Change Readiness at Adventist Health System: How Organizational Culture Can Help Hospitals Implement CPOE Successfully

Volume 5, Issue 2, 2010
casestudy
Change Readiness at Adventist Health System: How Organizational
Culture Can Help Hospitals Implement CPOE Successfully

In 2009, Carlyle Walton, CEO of Metroplex
Health System faced a difficult challenge. As the new
CEO of the 233-bed, multi-campus facility operated
by Adventist Health System, Walton walked into an “I have found the Denison
organization that, on the surface, was operating well,
but underneath was characterized by silos, mistrust Organizational Culture Survey and
and resistance. They were also about to embark on the work that Dr. Smith and his team
a hospital-wide project to implement a Computerized
Provider Order Entry (CPOE) system – a tough
have done to be extremely beneficial
challenge for hospitals in the best of circumstances. to our organization as a whole – I
As a new CEO still trying to understand his new have thanked Dr. Smith repeatedly
organization, Walton needed help to get the hospital
team through the transition successfully while for introducing this process into our
continuing their mission to serve their patients organization because
with excellence. Walton certainly had a lot to do.
Thankfully, Dr. Philip Smith, MD, Chief Medical it’s a whole lot more than
Information Officer at Adventist Health System, and implementing CPOE.”
his team were there to help.

Organizational Culture and CPOE: A Process for Carlyle Walton, CEO
Implementation Metroplex Health System
Philip A. Smith, MD is the Vice President of
Information Services and the Chief Medical
Information Officer for Adventist Health System. Implementation of a CPOE system is not as easy
Between 2009-2011, Smith’s directive is to as simply installing a new program on the hospital’s
implement Computerized Provider Order Entry computer system, however. Many hospitals
Systems (CPOE) in each of Adventist Health and health care facilities underestimate the vast
System’s 38 hospitals. organizational changes required to successfully
implement this system. Challenges include: new
The advantages of CPOE are many: work for clinicians, changes in workflow, resistance
• Reducing errors that can occur with handwritten and negative feelings toward technology, changes
orders in communication patterns and practices, fear of an
• Improving safeguards for drug interactions and overdependence on technology and a whole host of
allergies adjustments to the organizational structure, culture
• Reducing lag time between order and delivery to and roles within the organization. “Most hospitals
patient are doing it backwards,” states Smith, “they aren’t
• Improving overall quality of the patient experience looking at any kind of organizational assessment
along with the CPOE implementation and addressing

All content © copyright 2005-2010 Denison Consulting, LLC. All rights reserved. l www.denisonculture.com l Page 1

the cultural aspects necessary to make the
engagement work. Those hospitals aren’t having Sample Change Readiness Timeline
the same kinds of successful implementations that
we are having.” To get it right, according to Smith, Month 1
hospitals must look at the way the organization Denison Organizational
works as part of their CPOE implementation. Culture Survey
Focus Groups
Smith and his team of three organizational
specialists have developed a multi-faceted Month 2
approach to implementing CPOE within the Debriefing Leadership Team
hospitals of Adventist Health System with great Action Planning for Change
success. Through their Change Management Readiness
Analysis, they work with the hospitals to identify
and create changes necessary to make the Month 3
organization work effectively. Their approach starts Action Planning Implementation
with an examination of the hospital’s organizational Begins
culture in order to assess their readiness to change.
The Denison Organizational Culture Survey is Month 4
administered to a cross section of employees Training for Champions in
at each hospital. This includes a sample of the Key Areas of Action
Executive Team, Management and Medical Staff.
Within the Denison survey, Smith’s team asks some Month 5
very targeted open-ended questions including: Town Hall Meetings on CPOE
“What part of your role keeps you awake at night?” Communications to Staff
and “What line of service do you think needs the
most improvement?” They also conduct a series of Month 6-7
interviews with these groups to dig deeper into the Training for All Staff on CPOE
current context of the hospital.
Month 8
The Denison Organizational Culture Survey helps Launch of CPOE System
the hospital identify issues they may have in terms
of communication, trust, mission and vision,
customer service, empowerment, training and This is a sample timeline for using the Denison
development, and workflow processes – important Organizational Culture Survey based on the work
issues to identify when implementing a change as of Dr. Smith and his colleagues. This solution
far reaching as instituting CPOE. Smith and his first assesses the hospital’s change readiness
team conduct a half-day workshop with the leader and allows them to begin to make the necessary
and their team to debrief the results; helping them changes to their organizational structure to
understand what their current organization looks implement CPOE effectively.
like and what they should expect.
able to put changes in place to rebuild trust and
In one case, the Denison Organizational Culture empowerment in the staff. Another hospital group
Survey results helped reveal that the hospital staff acknowledged that communication at the leadership
wasn’t feeling empowered. When Smith and the level was ineffective. Upon further review, Smith’s
leadership team dug in further they realized that team recognized that all meetings were done in a
this was a result of operational decisions made room that was set up classroom style. A simple
years prior during a time of crisis that required change to reconfigure the physical setup of the
a supervisor’s approval for any decision. The room into a circle or U-shape helped promote
hospital then reviewed that process and realized active communication within the group. These
it wasn’t working for them anymore; they were are two simple examples that show the effect


unproductive beliefs can have on the behaviors of have a very strong opinion of themselves – in many
the organization as a whole. These are important cases, a full color profile. As you dig down deeper into
behaviors to address in the early stages to lay the other levels of the organization, the color on the profile
groundwork for a successful CPOE implementation. becomes much more sparse. Smith’s team uses this
to their advantage: “The experience establishes for us
During the course of the next 90 days, 10 that we know that the leadership team can play the
champions from the Vice President and Director game – they know how to take the surveys. We show
levels are identified from within the organization. them the qualitative data such as the open-ended
The champions receive training in areas such as responses that they can’t argue with and it establishes
communication, workflow and measurement. They our credibility – allowing the façade to fade and real
are tasked to work on specific issues identified conversations to take place,” says Smith.
within the culture survey results in the context of the
CPOE implementation. For example, if trust is an “In many ways, this process is most important for
issue within the organization, Smith’s team and the the leadership team,” comments Smith. Helping the
hospital team tailor their strategies for the CPOE leadership team create a solid business case for
project with that in mind; giving the champions the implementing CPOE enables them to respond better
knowledge and training they need to be successful. when they meet resistance within the hospital. “I’ve
seen other implementations where the executive team
For the next two months, town hall meetings are caves in when physicians are resistant,” says Smith,
held with the hospital staff – from the doctors “it’s really hard to recover from that.” Hospitals can’t
to the maintenance staff – to explain CPOE and afford to underestimate the organizational changes
give them the opportunity to ask questions about that arise with such an important implementation.
the new system. “Sneak Peek Stations” are set
up throughout the hospital to allow personnel to What Happens in Real Life?
look through the system. Smith’s team and the
champions also give special focus to high-risk No one knows this process and the effects that it has
groups including specific doctor groups and the on a hospital organization better than Carlyle Walton.
billing department to give them the extra guidance Walton has been privileged to go through this process
and support to overcome any apprehension with Smith not once, but twice: once in 2008 at
they may be feeling. Six weeks of training is then Takoma Regional Hospital in Greeneville, Tennessee
implemented before going live. From start to finish, (see sidebar) and again in 2010 at Metroplex Health
the process takes about eight months to complete. System in Killeen, Texas. In both instances, the
Denison Organizational Culture Survey was utilized as
a key tool to gauge the organization’s readiness for
Why is Culture Important? change.
During the process, Smith and the leadership
team reflect on the Denison Organizational Walton found Denison’s ability to segment the data
Culture Survey results in the context of the other based on different stakeholders to be a key advantage
information they have gathered about the hospital. in the process. Getting a pulse on the different groups
Oftentimes, Smith has found, there can be a very and then tailoring the plans for those groups that may
large disconnect between how different groups
see the hospital. The survey has been instrumental
in helping them uncover this. “It’s pretty incredible
because when they have this information, they “It was clear to me that the
immediately become more honest with us, it’s information the Denison results
almost magical,” states Smith. “It helps us break
down any resistance or barriers we may face relay transcended the CPOE
because they don’t reject it. Instead, it really implementation”
gets the conversation going and establishes our
credibility as a team.” Many times, when looking at
the leadership team’s Culture Survey results, they


be at risk has been critical for the hospitals at each the merger was final, news of the deal was leaked
of the sites. Walton also immediately saw more to inside Metroplex causing a major erosion of trust
this process than CPOE, “it was clear to me that the between the hospital staff and the administration.
information the Denison results relay transcended The Denison Organizational Culture Survey results
the CPOE implementation and found it to be an highlighted the divide between the medical staff and
excellent tool to truly unmask the organization. It the administration and brought to light a detached
forces you to look into a mirror relative to where you perception held by the administration. Walton
are as an organization.” comments that the Culture Survey results showed
that the leadership team believed that they were
Challenges at Metroplex Health System highly committed to the Mission of the hospital but
that they had an over-inflated opinion of their culture
Metroplex took the Denison Organizational Culture relative to how the rest of the hospital saw it.
Survey in December, 2009, completing the CPOE “When the results say something you don’t like,”
process in August, 2010. “Coming in as a new says Walton, “it’s easy to start asking questions
CEO, the Denison survey and interview results about validity of the instrument or looking for
presented by Smith and his team, were extremely excuses. We knew we had to get beyond that and
helpful and also extremely painful, to be honest,” clearly communicate to our team that this wasn’t
says Walton. The previous two years had been about good or bad but about our culture and how
tumultuous for Metroplex. They had recently merged we see ourselves. We were telling ourselves through
with a long-time competitor, Scott & White. Before these results that we needed to be consistent in
Executive and Medical
Leadership and Medical Staff Perceptions of Culture at Metroplex Health System
Executive Medical Staff
Leadership Team Medical Staff
External Focus External Focus

97 99

99 97
38

5
99 94 16 20

Beliefs and 1 Beliefs and 11
Flexible Stable Flexible Stable
Assumptions Assumptions
5 20
98 99 2 21
1

98 99
73
96 99

Internal Focus Internal Focus

These two circumplexes show the stark divergence between the perceptions of the leadership team
at Metroplex Health System and those of the medical staff regarding the organization’s culture. Phillip
Smith, MD, CMIO, and his team from Adventist Health System used these results along with their
interviews and other qualitative data to open up some honest conversations with leaders at the hospital.
The culture results shed light on important issues in empowerment, communication, accountability and
trust that were critical to address in order to ensure a successful CPOE implementation.


in daily hospital life by participating in department
meetings, having intentional conversations and
being readily available to medical and hospital staff.
“The Denison Organizational
Walton himself started having monthly “President’s
Culture Survey Luncheons” with 25 randomly selected employees.
provided us with a wonderful These luncheons were designed as an opportunity
for Walton to listen to the staff answer two key
baseline to evaluate questions: What do you like about being here? And
our culture and to debug what can we be doing better? The action items
from those meetings were then communicated
some of the issues that were back to the participants with timeframes for
getting in the way of improving completion. They consciously began to create a
ourselves and providing culture of organizational openness, accountability
and responsiveness.
excellence to our patients.”
The culture results also highlighted low
Empowerment scores. Further discussion
revealed that much of the approval and authority
what we do and how we function.” After the initial was centralized at the administration level. “The
shock of the results, it was clear to all that they Denison results were just screaming this at us,”
need to use the CPOE implementation process as as Walton puts it. With the help of Smith and
an opportunity for organizational transformation. The his team, the hospital reviewed their approval
challenge was going to be in communicating the process to determine what needed administrative
results clearly and in creating actionable plans. approval and what could be put back at the level
most suited to make the decision. Low scores in
The Denison Organizational Culture Survey results Capability Development, Organizational Change
were shared by Dr. Smith and his team with the and Creating Change also emphasized a need for
hospital staff – this gave credibility to the results professional development. The leadership team and
and offered a secure sense of anonymity and the medical staff understood that they needed to be
confidentiality to the results. Hospital members more intentional in their professional development
were assured that they were listened to and that efforts and created professional development plans
their story was told. Results were also shared for all critical staff members. Feedback from the
through a special edition of the employee newsletter written verbatim comments and low scores in the
dedicated to sharing the Denison Organizational Adaptability trait of the Denison, prompted the
Culture Survey results. It explained for all hospital hospital to attend to their Patient Experience team
employees the positive results of the survey as well and to redesign their entire service excellence plan.
as the opportunities for change. Addressing each of these areas helped lay the
groundwork for the CPOE implementation that was
Before the formal process of implementing CPOE to come.
within Metroplex took place, Smith, Walton and the
leadership team began to address cultural issues “For me, it’s about hardwiring excellence into our
in order to lay the groundwork for a successful organization. When our patients and their families
implementation. First they addressed the perception come here, they expect a consistently excellent
that the administration was in an ivory tower. There level of service. Coming in as a new CEO, the
was a widely held perception that leadership was Denison Organizational Culture Survey provided us
not very approachable or trustworthy. Walton and with a wonderful baseline to evaluate our culture
the other leaders needed to make themselves more and to debug some of the issues that were getting
visible throughout their facilities. As a result, the in the way of improving ourselves and providing
leadership team dedicated themselves to taking part excellence to our patients.”


About Metroplex Health System
Metroplex Health System is part of the Adventist Health System and offers an array of medical and
wellness services to West Bell, Coryell and Lampasas counties in Texas. Metroplex is dedicated to
meeting the needs of its patients providing quality health care services through its 233 bed, multi-
campus facility. The system employs about 1200 area residents and cares for more than 125,000
patients each year and is the largest community health care provider to the military in the nation. It
supports a staff of more than 260 physicians in 43 medical specialties.

www.mplex.org

About Adventist Health System
Adventist Health System is a not-for-profit healthcare organization. Founded in 1973 to support
and strengthen Seventh-day Adventist healthcare organizations in the Southern and Southwestern
regions of the United States, Adventist Health System has quickly grown to become the largest
not-for-profit Protestant healthcare provider in the nation.

Today, Adventist Health System supports 38 hospitals and employs 50,000 individuals. Adventist
Health System hospitals are comprised of 6,600 plus licensed beds, providing care for 4 million
patients each year in inpatient, outpatient and emergency room visits.

www.adventisthealthsystem.com

Related Resources
Denison Consulting. (2005). Research Notes: Denison Consulting. (2009). Case Study: Sutter
Overview of the Denison Model. Ann Arbor, MI: Connect: Cultivating Culture at the Start. Ann
Author Arbor, MI: Author

Denison Consulting. (2008). Case Study: Using Denison Consulting. (2010). ResearchNote:
Culture to Recruit Top Talent: HealthPlus of Balanced Profile, Better Organizations: Learning
Michigan. Ann Arbor, MI: Author to Balance. Ann Arbor, MI: Author

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Change Readiness at Adventist Health System: How Organizational Culture Can Help Hospitals Implement CPOE Successfully

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Change Readiness at Adventist Health System: How Organizational Culture Can Help Hospitals Implement CPOE Successfully