OBSERVE: Seven Steps for Managing Change

We all know it: change is inevitable. That’s probably more true in healthcare than anywhere else, and change is a fact of life for hospice and home health agencies (HHAs).

Frequent change is mandated by the Centers for Medicare & Medicaid Services (CMS) and by state regulatory agencies. Just in the last few years HHAs have seen: 

  • the Value-Based Purchasing model (VBP: 2016)
  • an overhaul of the Conditions of Participation (COP: 2018)
  • changes to the Outcome Assessment Information Set (OASIS-C2: 2017, OASIS-D: 2019)
  • a payment model upheaval with the Patient Driven Groupings Model (PDGM: 2020)
  • new electronic visit verification requirements (EVV: 2020 and 2023). 

Hospice agencies have seen a variety of hospice billing initiatives and the Hospice Item Set (HIS: 2014). The new Hospice Outcomes & Patient Evaluation (HOPE) is currently in development.

In addition to regulatory mandates, hospice and HHAs may undergo all-too-frequent operational change in response to:

  • changing provider and referral requirements
  • advances in technology affecting the electronic medical record (EMR)
  • emerging new technologies such as telemonitoring and telehealth 
  • merging provider networks and health systems
  • regional or national initiatives such as electronic Health Information Exchanges (HIEs)
  • emergency preparedness requirements and directives 
  • problems or opportunities within the agency itself

We’ve all heard it: change is hard. Once again, this may be particularly true for healthcare in general, and for hospice and HHAs specifically. Predictable or not, changes of any kind can affect agencies at every level, as agency employees are asked to abandon familiar procedures and workflows and to learn, accept, and embrace new ones. This can impact employee satisfaction and morale, staff turnover, and even the quality of patient care. Organizational and procedural changes can impact departmental and agency budgets and the overall health and wellbeing of the agency itself.

“Those who expect moments of change to be comfortable 
and free of conflict have not learned their history.” 

– Joan Wallach Scott

Ultimately, how we confront the challenges of a change initiative can determine the success or failure of that initiative. We need to know what to do, whom to involve, and what to say. We need to understand—and effectively communicate—why the change is necessary and how the agency, its employees, and/or its patients will benefit. Managing change can be a complex and challenging process, but there are ways to do so that can help minimize the negative impacts, maximize the benefits, and keep stress levels down.

Models of Change Management

Most current theories of change management stem from the influential works of Kurt Lewin (1890-1947) and/or John Kotter (1947–). While neither of these models is fine-tuned to hospice or HHAs, both models outline relevant concerns and concepts. 

Lewin’s model identified three stages of change. While somewhat simplistic on the surface, the model comprises most of what we consider important to successful change management: 

  1. Unfreeze: preparing for change by assessing current conditions and acquiring the necessary support and resources
  2. Change: developing and implementing a plan; evaluating its effectiveness 
  3. Freeze (or Refreeze): sustaining the change through ongoing evaluation

In Kotter’s 1996 book Leading Change, he outlined an eight-step process for managing and leading change: 

  1. Create urgency: explaining the need for the change
  2. Form a powerful coalition: building teams to drive the process
  3. Create a vision: developing a strategic plan
  4. Communicate the vision: utilizing the coalition to spread the word
  5. Remove obstacles: identifying and removing barriers to change
  6. Create short-term wins: demonstrating the advantages of change
  7. Build on the change: analyzing the process and setting new goals
  8. Anchor the change: embracing the change within the organization

O-B-S-E-R-V-E: Seven Steps

With previous models in mind, we have organized the essential tasks of change management into the OBSERVE model: seven key steps for managing change effectively. Transparency and integrity are crucial throughout every step of the process. Be objective in your analyses, clear in your vision, open in your communications, and honest in your evaluations. 

1.  Objective Analysis of the Problem

Whether the change is voluntary or mandated, the first step should always be an objective analysis of your agency’s readiness for change. This will help you develop your vision and get a clear picture of the challenges ahead. Depending on the initiative, your analysis might include an observation of current processes and procedures, review of relevant data and statistics, employee focus groups and/or questionnaires, and an assessment of the current level of support from management and within the agency as a whole. 

Consider the SWOT approach to help focus your analysis on crucial factors––both tangible and intangible––that may affect your initiative: 

  • Strengths: Identify available resources: personnel, equipment, support, time, momentum, etc.
  • Weaknesses: Identify and remove potential barriers to change such as time, budget, or personnel constraints; insufficient information; staff resistance or lack of support; etc. 
  • Opportunities: Identify the benefits of the change  
  • Threats: Identify and address the risks involved in the change
“A ‘one size-fits-all solution’ or ‘best practice’ 
doesn’t always work in health care because most 
quality and safety issues that healthcare organizations face 
are complex and differ from place to place.”

– Klaus Nether, Executive Director

Center for Transforming Healthcare

Focus Groups

Be sure to involve a variety of employees and departments: administration and management, field clinicians and office support, supervisory and IT (information technology). Depending on the initiative, you may want to consider involving agency patients and/or caregivers as well. 

Focus groups can be a good way to identify potential “stakeholders” and team members early on (see “Building the Framework”). At the same, it’s important to identify employees who are resistant to or actively against the change. If these skeptics or pessimists are influential with their peers or within their departments, they can represent a significant challenge to the success of your change initiative. Extra effort should be taken to educate and engage these employees (see “Engage” below). 

2.  Building the Framework

This is really the “nitty-gritty” of your change initiative. You need to identify the specific individuals and groups of individuals who will help garner support for the change, communicate the details, refine and carry out your plan, and ultimately determine the success or failure of your initiative. These are the people who should be out front as visible champions for the change throughout the entire process.

Identifying the Stakeholders

The stakeholders you identify will comprise representatives from all relevant departments and job categories. Stakeholders will be important throughout every step of the change initiative, helping to refine the plan, the message, and the process. They will be your broadcasters and your sounding boards, your investigators and your guinea pigs. Identifying the right stakeholders may not guarantee success, but failing to do so will certainly be a factor if the initiative fails.

Ask: Who will be impacted by the initiative? Consider:

  • Whose routine or workflow will be affected before, during, and/or after the change?
  • Who will benefit from the new initiative? Consider increased efficiency or effectiveness, time or money savings, better patient outcomes, etc.

Ask: Who will have the biggest impact on the implementation itself? Whose involvement is critical at any given stage of the initiative? Consider policies and procedures, scheduling, training, technological requirements, etc. Look for employees who:

  • are dedicated and committed to the agency and its mission
  • are enthusiastic supporters of the change initiative
  • are good problem-solvers and creative thinkers
  • work well with others
  • are influential with their colleagues 

Start by identifying those employees who will be most impacted by, or impactful during, your change initiative. Your key stakeholders are those who are both, because they will have the motivation and the means to lead the change and affect success. These individuals should be your team leaders and project managers, your mentors and trainers.

Effective Leadership 

Critical to the success of any change initiative is a decisive and energetic leader who can manage and drive the change. In addition to the stakeholder characteristics above, an effective leader must:

  • be open and adaptable to new ways of thinking and acting
  • be a capable communicator: able to inform and motivate their colleagues
  • be empathetic: able to understand the perspectives and challenges unique to different individuals within the agency

According to Bryan Barajas, Marketing Director for PreCheck, a good leader will be a good delegator as well: “Healthcare leaders must be able to rely on the strengths of various departments and assets within their organizations to forge new paths.”

Implementation Teams

A productive implementation team can motivate peers and colleagues, build positive momentum, clarify the message, and drive consistent progress. You/your project leader(s) should maintain regular contact with the team(s) to gather their input on the progress and direction of the initiative, and to offer guidance or advice as necessary.

Implementation teams should be representative of your agency. In addition to the identified leader(s) and key stakeholders, be sure to include staff from all relevant levels and departments within your agency. 

Team requirements and responsibilities will vary with the scope of your initiative, but you should give your team(s) as much autonomy as possible. Encourage them to take advantage of the unique strengths of each individual member and allow them to help define their roles in the change initiative.

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

– Jeffrey Brickman, Harvard Business Review


3.  The Strategic Plan 

Your vision for change should be delineated in a strategic, comprehensive, collaborative plan. The plan should incorporate the “big picture” of your change initiative while addressing the specifics of What, When, Why, and Who.  

The What

Make sure your plan details all aspects of the initiative: analysis and development, communication and training, implementation and evaluation. Also consider:

  • What are the broad objectives of this initiative, and what benefits do you hope to see (patient outcomes, regulatory compliance, billing or reimbursement, procedural efficiency/effectiveness)? 
  • What will define ultimate success?
  • What areas of operation will be impacted by this change (patient care, documentation, scheduling, day-to-day workflow, billing, etc.)?  
  • What are the risks associated with this change (what potential negative impacts could it have on agency procedures, employee morale, patient care, etc.?) 
  • What are the short-term goals (quantitative or qualitative) that can be evaluated as a measure of performance and progress?
  • What will happen if target goals are not met?
  • What will happen if people do not adhere to new practices or procedures?

The When

Include a timeline for all steps and stages so employees will know what to expect, and what is expected of them, throughout the process. Also consider:

  • When should employees be informed of the change initiative?
  • When should they be educated on new policies and procedures?

The Why

Address the change from all possible perspectives. Make sure you can answer:

  • Why is this change necessary/important?
  • Why is it necessary now?
  • Why and how is the change relevant to each involved employee/department?

The Who

Clearly define your expectations for all involved parties:

  • Who––which individual/team/department––will be responsible for each component of the initiative?
  • Who will be held accountable for achievement of short-term goals? 

Remember that your plan should be collaborative. That means you’ll need input from your teams and stakeholders, and it means your plan should be flexible enough to accommodate that input. 

“It is a bad plan that admits of no modification.” 

– Publilius Syrus, First Century BC

4.  Engage

Engaging stakeholders and employees involves garnering support through effective communication. People need to feel connected to a change initiative in order “buy in”: not only accepting the change, but embracing it. If your initiative lacks sufficient support, it is doomed to failure––or at least to inefficiency or ineffectiveness. This is why clear, consistent, open communication is critical to your success.

Begin at the top: a lack of support from senior management can quickly ripple down through the agency and jeopardize the success of the initiative. It’s just as important, however, to engage across all disciplines and levels within your agency. 

Effective communication means asking the right questions and really listening to the responses. While the need for change will be apparent to some, it may be less obvious to others. You, your key stakeholders, and your implementation team(s) must engage staff in all departments and at all levels. Listen to what people are really saying, asking, and feeling so that you can address their concerns and questions appropriately, and pay close attention to any employee you identify as a particular challenge (the skeptics). 

Consider that perceptions—accurate or not—will factor powerfully in the ultimate success or failure of your initiative. Ask:

  • What is important to stakeholders and other employees? 
  • How do they think the change will affect them? Is this perception accurate from your perspective?
  • How does the change align with their individual or organizational values? Are there real or perceived conflicts?
  • Are they fearful of or resistant to the change? If so, why?
  • How does (or doesn’t) the change initiative mesh with individual/departmental/ organizational mission, values and/or objectives.
  • What motivates them in their work, and what might motivate them to embrace this change?

All stakeholders and employees need to understand the What, the When, and the Why of a change, and how it will affect them. When sharing information always consider:

  1. The right information: Everyone should know and understand why the change is important and/or necessary. What data do you have to support the need for your initiative? Determine what’s important and relevant to each “target audience” and tailor your message to their varying interests and motivations. Remember that not everyone needs to know everything, but everyone should know that what they’re being told is honest and straightforward.
  2. The right people: Again, not everyone needs—or wants—to know everything, but everyone should know and understand their/their department’s role in the change initiative and how they fit into the big picture.
  3. The right time: Consider the timing of your communication and recognize that some stakeholders will need to be involved from the outset.
  4. The right way: Consider each target audience when determining the most effective means of communication (emails and blogs, one-on-one or small group conversations, face-to-face or virtual meetings, in-person or online training seminars).

Listen first and last… and every time in between. Consider what will motivate your stakeholders and employees to embrace the change, and be ready and willing to reframe the message—or even revise the vision itself—if necessary.

“Listen and learn how to support people rather than 
dictate or direct them. Become actively engaged in collaborating 
with people as they work to solve the problems of the organization. 
At different times, be coaches, mentors, facilitators.”

– Jeffrey Brickman, Harvard Business Review 

5.  The Roll-Out

“Going live” with your change initiative should only happen when you have: 

  • completed an objective analysis
  • identified the stakeholders and established the implementation team(s)
  • formulated your strategic plan
  • set clear expectations for all involved parties
  • communicated with stakeholders and others to share your vision and garner support

As you roll out your change initiative, make sure that key stakeholders and team members remain out front and visible as role models for the change. Consider pairing your key stakeholders, supportive employees, and high performers with your identified––or anticipated––skeptics; this can influence both attitudes and performance.

6.  Verify

As you roll out your change initiative, you’ll need to verify the effectiveness of your plan frequently and consistently. Use your key stakeholders and implementation team(s) to: 

  • monitor employee/agency adherence to new policies and procedures
  • address problems or non-compliance issues immediately and consistently 
  • identify challenges
  • pinpoint new barriers
  • review and assess your progress by tracking short-term goals

Celebrate the achievement of short-term goals and other successes as soon and as often as possible in order to foster a sense of accomplishment and progress. Even when you can’t celebrate a result, find a way to acknowledge the contributions and hard work of involved parties. 

Make sure that you are monitoring and verifying improvement, not just the change itself. A simple example: if your change initiative is for a new workflow designed to improve efficiency and effectiveness, you’ll want to verify not only that new workflow guidelines and procedures are being followed, but that efficiency and effectiveness are actually improving. 

Remember that your plan should be flexible. Be prepared to adapt: refine or revise the roll-out as necessary in order to address problems and overcome barriers.

7.  Ensuring Success

Rolling out your change initiative isn’t the end of the process. A change that is initially successful can ultimately fail if it isn’t supported and sustained for the long term. Continue to review and assess new policies and procedures in order to ensure the change is firmly established within your agency. 

Continue to address non-compliance issues consistently. According to Joan F. Brett and Margaret M. Luciano of the Harvard Business Review, “the status quo persists when bad behaviors at any level of the organization are tolerated… When leadership understands that turning a blind eye to one bad behavior can decimate the adoption of innovation by others, they may be more willing to hold difficult conversations with the highest-status employees in their organization.” 

Evaluating the Process

Sustaining success requires more than evaluating success or failure and addressing noncompliance. You’ll need to evaluate the change management process itself: the analysis, the stakeholders and teams, the strategic plan, and the roll-out strategy. Some points to consider: 

  • What went right, and what factors most influenced the positive outcome? 
  • What went wrong, and how could we do it differently/better? 
  • Was the initial analysis of the agency and the initiative sufficiently complete and objective?
  • Were there unanticipated barriers or issues that arose during implementation?
  • Which barriers proved hardest to overcome, and how could they be addressed differently in the future?
  • Were there aspects of the strategic plan that were flawed or unrealistic? Were these aspects specific to the initiative or more universal considerations? 
  • Were there any issues that might forecast ongoing or future challenges?
  • Which individuals and/or team(s) were the most productive?
  • Which stakeholders proved most valuable and influential to the initiative? Were you accurate in your identification of key stakeholders?
  • Which employees were particularly supportive of the initiative? Are they still?
  • Who were the skeptics and pessimists? Have their feelings changed?  
  • What is the current attitude toward the change within the agency as a whole?
“Change is inevitable. 
Change for the better is a full-time job.” 

– Adlai Stevenson I

Fostering a Culture of Change

For home health and hospice agencies, change will continue to be a reality and a necessity. Following a procedural guide such as our OBSERVE model can help you successfully navigate a change initiative, but it is your agency’s “change readiness” that can best predict sustained and ongoing success. The difficulty––and ultimate success or failure––of future changes depends on your agency’s acceptance of, enthusiasm for, and adaptability to change in general. We refer to this change readiness as a “culture of change.”

Developing a culture of change takes time. It involves engaging, educating, and motivating staff in new, often challenging, ways. Promote innovation, adaptability, and vision by encouraging employees at all levels to share ideas for positive change. Brett and Luciano advise paying attention to the behaviors you tolerate and reward: “Engrained cultural norms and power relationships about speaking up needed to be shaken. Rewarding new behaviors that contradicted the existing norms reinforced the message that it is safe to act in new ways.” 

Fostering a culture of change means your agency will be more innovative, more adaptable, more resilient, and more ready for whatever challenges lie ahead.

Managing Change in Times of Crisis 

Never is effective change management more critical than during times of crisis. An established culture of change within your agency can help your employees adapt more quickly and readily to sudden and/or significant changes and allow your agency to respond proactively to the crisis at hand.

During a crisis it is important to be able to quickly identify and engage effective leaders and key stakeholders. Knowing who is most adaptable to and supportive of change in general will give you a head start in this process, but there are leadership qualities you should look for that are paramount for crisis management: 

  • Decisiveness: Leaders will be required to make quick decisions with limited information and prioritize concurrent initiatives.
  • Empathy and compassion: Leaders must acknowledge and support the fears and uncertainties associated with the crisis in order to effectively guide agency staff through the changes and challenges ahead.

What COVID-19 Is Teaching Us

There has been no bigger health crisis in our lifetime than the emergence of the novel coronavirus last winter. Change is difficult at the best of times, but it’s safe to say that the global COVID-19 pandemic has taxed the change management resources of every healthcare organization around the world.

“Nothing has expedited the importance of folding change 
management principles into healthcare operations like COVID-19.
Those… organizations [that] feature strong internal networks, 
excellent communication processes, and leadership with 
the ability to move quickly and intentionally have been able 
to adjust to these new realities most effectively.”

Connex Partners

Healthcare providers and employees are on the frontline of the pandemic. The concerns and fears they face are well-known, well-documented, and not unique to the healthcare arena. What is unique, however, is the sheer number of stressors experienced by some of these providers and employees, and the number and magnitude of changes required to address them. Agencies who were change ready before COVID-19 were more equipped to handle the multitude of change initiatives they face, and are still facing.

COVID-related initiatives comprise operational, organizational, technological, clinical, and educational changes that require decisive leadership and effective teamwork. Perhaps more than anything, change management under COVID-19 has highlighted the importance of:

  • Effective communication: accurate, straightforward, timely information about the crisis and your agency’s response to it can help avoid confusion and reduce anxiety.
  • Compassionate engagement: a responsive, people-centered approach can help employees feel valued and protected by their agency (physically, emotionally, and financially) and consequently more able and willing to confront challenges and embrace difficult change. 

Will You Be Ready for the Next Crisis?

The COVID pandemic has highlighted the importance of change readiness in general. In addition, it has identified some key areas agencies can focus on now in order to be more prepared for future crises:

  • Crisis Guidelines: Establish guidelines to direct procedural and operational flexibility during emergencies (infection control policies, workflow modification, employee sickness and leave policies, staff deployment, departmental reorganization, etc.) 
  • Crisis Response Team: Consider developing a crisis response or management team; make sure they are familiar with/trained in your agency’s crisis guidelines and able to respond immediately.
  • Communication: Make sure effective communication channels are established and understood. Confirm that new ways of disseminating and sharing information (live streaming, video conferencing, etc.) are understood and accepted throughout your agency. 
  • IT Requirements: Make sure technology (hardware, infrastructure, and software solutions) is up to date and able to accommodate the challenges of crisis management.

Change Management and Your EMR

The COVID-19 crisis has proven the critical need for reliable, accessible data across the care continuum. Juan Luis Cruz, a hospital CIO in Madrid, Spain, said: “We have seen that having the data in place is fundamental for saving lives… Data has been crucial to plan resources, classify patients and help in decision-making.” 

COVID-19 has demonstrated how crisis can drive technological advances, as well. Seemingly overnight, telemedicine went from convenient alternative to life-saving necessity, and from marginal acceptance to widespread demand. 

Your EMR’s ability to react and adapt to change can either facilitate or impede your agency’s change management efforts. Make sure your vendor is up to the challenges:

  • Interoperability: Can critical patient data be transferred and accessible to other providers within your health network and HIE?
  • Cybersecurity: Is patient data secure, both within your agency and as it flows to other provider systems?
  • Product Adaptability: Can your EMR be easily customized to your agency’s changing needs?
  • Customer Support: Is your EMR vendor available and responsive to your needs?
“Change, before you have to.”

– Jack Welch, former CEO, General Electric