1. TMHG 526
CHANGE
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
Mahidol University
April 11, 2013
http://www.slideshare.net/Nawanan

2. Outline
• Change & IT
• Theories on Change
• Change Management
• Change Management &
Sociotechnical Issues in Informatics
• Case Studies

3. Change Management References
Lorenzi & Riley (2004)

4. Change Management References
http://www.ncbi.nlm.nih.gov/pubmed/10730594

5. “The only constant is
change”
Heraclitus

6. Change & IT

7. Class Exercise #1
Discuss with your neighbor:
• What changes does an
IT implementation bring about?
• What are the risks of those changes?
• What are the implications of those
changes for implementers?

8. Reasons for Change
• Fix existing problems
• Add more desirable features
• Process improvement
• Address a specific policy/strategy
• Business needs
• Keep up with new technologies
• Regulatory compliance
• Could be internal or external

9. “To improve is to change...”
Winston Churchill

10. IT Implementation Failures
Lorenzi & Riley (2000)

11. IT Implementation Failures
Lorenzi & Riley (2000)

12. IT Implementation Failures
Lorenzi & Riley (2000)

13. Theories on Change

14. Theories on Change
• First-order change
• “A variation in the way processes and
procedures have been done in a given
system, leaving the system itself relatively
unchanged.”
• E.g. creating new reports, new ways to
collect same data, refining existing
processes
Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

15. Theories on Change
• Second-order change
• The system itself is changed
• Usually a result of a strategic change or a
major crisis such as a threat against system
survival
• Involves redefinition or reconceptualization
of the organization’s business and how it’s
conducted
• E.g. changing from paper to electronic
medical records, automated teller machines
Watzlawick, Weakland, & Fisch (1974), cited in Lorenzi & Riley (2000)

16. Theories on Change
• Middle-order change
• “Represents a compromise; the
magnitude of change is greater than first-
order change, yet it neither affects the
critical success factors nor is strategic in
nature.”
Golembiewski, Billingsley, & Yeager (1976), cited in Lorenzi & Riley (2000)

17. Theories on Change
• Lewin’s Field Theory: 3 fundamental types of
conflict situations in a person (“force fields”)
• Standing midway between 2 positive goals of
approximately equal strength
• When there are 2 good systems to purchase
• Standing between 2 approximately equal negative
goals
• Make a choice of a system that will not completely
meet the needs
• Opposing positive and negative forces
• System users vs. IT people
Lorenzi & Riley (2000)

18. Change Resistance

19. Change Resistance in the News
Washington Post (March 21, 2005)
“One of the most important lessons learned to date is that the complexity
of human change management may be easily underestimated”
Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”

20. Cost of Change in IT
• Time & effort to learn
• Sense of control / sense of belonging of
workers
• Sense of control of middle managers
(information systems increase ability of
executives to know what’s going on and have
more direct control)
• Loss of position, power, networks
“Power shift”
Lorenzi & Riley (2000)

21. “The changes we dread
most may contain our
salvation”
Barbara Kingsolver, in Small Wonder

22. Change Management

23. Change Management
• “The process by which an organization
gets to its future state, its vision.”
• Starts with creating a vision for change
and empowering people as change
agents to achieve the vision.
• “Change management encompasses
the effective strategies and programs
to enable those change agents to
achieve the new vision.”
Lorenzi & Riley (2000)

24. Change Management Process
• Assessment
• Feedback and Options
• Strategy Development
• Implementation
• Reassessment
Lorenzi & Riley (2004)

25. Types of Change
• Operational changes
• Changes that affect the way the ongoing business
operations are conducted
• Strategic changes
• Changes in strategic business direction
• Cultural changes
• Affect basic organizational philosophies by which the
business is conducted (e.g. implementing CQI)
• Political changes
• Staffing changes, primarily for political reasons
Lorenzi & Riley (2000)

26. Types of Change
• Microchanges
• Differences in degree
• E.g., modifications, enhancements, improvements, &
upgrades of information systems
• Megachanges
• Differences in kind
• E.g., a new system or a very major revision
Lorenzi & Riley (2000)

27. The Special People
Ash et al. (2003)

28. The Special People
• Administrative – CIO
Leadership Level • Selects champions
• Gains support
–CEO • Possesses vision
• Provides top • Maintains a thick skin
level support and – CMIO
vision • Interprets
• Possesses vision
• Holds steadfast • Maintains a thick skin
• Connects with • Influences peers
the staff • Supports the clinical
support staff
• Listens • Champions
• Champions
Ash et al. (2003)

29. The Special People
• Clinical Leadership – Curmudgeons
Level • “Skeptic who is
usually quite vocal
– Champions in his or her disdain
• Necessary of the system”
• Hold steadfast • Provide feedback
• Influence peers • Furnish leadership
• Understand other – Clinical advisory
physicians
committees
– Opinion leaders • Solve problems
• Provide a balanced • Connect units
view
• Influence peers
Ash et al. (2003)

30. The Special People
• Bridger/Support level –Skills
–Trainers & • Possess clinical
support team backgrounds
• Necessary • Gain skills on the
job
• Provide help at the • Show patience,
elbow tenacity, and
• Make changes assertiveness
• Provide training
• Test the systems
Ash et al. (2003)

31. Change Management and
Sociotechnical Issues in
Informatics

32. Sociotechnical Systems
• Coined in 1960s by Eric Trist, Ken Bamforth &
Fred Emery
• “An approach to complex organizational work
design that recognizes the interaction between
people and technology in workplaces.”
(Wikipedia)
• “Interaction between society's complex
infrastructures and human behaviour.”
(Wikipedia)
http://en.wikipedia.org/wiki/Sociotechnical_system

33. People-Process-Technology
Technology
People Process

34. “People & Organizational Issues” (POI)
• POI focuses on interactions between people
and technology, including designing,
implementing, and deploying safe and usable
health information systems and technology.
• AMIA POIWG addresses issues such as
• How systems change us and our social and clinical
environments
• How we should change them
• What we need to do to take the fullest advantage of
them to improve [...] health and health care.
• Our members strive to understand,
evaluate, and improve human-computer
and socio-technical interactions.
http://www.amia.org/programs/working-groups/people-and-organizational-issues

35. “People & Organizational Issues” (POI)
• We bring varied perspectives, methods, and tools
from
• Humanities, Social science, Cognitive science
• Computer science and informatics
• Business disciplines
• Patient safety
• Workflow
• Collaborative work and decision-making
• Human-computer interaction & Usability
• Human factors
• Project and change management
• Adoption and diffusion of innovations
• Unintended consequences
• Policy.
http://www.amia.org/programs/working-groups/people-and-organizational-issues

36. Considerations for a successful CPOE
implementation
Considerations
Motivation for implementation
CPOE vision, leadership, and personnel
Costs
Integration: Workflow, health care processes
Value to users/Decision support systems
Project management and staging of implementation
Technology
Training and Support 24 x 7
Learning/Evaluation/Improvement
Ash et al. (2003)

37. Minimizing MD’s Change Resistance
• Involve physician champions
• Create a sense of ownership through
communications & involvement
• Understand their values
• Be attentive to climate in the organization
• Provide adequate training & support
Riley & Lorenzi (1995)

38. User Involvement in Health IT:
A True Story

39. Reasons for User Involvement
• Better understanding of needs & requirements
• Leveraging user expertise about their tasks & how
organization functions
• Assess importance of specific features for
prioritization
• Users better understand project, develop realistic
expectations
• Venues for negotiation, conflict resolution
• Sense of ownership
• Pare & Sicotte (2006): Physician ownership
important for clinical information systems
Ives & Olson (1984)

40. The Missing Piece in IT Adoption
Technological Sophistication
Functional Sophistication
Integration Sophistication
Managerial Sophistication
Proposed Addition
Theera-Ampornpunt (2011)

41. Critical Success Factors in Health IT
Projects
Communications of plans & progresses
Physician & non-physician user involvement
Attention to workflow changes
Well-executed project management
Adequate user training
Organizational learning
Organizational innovativeness
Theera-Ampornpunt (2011)

42. Theory of Hospital Adoption of
Information Systems (THAIS)
Theera-Ampornpunt (2011)

43. Gartner Hype Cycle
Image source: Jeremy Kemp via http://en.wikipedia.org/wiki/Hype_cycle
http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp

44. Rogers’ Diffusion of Innovations:
Adoption Curve
Rogers (2003)

45. Leading a Change
http://www.ted.com/talks/lang/th/derek_sivers_how_to_start_a_movement.html

46. Summary
• All IT implementations are change
• Changes differ in nature, scale, and magnitude
• Change resistance is common and natural
• Overcoming change resistance requires a good
change management strategy
• Pay attention to the “POI” or sociotechnical aspect
• Balance between People, Process, & Technology
• Shared vision & commitment, user engagement,
communication, workflow considerations, & training
are key
• Understand the Adoption Curve

47. Case Studies

48. Case Studies on Change Management
Leviss (Editor) Leviss (Editor)
(2010) (2013)