Managing Difficult Change at Your Medical Practice

The last 12 months have been nothing if not eventful for Calvert Internal Medicine Group. The 22-provider multispecialty practice in southern Maryland replaced its first generation electronic health record with a new one earlier this year, and deployed a practice management system at the same time. After a lengthy recruiting process, their administrator, who is retiring after 28 years, also helped hire his replacement. And, the group is in the midst of becoming certified as a patient-centered medical home under the state run pilot program - a paperwork-intensive ordeal. "I wouldn't say we're through most of it, because it's a continuum," says Jonathan Lowenthal, a primary-care physician with the practice who is helping to lead the charge. "Like any transition, it's been challenging, but we're excited about our new administrator and we survived the EHR transition."

Calvert Internal Medicine Group is hardly unique. The push for quality improvement as a benchmark for reimbursement is driving change in the healthcare setting as never before. Practices across the country are adopting software solutions to better manage patient care. Others are merging with hospitals and larger groups in a bid to leverage economies of scale. And a small, but growing contingent of medical practices are exploring the option of joining an accountable care organization (ACO) to pursue shared-savings payments that result from greater cost control.

Advocates say such efforts to evolve are a win-win for practices and consumers alike. That may be true. But it's also giving the folks in the trenches - the clinical and clerical staff whose daily routines get disrupted - plenty of angst. "Transition is not easy," says Ken Hertz, a consultant with MGMA Health Care Consulting Group. "Whenever you have any sort of change it impacts the practice's culture (which includes your basic organizational assumptions), the values and beliefs you have, and how people behave." Most managers, he notes, focus exclusively on the tangibles - timetables and training classes - when integrating an organizational change. But that's just the tip of the iceberg. It's what lies beneath the water line, including office politics, morale, and staff buy-in, that "can sink the Titanic," says Hertz.

Be an open book

The first step to keeping your team on task during times of difficult change is to communicate early and often, says Jack Valancy, a practice management consultant in Cleveland Heights, Ohio. Hold regular meetings with staff to discuss the direction your practice is planning to take - and more importantly to solicit their input and ideas. Consistent dialogue not only gives the rumor mill a rest, which helps the staff stay focused, but conveys the degree to which management values the contribution of each employee. "Involve the people in the process and don't mislead," says Valancy. "Solicit their ideas and listen to their concerns. Otherwise they may feel this is something being imposed upon them and you might get resistance." Throughout the process, he adds, the administrator in your office should also advertise an open-door policy, in which staff members can pop in and discuss concerns on a one-on-one basis.

Don't sugarcoat either, says Judy Capko, a medical practice management consultant and author of "Secrets of the Best Run Practices." If your practice is being sold, she says, level with your staff about what that might mean for them, especially if it includes a change of job responsibilities or potential layoffs. "Be honest and face the brutal truth," she says. "Don't let the grapevine do the talking or the message will get distorted and will thwart efforts to go forward."

A 1997 report by the Cornell University International Workplace Studies Program supports that premise. "In an environment in which employees are not even certain whether they will have a job, it is unrealistic to expect them to be able to focus and prepare themselves for working in a new way," the report, entitled "Communication for Managing Workplace Change," states.

Explain yourself

It is equally important to enumerate the reasons why the proposed change is necessary. Do you have to comply with regulatory mandates? Is it better for your patients? Will a merger render your practice better able to manage costs and thus prevent layoffs? Such communication should include not only general information about why the change is taking place, but also the personal implications to the employee - the location of their workstation, filing changes, changes to the phone system, handling of supplies, the Cornell report suggests. Indeed, without such context, the physicians and staff in your group may be inclined to mutiny. "The only way you ever get people to buy into change is to show them the benefit - not to the organization, but to the individuals themselves," says Capko.

That's what worked for Calvert Internal Medicine Group, where Lowenthal insists morale remains strong despite their year of transition. "You have to show the financial benefit," says Lowenthal. "That blunts cynicism. If you tell people it'll benefit them financially, they still have to endure the transition, but at least they can see the upside and won't be as overwhelmed by the process." Incentives for acceptance also help. After the launch of their new EHR, for example, Lowenthal's group implemented a bonus system that rewards medical assistants for ensuring documentation is in the chart ahead of patient visits. They also earn points for asking patients about vaccinations, and female patients about the date of their last mammogram. "When we did our medical home certification, we gave everyone a small bonus and we give out prizes with financial rewards, like gift cards, to the clerical staff," says Lowenthal. "It makes them feel like they're part of the process and being compensated for it."

Alleviate fears

As you talk with your team, keep in mind that your job first and foremost is to reassure. Remember, a change in operating procedures puts your staff in a vulnerable spot, making them more likely to delay or dilute the process. They may fear the proposed change will create more work for them, impact their job satisfaction, or lead to layoffs. Such anxiety can have a profound impact on your work environment. A 10-year study of Boeing Commercial Airlines, between 1996 and 2006, revealed that blood pressure, depression, and incidence of headaches increased significantly among its employees following the company's merger with competitor McDonnell-Douglas. Employee absences nearly doubled, according to the report, conducted by the Interuniversity Project on Workplace Change and Its Effects. "It's worth noting that managers were often as impacted as non-managers - their attitudes and health also tended to deteriorate" following the merger and initial layoffs, it stated. "Our work, consistent with several other researchers, shows that layoff survivors tend to become more insecure about their jobs, less likely to innovate and take risks, less committed to their organization, and less trusting of top management."

"Whenever you have big changes in your practice, people are going to be concerned about job security and income security," says Valancy. "They may worry about whether they're going to lose status in the new pecking order." If you're implementing new software, he suggests, stress your commitment to bringing each member of the staff up to speed at their own pace, and emphasize your willingness to shuffle schedules to accommodate training sessions. Older staff may be particularly concerned that they won't be able to learn the new software system fast enough to keep up with their more tech-savvy colleagues. Likewise, if you're switching to a compensation model that employs quality metrics, explain how that might impact their paychecks - for better or worse. Not knowing, says Valancy, creates far more anxiety than the truth. And, if new leadership has been retained, make an effort to introduce the new hire to the team in an informal setting before the official start date to let them socialize and ask questions.

Paul Kayne, the outgoing administrator of Seacoast Orthopedics and Sports Medicine in Somersworth, N.H., who announced his pending retirement three years ago, did one better - giving the managers in his 16-provider practice an opportunity to meet with the two final job candidates during the interview process. Each manager will also get the opportunity to brief Kayne's replacement before he officially begins through a series of private phone calls. "Before he even arrives, he'll have a pretty good feel for who they are and what they are dealing with," says Kayne. "When you give people an opportunity to be part of the process before, during, and after a change, it helps a great deal. Instead of worrying, it gives them time to respond."

Plan ahead

Those who are spearheading transition must also give themselves adequate time to plan, says Kayne. That means staying organized and being flexible enough to delay if you determine that the timeline you originally set is unrealistic. "I'd rather put it off for six months than be thrown into something where I'm constantly putting out fires," says Kayne. According to him, a proper EHR installation requires at least a year of prep work, allowing time to create a task force or committees, explore alternative products, and study the impact on work flow in each department. Ideally, each department will have a representative on the task force to act as their advocate. "The more you can prepare your staff and involve them in the process the better positioned you will be to minimize disruptions," says Kayne. "If you don't do the homework upfront, it'll be traumatic and it doesn't have to be that way."{C}

Thoughtful planning has another advantage, of course, in the message it sends to your troops. "Change may be upsetting, but when they see the amount of energy going into the planning, they are going to get on board and start asking wonderful questions," says Kayne. "The more they see management trying to work out the details, the less likely they will be to try and sabotage it."

Facing resistance

No matter how much support you have, chances are good you'll have at least one stakeholder in your practice who can't be swayed. Perhaps one of your physicians is nearing retirement and doesn't wish to incur the expense of expanding square footage or implementing an EHR. "The reality is that you're always going to have people on different sides and the goal is not to make that person feel terrible or isolate them; the goal is the reverse," says Kayne. "Spend a little more time with that person and get to know their concerns so you can be prepared to address them." It helps, too, to leverage support from the pioneers in your group, particularly those who are well-respected among their peers. "Don't let someone who is negative about change be the loudest spokesperson," says Kayne. "Make sure you have the support you need, and that the people who are supportive turn up their volume and speak up as well."

In some cases, an independent third party can help resolve division by taking emotion and ego off the table. For his part, Lowenthal's group held a weekend retreat with a consultant to hash out the plans for his practice, inviting all physicians and the office administrator to attend. "The most important thing is making physicians feel empowered and excited about it," he says, noting a follow-up retreat to discuss progress thus far is in the offing.

Where practical, says Capko, you might also try negotiating with a stakeholder who is digging in his heels, perhaps shifting a larger percentage of the overhead expense to the physicians who will benefit most from the change. If that doesn't work, it's time to play hardball. "As far as naysayers, you must evaluate each one individually," she says. "Who belongs on this team and who will be an impediment?" For those who will hold you back and don't add value, she says, "it may be time to cut your losses and accept their resignation."

Show commitment

It goes without saying, but strong leadership is also important. "An active visionary leader is very important as motivator and example," the Cornell report notes. "Perceived management commitment is important for satisfaction and commitment to the new workplace strategy." The report adds that leadership must also "track the rumor mill and clarify misinformation" as quickly as possible.

Kayne agrees, noting it's the job of all leaders in your practice - the administrator, managers, and physician shareholders - to remain positive and generate enthusiasm for the proposed change. "It's all in the packaging and presentation," he says. Acknowledge the inevitable growing pains, he says, but focus on the payoff down the road - the elimination of redundant tasks, opportunities for advancement, less busy work, a better patient experience. All the while, says Capko, share your vision for the practice and highlight the significant role your team will play in bringing it to fruition. "Be passionate about the gains you hope to achieve and how you see a brighter future," she says. "Make sure you are clear and sincere."

Change can be good. When managed effectively, it can reinvigorate your practice and create a teamwork mentality within your practice. But done without consideration for the concerns of your staff and it could create a problem bigger than the one you're trying to solve. The key to success, says Hertz, is remembering that it all comes down to human resources. "This is about people," he says. "Whether it's a new practice management system or a change of ownership, you have to keep in mind that this is about feelings and emotions. Change is the easy part. It's the transition [that] is hard."{C}

In Summary

The first step to keeping your team on task during times of difficult change is to communicate early and often. Here are some tips to keep in mind when ushering in change:

•Always include your employees in the planning process
•Explain to staff members why the proposed change is important
•Remember that change can inspire fear about job security and future promotions
•Be prepared to negotiate with employees who resist practice change
•Motivate staff with enthusiasm and honesty

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the January 2012 issue of Physicians Practice.