does not get so comfortable with

Table 7.1d Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 4)

Tasks 11 and 12—Discharge Plans, Etc.



Patient destination unknown

Bed (nursing home, etc.) availability. Nonacceptance on weekend

New nursing home M–H Delayed discharge

Equipment not delivered on time

Disposable supplies provided to patient on discharge

Patient DME delivered to patient home or family pickup

Patient expectation is 11:00 AM discharge

Patient education

Availability of volunteer escorts

Escorts? 1:00 PM?

Table 7.1e Orthopedics Service Delivery—Process Redesign Force Field Analysis (Part 5)

Task 13—Follow-Up via Phone or Home Visit



No time to call patient to do follow-up assessment

• Volunteers• Use transitional

employees

Cost of home visits Screen through pre-op teaching


the relatively minor improvements provided by the short-term solutions that they forgo completing the implementation of the more significant long-term solutions. The team needs to push toward the longer-lasting solutions in order to deliver on the stretch goals and outcomes.

Before proceeding with the process, it is important to note that this part of the approach helps further identify not only if, but specifically what types of technology may enable the ideal process. As solutions and alternatives are identified, potential technology solutions begin to appear, and in some cases reappear. For example, in an emergency room patient flow process rede-sign, some sort of a real-time patient tracking mechanism kept appearing and reappearing as a solution to many of the obstacles to implementing an ideal patient flow process. After several attempts to implement some of the proposed short-term solutions, the team realized that this type of technology was a major ideal process enabler. Thus, the team could identify not only the system benefits but the system criteria as well by fully understanding what problems the technology would or would not solve and by understand-ing how it would fit into the newly redesigned process. This, in turn, helps determine the ROI and begin to make the business case for the technology.

Develop the Implementation Work Plan

It is sometimes difficult to discern where the modified force field analysis ends and the implementation planning begins. Basically, the items and tasks placed on the implementation plan come from the second column of the modified force field analysis (Tables 7.1a through 7.1e). It is important to note that not every alternative solution makes the cut and ends up on the work plan.

To decide which alternatives are appropriate for the implementation work plan as specific implementation activities or tasks, the various alternatives are evaluated on the basis of how well they would help the process meet the objectives of the ideal process. Benefits and costs, if known at this point, can also be evaluated on a gross level. Those candidate alternatives that seem to enable the process to meet the ideal process objectives are placed on the work plan, even if at first glance they seem too costly or too difficult or even impossible to do. As mentioned, some items will be short term (less than three months) and easy to implement, while fundamental, significant changes will usually take anywhere from six months to a year to implement. Each task or subtask should be assigned a champion, a time frame, and its own project plan. And each must be linked back to particular deliverables


on the work plan so that when the going gets rough, and it will, no one forgets why the changes need to occur. Table 7.2 provides a sample section of the work plan that was derived from the alternatives identified from task 9 in Table 7.1b. This example illustrates not only what the work plan should include, but also shows how the team selects and moves items from the modified force field analysis to the work plan.

It is apparent from the simple example that these implementation work plans can get complex and lengthy. Actual implementation activities can be very time consuming for the process owners and team leaders. If the team leaders are still attempting to handle their regular workload in addition to pro-cess redesign, I strongly recommended that at this point, they delegate most, if not all, of their day-to-day duties. If team leaders have the opportunity to positively and significantly engage in the overall reengineering and redesign the processes, this is arguably the most important use of their time as leaders.

Employ Project Management Techniques

Many books and articles, as well as the body of knowledge contained in the Project Management Institute’s A Guide to the Project Management Body of Knowledge (PMBOK Guide), provide knowledge about project manage-ment. These resources describe the benefits of project management, how to

Table 7.2 Orthopedics Service Delivery: Task 9—Partial Implementation Work Plan

Task Responsible Time Frame Status

1. Fill open position Nurse manager (NM) with human resources

Within three months

Active

2. Address coverage: allow a flexible schedule for mealtime, do therapy after breakfast, and make a global schedule available

Assistant NM for each shift plus NM

Within one month

Complete

3. Conduct preadmission teaching (PAT) class

Clinical nurse education specialist

Ongoing—twice a month

Ongoing

4. Develop patient status communication mechanism for therapy

OP/PT/NM Within three months

Active


employ it, as well as the tools for effective and successful project manage-ment. This section does not attempt to repeat the vast project management body of knowledge that is available. However, this section will address unique reengineering and project management challenges. Project manage-ment is a critical function to be performed by the team facilitators along with the team leaders as they work through the reengineering or process redesign process. I recommend that at least one of each team’s facilitators or leaders be strong in this area and that they have practical experience man-aging fairly complex projects. For the team’s designated project manager to demonstrate effective project management on a process redesign project, that individual must be a clear and succinct communicator, with an attention to detail and the ability to apply consistent and persistent follow-through to make sure that all of the assigned tasks are completed in a timely manner. If problems or delays occur, he or she must be able to communicate this to the appropriate people in a timely fashion so that additional resources or time may be applied as necessary. This individual must also be able to see how the implementation work plan tasks are interrelated and to identify any dependencies that exist between the various tasks. These individuals must be flexible. At the same time, they must be able to quickly identify the critical path on the implementation plan. The individual in charge of proj-ect management must be as skilled at building relationships and influencing others as he or she is with the project management tools and methodologies.

The first level of project management must occur while the team is going through the process redesign methodology. It is important in this early stage to keep the team on track and focused on the goals. Project management also encompasses the steps leading up to the actual implementation when team leaders must keep the team on track and focused on the process reen-gineering and redesign goals. Although the approach discussed here is much more holistic and gets the team to the implementation phase more quickly than traditional quality improvement, there is not less work involved. Project management techniques are vital for coordinating that work. However, the magnitude of change in process redesign and reengineering means that the real challenge often begins with implementation, as leaders and employees begin to grasp and see the true magnitude of change required.

The individual in charge of project management must be as skilled at building relationships and influencing others as he or she is with the project management tools and methodologies.


Project management techniques can help the team successfully resolve any implementation problems and make the redesign process happen while keeping the team focused on the goal. And, even though during the force field analysis, the higher-priority implementation items were gleaned from all the potential solution alternatives, the facilitator and team leaders must work together to make sure that subgroups of the team do not go back and work on lower-priority issues—even if they seem easy to get at. All the team’s energy and resources must remain focused on the vital, high-priority implementation activities. At a later time, the lower-priority items may be addressed if they are still relevant. Making fundamental change happen to key business processes does not leave much time for extraneous activities and time spent on less important tasks.

Once implementation is under way, all of the team’s collective project management skills will be taxed. Minimally, I suggest that the team use and follow a work plan such as that illustrated in Table 7.2. Table 7.3 provides a simple work plan template. Table 7.4 illustrates the use of that template. Once implementation begins, the team may want to meet daily, weekly, biweekly, or monthly to check status, stay on top of the work plan, and make sure that deadlines are being met in a timely fashion. Some implementation teams may even have their own specific individualized work plans because of the mag-nitude of change required in the one or two tasks that are assigned to them. In some cases, I have seen teams use a work plan in an outline spreadsheet format so that the project subtasks ultimately roll up to the major tasks. With most process redesign efforts, project management software, such as Microsoft Project, may be appropriate and can be extremely helpful.

How to Keep the Team on Track

As I have worked with executive teams and others, I have found that there are some key ingredients for successful teams. In this section, I share some of my learnings and recommendations. Below is a checklist of ideas to help team leaders and facilitators keep the reengineering teams on track.

◾ Check in frequently with individuals, as well as at the beginning and end of each meeting. Ask questions such as, Does everyone understand where we are, where we are headed, and what our challenges are? Does everyone understand the project and team goals? Does everyone understand their role and the role of the team? What questions do you have? What concerns do you have?

Methodology for Reengineering and Process Redesign Teams ◾ 117Ta

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◾ Communicate, communicate, communicate, and always remember that you communicate to engage, not tell.

◾ Keep everyone sharply focused on the collective goal. ◾ Develop a strong clear agenda for each meeting. ◾ Ensure that there is clear accountability for what the team is responsible for and clear accountability about what each team member is respon-sible for.

Below are two checklists that leaders and facilitators can keep in mind for reengineering and work teams alike.

Ten Ingredients for a Successful Team

1. Clear specific team goals (What is the team’s purpose?) 2. A plan for improvement (What is the team working on to make better?) 3. Clearly defined roles 4. Clear communication 5. Beneficial team behaviors (behaviors that make the team more effective) 6. Well-defined decision-making processes 7. Balanced participation 8. Established ground rules 9. Awareness of the group process 10. Scientific approach or methodology

Best Practices Checklist for Project Managers and Team Facilitators

◾ Know yourself and your own triggers. ◾ Hold a preteam workshop to clarify the goals, begin building morale, and get to know each other’s communications styles and change profiles.

◾ Provide a warm-up and reconnection at each meeting, reminding the team of the purpose, goal, and major milestones met—focus on performance.

◾ Start a meeting with ground rules. ◾ Build on each other’s strengths. ◾ Provide frequent updates. ◾ Facilitate robust discussions, and do not back away from conflict. ◾ Communicate more than you think will ever be necessary.


◾ Use creativity and brainstorming when you get stuck—involve the whole team.

◾ Use a meeting agenda and “meeting purpose.”

Best Practices for Meeting Management

◾ Prepare for the meeting. ◾ Use an agenda:

– Have a purpose for each meeting. (What is it you are hoping to accomplish in this particular meeting?)

– List topics covered (clearly stated), who will lead the discussion, and desired outcomes for each topic, e.g., a decision? A plan? A list of options?

– Establish time estimates for each topic. ◾ Include ground rules. ◾ Start on time. ◾ Fill key meeting roles—facilitator, note taker, and timekeeper. ◾ Use a warm-up exercise for the first few meetings and make sure every-one knows everyone in the room and their roles (on the team and within the organization).

123

Chapter 8

Role of Technology and Innovation

In earlier sections, I have referred to the important role of technology and innovation in reengineering and redesigning processes. Where technology in process improvement efforts can seem to be simply an interesting side issue to explore later, in reengineering, it is absolutely vital to creating the ideal or radi-cally redesigned process. Often it is a new technology alone, or an innovative use of existing technology, that makes the ideal process possible and real.

Technology’s role should be kept constantly in mind by team facilita-tors and team leaders, as well as by senior leaders of the organization. They must be willing to explore and embrace new technology and its implications when appropriate. They must view any and all technology as a potential enabler for the reengineered process. Though they are not required to be technology gurus themselves, they must have a healthy curiosity about it and be willing to seek out technological advances, ideas, and knowledge for the team. This pursuit of technological solutions must not be limited to the health care industry or to one type of technology—a favorite being informa-tion technology. There are many great potential ideas and solutions used in other industries, such as in hotels, banks, restaurants, and retail, which can lead to breakthroughs in how patients experience health care processes. Though innovative uses of new information technology often provide

Often it is a new technology alone, or an innovative use of existing tech-nology, that makes the ideal process possible and real.


breakthroughs to enable a truly radical ideal process design, other technolo-gies such as voice, nanotechnology, or medical technologies should also be carefully explored and considered.

To foster openness among the team members to consider technology for breakthroughs, the facilitator must work with the team beginning with the development of objectives and during the ideal process design to make sure the team does not let current realities limit their creativity and ability to design the ideal process. As a facilitator, it is best to first ask the team to describe the objectives and then flowchart the process as if there were no constraints and no limits. The team should assume they have all the information, supplies, money, and time needed to make the process a perfect one. Since this can seem impractical and almost a fantasy, it can be a difficult exercise for some. At first, the team may be very quiet and hesitant to have fun and begin the brainstorming process. Eventually, one person will start by tossing out an ideal process step, and then the dam will seem to break with creative ideas, which almost always includes innovative uses of technology—old or new. The team can be assured that ultimately the group will take these “wild” ideas, bring them back to earth, and root them in the practical here and now.

Use of Redesign Principles

The redesign principles described earlier can further challenge team mem-bers to make their design more ideal by pinpointing where major break-throughs may be required, causing them to think about where technological solutions might be appropriate. The following list gives the common rede-sign principles and explains how they might be used to trigger team mem-bers’ imaginations regarding technological solutions:

◾ Organize around outcomes, not tasks.

◾ Focus on the purpose of the process (e.g., healing patients, provid-ing therapies, registering patients, or getting X-rays). Are there ways technology can help us do this better? For example, can patient moves be decreased through the use of portable or decentralized medical

Organize around outcomes, not tasks.

Role of Technology and Innovation ◾ 125

technologies, or digital imaging technologies? What other possibilities might we consider?

◾ Be flexible in anticipation of future needs. Make sure your reengineered processes are not limiting, or that they do not lock you into proprietary technology or obsolete organizational structures. In some cases, technolo-gies have locked organizations into proprietary legacy systems, which severely limit flexibility. It is important to make sure that any new tech-nological solutions do not commit the same error. The team may find a new niche technology that will definitely solve a redesign issue. However, they must assess if the technology is too new or if the company respon-sible for it is too small or undercapitalized to be around for the long haul. Oftentimes, if the technology is too new, it will also be expensive and more difficult to cost justify. At that point, the technology may not be an appropriate solution. However, someone on the team may want to moni-tor it to determine when and if it develops efficiently, and if the costs come down to make it an enabling technology. On the organizational side, make sure the team is not limiting their considerations to the current organizational structure or the various functions within that structure.

◾ Put the decision points where the work is performed. Make sure that when a patient needs care, it can be decided on and administered at the bedside, or wherever he or she is located. At first glance, this prin-ciple seems to be mostly about employee empowerment or author-ity; however, it is also about access to the right information at the right time. Information technology that provides on-the-spot access to accurate information can enable employees to make these deci-sions. Automated pathways, for example, may provide a visual clue about where a patient is on the pathway, but they also indicate when a patient “falls off” the pathway, along with appropriate interventions the caregiver can select to help get the patient back on the pathway. With Accountable Care Organizations (ACOs) and organizations implementing population health care models, this is more important than ever before. Caregivers need to manage patients wherever they are within the con-tinuum of care and within the community. A key point is that the data needs to be presented in such a way that decisions can be made. If the

Put the decision points where the work is performed.


caregiver has to scroll through a multitude of screens to see the status of the patient to make a decision, delays are built in and potential errors are made as a clinician jots down key values from ten or more different screens onto a scrap of paper. Yes, unfortunately, it still does happen!

◾ Build control into processes. This can be done by designing a logical process, minimizing hand-offs, and putting the decision point where the work is performed. If technology can simplify the process and reduce delays in hand-offs, as well as indicate when parts of the pro-cess require attention or intervention, inherent process control can be optimized. Also, make it difficult for human errors to occur, especially in high-risk areas. Examples include alerts for possible medication administration errors or drug interactions.

◾ Do not be limited by current logistical constraints. Treat dispersed resources as though they were local. Teams often limit their creativ-ity when redesigning the new process owing to current logistical con-straints on patient, information, and materials flow. Team members need to imagine that those day-to-day constraints are momentarily suspended. The facilitator should ask questions such as, “What if you did not have to wait for the patient information or the chart? What if all the supplies and equipment were available instantaneously when you needed them in the operating room or the examination room, for instance? What if you did not have to move the patient all around the organization to provide diagnosis and treatments?” Often, caregivers are searching for key pieces of information. What if this information was available to the care team wherever the patient was located, as well as remotely from the physician’s or consultant’s office or home? This pro-cess redesign principle provides many team discussions and opportuni-ties to explore technology for radical process breakthroughs.

◾ Build or enhance strategic links with external entities. This principle can be particularly powerful and relevant with the advent of popula-tion health and ACOs. Once the team begins to look outside of the traditional patient care process and begins to partner with physicians, patients, and families—before they reach the facility walls and even

Build or enhance strategic links with external entities.


after they leave—incredible breakthroughs can occur. For example, you can build strong links with physicians by providing access to hos-pital and clinic-based systems from their offices, allowing them to view schedules, enter orders, and look up test results. In addition, you can engage the patient and family innovatively in how they access their information and how they interact with you within the community for care at the right time and place for them.

◾ Capture information once and at the source. In the health care industry especially, patients are asked redundant questions every time they are handed off from one department to another, or from one individual to the next. Team members must suspend current reality and imagine that the newly redesigned process will allow health care providers to ask questions once, then record and represent the information in a way that all caregivers have access to it and can make decisions without compro-mising patient confidentiality. In many cases, technology may become the principal enabler for this goal.

Use of Value-Added/Non-Value-Added Flowcharting to Assess If and How Technology Can Help

Teams can also use value-added/non-value-added flowcharting to iden-tify areas where technology may provide potential areas for innova-tive process redesign breakthroughs. Certainly, technology—whether it be medical, scientific testing, or information technology—may be used to streamline activities in a process, including the value-added ones. However, technological solutions may be particularly appropriate for non-value-added activities. Often, processes contain redundant steps, which help ensure that everyone in the process has the information, the sup-plies, and the patient at the right place and at the right time. Technology may be the enabler that allows non-value-added activities to be elimi-nated, combined, or minimized. Non-value-added work includes moves, delays, redundancies, or any other situations where we find waste in the system. All of these types of waste should be considered for elimination. The team should investigate if technology can provide solutions that will

Capture information once and at the source.


minimize the waste or mitigate its impact. Per Lean thinking, waste types are listed in Table 8.1.

Usually, technology can assist with moving materials and people, and delays can be avoided. Perhaps tasks can be performed in a parallel fash-ion rather than sequentially. Often, redundant tasks occur because people do not have instantaneous and simultaneous access to information or sup-plies. The team should be encouraged to get creative and be open-minded with technological ideas. If it turns out that the technology solutions cannot currently be cost justified, at least the team will know about the technology. Later, as technology prices drop, the technology may become an economi-cally justifiable solution.

Table 8.1 Lean Waste Types by Sector

Waste Type Manufacturing Sector Wastes Service Sector Wastes

Defects Scrap, rework, replacement production, inspection

Order entry, design, or engineering errors

Waiting Stock-outs, lot processing delays, equipment downtime, capacity bottlenecks

System downtime, response time, approvals

Overproduction Manufacturing items for which there are no orders

Printing paperwork, purchasing items before they are needed, processing paperwork before the next person is ready for it

Transportation Transporting work-in-process (WIP) long distances, trucking to and from an off-site storage facility

Multiple sites outside of walking distance, off-site training

Inventory Excess raw material, WIP, or finished goods

Office supplies, sales literature, and reports

Complexity More parts, process steps, or time than necessary to meet customer needs

Reentry of data, extra copies, excessive reporting, etc.

Unused creativity

Lost time, ideas, skills, improvements, and suggestions from employees

Limited tools or authority available to employees to carry out basic tasks


The value-added/non-value-added flowcharting technique may also assist in projecting and documenting cost savings that might be realized if new technology is implemented. As this technique is used by the team to flow-chart the current or ideal process, and it appears that a technology may be a way to eliminate process steps, delays, moves, or other types of non-value-added work, the flowchart provides a way to analyze and justify cost savings due to the implementation of new technology, thus providing a way to cost justify the necessary capital expenditures.

For a simple example, let’s say your team’s value-added/non-value-added flowchart of the patient flow process through your emergency room (ER) indicates that every patient waits, on average, twelve minutes for a phle-botomist to arrive to draw blood and then thirty minutes for the laboratory to process blood work and turn around the results. This delay is obviously on the non-value-added side of the flowchart, and the team has acquired or developed the necessary time study statistics to accurately measure this. Let’s further suppose the team has determined that if an emergency medical technician, nurse, or physician could draw the patient’s blood at the bed-side while performing the assessment or providing other routine care and comfort, ten minutes of the time spent waiting for a phlebotomist could be reduced.

The team hypothesizes that if the organization purchases appropriate bedside laboratory testing equipment, about 80% of the required blood work could be performed at the bedside with fairly immediate results. Thus, the team can assume that using a non-phlebotomist to draw the blood will reduce the delay time by ten minutes. If this delay time can be minimized on 90% of the organization’s 80,000 visits per year—roughly 72,000 visits—the time saved equals a nontrivial 12,000 hours of patient time. Additionally, if the team surmises that bedside laboratory testing equipment can cut down the processing of results time by fifteen minutes for 80% of those

The team should be encouraged to get creative and be open-minded with technology ideas.

The value-added/non-value-added flowchart provides a way to analyze and justify cost savings due to the implementation of new technology, thus providing a way to cost justify the necessary capital expenditures.


80,000 patients seen in a year, this translates to an additional 16,000 hours of patient process time saved per year. Now, the grand total is 28,000 hours per year that patients are no longer waiting. This reduction in time is particularly valuable to those organizations with large backlogs in their ER and where perhaps patients are turned away because of the long waiting times. In some cases, this reduction in time may result in a higher revenue since more patients can be served, and the organization receives better reimbursements due to improved patient satisfaction and the ability to serve more patients and better care for the community.

This number may not appear to translate directly into dollars. Each organization’s financial situation or reimbursements and expenses will be different. However, if the average ER visit length of stay goes from three hours and fifty-five minutes down to three hours and thirty minutes on 80%–90% of patients, not only are patients and families happier, but the ER capacity is also effectively increased by moving patients more quickly through the process without any kind of care or treatment shortcuts. If each of the 80,000 visits require on average the original three hours and fifty-five minutes, this equates to 313,000 (3.92 × 80,000) patient hours per year that must be staffed and covered. This means that adequate gurneys, treatment areas, and equipment must be available for use throughout the time. Reducing this time to three hours and thirty minutes for a conser-vative estimate of 80% of our patients changes the numbers to 285,600 patient hours per year that must be covered by adequate staff, supplies, space, materials, gurneys, and so on. Thus, in this team’s scenario, assum-ing the team’s projections are accurate and fully realized, the organization gains almost 28,000 patient hours per year that can be used to justify bed-side testing or additional technologies.

How the 28,000 hours are translated to dollars that might cost justify the testing equipment depends on the ER’s specific situation. For example, if the ER has a fairly stable or decreasing population, these hours might translate to less staff or space required. Reduced staff obviously translates to dollars saved. The new use of ER space that is no longer needed can also determine the financial value of the process change. If the ER’s popu-lation is growing out of its facility, this process change might allow the ER visits to grow by roughly 8000 visits per year before adding more capacity, assuming there is adequate space to begin with. If the community’s frus-tration and ill will can be avoided when their loved ones are turned away because the ER is full, and if the costly expenditures of adding space and staffing the new space are avoided, the technology may be easily justified.


Use of Force Field Analysis

Force field analysis can illustrate how a technology or various technologies may help minimize or eliminate obstacles to implementing the ideal process. The ER patient flow process example can again illustrate how this works. Let us say that to implement several major components of our ideal process, multiple caregivers must be able to quickly find out where the patient is located within the ER to expedite treatment. At the same time, these care-givers must know where the ER patient is in the ER treatment process. For example, has a physician seen the patient yet? Is the patient awaiting labo-ratory results? Is a physician awaiting a radiology report before treating the patient? The team may brainstorm some fairly creative alternative solutions to the problem of patient location and process status. They might discuss a flag or light system to indicate the process or location of the patient. The team might discuss and reject the use of the overhead page system to locate patients as being too noisy and disruptive. It also frightens the family when they get the impression that the ER staff cannot seem to find and keep track of their loved one. Another possibility is a huge whiteboard or chalkboard that the unit clerk uses to track and communicate about patient location and status. However, the team soon realizes that in their large ER with 100,000 plus visits per year and more than fifty treatment areas, they will not be able to find and locate a whiteboard large enough nor make the information visible enough that busy staff could use it. Nor would a clerk or clerks have hope of keeping up with the location and status of 250–300 patients per day. Another major concern is that of privacy and confidentiality of the patients. Then someone on the team mentions that they have heard there are vendors that may sell automated patient tracking systems for ERs.

Could this be an enabling technology for our specific process? By review-ing how many times throughout the force field analysis this obstacle solu-tion occurs and by further evaluating which obstacles and problems the technology is required to solve, the team can begin to list system or tech-nology objectives and even major criteria. These objectives and criteria can then be fashioned into a request for information that is sent to vendors who

Force field analysis can illustrate how a technology or various technolo-gies may help minimize or eliminate obstacles to implementing the ideal process.


may have a system or technology that meets specific needs (like vendors of patient tracking software for ERs used in this example). If the team does not have any idea if any vendors even exist, they may want to consult with information technology professionals within their organizations and within the industry. There are considerable reference materials and information on the web. There are resources that allow you to browse an updated list of vendors and reviews of those vendors who supply particular types of soft-ware. You can compare their features and strengths to your needs without spending unproductive hours looking for technology solution candidates. In addition, solutions outside of the industry should be explored. Several years ago, one client organization got their patient tracking ideas from a vendor who tracks flights and gates at airports.

Ultimately, many teams I have worked with have been able to craft the system or technology objectives and prioritized criteria into a workable, appro-priately detailed, but readable, request for proposal (RFP). In using force field analysis to get to the RFP, the team is able to produce a document that clearly communicates its objectives and describes a prioritized list of criteria unique to the specific redesigned process. Given that many RFPs are often nothing more than a lengthy laundry list of required and nice-to-have criteria all mixed together, most vendors will welcome the opportunity to respond to an honest, succinct, and clear RFP that helps them understand the problems your orga-nization is hoping to solve with their technology. It also gives them a chance to propose creative and innovative solutions to the problems you are trying to address. By using objectives and criteria derived from the force field analysis, the RFP describes the objectives and requirements for systems that will enable and support the ideal process rather than designing the technology solution around the current process that may be completely redesigned and discarded.

Review of Information-Based Activities

Another more global way to specifically look for information technologies that may enable your redesigned process is to look at how information is currently acquired, moved, stored, and presented. The team should then be challenged to envision how information technology could help acquire, move, store, and present that information in the ideal process. This exercise provides many opportunities for breakthroughs. For example, patient demo-graphics that are acquired on the spot using a logbook and a pencil could possibly be acquired over the phone before the patient’s arrival and entered


directly into the computer. Alternatively, the patient, using a touchscreen or pen-based system, could enter and update their own demographic informa-tion while they are in the waiting room or via the web before arrival. Many urgent care centers and organizations already do this. The team should also consider how updated demographic information gets to the various care-givers throughout the continuum. Instead of distributing paper updates, everyone might be able to refer to the same up-to-date information in a document imaging system or via the corporate website. Demographic infor-mation should be stored in a common database as opposed to being stored in many different places. Though this approach can at first seem expensive and complex, entering and storing information once—in one place for all those who acquire it and who require access to it—and making sure it is accurate and as up-to-date as possible, can ultimately save time and money, if not lives. How that information is presented to the caregivers is key. Beyond the obvious issue of incorrectly presented data leading to incor-rect decisions, poorly presented data often leads various end-users to col-lect, store, and present data in their own way. Thus, data is often collected, stored, and presented in almost as many different ways as there are end users. The challenge of getting all the separate information onto a common database, as well as placating the end users who like their data the way they had it, often hinders organizations from providing common information. It can also be quite dangerous when there is no one source of information so one never knows what the correct information is. Here is where new, more sophisticated cloud-based and web technologies and applications may pro-vide breakthroughs.

The team should then be challenged to envision how information tech-nology might help acquire, move, store, and present that information in the ideal process.

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Chapter 9

Critical Success Factors

Given that organizations and teams are able to do reengineering and process redesign if they have the will and use the approach such as the one described in this book, why do so many fail? In their book The Reengineering Revolution, Michael Hammer and Steven A. Stanton (1995) list the top ten reasons why reengineering fails or fails to get started in organi-zations. I and many others can vouch for the fact that these reasons apply as much to health care processes as they do to other industries. Do not be dismayed if your organization experiences one or two of the errors on this list—you are not alone. Though Hammer and Stanton’s book was written in the mid-1990s, its caveats still hold true today. Carefully review your major change initiatives and see if any of the following apply to your situation:

1. Organizations do not actually reengineer or redesign their processes, but say that they are. Organizations often try to fix a process instead of changing it. When the term “reengineering” became ubiquitous and a fad word, it became attached to all kinds of programs that did not involve process redesign at all. As an example, one hospital administrator had four of his individual managers present simple departmental changes they had implemented to demonstrate that his people were “already into reengineering and process redesign.” Fortunately, most of the audience

Organizations do not actually reengineer or redesign their processes, but say that is what they are doing. Organizations often try to fix a process instead of changing it.


recognized that these managers were simply presenting routine man-agement activities, far from fundamental redesign of their key business processes. A more egregious example is where reengineering came to be known as one of several euphemisms for layoffs. This is probably the single main reason that leaders began to shy away from the concept of reengineering. For those who really wanted to do the fundamental work of changing the organization, the term carried too much baggage. Those who were using the term as a euphemism for layoffs were quickly found out and had to cast around for a different term.

2. Organizations do not actually focus on key business processes. It is nec-essary to take a process perspective or as Hammer and Champy write, “Without taking a business perspective of business, business improvement efforts amount to simply rearranging the deck chairs on the Titanic.” Well-intentioned departmental managers will state they are redesigning or “reen-gineering their departments” when what they should do is analyze and redesign the processes the customer experiences, which are rarely, if ever, located in strictly one department. This is a common trap that many of us fall into. Even as a senior executive and consultant, I find myself being requested to “reengineer care” or redesign some department or other non-process. It is a challenge to explain that though I am willing to consult with a client or work to help them solve their problem, reengineering or process redesign cannot and will not occur if we do not focus on processes. And in that same analysis, I would also include the intersection between the people and the interlocking processes in which they work. These opportunities give me a chance to further educate individuals and the institution about what process redesign is and what it is not. Sometimes, my goal becomes to help them understand what a process is and is not so they can begin to identify and analyze process opportunities.

3. Organizations spend a lot of time analyzing the current situation. This is a favorite activity of both internal and external consultants, who spend many hours, weeks, and even months on the familiar current process—perhaps because it is comfortable, nonthreatening, does not

Without taking a business perspective of business, business improve-ment efforts amount to simply rearranging the deck chairs on the Titanic. (Hammer and Champy, 1994)

Critical Success Factors ◾ 137

really require any knowledge of process redesign, and certainly is not as transformational as reengineering. For some, the lengthy analysis of the current situation represents increased billable hours, as well as extra time to get themselves up to speed on the organization and the need for reengineering. I suspect that some hope to delay long enough for the process redesign “fad” to pass. (Some would argue it already did.)

4. Organizations are timid in their approach to reengineering. In James Champy and Harry Greenspun’s (2010) latest book, Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery, the authors suggest that organizations take an incremental approach to reengineering. Per Hammer, and in my experience, the incremental approach sounds more like good old-fashioned con-tinuous improvement and is not really redesign or reengineering. And as previously mentioned, if continuous improvement or pro-cess improvement will get you results you need, by all means use those approaches. The temptation is to settle for short-term marginal improvements rather than persevering toward the ultimate rede-signed processes. With one former client, the team was so excited with the progress provided by the short-term solutions that they almost lost sight of the amazing gains that were achievable if they could push forward and implement the longer-term solutions. They almost stopped extremely short of meeting their overall objectives and aggressive targets.

5. Organizations proceed without strong executive leadership. Though it is true that some small-scale work redesign and simple processes can be successful, if you are fundamentally reengineering your key pro-cesses and transforming the way your organization delivers goods, services, and especially how it cares for patients, your organization’s efforts must be led by senior executives. In reengineering or process redesign efforts, the reengineering or process redesign initiative is the CEO’s project. If your reengineering or work process redesign efforts are not your CEO’s project, your organization is probably not going to accomplish major reengineering and process redesign. Instead, you will end up with an impressively long list of reasons why you do not need any change whatsoever, or a list of competing projects that do not help move the organization forward. One CEO I worked with went so far as to say that the difference between continuous improvement and


reengineering is that in continuous improvement, the CEO’s support is required, while in reengineering, the reengineering project is the CEO’s project.

6. Organizations place prior constraints on the definition of the problem and the scope of the process redesign effort, or place some aspects of the business off limits. Your teams must hear and even see examples that there are no sacred cows in the organization. By definition, in reengineer-ing, you are not only making fundamental change occur in your organi-zation, but you are also asking why you do things and why you engage in any or all of your processes. Limiting the scope limits the innovation, potential solutions and benefits, and organizational change opportunities.

7. Organizations do reengineering and process redesign too slowly. If your team meets for too protracted a time period, your efforts will be perceived to be just another process improvement or incremental initiative. This may also inadvertently send a message that there is not such a crisis or need for change. In more than one client engage-ment, the teams were given seemingly impossibly short time frames to meet stretch targets. They met those targets and went beyond them. The haste and pressure were motivators and signals that the initiative was vital to the long-term financial and competitive health of the organization.

8. Organizations go directly from conceptual design to implementation. One team I worked with was so excited about the conceptual design that they leapt fearlessly and naïvely into implementation with predict-ably disastrous results. They took two quick steps forward to take at least four large steps backward. Even though the team needs to be quick and nimble, they still need to follow the methodology and do the work. There are no shortcuts.

9. Organizations adopt a conventional implementation style. This can be an easy trap to fall into. Conventional implementation styles tend to be bureaucratic and incremental in nature. Process redesign solutions

Even though the team needs to be quick and nimble, they still need to follow the methodology and do the work. There are no shortcuts.


will by nature be rather avant-garde and will require quick implemen-tations that may challenge the traditional command-and-control struc-tures in most institutions. Implementation requires a faith and a vision about new technologies that the leadership and team members may not be familiar with. People will begin to say things like, “Things are happening so fast, we are not having sufficient time to carefully plan.” Leaders and teams need to be tactfully but relentlessly reminded that rapid change, as long as it meets the targets and goals set forth by the steering committee and the process redesign or reengineering team, is the purpose of the exercise when engaging in process rede-sign. If speed were not of the essence, a more methodical continu-ous improvement approach would have been more effective and less disruptive.

10. Organizations ignore the concerns of their people. Management must pay attention to what is going on in people’s heads and hearts as well as what is happening on their desks. People will be fearful as they began to witness the magnitude of change in their workplace. Leadership must be as honest as possible and realize that people are the organization’s most valuable asset. The employees will help make or break the success of the redesigned solutions. It is wise to recall that it is the organization’s employees who are identifying the innovative approaches that make the process redesign a practical reality.

The purpose of this list of pitfalls is not to place blame on anyone but to provide a list of caveats and things to avoid. According to the late Michael Hammer, when reengineering or process redesign efforts fail, no matter what the proximate cause, the underlying reason can invariably be traced to senior management’s inadequate understanding or leadership of the effort. Conversely, the good news is that management has within its power the ability to steer the organization away from these top ten rea-sons for failure. But again, reengineering or process redesign must be the CEO’s project, and he or she must have the time, courage, and resources to devote to it.

Management must pay attention to what is going on in people’s heads and hearts as well as what is happening on their desks.


Critical Success Factors for Reengineering and Process Redesign

In a fight between you and the world, bet on the world.

Franz Kafka

Given the list above and the usual organizational inertia, it is understand-able why most companies that attempt reengineering fail to achieve the results they had hoped for. Most of the failures occur when organizations face the reality of the hard work and culture changes required for imple-mentation. During the early craze of reengineering and according to a sur-vey of one hundred hospitals and clinics by David Zimmerman and John J. Skalko (1994), in their book Reengineering Health Care: A Vision for the Future, only 30% of the organizations undertaking process redesign reduced costs substantially. Another 20% showed some reduction in costs, while 50% of the organizations had no cost savings whatsoever. Without funda-mental real reengineering efforts, results on average will be disappointing. Given the high probability of potential failure, there are certain things that organizations can do to realize the expected results of their reengineering and process redesign efforts. The following sections describe and reiterate critical success factors for making process redesign a success in your orga-nization. The first factor is key. As is the case in organizational change and transformation, process improvement, Lean, or Six Sigma, when results or improvements are not realized it is due to senior leadership’s unwillingness or inability to lead the effort. This was noted by Hammer regarding reengi-neering, and it holds true regardless of the approach used.

Senior Leadership Must Lead the Effort

First and foremost, senior health care and medical executives must lead and be involved in the efforts to guide the reengineering process. Two key play-ers to cochair the reengineering steering committee should be the executive director of the organization and the medical director. These leaders must deeply believe in the imperative to reengineer and redesign core processes, and they must ensure that process redesign efforts are identified and pri-oritized from an organization-wide perspective. To get the most gains from redesign, these two critical leaders must help the organization remain posi-tive and optimistic and think in terms of dramatic reduction in costs and


improvements in customer satisfaction and patient quality. One wit on the seminar circuit advises, “When you’re going after Moby Dick, make sure you take along the tartar sauce.”

Status Quo Cannot Be Acceptable

The organization’s leadership must be able to accept the fact that the sta-tus quo, with all the current health care delivery processes, is simply not adequate. Reengineering is nothing short of an organizational transforma-tion. Even though many patients, families, and payers feel that health care processes are broken, this can be the most difficult issue reengineering teams must grapple with. Many of the key players and the teams may have designed or developed the current processes, and they are naturally wary of any new ways of providing patient care. Literature reviews and outcomes analyses of new or similar practices can put some of these fears to rest. But often, when it comes time to implement the new processes, and the first challenges arise, these individuals are quick to champion the old way of delivering care. They may become highly critical of the redesigned process and suddenly become very sentimental and remember the old process as having no faults whatsoever.

Senior Leadership and Team Members Must Fully Engage in the Reengineering Initiative

Senior leadership must be totally committed to the need for reengineering and process redesign and the reasons for doing it. They, along with team leaders, must also fully understand and support the objectives for each indi-vidual process that is to be redesigned. It cannot be stressed enough how important it is that all the team members agree on those objectives and that they can clearly see that their team leaders and senior leaders also support and agree with those objectives. In some unfortunate cases, well-intentioned process redesign efforts get stopped or delayed because not all of the senior team members really want the fundamental changes to occur. Or they feel that the fundamental changes are necessary but too premature. For example,

The organization’s leadership must be able to accept the fact that the status quo, with all the current health care delivery processes, is simply not ade-quate. Reengineering is nothing short of an organizational transformation.


costs do need to be taken out of the system. However, until the fee-for-service model for reimbursement is completely discontinued and health care organi-zations are paid either a capitated fee or a set amount to manage a particular population of patients, leaders and teams can argue that by reducing costs in process, reimbursements may also be reduced. They may be correct because if we reduce volumes and activities—whether value-added or not—or if we reduce the number of patients going through parts of the organization where more revenue is generated by higher levels of utilization, it is likely we will significantly and negatively affect revenues. However, we can try to get ahead and be prepared for new models of patient care such as population manage-ment and/or capitated payments. I still find situations where not everyone is convinced that day is coming or even that it is already here.

Within the overall reengineering and process redesign efforts, the newly redesigned processes usually meet most, if not all, of the teams’ objectives for the ideal processes, while the old processes meet few if any of those objec-tives. However, problems arise when managers or employees on the team realize that though the new process is optimized for the patient and meets the overall objectives, it may not be optimized for them individually or for the needs of their department and the way it is currently organized. Those indi-viduals may realize that they are going to lose a perceived significant amount of control or even a monopoly over information or resources of some sort.

Resistance Should Be Expected

Faced with the choice between changing one’s mind and proving that there is no need to do so, almost everybody gets busy on the proof.

John Kenneth Galbraith

Leaders and organizations going through major process redesign must expect resistance to change. Resistance is normal when people’s lives and livelihoods are being transformed, and that resistance will manifest in a variety of ways, including fear, denial, bashing of the data, and the “but we’re different” reflex to name just a few. They will argue against the need to do fundamental change, or they will even dispute the timing of that fundamental change.

Senior leadership must be totally committed to the need for reengineer-ing and process redesign and the reasons for doing it.


In Hammer and Stanton’s The Reengineering Revolution, the authors list the following principles for overcoming resistance to change:

◾ Resistance is natural and inevitable: expect it. People do not like change, not even incremental change. They are not going to like funda-mental major change that challenges all the unwritten and written laws of the organization.

◾ Resistance does not always show its face: find it. Early on, I learned this the hard way when a seemingly cooperative and participative team member waited until the actual implementation of a new process to sabotage the process redesign effort. This individual had invented the old method or process and could hardly wait to see the team fail.

◾ Resistance has many motivations: accept this. There are as many reasons for resisting change as there are people resisting that change. Even such seemingly trivial motivations as having to shift work schedule by an hour can be very powerful. For example, the individual who now has to start his or her work shift an hour later to better accommodate patients or customers may feel that it is impossible to find suitable child-care arrangements or to handle other complexities in his or her life.

◾ Deal with people’s concerns rather than their arguments. People are often afraid to admit their true fears. For example, they might couch a fear of losing control under the cloak of “patient care will be adversely affected” or other such inarguable concerns. However, if team members identified all possible concerns, identified the major objectives, and put the relevant process measures in place, these “inarguable” concerns are minimized, and the real personal concerns can be identified, discussed, and addressed.

◾ There is no one way to deal with resistance. Learn to expect it, find it, understand it, and address it.

Above all, never underestimate the strength of the resistance and never assume that you can assume or know where all of it will originate. Particularly be very careful of fear. It is the one thing that ultimately prevents real transformational reengineering, process redesign, and organizational change from getting off the ground. Change will threaten the status quo and the leadership team to its core. If the leadership team members do not stay focused on and united around the overall purpose and goals of the rede-sign initiative, the efforts can quickly fall apart. They have to fundamentally understand that many things will change: processes, structures, and systems. Things that they may have championed or implemented in the past may


no longer serve the organization. It is not personal, just different times with different challenges. This can be a very frightening journey. As depicted in Figure 9.1, change represents many things to people.

Change causes people to feel less confident, competent, comfortable, and in control of their situation while the status quo, as bad as it may be, is pre-dictable and people understand where they stand.

Medical Staff Must Be Involved

The critical success factor of keeping medical staff involved in health care reengineering should perhaps go without saying. However, I must repeat it in order to emphasize it. Given the fact that physicians usually coordinate

Status quo = expectations

met

Change = disruptions in expectations

Competence

Comfort

Control

Confidence

Figure 9.1 What does change represent to people?


patient care processes and therefore drive resource consumption, it is impera-tive that they are involved in redesigning clinical, if not most, processes. In organizations where they have been heavily involved in the development of clinical pathways and guidelines, physicians already have a firm understand-ing of processes and the opportunities to fundamentally improve them, adopt best practices, and standardize them for appropriate patients. One organiza-tion that involved roughly three hundred individuals on teams to reengineer seven clinical service lines found that one-third of the team participants appointed by team leaders were physicians, half of whom were attending physicians. Though there may be disincentives to physicians to be concerned about reductions in a health care organization’s costs, most realize they are in a partnership with hospitals, however tenuous it may be, and therefore for them to be successful the hospital must be successful and vice versa.

Team Leaders Must Be Strong and Respected

Team leadership must consist of strong, credible, and respected individuals (medical, clinical, and administrative) who believe in the imperative of the reengineering initiative, and who can help champion the implementation process. Team leaders must be able to comfortably and passionately sell the need to redesign patient care and business processes, as well as the resulting recommendations and changes, to their peers and colleagues. For example, one successful physician team leader used her medical service business meetings to educate her peers in internal medicine about why clinical pro-cesses needed to change, and how the team’s recommendations would ben-efit them, their patients, and their patients’ families.

Team Members Must Come from All Parts and All Levels of the Organization

Another critical success factor is to ensure the teams consist of members from various levels of the organization. Teams that include managers, supervisors, and frontline employees are usually the most successful. The frontline staff is often most aware of the obstacles and opportunities for improvement, plus

Given the fact that physicians usually coordinate patient care processes and therefore drive resource consumption, it is imperative that they are involved in redesigning clinical, if not most, processes.


they are very familiar with the processes on a day-to-day basis. However, the supervisors can help answer questions and champion the implementation of the action items for redesign solutions. For this team mix to work, the supervisory staff and frontline employees must have an acceptable working relationship and some idea of how to participate in a team process and how to do continu-ous improvement. For example, employees should not fear speaking up and sharing their detailed knowledge of the process, while supervisors must be very careful of either monopolizing discussions or being negative toward sugges-tions made by the team. In short, everyone needs to listen respectfully to their teammates regardless of title or where they sit on the organizational chart.

Mindsets and Approaches Must Change from Function to Process

Once the team convenes, the facilitators and team leaders must help the team change its collective mindset from a functional orientation (the proverbial silos) to a process orientation. Even though the team is multidisciplinary and has representatives of key hospital functions or departments, these repre-sentatives must understand that they are not there to represent their depart-ments’ interests, but that they need to focus on the process from the patient’s or the customer’s perspective. This can be extremely difficult for people who are not used to thinking in process terms. However, identifying key objectives (which is step 2 in the process redesign methodology discussed in Chapter 7) can go a long way in helping individuals understand that their role as a team member is to help the team and the organization meet the objectives of the process redesign, and not to optimize one department’s results at the expense of the organization’s results or at the expense of the patients and the outcomes they experience. Also, individuals who have previ-ously participated in process improvement teams will have the advantage of understanding first what a process is, and second how to analyze it. If nec-essary, the facilitator may want to employ just-in-time training on processes or exercises that help team members look at and analyze processes.

Teams that include managers, supervisors, and frontline employees are usually the most successful. The frontline staff is often most aware of the obstacles and opportunities for improvement, plus they are very familiar with the processes on a day-to-day basis. However, the supervisors can help answer questions and champion the implementation of the action items for redesign solutions.


Change Must Be Orchestrated and Led

Since redesigning core business or clinical services involves dramatic and fundamental changes to the entire organization, change itself and how peo-ple process and react to it must be consciously considered to ensure that the inevitable resistance and hard work required does not engulf and drown the reengineering efforts. Change, at both an organizational and individual level, must be acknowledged and supported. After all, reengineering and redesign do not and cannot just happen to your organization. It will and must happen in the hearts and minds of your employees and your associates before it can happen to the organization. For example, employees will now be part of a patient care process team rather than just a member of a functional depart-ment. This will change the nature of their relationships with their work colleagues. Their days may be spent on activities previously performed by several other departments, rather than a narrow list of tasks they may have been originally hired to perform, which they are very comfortable doing. Managers who have been trained and who have mastered the skills of supervisors will have to transform themselves into coaches instead. Neither the employee nor the manager will probably have a role model for this new multidisciplinary approach or the coach’s role. These new responsibilities require different skillsets and therefore different types of training.

To get employees in the organization through the transition, executive lead-ership must provide a “magnet,” or an incentive, or something to attract people toward the newly redesigned processes, along with a wedge, which is the force to move people into the changing processes or mindset and/or have them suf-fer the consequences. Basically, you must provide a carrot and a stick—or, as I am calling it, the magnet and the wedge. Individuals need to see that there is a vision and a reason to sacrifice, while understanding the consequences if they position themselves as part of the problem or as an obstacle instead of part of the solution. You may wish to refer back to Chapter 3, which discusses change readiness and reviews how we all perceive and react to change differently.

Hammer and Champy (1994), in their book Reengineering the Corporation: A Manifesto for Business Revolution, talks about approaches for overcoming resistance to change. At least three of his five suggestions deal directly or indi-rectly with education. One approach is to provide information, which includes supplying people with the details of what is happening and what they need to know to do their job. Knowledge reduces uncertainty and helps dispel fear. Another suggestion is intervention, which means dealing with people one-on-one to offer them support and reassurance so that they can


overcome their individual as well as team discomfort and fear. This point illustrates that acceptance of change happens one person at a time, and that leaders must be actively engaged in making this happen. It is not something that can be delegated. To a significant extent, leaders must engage the orga-nization, which means convincing people that change is absolutely inevitable and that the company has no other option if it wishes to survive, grow, and thrive in its new and ever-changing environment.

Values in a reengineered organization must change from being protec-tive of turf, control, or authority, to being productive and serving the needs of the patients and the customers. Employees must shed the tried-and-true method of pleasing the boss or manager, and feel empowered to meet the needs of and care for their patients and customers first. This assumes that if the patient’s needs or customer’s needs are efficiently and effectively met, then so are those of the manager. If this is not true, one needs to examine the motives and values of leadership. Old values will not change until employees see that the new customer-oriented processes are val-ued over turf protection and the old way of doing things. A very powerful way of quickly changing values is to change the incentive and compensa-tion programs. The organization’s emphasis, measures, and rewards for all employees must revolve around the desired results. In addition to aligning management systems and incentives in a way that rewards the new behav-iors, it is imperative that you provide the education and training for employ-ees so they have the new skills and capabilities to behave differently and perform in the new roles required within the newly redesigned processes.

A transition of particular importance is that of the change in priority from focusing on activities to focusing on results. Instead of thinking in terms of producing tests, visits, X-rays, treatments, and other tasks and activi-ties performed by traditional departments, we must shift our focus to that which is most important to our patients, families, payers, and employers: the results. In other words, at the conclusion of their encounter with a health care provider or professional, however short or long, we must ask, “Were the patient’s needs for a particular health outcome met?” For example, the oncol-ogy patient does not come in for diagnostic tests, blood work, or radiation therapy, he or she comes in order to stop his or her cancer, or at least send

Values in a reengineered organization must change from being protective of turf, control, or authority, to being productive and serving the needs of the patients and the customers.


it into remission. Other results a patient may seek include a reduction in pain, a reduction in symptoms, and the ability to lead a normal life. Parents-to-be come to the hospital to deliver a healthy infant, not to be triaged, registered, have their data entered into a computer, or sent a bill.

Figure 9.2 provides a summary of the transformation of perspectives that organizations and their leaders must undertake for real organizational change to happen.

So what can leaders do to actively facilitate change in their organiza-tions? In Taking Charge of Change: 10 Principles for Managing People and Performance, Douglas K. Smith (1997) outlines ten management principles for taking charge of change. They are as follows:

1. Focus on how changes in the way people work will improve per-formance. You must help people understand the benefits and con-sequences of their efforts to learn new behaviors, skills, or working relationships. Though the changes can seem disruptive at first, the rede-signed processes will make it easier to meet the patient’s and customer’s

From To

Jobs

Structure

Axis

Manager

Executive

Priority

Measures

Focus

Values

Multidimensional

Team

Process

Coach

Leader

Result

Operational

Customer

Productive

Narrow

Hierarchy

Function

Supervisor

Bookkeeper

Activity

Financial

Manager

Protective

Figure 9.2 Reengineering transition. (Courtesy of the First Consulting Group.)


needs, making for an easier day for the team member. This can be part of the magnet or the incentive. Leaders must patiently and repeatedly explain how the change will benefit the organization and ultimately the employees themselves.

2. Continually give people more responsibility for their own change. Each individual must take responsibility for his or her own process and individual change. Empower individuals to make the process changes necessary as well as cultural changes to enable the success of the new processes. This may mean allowing teams and individuals enough leeway to experiment, try new things, and maybe make some mistakes along the way. Change that is cocreated is generally more creative, more effective, more flexible, and more capable of being sustained over time. One hospital leader’s favorite cartoon depicts a two-column tally of suc-cesses (very few) and learning experiences (very many) (see Figure 9.3). However, the lessons learned will be worth their weight in gold as new process and organizational changes get implemented.

3. Make sure each person always knows how his or her performance and the ability to implement the necessary change make an impact on the purpose and results of the company. Line of sight for employees to the organization’s strategy is key. This perspective helps employees under-stand how they fit into the bigger picture, and how the individual’s and company’s successes are intricately intertwined. It also helps employees understand at a deeper level why they are being asked to implement the redesigned processes. Most employees are inspired and motivated when they realize that they are indeed not a cog in the wheel and that their efforts and the results they produce really do have an impact on the orga-nization’s success. This in and of itself can be quite empowering.

Change that is cocreated is generally more creative, more effective, more flexible, and more capable of being sustained over time.

Successes Learning experiences

Figure 9.3 Success tally.


4. Put people in a position to learn by doing, and provide them with the support needed just-in-time to perform the new tasks. Instead of giv-ing people a large amount of up-front training that they will forget if it is not used immediately, give them the specific tools training right when they need it to reach each goal. We use this technique success-fully when conducting the reengineering and process redesign and tools workshop. A brief overview of the specific tool is provided initially by the facilitator. Then the team immediately begins to employ the tool, learning to use it as they analyze and solve real issues and redesign their processes.

5. Embrace improvisation as the best path to both performance and change. When the processes are new, no one person has the skills, behaviors, or working relationships needed to perform. Thus, it is fruit-less to search for the one “right” set of decisions, strategies, and policies before acting. Instead, the team must try new ideas, see what works and what does not, and keep moving closer to a solution. In process redesign, like in life, there usually is no one perfect answer. Nor does every solution fix exactly the problem that the team is hoping to solve. However, by experimenting and trying different alternatives, or even variations on a theme, a team can often come up with a solution that has a positive impact far beyond that which had originally been imag-ined. In one case, I told the team there were three phases. In truth, when we started, we did not know that there were multiple phases. In fact, on at least two of the phases, we sort of rolled them out as they were being developed. Though we did make a few mistakes, we viewed them as learning experiences, gained from them, and went for-ward even wiser with better future solutions as a result.

6. Use team performance to drive change whenever demanded. Teamwork, the ability to work together, is not the same as team per-formance, which is the ability to accomplish objectives and outcomes in a consistent and excellent fashion. In the health care industry, this is particularly imperative since care is provided by teams of caregivers

This perspective helps employees understand how they fit into the bigger picture and how the individual’s and company’s successes are intricately intertwined.


rather than by fully autonomous individuals. If one part of the health care team breaks down, it does not matter if another part is exemplary. The outcomes to the patients are possibly adversely affected, or critical damage control is required to avoid more serious problems.

7. Concentrate both organizational reengineering and process design on the work people do, not on the decision-making authority they have. Though this is usually not the way we set up our organizational struc-ture, the attention to changing how people work, instead of how the organization is structured, is vital. I have seen some organizations change the organizational reporting structure without redesigning the core processes, resulting in higher costs and reduced patient and employee satisfaction. One organization reengineered and employed process redesign quite a while before redesigning the organizational structure. Teams need to first redesign clinical processes, focus on patients and customers, and then explore how organizational structure can help reinforce and support the newly redesigned processes. This can be somewhat dicey as the possibly unsupportive old organization structure can attempt to thwart implementation efforts. Inventing the processes first and then building the organization structure around them is in the reverse order of how traditional organizations were designed.

8. Create and focus energy and meaningful language because they are the scarcest resources during periods of change. One hospital developed an overview model and language to describe it to keep everyone focused on the efforts. This model and the associated lingo were then used along with compressed deadlines that were outside internal control in order to infuse the effort with energy and a sense of urgency.

9. Stimulate and sustain behavior-driven change by harmonizing initia-tives throughout the organization. Here, it is useful to take any and all initiatives directly or even indirectly related, and put them under the umbrella of an overall steering committee where they can be prioritized and coordinated. Major organization change will be difficult to imple-ment if it is perceived to be just one of several fragmented efforts in the organization.

10. Practice leadership by showing the courage to live the change you wish to bring about. Walking the talk is all about leaders who are willing to


expend their own time and energy to constantly motivate and sustain the change process throughout the organization for as long as it takes. Just like everyone else on the process redesign teams, it is likely that managers will often be outside of their comfort zone.

Key Success Factors and Conclusion

I leave you with several key crucial success factors that are true of major organizational change regardless of the approach.

Communication Must Be a Priority

Communication is a key, if not the key to managing and implementing change within an organization. We must go beyond communicating and figure out ways to fully engage others in the organization. In fact, John Kotter has changed his advice of “communicate” to “engage employees in the change” to acknowledge that it is not enough to just tell information. As the saying goes, “Facts tell, stories sell.” And ultimately the stories told have to be from and within the employees. Organization and team leader-ship must communicate with employees, colleagues, and peers at all levels of the organization throughout the reengineering effort. A leader’s job is not done after just a few presentations of the vision and the reason for the need to change. The vision, along with the recommendations and changes required to implement that vision, must be continuously and persistently communicated in a variety of venues. Face-to-face communication is gener-ally the most credible approach and should be used as much as possible, with written forms of communication used as supplements to reinforce the message. One organization used existing and special meetings, newsletters, update reports, memos, special breakfasts and luncheon meetings, along with business meetings and graphics in existing organizational publications to get the word out and to keep it at the forefront of everyone’s mind. In addition, senior leaders may wish to blog and do video clips to get a con-stant message out. These can then be followed by e-mail messages, which include frequently asked questions. The goal is to engage or reengage the greater than 60% of disengaged employees (per Gallup) around the reengi-neering efforts.

Major impediments to communication include disbelief, false familiarity, fear of layoffs, the ubiquitous rumor mill, and sloppy execution. Hammer


and Stanton (2005) outline the following 10 principles of reengineering communication.

1. Segment the audience. Identify who needs to know what pieces of the information and when they need to know it. A good communica-tion planning process requires that this step be applied to all major change initiatives—a communication timeline with deliverables, if you will.

2. Use multiple channels. Do not just rely on the organization’s newsletter or website alone. Post the change information and any team progress constantly. Talk it up in staff meetings and formal presentations. Use your company’s blog and intranet to get the word out. In one major hospital-wide effort, a special publication or newsletter was developed to highlight and communicate changes occurring as a result of the pro-cess redesign effort.

3. Use multiple voices. Have different individuals restate the information in their own words so that different audiences can relate to it.

4. Be clear. Be careful of buzzwords, terminology, and acronyms. And never assume you have communicated clearly. One organization com-municated that sixty beds were to be reallocated. Word among the employees was that sixty employees were to be laid off. You can never be sure that what you are communicating is hitting the mark and that the correct message is received.

5. Communicate, communicate, and communicate. And then communicate again.

6. Honesty is the only policy. Do not believe that half-truths protect any-one. Rapid changes can seem to breed distrust. Honesty is the only antidote.

7. Use emotions, not just logic. You cannot only influence people intel-lectually. You must tell a compelling story that touches their hearts and souls. And, if you are not honestly passionate about the fundamental change, why then are you doing it? Share that passion and your faith in the organization’s ability to do what it needs to do.


8. Heal, console, and encourage. This may well be one of the most frighten-ing and traumatic times in your organization’s history. Leaders need to be speaking with employees and teams and helping them understand that they know how difficult the task is, but that they are also hopeful and encouraged that if anyone can make these changes, this organization can.

9. Make the message tangible. Coming from a base of fear and using pro-posed bills in Congress or new legislation as a reason to change is not as inspiring as saying, “We are working to be a premier medical center that will continue to thrive and provide the highest quality health care to our community and to our patients as well as the best career oppor-tunities in this region.”

10. Always listen, listen, and listen. Do not assume you understand where people are coming from.

11. I suggest one piece of additional advice. Be authentic and speak from your heart. The more vulnerable and open you are, the easier it will be to influence others and win their trust.

Remember, as George Bernard Shaw says, “The single biggest problem in communication is the illusion that it has taken place.”

Major Process Redesign Is Not a Quick Fix

Another critical success factor is the realization that major process redesign commits your organization for the long haul. Process redesign is not a quick fix. It will take considerable amounts of time, hard work, and resources. It will be disruptive to your organization in at least the short term. Changes will be profound and will be in place for years to come with other changes coming up behind them. Teams should not let themselves be so mesmer-ized by the improvements and benefits of quick short-term solutions as to be unable to forge ahead to the longer-term, more important, “and probably more difficult to implement” broader solutions.

Organizations Must Change, Too

It is important to understand the core business processes cannot be radically redesigned without changing the organization and the management systems


that support your organization’s processes. Newly designed business processes determine jobs, positions, and organizational structure. These new jobs and the corresponding structure require new management and measurement systems that in turn induce the values and beliefs that will bring about the success of the new business processes in a synergistic cycle. Refer to Figure 9.4.

This approach is a chance to redesign the organization from the inside out and in an iterative fashion. The completely new processes and ways of deliv-ering care will require new organization structures and incentives, and differ-ent leadership and employee skillsets. This is only one reason this approach can seem daunting or layoffs can occur across the board and be attributed to process redesign or workforce redesign. Either approach does not yield the desired results and, in the worst-case scenario, can do more harm to the orga-nization in terms of patient safety, clinical quality, and employee engagement.

You may also want to refer back to Chapter 3 on how individuals and teams experience change, and Chapter 4 on organizational change. This approach integrates process improvement, redesign, and reengineering approaches with organization development and change principles.

Use of Project Management Principles and Techniques Is Important

Another important critical success factor to organization-wide process rede-sign is skillful and well-planned project management. In Chapter 7, you saw

Business

processes

Values and

beliefs

Jobs and

structure

Managementand measurement

systems

Business cycle

Determine Enable

Require

Induce

Figure 9.4 Synergistic business cycle.


how the force field analysis eventually turns into an implementation work plan. Teams will create literally hundreds of recommendations for both incremental and broad changes. Some of the recommendations may require their own detailed implementation plans. These items need to be priori-tized, so that the items with the largest impact are implemented in a timely fashion along with the required training, tools, investment, and resources. It is incredibly important that all the activity does not lead to organizational chaos—leadership must prioritize action items on an ongoing basis. The simple work plan template shown in Chapter 7 (Table 7.3) can be easily used by the team facilitators as a master plan for implementation. Of course, MS Project and other software, both local and enterprise-wide, may be used if you have the skilled individuals to support it.

Face-to-face and electronic updates to the overall steering committee can potentially consist of a review of this simple project work plan. Chapter 7 (Table 7.4) illustrates a detailed example drawn from a cardiac line team. Detailed team implementation plans that are ultimately linked to the mas-ter plan may need to be developed using a project management software. The key here is that your work plans clearly define what is to be done, by whom, by what time frame, for what benefit (i.e., reduced costs or improved patient satisfaction), and what the expected deliverables of the various tasks will be.

Given the challenges and the number of critical success factors for this approach, it can seem to be a daunting task to tackle process redesign— especially since there are so many priorities, and perhaps you have strug-gled in the past with improvement methodologies. However, using this holistic organizational approach to redesigning how you provide care and services will ultimately have a positive impact on you, your team, your asso-ciates, and your community.

159

References

Champy, J., & Greenspun, H. (2010). Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery. Upper Saddle River, NJ: FT Press.

Cohen, D. S. (2005). The Heart of Change Field Guide: Tools and Tactics for Leading Change in Your Organization. Boston: Harvard Business School Press.

Cooperrider, D., & Whitney, D. (2005). Appreciative Inquiry: A Positive Revolution in Change. San Francisco: Berrett-Koehler Publishers.

Dunn, L. (2014a). How much do healthcare organizations need to improve? Becker’s Hospital Review. Available at http://www.beckershospitalreview.com /healthcare-blog/how-much-do-healthcare-organizations-need-to-improve .html.

Dunn, L. (2014b). CEOs love talking about culture. Here’s why they shouldn’t. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com /healthcare-blog/ceos-love-talking-about-culture-here-s-why-they-shouldn-t .html.

Gamble, M. (2014). 10 Findings on hospital CEOs’ strategic priorities. Becker’s Hospital Review. Available at http://www.beckershospitalreview.com/hospital -management-administration/10-findings-on-hospital-ceos-strategic-priorities .html.

Hammer, M., & Champy, J. A. (1994). Reengineering the Corporation: A Manifesto for Business Revolution. New York: HarperCollins Business.

Hammer, M., & Stanton, S. (1995). The Reengineering Revolution: A Handbook. New York: HarperBusiness.

Haneberg, L. (2005). Organization Development Basics. Alexandria, VA: ASTD Press.

Joiner Associates Inc. (1995). The Team Memory Jogger. Salem, NH: Goal/QPC.Kotter, J. P., & Cohen, D. S. (2002). The Heart of Change. Boston: Harvard Business

School Press.Lencioni, P. (2002). The Five Dysfunctions of a Team: A Leadership Fable. San

Francisco: Jossey-Bass.

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Lewin, K. (1939). Field theory and experiment in social psychology: Concepts and methods. American Journal of Psychology, vol. 44, pp. 868–896.

McNulty, T., & Ferlie, E. (2002). Reengineering Health Care: The Complexities of Organizational Transformation. New York: Oxford University Press.

Scholtes, P. R., Joiner, B. L., & Streibel, B. J. (2003). The Team Handbook (3rd ed.). Madison, WI: Oriel Inc.

Smith, D. K. (1997). Taking Charge of Change: Ten Principles for Managing People and Performance. New York: Perseus Publishing.

Zimmerman, D., & Skalko, J. J. (1994). Reengineering Healthcare: A Vision for the Future. Brattleboro, NC: Eagle Press.

Health Care Management / Process Improvement

“Jean Ann captures the keys to total success based on her unique and valuable insights along with her strategic and holistic perspectives to total health care transformation.”—Imelda K. Butler, Managing Director of Century Management and Co-founder of the Odyssey Consulting Institute, Dublin, Ireland

“... an invaluable tool for health care executives as they address the pain points of moving from fee for service to fee for value.”—Michael W. Davis, Principal, Mountain Summits Advisors LLC, Denver, Colorado, USA

“...a refreshingly practical road map with real solutions that any health care organization should find beneficial.”—Ivo Nelson, Chief Executive Officer and Chairman, Next Wave Health, Houston, Texas, USA

“...emphasizes the coupling of health systems engineering and process improvement tools and techniques with effective change management to achieve successful cultural transformation and high performing and innovative health care organizations.”—Barry T. Ross, LFHIMSS, DSHS, University of Pittsburgh, Pennsylvania, USA

“I highly recommend that anyone who is a leader read Dr. Larson’s insights regarding the importance of process improvement and culture in change management and quality improvement.”—Gene Michalski, President and Chief Executive Officer, Beaumont Health, Royal Oak, Michigan, USA

“Jean Ann cleverly aligns the best tools and techniques together that drive reliable, sustainable change to our modern health care organizations.”—Rudy Santacroce, PE, Vice President, Operational Excellence, RTKL and Associates, Dallas, Texas, USA

“Jean Ann’s education as an engineer coupled with her vast experience as a senior leader in large health care organizations confirm her as the expert to document this practical approach on how to implement change in your health care organization.” —Elizabeth Jeffries, RN, CSP, CPAE, Executive Coach, Keynote Speaker, and Author of The Heart of Leadership: How to Inspire, Encourage and Motivate People to Follow You

“This book is the only resource you will need to charge forward with courage and confidence to move your organization to unbridled success.”—Val Gokenbach, DM, RN, MBA, Robert Wood Johnson Foundation, Detroit, Michigan, USA

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