The health science center where I have worked for 16 months (I will be retired when you read this) is undergoing major changes under new leadership at many levels. As I watch the process it brings to mind the difficulty and necessity of change. It is a cliché to say that change is inevitable. Though we can appreciate that change may be a positive or neutral experience, we more often speak of it as painful or negative. Pain ranging from minor inconvenience to destructiveness is a part of all change, which is why most of us try to avoid it—e.g., the “if it ain't broke…” attitude. But there are complex changes that are not so easy to avoid that inflict pain on someone, especially when the change involves a large number of people.
It is not so much a question of painful or non-painful change, but how much pain for how many people and whether the change had the desired positive effect that outweighed the negatives, both expected and unforeseen. Was it all worth it in the long run?
A study by John P. Kotter published many years ago addresses some of these issues (“Leading Change: Why Transformation Efforts Fail,” Harvard Business Review, March-April 1995).
After analyzing more than 100 large and small companies attempting fundamental change to “try to remake themselves,” Kotter found that a few were very successful, a few were utter failures, and the rest were in between, with the average being more toward failure.
From these studies he found that the great successes always went through a series of stages, all necessary and in a specific sequence. I list those stages and add comments of my own.
- Establishing a sense of urgency. In Kotter's study over half of all change efforts never get off the ground because of the failure to get aggressive cooperation from senior and middle management, to get them out of their comfort zone. “A paralyzed senior management often comes from having too many managers and not enough leaders. Management's mandate is to minimize risk and to keep the current system operating.” This is the antithesis of change. Kotter found that success was much more likely with a new leader, a great leader, and/or a change champion.
- For both traditional business and medical centers, change is facilitated by making the status quo seem more dangerous than launching into the unknown—e.g., loss of market share, patient/customer dissatisfaction, missing an important trend or technology, inability to recruit the best outside talent, and settling for inferior internal candidates.
- Forming a powerful guiding coalition. “In cases of successful transformation efforts, the leadership coalition grows over time. Whenever some minimum mass is not achieved early in the effort, nothing much worthwhile happens.” This group can range from 5 to 50 depending on the size of the organization.
- In a major change at an academic medical center, for example, an initial group may start with only five members, but the coalition must ultimately include key department chairmen and hospital leaders and should include members who are not part of senior management—e.g., a board member, unit charge nurse, or patient.
- Failure at this stage often is due to the lack of a history of teamwork—the departmental silos so prevalent in academic medical centers are a classical example.
- Creating a vision. “Without a coherent and sensible vision, a change effort dissolves into a list of confusing and incompatible projects.” The vision must be a picture of the future that is relatively easy to communicate and appeals, in a medical center, to patients, physicians, hospital staff, faculty, and the public at large.
- Refining the vision may take some time. Some transformations generate lots of goals, deadlines, benchmarks, and paper without a clear and compelling statement of where all this was leading. If most employees are confused or alienated by the process, the attempt at creating a vision and conveying it effectively has failed. There are many more “strategic plans” sitting on shelves collecting dust and forgotten than those successfully implemented (and periodically updated).
- Undercommunicating the vision by a factor of 10. This is a variant of # 3 above. There are three main types of communications failure: (a) A good vision communicated only at one big meeting or one communication; (b) the top guy attends many meetings to convey the vision, still only a tiny fraction of the communication necessary from all levels below the top guy; and (c) good communication of vision with ample frequency, but some prominent senior leaders behave dismissively or ignore the process, leading to cynicism among the troops.
- Empowering others to act on the vision and removing obstacles to the new vision. Enlarging the group of people empowered to try new approaches tends to solidify the change process. But removing obstacles to those actions is a key requirement. The obstacle may be (in a medical center) an administrator, department head, or a leader in nursing or pharmacy.
- But the obstacle may also be organizational structure. When trying to establish a cancer center within a university structure, many attempts fail or take an unusually long period to complete because the traditional departmental structure has antibodies to the establishment of any new center of power, particularly when the change impacts the departments, which it must.
- Even when successfully established, many of these cancer centers are basically unstable because a new and unsupportive chairman or administrator can cripple them.
- Planning for and creating short-term wins. Transformation takes time and momentum is easily lost if some tangible progress is not evident within a year or so. This may be measurable improvement in the quality of care in a medical center or an increase in market share for at least part of the organization. The process may create short-term wins by establishing achievable objectives within the year and publicly rewarding those who reach those goals. Then the renewal process is credited with progress and attracts more adherents.
But declaring victory after short-term gains is a mistake and can deflate progress. The last two stages are consolidating gains and institutionalizing the new approaches. Unless the positive changes are rooted in the culture and social norms of the organization, they are not likely to stick.
A successful transformation can revive a company or a medical center, make it more competitive, more stable, and more fulfilling and fun to be part of.
It is a pity that successful transformations are relatively uncommon and so many that are successful so easily revert back to the old rut when the responsible leaders move on, as they all eventually will. Unless the culture and expectations are changed and then defended vigorously, an often long and painful process, the benefits of all that work may eventually disappear.
Some people are hurt by change because they are unable or unwilling to adapt; the new culture may be viewed as “wrong.” If wrong only means different, then the person is at risk for being cut loose for recalcitrance.
If an individual views the new culture as unethical or amoral and does not wish to participate for that reason, then leaving the organization or unit undergoing the change is the only option. Others are hurt because the new structure requires different skills for which they are not suited. A moral organization will provide training or a transfer to keep an otherwise good employee in the fold.
In some change circumstances, people are hurt with a lack of respect and a rash disregard for their feelings. Then the change process becomes destructive and heartless, destroys morale, and ultimately fails no matter how well the organization's leadership goes through Kotter's stages.
That damage and soiled reputation can cripple the organization for years to come. Change is important, but not at any cost.
Joe Simone has been selected to receive this year's American Society of Clinical Oncology-American Cancer Society Award, which will be presented at the ASCO Annual Meeting in June, during which he will also deliver an accompanying lecture. The award is being given for his “contributions to the prevention and management of cancer and for his leadership in the field of oncology.”