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Success Factors for Strategic Change Initiatives: A Qualitative Study of Healthcare Administrators’ Perspectives Bita Arbab Kash, PhD, FACHE, assistant professor, Texas A&M University Health Science Center, College Station; Aaron Spaulding, PhD, assistant professor, Brooks College of Health, University of North Florida, Jacksonville; Christopher F. Johnson, PhD, director. Graduate Program in Health Services Administration, School of Public Health, University of Washington, Seattle; and Larry Gamm, PhD, director. Center for Health Organization Transformation, Texas A&M University Health Science Center

E X E C U T I V E S U M M A R Y Success factors related to the implementation of change initiatives are well docu- mented and discussed in the management literature, but they are seldom studied in healthcare organizations engaged in multiple strategic change initiatives. The pur- pose of this study was to identify key success factors related to implementation of change initiatives based on rich qualitative data gathered from health leader inter- views at two large health systems implementing multiple change initiatives.

In-depth personal interviews with 61 healthcare leaders in the two large systems were conducted and inductive qualitative analysis was employed to identify success factors associated with 13 change initiatives. Results firom this analysis were compared to success factors identified in the literature, and generalizations were drawn that add significantly to the management literature, especially to that in the healthcare sector.

Ten specific success factors were identified for the implementation of change initiatives. The top three success factors were (1) culture and values, (2) business processes, and (3) people and engagement. Two of the identified success factors are unique to the healthcare sector and not found in the literature on change models: service quality and client satisfaction (ranked fourth of 10) and access to information (ranked ninth).

Results demonstrate the importance of human resource functions, alignment of culture and values with change, and business processes that facilitate effective commu- nication and access to information to achieve many change initiatives. The responses also suggest opportunities for leaders of healthcare organizations to more formally recognize the degree to which various change initiatives are dependent on one another.

For more information about the concepts in this article, contact Dr. Kash at bakash@srph.tamhsc.edu.

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I N T R O O U C T I O N Strategic change capabilities have become a primary focus as hospitals and healthcare systems attempt to perpetu- ally improve and position themselves in a competitive market characterized by continuous regulatory changes and opportunities for reorganization and grov r̂th. Yet few empirical studies focus- ing on success factors for effective orga- nizational change have been conducted in hospitals or healthcare settings (Rosacker, Zuckweiler, & Buelow, 2010).

The present study draws on man- agement literature and examples of the successful implementation of strate- gic change initiatives in healthcare to further improve our understanding of how to plan for and implement such an initiative. The purpose of this study was to explore and identify specific change initiative success factors as depicted by healthcare leaders’ assessments of change efforts in their health systems. Success factors available in the manage- ment literature are identifted and con- trasted to responses gathered ftom more than 60 administrators at two large healthcare systems engaged in multiple change initiatives.

Prior research attempted to evalu- ate how strategic change initiatives are implemented (Edmondson, Böhmer, & Pisano, 2001), how leaders promote organizational successes (Bass & Rig- gio, 2006), and how culture affects organizational performance (Pfeffer & Veiga, 1999). Many of these strategies have even been categorized and sum- marized according to the organizational change theories applied (Van de Ven & Poole, 1995). However, variation ftequently occurs within and across

systems in innovative program suc- cess (Armutlu, Foley, Surette, Belzile, & McCusker, 2008; Hosier & Nadle, 2000; Manzo et al., 2005; Silow-Carroll, Alteras, & Meyer, 2007), and it may be that variations in success are related to an organization’s ability to acquire and use new knowledge to ensure successful initiatives (Kash, Spaulding, Gamm, & Johnson, 2013).

Healthcare strategic change initia- tives research primarily focuses on out- comes that measure only one dimension of success at one level of the organiza- tion (Vest & Camm, 2009). Generally, evaluations of change efforts have been found to fall short of increasingly high standards within health services research (Begun, Zimmerman, & Dooley, 2003). The healthcare management literature may benefit ftom a more industry- specific examination of success factors related to strategic change initiatives that will assist healthcare organizations along their transformation journeys.

CONCEPTUAL FRAMEWORK To define success factors, we viewed hos- pitals as open systems. Open systems are defined as those facing uncertainty in both their internal and external environ- ment (Meyer & O’Brien-Pallas, 2010), making complex organizational change literature more pertinent to today’s healthcare organization (the hospital system) than is the traditional change management literature of the pre- 19 80s. Therefore, we restricted models of successful change initiatives to those described in the emergent change lit- erature of the post-1980s. The emergent approach to change assumes that change is not linear or sequentially planned and

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implemented over time but rather is an open-ended process requiring adapta- tion and some planned changes and initiatives (Burnes, 1996, 2004; Daw- son, 1994). In a comprehensive review of emergent change literature. Rune (2005) summarizes and compares three models of successful emergent change models, which we use as the analyti- cal framework for this article. The three models include Kanter, Stein, and Jick’s (1992) Ten Commandments for Execut- ing Change; Kotter’s (1996) Eight-Stage Process for Successful Organizational

Transformation; and Luecke’s (2003) Seven Steps. Additionally, we view these models through the lens of Young’s (2005) Seven Lessons From the VHA model of empirical research on organi- zational transformation in the Veterans Health Administration (VHA) system in the early 1990s, which is one of the few applicable studies of lessons learned from the implementation of multiple change initiatives in the healthcare sector. Figure 1 summarizes and cross- references the success factors for change across these four models.

F i G U R E 1 Comparison ot Success Factors for Change iVIodeis

Success Factors for Change (all sectors)

Kanter et al. (1992)

Organization analysis

Kotter (1996) Luedce(2003)

C

Develop vision and strategy

Separate from past

Create urgency

Identify and support leadership

Gather support

Implementation plan

Enable supportive actions

Communicate change process

Institutionalize change

Short-term wins

Capitalize on gains

Focus on results

Let changes spread without pushing

Monitor

Success Factors for Change (healthcare)

Young(2005)

rganization analysis

Implementation plan

Communicate change process

)nd adjust strategy as needed

Provide training and education

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As we compare the models, we can see certain common concepts related to the need for change. These concepts include strong leadership, effective communication and people involve- ment, and system-wide unity. The first three models (Kanter et al., Kotter, and Luecke) stress the importance of a shared vision and strategies that direct us to that shared vision. Two models (Kanter et al. and Young) stress the need for a well-aafted implementation plan, while the other two models (Kotter and Luecke) stress flexibility, empowered action, and the ability to adjust strategy in implementing change. These four models of successful change, including success factors and lessons learned from the implementation of organization- wide change initiatives, became the backdrop for our qualitative research results, which address success factors for the implementation of strategic change initiatives in healthcare.

iVIETHODS This study presents an assessment of various strategic change initiatives at two large healthcare organizations: a stand-alone children’s health system and a metropolitan, regional, mul- tihospital system. We conducted 61 in-person, semistructured interviews with healthcare leaders at these settings. Inductive qualitative content analysis was employed to identify themes related to success factors for strategic change initiatives as described by interviewees. Study participants’ responses also gener- ated answers to questions relating to the number and nature of strategic change initiatives.

Data Coilection and Participants The interview process was a focused, open-ended discussion designed to prompt the participants to share infor- mation about the organization’s initia- tives while focusing on initiative success factors (Blumer, 1969; Bogdan & Biklen, 1992). Of the 61 interviews conducted, 32 took place at the children’s health system and 29 took place at the mul- tihospital system. The interviews were administered from June to September 2009. Four interviewers—an assistant professor, an associate professor, a full professor, and a PhD student—were deployed in teams of two to conduct the interviews. At both organizations, the research team used a snowball sample approach whereby it started with the senior executive team and progressed through the organizational hierarchy as interviewees identified other individuals who played important roles in one or more initiatives. Additional interviews ceased when no new individuals were identified as key to the initiatives (Bier- nacki & Waldorf, 1981). The final list of interviewees included administrators who held titles from assistant director to chief executive officer and physician leaders who served as chief medical offi- cer or chief of a department.

Initial meetings were held with several top leaders of each organiza- tion to identify, name, and define a set of change initiatives for each system. On the basis ofthat information, the researchers developed a script of 15 questions and commenced the indi- vidual interviews. Each participant was also allowed time to add information or provide related information that the

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questions did not probe. All participants were provided documentation concern- ing the purpose of the study and given an informed consent document to complete prior to the interview. At both organizations, the research team used the combined positional and snowball sample approach described earlier. The responses were collected by each inter- viewer by means of handwritten field notes and were transcribed and stored in an electronic database.

The survey documented the admin- istrators’ rating of the importance of the initiatives, the interviewees’ degree of involvement with each initiative, and identification of who else was involved with each initiative. Of particular impor- tance to this study were open-ended questions asking participants to identify critical success factors for each initiative.

Analytical Approach For purposes of this article, we focused on two analytical steps:

1. Compiling demographic data collected to present a profile of the 61 interviewees, including age, gender, healthcare experience, tenure, and rank

2. Conducting qualitative analysis to identify common themes related to success factors for the implementation of change initiatives identified by the interviewees using rich qualitative data from the 61 personal interviews

The structure of the qualitative anal- ysis was not led by previous knowledge about success factors or steps toward successful implementation of change

initiatives as presented in the literature review. The research team approached the results of the administrators’ inter- views with the purpose of theory build- ing by identifying all the dimensions and themes related to success factors for the implementation of change initiatives in the healthcare setting. The research team followed grounded theory meth- odology by applying inductive content analysis when coding the interview data. Team members used open coding and then organized the codes into corre- sponding subcategories, which resulted in the overarching themes (Strauss & Corbin, 1997). Codes were identified and named at different levels of analysis and consisted mostly of descriptive, with some inferential, code and theme names (Miles & Huberman, 1994). Coding of the interview transcripts was performed in teams of two researchers with the addition of a third independent coder, who validated the initial coding and helped settle discrepancies. The themes and their corresponding codes are pre- sented in Figure 2 and discussed further in the Results section.

Each theme resulted from a pattern identified in the interviewees’ responses. During the coding process, the research team made an initial pass through the transcripts followed by a review of the coding and assignment criteria (Miles & Huberman, 1994). Team members met regularly to reevaluate code assignments and corrections based on the definitions resulting from cross-examination. This process helped ensure interrater reliabil- ity as codes were assigned, and members reviewed each other’s coded material to ensure consistency.

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RESULTS First, we offer a brief description of the two research settings, the children’s health system and the multihospital health system, including the nature of the strategic change initiatives studied. Second, we present profiles of the inter- view participants to provide some con- textual background to their response. Finally, we present success factor themes resulting ftom the interviews.

Children’s Health System The children’s health system is located in a large metropolitan area. Interview participants included executive leaders, vice presidents, directors, and assistant directors in the main operating structure of the organization. This organization was pursuing the following strategic change initiatives:

1. Two building projects—a clinical building to house a new program, and a new satellite hospital

2. Research initiatives involving large investments

3. The launch of a physician service organization to serve as a hospital- based billing and collections service for staff and contracted physicians’ professional fees

4. The implementation and integration of a new electronic health record system (EHR)

5. A medical school consolidation initiative, which involved restructuring and formalizing the system’s relationship with a medical partner to improve the overall health of the children in the service area

6. An inpatient quality and patient safety program

7. Various patient flow improvement initiatives

8. A cost containment initiative to improve staff management and resource utilization

Multihospital Health System The multihospital system is a large, regional, multihospital health system. The study participants were located at the system’s corporate office and were responsible for its overall direc- tion, operation, and financial health. At the time of the analysis, five initia- tives designed to transform the way the health system and its member hospitals operated were being pursued as part of the system’s strategic plan. Each initia- tive was associated with specific goals to be met over the next 5 to 10 yea