Why It Matters
People’s resistance to adopting a new process or behavior is all too common in improvement projects. During the last year, IHI’s Innovation Team researched the human side of change as an underappreciated approach to improvement efforts.
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How to Make Change Happen

By Kate Hilton | Monday, April 30, 2018


Like many medical professionals, Dr. Michael Rose is committed to getting the best outcomes for his patients. As an anesthesiologist at McLeod Regional Medical Center in Florence, South Carolina, Dr. Rose knew his team could do better for their surgery patients. He was aware of a problem in need of solving and had an evidence-based intervention with promising results: the surgical safety checklist and debrief.

Today the surgical safety checklist and debrief is well accepted across the medical community. But in 2009, after over 18 months of awareness raising, training, marketing, and even an organizational mandate from McLeod’s CEO, Dr. Rose’s effort to influence his peers and surgical teams to adopt the checklist hovered at 30 percent. He wasn’t sure where to turn next.

Does this sound familiar?

People’s resistance to adopting a new process or behavior is all too common in improvement projects. At the outset, it might seem straightforward to apply an evidence-based intervention to a problem to get results. But part of change is that people resist it.

During the last year, IHI’s Innovation Team researched the psychology of change as an underappreciated approach to improvement efforts. We found a wealth of knowledge across the many sub-fields of psychology. Organizing, team building, adaptive leadership, behavioral science, human-centered design, and many other disciplines offer important insights for addressing the human side of change. We took this learning and developed a psychology of change framework to enhance our ability to achieve results and sustain improvements.

Learn More: IHI Virtual Expedition: The Psychology of Change: Tools and Framework

As quality improvers, we have not paid enough attention to the human side of change. We have assumed that having the right idea and a clear aim is sufficient to get the job done. We haven’t stopped to ask, “Why is this important to me? To those on my team?” We don’t think enough about the importance of building our working relationships in ways that create safe environments to experiment and improve.

Instead, when we find an evidence-based solution to a problem, we often try to implement changes from the top down. We change our environments. We create new standard work. New forms. New teams. New processes. New mandates. We put so much effort into implementing improved systems, that we often fail to start with the most important side of change — you! Your team. Your people.

W. Edwards Deming warned us about this. He constantly stressed the importance of addressing the psychology of change — it’s one of the four tenants of his System of Profound Knowledge. Deming emphasized that people — not processes or products — are our fundamental source of value in our systems. People must be treated as partners. They need working environments where fear is driven out and individuals can experiment, fail forward, and discover together.

Activating people’s agency is at the center of our psychology of change framework. Agency describes our ability to choose to act with purpose. Choosing to do something takes courage, particularly when dealing with the uncertainty involved in change. When our choices and actions lead us closer to our aim, we are exercising power — or the ability to act with purpose. So, activating people’s agency is about developing their courage to act and their power to make those actions matter.

Think of Dr. Michael Rose at McLeod Medical Center. As an individual, he had the courage and power to make change. He set up informational sessions and educational posters to encourage people to use the checklist. He worked with the CEO to scale it across the organization. Dr. Rose’s agency was activated. But what about the rest of the frontline staff on surgical teams? What about their agency?

Like Deming, Dr. Rose realized that a pivot to his people was needed to make change happen — so he employed psychology of change methods. He recruited an interprofessional leadership team to share power and build relationships across silos of expertise. They invited colleagues into open conversations that started with an exploration of their calling to their professions. Together, they told stories that connected them to intrinsic motivations for healing. In the process, they listened deeply and asked open-ended questions to activate others’ agency around the surgical safety checklist and debrief. This moved their people past resistance and superficial forms of “buy in” to shared ownership and commitment to the intervention — and as importantly, to each other.

Since 2011, 100 percent of surgical teams use the checklist at McLeod. The mortality rate has dropped by 35 percent, and surgical teams report improved safety culture measures. Surgical staff satisfaction increased, and the reduction of hours per case resulted in an economic return of 80,000 hours annually.

Creating space for these conversations is not a technical tool, but it does draw on intentional practices for connecting to our shared humanity. As Keith Torgerson, Chief CRNA at McLeod, said: “This helped us lead purposeful change amid a traditional culture of fear and domination. Now we have a culture that is empowering to all involved.” It is an approach that leverages human psychology to unleash individuals, teams, and organizations to improve and change together.

This post was co-written by Kate Hilton, IHI faculty, and Alex Anderson, Research Associate for the IHI innovation team. Learn more in the upcoming IHI VIrtual Expedition, The Psychology of Change: Tools and Framework.

You might also be interested in:

WIHI free audio program: How to Make Change Happen: An Introduction to IHI's Psychology of Change Framework

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