CME6 - LEADERSHIP AND STRATEGIC MANAGEMENT FOR HEALTH PROFESSIONALS
|Year : 2015 | Volume
| Issue : 2 | Page : 85-89
Change Management Skills
Sanjiv Kumar1, Neeta Kumar2, Vaishali Deshmukh3, Vivek S Adhish4
1 Executive Director, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, National Institute of Health and Family Welfare Campus, New Delhi, India
2 Department of Pathology, Faculty of Dentistry, Jamia Milia Islamia, New Delhi, India
3 Program Officer, The Inclen Trust, Executive Office, New Delhi, India
4 Department of Community Health Administration, National Institute of Health and Family Welfare, Munirka, New Delhi, India
|Date of Submission||10-Mar-2015|
|Date of Acceptance||14-Mar-2015|
|Date of Web Publication||24-Mar-2015|
Dr. Sanjiv Kumar
Executive Director, National Health Systems Resource Centre, National Health Mission, Ministry of Health and Family Welfare, Government of India, National Institute of Health and Family Welfare Campus, Baba Gangnath Marg, Munirka, New Delhi - 110 067
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S, Kumar N, Deshmukh V, Adhish VS. Change Management Skills. Indian J Community Med 2015;40:85-9
"Change is the only constant."
-Heraclitus, Greek Philosopher, 500BC
| Introduction|| |
Change has always been there since beginning of the universe. The pace and magnitude of change has accelerated in recent times. The environment within health sector and outside is changing much faster today. The managerial skills of change management are more important in today's world of globalization and rapidly changing technology. Jim Collins Level 5 leadership model  illustrates a health professional acquiring higher levels of managerial and leadership skills as s/he moves from highly capable individual to contributing team member, competent manager, to effective leader. The management skills of anticipating change, adapting to it, and keeping an eye on what is changing within and outside health sector are necessary for health professionals to acquire. It refers to the third domain of skills in the three domain model of leadership. 
What changes and what does not change
It is important to understand what can and cannot change. Change is best expressed by the Chinese concept of ying and yang. Certain things like core values, character, and personality are some aspects of individual's life which do not change with time; whereas, appearance, educational qualification, physical possessions, and skills do change. Similarly core values of an organization do not change. Organizations have areas of comparative advantage and unique selling points they may like to retain. Whereas they need to keep changing with new technology, competition, product range, product upgrades, diversification, etc., which require proper change management.
| Why Change Occurs in Health Sector|| |
The changes with in and outside health sector drive the change in health sector.
Factors responsible for changes within health sector
Various factors bring changes within health sector which include:
- Technological advances and their application in the health sector: Technological innovations are being introduced every day due to easy availability of internet, mobile telephony and other technologies and reach rest of the world much faster. These technological innovations provide opportunities for expert to provide top class services even in difficult to reach remote areas. The potential of these remains untapped by public health system initiatives such as Mother Child Tracking System, e-Asha, e-Aushadhi, and Mobile Kunji are the real-time uploading of data from district/subdistrict. Other than this telemedicine, teleradiology, and teleophthalmology are being scaled up or expanded directly from health facilities.
- Demand for quality assurance: The systems are becoming more quality conscious due to demand from customers, policy makers, and increasing focus on results. Customer awareness, needs, expectations, consumer protection act, and legal accountability are increasing and they are looking at healthcare as any other service. The growing knowledge of customer puts pressure on health professionals and health systems to change by providing quality services with zero error.
- Epidemiology of diseases and emerging and re-emerging infectious diseases like Ebola, avian flu, and rapidly expanding infections by drug resistant organisms is becoming a challenge to public health.
- Era of evidence-based policy, health, and medical care: The established healthcare practices are being challenged to be replaced by evidence-based practices. Every policy direction needs to be supported with evidence that stands scientific scrutiny. Even the time-honored expert opinions no longer hold ground if, not supported by evidence. The need to curb unnecessary investigations, interventions, and irrational use of drugs, at times for profit motive needs to be curbed.
- Health as a human right: There is more and more attention to provide equal health status and access to healthcare to the poor and the marginalized. There is a necessity to get disaggregated data to unmask in equity in access to healthcare and address these. There is more attention to bring financial protection to the poor in availing medical services.
- Privatization and commercial interests: Rapid privatization in healthcare is filling in the void left by public health system including medical and paramedic education. The need for public-private partnership to complement public health system cannot be ignored. Since the primary motive of private sector is profit making, it requires a close watch and regulation by the government to curb profiteering and unfair practices.
Factors responsible for change from outside health sector
The changes in other sectors impact healthcare technology, transmission of health data and information, and lifestyles that have implications for health. These include:
- Globalization: The impact of growing international trade on health systems and policies, improving communication, and increasing flow of goods impact availability of healthcare and related products. Increasing international travel, medical and other tourism, and migration facilitate the spread of infectious and antimicrobial resistant diseases. The illicit drugs trade, trade liberalization, intellectual property rights, and generic drugs impact the cost of medicine and drugs  and medical care. Medical tourism to India was USD 78.6 billion in 2012 and is expected to grow to 158.2 billion by 2017.  It motivates private sector to achieve and maintain international standards in medical care.
- Changing lifestyle and demographic profile: The lifestyle is changing with physical inactivity, refined unhealthy foods, and anxiety in day-to-day work and weakening family ties with consequences of lifestyle related diseases. These require more attention to behavior change. Changing one's behavior needs equal attention to logic and emotional buy-in.  Changing patient behavior is a must, otherwise health system would fail in their mission. Of improving health outcomes,  an increasing life expectancy needs more attention to geriatric health and noncommunicable diseases. A large proportion of young population in India offers an opportunity to develop desirable healthy behavior as foundation of healthy lifestyle to prevent noncommunicable diseases and address their nutrition, growth, and development needs.
- Availability of health literature online: Today most of the scientific literature, journals, updates, and guidelines related to public health and medical specialties are available online. Many online courses from leading international institutions are available. The leaders and managers in health system need to keep an eye on it and update their skills in technical and managerial areas. Similarly, the public has access to this information and service providers need to be prepared to answer questions of informed beneficiaries.
- Climate change and environmental degradation: Pollution both indoor and outdoor and climate change are becoming increasingly important factors adversely impacting health across the world. With increase in estimated deaths from air pollution have increased to 620,000 in 2010 from 100,000 in 2000 and has become fifth major killer in India.  The weather pattern is changing. Extreme weather events and natural disasters adversely impact health conditions. Health professionals need to deal with these and actively engage with other ministries to reverse environmental degradation.
- Active media and civil society organizations: The media and civil society organizations play an increasingly important role in highlighting health issues. It focuses more on failure of the health systems and less on success stories. Public health professionals need to partner with them to educate the public and make the system more transparent to build credibility.
- Contribution of other sectors to health: The social determinants of health such as water, sanitation, education, road and transportation, and environment contribute more to health than health sector. Recent emphasis on "Health in All Policies" requires public health professionals to understand social determinants of health and acquire skills to influence and collaborate with other sectors to improve health.
| Managing Change|| |
The individuals and organizations not adapting to change get left behind and fail to achieve desired results, incur extra costs and efforts, miss opportunities, become outdated, loose business, get demoralized, and delay activities and projects. A successful manager needs to manage change for self and for her/his organization.
Managing change for self
Like universe, each one of us has been changing since birth, from toddler to child to adolescent, young adult, family person, professional, retired person, and so on. One also changes with and for personal growth; continuous advancement in personal, family, and professional life; and lifelong learning. As we go through lifecycle, one has to keep reinventing and reevaluating oneself and adapt from one phase of life to the next. Family is changing and so do people and the environment around us. One's ability to respond to change in life is a strong predictor of professional success. Charles Garfield studied 500 peak performers in different industries. He concluded that they were not necessarily the most talented or the most able or even the luckiest. The one thing they had in common was their ability to respond to change in their lives. This was even true for other species as Charles Darwin concluded from nature: "It is not the strongest of the species that survive nor the most intelligent, but the most responsive to change".  This is true for us the humans as well even in one life span [Table 1].
|Table 1: Types of change that impact health professionals and their organizations (adapted from(8) |
Click here to view
Competencies for self to achieve personal goals
An effective leader makes an active effort to acquire and improve on his skills to adapt to changing environment and learn new available technology and maximizes benefit from it. He strongly believes in lifelong learning, seeks regular formal and informal feedback on how he is doing, and is aware of his weaknesses and strengths.
It is important to clearly define where I am (present situation, skills, occupation, and position within the organization or skill sets) and where I want to get (future situation, skills, occupation, position within the organization or skill sets). How do I get there (transition or transformation) and how much time I have to get there (transition period). The key activities I need to undertake to get there, the timeline, the milestones, people involved, new partners, allies, and what I loose and gain in the process (transition management plan). A transition management plan starts with final outcome and works backwards from there [Table 2]. 
"We like change better when it comes by invitation instead of imposition." -Kelly Standing
Managing organizational change
A good leader keeps an eye on what is going on in the organization, changes within the sector and outside the sector and what are the implications for the organization. He keeps an eye on how the diseases pattern, trends, projections, factors within and outside health sector, availability of technology, their application in health sector, and the way health institutions function are being managed.  The newer health interventions are improving management of health problems. He plans ahead and prepares his organization to benefit from these developments. He also keeps in mind how his organization contributes to benefit the community. No organization exists in a vacuum, and its existence and growth is linked to the society, its norms and values. He actively engages himself and his employees in activities to benefit the community. The leader develops and uses an active network of formal and informal contacts beyond the organization/team he leads to get a regular feedback on how the organization he leads is perceived. He drives change in self, team members, and the organization to adapt to the anticipated and emerging changes within and outside the sector.
Leading and managing change
Addressing healthcare challenges entail leading change management. For sustainable improvement in health system understanding the influence of change within and outside the organization is imperative. To improve the health of the community, one needs to be clear about the errors occurring in the community and have clarity about what needs to change and how to find a way through the change process. The change management is feasible in clinical or management practices, organizational structure and systems, and national or organizational policies and strategy; depending upon the scope and complexity of the challenges that may lead to change.  Leading and managing organization change is about supporting each in the organization to adopt and adapt to change.
Organizational change and its management
The term "change" refers to any alteration that occurs in the overall work environment of an organization.  Change plans make the results tangible, and help control the processes, guide decision-making, and provide security around uncertainties.  This change involves a sequence of organizational processes that occurs over time. Lew in, in his model suggests three steps for bringing such changes through unfreezing, moving, and refreezing. In unfreezing step, the acting forces are reduced to keep the organization in its current condition. In the next step moving it involves the development of new values, attitudes, and behaviors through internalization, identification, or change in structure. In third step, process involves stabilizing the change at a new quasi-stationary equilibrium, which is called refreezing. However, Jogn Kotter (1996) developed an eight-step process for implementing change based on Lewin's three-step change model. 
The steps below summarize the process for implementing change (adapted from Kotter's and Lewin's models): 
- Create a compelling reason for change: Examine the market and competitive realities through identifying and discussing crises or major opportunities
- Create a cross-functional team with power to lead the change: The leader should assemble a team and give it enough power to lead the change.
- Create a vision and strategic plan to help direct the change effort while developing strategies for achieving that vision.
- Communicate the change vision and implement a communication strategy that consistently communicates the new vision and strategic plan. It is necessary to go beyond logic and reasoning and get emotional buy-in.
- Eliminate barriers to change: Encourage risk taking and creative problem solving. Get rid of obstacles, and change systems or structures that undermine the change vision.
- Encourage risk taking and creative problem solving: Generate quick, easy, and short-term wins. Plan for visible improvements in performance, or "wins" create those wins and recognize and reward people who made the wins possible.
- Consolidate gains and produce more change: Using increased credibility to change all systems, structures, and policies that do not fit together and do not fit the transformation vision. Hiring, promoting, and developing people who can implement the change vision. Reinvigorating the process with new projects, themes, and change agents.
- Reinforce new approaches in the culture: Create better performance through beneficiary- and result-oriented behavior. Articulate the connections between new behaviors and organizational success.
Role of change agents in managing change
Change agent is a person from inside or outside the organization that helps an organization transform itself.  Having an internal change agent who cares deeply about changing a practice is the most critical factor for success. Miller and Lawton (2002) said; "They are the invisible hands that turn vision into action".  Their role is to facilitate the work of the groups in developing, applying, and advocating new practices. Rogers' model reflects the origins of diffusion research focusing on the promotion of innovation in the areas of agriculture and health by government agencies. From the diffusion study, Rogers identified seven-point process of change agent activity from an initial contact to the end of the agent-client relationship.  To achieve the above, the change agent can lead the way only if change agent can recognize a challenge/gap between the desired achievement and actual achievement, identify promising practices for improving services, adapt and test one promising practice or set of practices to make sure it fits the context, implement the new practices to build a base, and scale up the successful new practices.
| Conclusion|| |
Change is an essential part of everyone's personal and professional life. It is important for health professional leaders to understand, prepare for, and manage change for both self and the organization one leads. Lack of skills to adapt to and manage change will lead to missed opportunities, career stagnation, demotivation for self and bad implementation, poor quality, delayed results, extra cost, and marginalization of the organization. A successful leader anticipates and adapts self and one's organization to change.
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[Table 1], [Table 2]