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Implementing Lean: Change Management Theories to Consider

Posted on Wed, Dec 21, 2016
Implementing Lean: Change Management Theories to Consider

By John Bitting, RN, BSN, MA

The healthcare industry is continually changing, and as leaders, we help staff as they struggle through change management challenges every day.

Evidence-based practice is the cornerstone of today’s medicine, and new research seems to happen at phenomenal rates. Intellectually we understand the need to change in order to improve and that “change is good.” However, the human part of us that prefers to be comfortable approaches change kicking and screaming. The adoption of the electronic health record is a good example. Good healthcare leaders and lean proponents love the data that can be revealed with a good reporting system in an electronic health record. Younger, tech-savvy, practitioners are even more comfortable in using the electronic devices and interfaces. But, in every electronic chart conversion, it is all too common for providers, nurses and allied health professionals to fight the inevitable. Some are even left by the wayside due to an inability to make the change.

Change is the foundation of lean. Through a lean event, we are going to change processes and even our environment. So, when implementing lean, we must be prepared to encounter and neutralize resistance, confusion and habits. You want to have a clear vision of the future state as well as the path to get there. You also want to have several arrows in your quiver for managing change.

Force Field Analysis

One model of change is Force Field Analysis (FFA) developed by Kurt Lewin (1951). It represents the concept of opposing forces in change. Change is viewed as a process of modifying two types of forces in a system; one which tends to maintain the status quo and the other which pushes for change. For change to occur, the balance of driving forces needs to overcome the restraining forces. Strengthening driving forces may include building win-win solutions. In developing a plan of action, Lewin recognized that actions to remove or reduce restraining forces were more effective than actions to increase driving forces, which would serve to increase tension in the system.

To change behavior, Lewin gave us his three step process:

  • Unfreeze
  • Movement
  • Refreezing

The first step in Lewin’s process is breaking the existing situation or status quo. Driving forces must move the situation into an uncomfortable place. Comfort is a powerful motivator, in both positive and negative ways. Discomfort can set the stage for “movement” to a new level of equilibrium. This is done by getting the followers to agree that the status quo is undesirable or not beneficial and encouraging them to look at things differently. The final phase is refreezing, or making the new situation the new status quo. The phase of refreezing is the sustainment of the change. The challenge of staying lean largely depends on how well you refreeze the new expectations.

The Seven Phases of Change

Gordon Lippitt expanded on Lewin’s theories and added seven phases. The seven phases of change model is not rigid or necessarily sequential, but instead flows between the different stages. It focuses on the change agent and how to use the phases to help guide the change.

The phases are:
  1. Identification and diagnosis of the problem
  2. Assessment of the motivation and capacity to change
  3. Assessment of the change agent’s ability to lead this change along with motivation factors that may influence them
  4. Change agent assumes the appropriate role
  5. Level of involvement of the change agent is determined
  6. Maintaining the change
  7. Stopping the helping relationship

Only when the team has confidently worked through each phase reaching acceptance of change has change occurred.

Advanced Change Theory

Another model for dealing with organizational change is the 13-part Advanced Change Theory (ACT). This model requires a lot of practice. It is called “Advanced” for a reason. It is a complex model for dealing with change. The concept seems fairly simple; it is the alignment of the change agent, the change target and the current reality. Getting those things aligned is the difficult part.

The complexity of the assumptions makes it a cumbersome model for a leader to use to enact change. However, some of the concepts within the model can help the leader as a change agent. Each leader will likely find assumptions they feel comfortable using.

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

Advanced Change Theory is one of many subjects included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about implementing lean at your facility and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

How leaders support, propagate and promote the change process will determine the success of the endeavor. The different theories are just that, theories. Some work very well. Others are hard to put into practice. Your personal level of comfort directly affects your ability to operationalize these concepts. New leaders must actively think about how to use these concepts with the lean team and other change processes. Seasoned leaders end up doing it as second nature. It is also easier when the leader believes in the change. It needs to be personal.

John Bitting, RN

John Bitting, RN, is a Divisional Director of Client Services for EmCare.