The field of palliative care is somewhat “counterculture” to mainstream biomedicine. In conventional biomedicine, symptoms are used merely as a means to an end, i.e., symptoms are used as clues to diagnose the underlying culprit, the disease.
Once identified, all energy is devoted to annihilating the culprit. In contrast, in the field of palliative care, the symptom (pain, dyspnea, nausea, etc.) itself is the focus and much effort is directed at alleviating the symptom. Understandably, this premise of palliative care sets it apart from the rest of mainstream biomedicine. Additionally, hospice and palliative medicine being the “newest kid on the block” of medical subspecialties fundamentally represents change. Therefore, effecting and sustaining change is a key survival skill for all palliative care professionals.
Effecting change is a process (not an event) and requires both strategic thinking and ongoing hard work. The Center for Advancement of Palliative Care (CAPC) founded by the pioneering efforts of Dr. Diane Meier offers a framework, requisite tools, and support for clinicians who want to change their local health care systems for the better by building new and expanding existing palliative care programs. 1 Additionally, clinicians have to become skilled in the process of change management in order to harness the full power of the CAPC tools to create successful palliative care programs.
Kotter’s Eight-Step Model for Change Management
Change management is a stepwise approach for ensuring that programmatic changes are implemented smoothly and systematically and that the lasting benefits of change are achieved. One of the most effective and widely used change management models was developed by John Kotter at the Harvard Business School.2 The Kotter model outlined below serves as a successful roadmap and can be used to operationalize any of your palliative care initiatives.
Set the Stage
Step 1: Establish a sense of urgency:
It is not that people are incapable of seeing the solution. Often people are incapable of seeing the problem. Once convinced that the problem does exist, most people are willing to adopt reasonable solutions. Local institutional data (for example: poor observed-to-expected mortality ratios for hospitalized patients) and compelling patient case studies are two effective tools that will typically galvanize stakeholders into supporting your palliative care initiative.
Step 2: Create a coalition for change:
Identify the true leaders=champions in your organization. Champions are people whose power and influence may come from a variety of sources, including job title, status, expertise, political importance, community connections, and special skills. Securing commitment=endorsement from and scheduling regular brief meetings with these champions will build collegiality and a common purpose that can be harnessed to create buy-in for the project.
Decide What to Do
Step 3: Develop a vision and strategy:
A vision can be defined as a desired realistic and credible future state that an organization hopes to achieve. An effective vision is a compelling dream that energizes the project team and provides both the emotional and intellectual energy for the series of actions that will ultimately result in the actualization of the vision. The team should write a brief vision statement and also identify the concrete tasks to be done to get closer to the vision.
Make it Happen
Step 4: Communicate the change vision to others:
The project team should assiduously look for and articulate the vision speech at every available formal and informal opportunity in order to secure stakeholder buy-in. The more the vision is publicized over time, the more effective it becomes.
Step 5: Identify and overcome resistance:
Any change initiative will always run into human resistance. Diagnosing and overcoming resistance is the backbone of change management. Overcoming resistance will serve to empower the people you need to execute the vision. Education, negotiation, and persuasion are the most effective tools in overcoming resistance to change. The palliative care communication skills that we use so successfully on patients and families are just as effective when used on colleagues and coworkers.
Step 6: Generate short term successes:
Nothing succeeds like success. The project team needs a taste of victory quite early in the change process. It is therefore critical to identify “low-hanging fruit” (simple and surefire milestones with little room for failure) and achieve them as a demonstration of the credibility and validity of the proposed initiative. Small and early successes will feed on themselves to create sufficient momentum and morale to overcome the perils and pitfalls related to the project.
Step 7: Consolidate gains and produce more change:
Kotter states that many change projects fail because small wins are confused for enduring victory. Enduring change needs to overcome organizational cultural resistance and this process takes time and effort. With every project milestone achieved (or failed), it is important to analyze and learn from the outcomes. It is also important to preserve and augment the momentum by recruiting new stake holders and celebrating successful project milestones.
Make it Stick
Step 8: Anchor the changes in the institutional culture:
Finally, the change has to be hardwired into the core of your organization. The healthcare environment is ever changing, with staff turnover, influx of new initiatives and shifting organizational priorities. Incorporating the initiative into local protocols and procedures and adopting a reminder system are two effective strategies to weave the change into the organizational fabric.
Finally, anything worth doing is also worth measuring. Brief surveys (colleagues and stakeholders as well as patients and families) that can be tailored to focus on specific features that are most relevant to the new initiative are the most commonly used metrics. Sharing project data with stakeholders further serves to bring in new streams of energy and resources.
Our lives are not the only ones that are affected
by what is happening to us and what we are doing at work. Everyone in our work lives (friends, co-workers, subordinates, supervisors) are touched in some way by what we do. Most importantly, the more we incorporate palliative care into our organizations and effect change, the more we enable and empower those around us to change for the better.
Lao Tzu the ancient Chinese philosopher eloquently summarizes this process as:
Learn from the people
Plan with the people
Begin with what they have
Build on what they know
Of the best leaders
When the task is accomplished
The people all remark
We have done it ourselves.
1. Meier D: Finding my place. J. Palliat. Med 2009;12:331–335.
2. Kotter JP: Leading change. Harvard Bus Rev 2007;85:96–103.