Introduction
[00:00:01] Stacey Richter: Episode 447. "Why An “EHR Strategy” Isn't Enough. You Could Call This The Change Management Show." Today, I speak with Ashleigh Gunter.
The Power of Messaging in Healthcare
There was a study a few years ago that I was very enamored with. The study found doctors tended to ignore signs, ie, signs hanging on walls. Asking them to wash their hands if the messaging on the sign wasn't right.
To listen to this episode or read the show notes with links mentioned, visit the episode page.
You know what sign message worked the best? When docs were reminded that not washing hands put patients health at risk. Did you think I was going to tell you that doctors ignored signs unless they got paid to wash their hands or something to do with some incentive? Well, that's not what I'm saying.
Whatever was going through the doctor's minds, an appeal to patient well-being drove them to action much better than alternatives, including when the sign talked about their own personal safety. Soap use rose by over 45 percent when the sign message resonated with a why that many clinicians had. Which was patient safety.
Why, with this anecdote, about hand washing, you may ask. It is so that I can say with evidence that if you want to transform something, anything in healthcare, if you want to get people in healthcare to do something, it is always going to start with said people, and you have to figure out their why. Keeping in mind, other people's why may or may not be the same as yours, no matter how intuitive you think the why is.
For example, hey, let's do value-based care. Or hey, how about we try to get direct contracts with self-insured employers? Or even, hey, let's make something, in air quotes, easy for all of our clinicians by sticking it in the EHR system. These are just three examples I thought of off the top of my head that immediately come to mind where the why is not actually self evident at all for why anybody should be on board for any of these rides.
Karen Simonton and Dr. Ben Schwartz wrote the other day, "It doesn't matter what area of healthcare you come from, if you can't see another's viewpoint, it's very difficult to motivate them to see yours". This is so true, even in the same tribe, the ortho tribe, primary care tribe, payer tribe, even the RHV tribe, it is a process.
Understanding Change Management
So let's dig in, because this is really important, actually, to everybody trying to do or sell or transform almost anything in healthcare.
Insights from Dr. Ben Schwartz
Here's from Dr. Ben Schwartz. He wrote this on LinkedIn the other day, and I edited it for brevity. He wrote, “I’m not a big fan of using corporate speak in medicine, but there's one core theme that comes up over and over and over again when thinking about healthcare innovation. Change management. The best tech tools, care models, and forward thinking concepts do not matter if you cannot convince anyone to adopt them. Many great ideas die on the vine because of resistance to change. In healthcare, all it takes is one ounce of resistance in a complicated, multi-layer system to sabotage an entire effort. I'm increasingly convinced that success of any innovative effort in healthcare, from health tech to value-based care and beyond, hinges on the ability to manage change. And then he writes, frontline care delivery experience is too often discounted here, in my opinion.
Hmm. Having spent what amounts to my entire career basically working to change behavior within the healthcare space, I could not agree more with Dr. Ben Schwartz. And may I just say that this, from the nailing of the why to the rest of any change management endeavor, is so misunderstood.
The Importance of User Experience
Like, if you're from a company trying to change clinician behavior or close a care gap, and you come to me as step one asking for an, in air quotes, EHR strategy, or more usually an EPIC strategy. Really dig in on the user experience as step one here. This is why I'm going to squint at you. It's like wanting to find new customers and you're going to start the new business strategy with a tight focus on credit card swipes.
So, look, frictionless Visa card swiping is gonna be something that, of course, we'd all want to do from an operational excellence standpoint, but it's only relevant after users decide to buy.
First things first. And first, they gotta have a goal that the thing fulfills. And that goal is going to be some kind of quadruple or quintuple aim kind of goal.
A goal that aligns with the why of the people that we want to change the behavior of. This is why all change management includes right up near the front, creating the case for change. What's the goal? What's the why there? Sidebar, but now my brain is spiraling.
Challenges with EHR Strategies
I saw a bar chart by Phil Ballentine the other day in Nikhil Krishnan's "Out-Of-Pocket" newsletter that showed, in the USA, in 2024, there are 18,982 live instances of Epic. Each one of those 18,982 live instances are all different. Different workflows, separate data, different ways to do the same thing. So even if having an, in air quotes, epic strategy actually was a complete master plan to change behavior in clinic, healthcare has no nationwide, everywhere it's all the same, so figure out your thing once and you're good to go thing going on.
There are 18,982 differences of opinion out there, but here's the actual and big kahuna real reason why I'm leery. An EPIC strategy is not equivalent to a change management strategy. That's the real point that I want to make.
It's necessary, very necessary even, but not sufficient. You want to make the way as easy as possible once the why goes down and the case for change is made, but even if it's one click and not your usual 14 to 60 clicks, there's no why there, there's no automatic case for change that slithers out of anybody's API like a spontaneous miracle.
I said this last week, too. Lots of things are really pretty easy. Lots of things are in EPIC. Yet no one uses them. I mean, let's talk about actually reading most of the best practice alerts that pop up. How about consistent use of smart sets in the majority of those 18,982 instances?
Ashleigh Gunter on Effective Change Management
Anyway, I couldn't be more pleased to have learned a thing or two from Ashleigh Gunter about change management and how to do this whole thing right. This conversation happens actually a while ago. It's re edited for 2024, call it a supercut, specifically considering change management at hospitals or physician organizations.
Ashleigh Gunther is president of Translucent Healthcare Consulting. She is also an expert in change management and how to align employees and staff so that an organization can move forward together. One quick spoiler before we proceed.
Steps to Successful Change Management
According to Ashleigh, there's five steps to effective change management that will ensure success.
Number one, having great leadership.
Number two, creating a case for change. This includes the whole why thing.
Number three, finding champions. Engaging people who have to change so that they can contribute and be supportive.
Four step over communicating. And then lastly and fifth, measuring how things are going and also celebrating small triumphs.
If you continue to be interested in this topic, do go back and listen to the show with Karen Root on shepherding innovation through a large company.
Engaging the Relentless Health Value Tribe
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[00:08:38] Rob Marty: Hi, this is Rob Marty. The Relentless Health Tribe has had a positive impact on my life since I first started listening two years ago. Support this tribe by leaving a review, subscribing to the newsletter, and, most importantly, inviting others to join the tribe by sharing the podcast with them. Go ahead! Forward it before you tackle that next project. Chances are the person you share it with will thank you.
[00:09:01] Stacey Richter: Thank you very much. With that, here is Ashleigh Gunter.
Interview with Ashleigh Gunter
Ashleigh Gunter, welcome to Relentless Health Value.
[00:09:08] Ashleigh Gunter: Thanks, Stacey. I'm glad to be here.
[00:09:09] Stacey Richter: We talk about transforming healthcare to improve outcomes and lower costs at the same time. I think what gets sort of lost in that glossy statement, I mean, I hear stories, not good ones, about how something that was pretty creative and had the best of intentions failed. But let's talk about change management in that context.
[00:09:35] Ashleigh Gunter: That story is so common. I'm doing something great for my population. We have this mindset of, if we communicate to people, then they're going to like it, right? We're going to tell them in advance and, and they're going to understand that we are inherently good people and, and we're making this change for them.
The reality is that communication in and of itself isn't change management. I will tell you a hundred percent of the time when I actually go through the process with an organization of building a change management plan. And when we don't do that, and I've seen it over and over again, we get people who don't trust that management is doing this for their benefit. They think that the executive team is just trying to save a buck. Healthcare is such an emotional thing, not taking the time to invest in the process of change management is really super detrimental to getting to the place that you have good health outcomes and lower cost and providers who are paid fairly. It's so important.
[00:10:44] Stacey Richter: Yeah, it just reminds me of there's a parable or a quote, which is sometimes the shortest way home is the long way around. Let's talk about I could see as being very vital, you know, let's just say there's a direct contract. How does this work on the provider organization side of the equation?
[00:11:03] Ashleigh Gunter: That's a great question. Honestly, I think we all assume that doctors are really smart people because they are. They've been to medical school and the, the challenge is that oftentimes we just assume doctors are going to understand a different payment model and a different process without us actually spending the time to educate and bring them along through the process.
And in my experience, doctors are incredibly smart people, but they didn't go to business school. They went to med school and they have people in their office at the front desk and their nursing staff and their revenue cycle staff. And there are processes that exist that aren't necessarily always set up to address these direct contracts.
And so the minute we change the process and an employee comes in with a card that doesn't look like the one they're used to at the front desk, we create disruption for the doctors. So you have to go through the exact same process of creating this case for change for the doctors and their offices. So they understand what's in it for them, and the answer to that is more control over how they get to treat their patients and greater revenue, more time to spend with their patient population, but that there are some bumps in the road in that they need to be able to handle a situation that their current EHR isn't necessarily built for and their current internal processes haven't been built for.
So spending the time to educate them upfront, create that raving fan and yes, this is the right answer for medicine and for me and then building out, you know, those processes and the right technology support to ensure that providers can handle these direct contracts is incredibly important.
[00:13:06] Stacey Richter: Yeah. And just to put a fine point on that, I was just reading reviews of an innovative direct contract that somebody had set up. So there was a health plan that was offering a kind of an innovative service and did a direct contract with a number of different provider organizations. Employees go to those provider organizations and the front desk person says that she or he has never seen this card before, they have no idea what to do with it.
It's like, OK, that's a fail right out of the gate. Everyone just lost. So there's certainly at a minimum a measure of training as part of this process that obviously didn't happen. You know, like this whole thing gets put into place with very little consideration relative to any sort of operational aspects, which I think it's funny because I was just having a conversation about this with someone the other day, just talking about how so often in healthcare, it seems that operational considerations get ignored.
Like for example, the whole thing with, you know, team based care, which is getting a really bad rap because if you just say, okay, we're going to work as a team, if you do that really badly, then now we went from someone being accountable for the results or patient outcomes or patients in general, to like no one being responsible.
[00:14:36] Ashleigh Gunter: No one being accountable.
[00:14:37] Stacey Richter: Yeah. Everything suffers.
[00:14:39] Ashleigh Gunter: Let me give you this other example. So think about it from this perspective. A patient comes in, the front desk figures out that yes, in fact, this is a directly contract patient. Great. However, the person who is doing the coding, doesn't get that message, and so they code as fee for service as opposed to direct contract.
And so all of a sudden, you've got this claim that is a fee for service claim in the EHR getting sent out to the TPA. And you've got this mess on your hands when the claim gets denied, everybody's confused and frustrated. The patient is thinking, well, wait a minute, you know, this is supposed to be covered as a part of my direct contract. What's going on here? So, It's this really challenging situation where you want to ensure you are educating the operational folks, whether it's rev cycle or your front desk or whomever it is, so they truly understand. You're using a different model, whether it's, you know, a prospective payment or it's just a direct contract at a percentage of Medicare or whatever the situation is, but ensuring that it's all flowing through the doctor's office appropriately. And avoiding that headache for both the patient and the practice.
[00:16:07] Stacey Richter: It's a challenging situation that doesn't need to happen. It's like an avoidable readmission, right? Like just doing it right up front can prevent these downstream headaches, which wind up taking five times as long than if it had just been sort of thought through up front from not only a what do we want to do standpoint, but from a how are we actually going to operationalize this? How are we going to communicate? So let's talk about change management for a sec. Like, is it a science? Is it a discipline? What is it? What are we talking about here?
[00:16:41] Ashleigh Gunter: It is a science, but it's also an art. Change management is the process that an organization and good leaders use to help move through the process of change.
There's nothing rocket science about it. I honestly, when people say change management, often people think It's either a communication plan or it's something super esoteric that causes us all to sit in a circle, hold hands, and sing Kumbaya, which is absolutely not the case. It is truly a set of steps that we go through to build some leadership, build a case for change, help engage the stakeholder population, help them understand what's going to happen in this change, communicate over and over and over again, and then actually celebrate once that change is made and talk about the amazing things that we've accomplished as a team.
The Role of Leadership in Change Management
[00:17:35] Stacey Richter: From what I understand, there are five main steps in a change management process. You mentioned before that the first step is great leadership.
What do you mean by great leadership? What is great leadership look like?
[00:17:48] Ashleigh Gunter: Change starts at the top in any organization, whether it's healthcare or any other situation. You have to have a sponsor who fundamentally believes that making a change in your benefits plan is the right thing for the employees and the right thing for the organization. And you have to have a leader that's willing to say that over and over and over again.
And then, you know, we ask that leader to build a team around him or her to help be the advocates for that change. Without that leadership team, it will fail without leadership.
[00:18:25] Stacey Richter: If the leader is not on board here or is not modeling, their behavior in alignment or congruently with the change, then you get what could be, I could see, an insurmountable sort of disconnect.
[00:18:40] Ashleigh Gunter: Right. You get a disconnect because if my leader's not engaged, why should I be engaged? There's, you know, there's no incentive for me. There's no, there's no benefit for me to do something if my leader doesn't think it's important. So leadership sets the tone.
[00:18:56] Stacey Richter: And then step two, after great leadership is creating the case for change.
Creating a Case for Change
[00:19:03] Ashleigh Gunter: That's right. One of the things that makes the change so hard is that it's so complicated. When we talk about this conceptually, the idea makes perfect sense at a 10,000 foot level. But when you start to drill down into the details. There's lots of complexity there. And so to get through the hard work that it takes to make a change, you really have to create that reason to do it.
So what's the company reason to make this change happen? You know, what is it that, that they're trying to achieve that they can achieve through making this change? So getting really clear about that and also getting clear, because if we think oh, sure, Mecca exists out there. We can go to this wonderful place, but, but I don't have any way to get there.
Then it's much harder to rally a group around trying to get to Mecca if you have no mechanism to get there. So what is it that you're going to do to make this change happen? And putting that in plain English, explain what's going on. That's so important when you're creating that case for change.
[00:20:13] Stacey Richter: What I'm distilling you saying down to is that established behavior patterns, change is always a little scary and a little bit frightening, and it might be a little bit more time consuming because I'm going to have to learn the new way to do it. I'm going to have to learn how to navigate in this new space. So if I clearly understand what I'm getting, like what the what's in it for me is, I'm much more willing to deal with this sort of short term pain because the long term gain is clear.
The Importance of Change Champions
[00:20:44] Ashleigh Gunter: That's 100 percent it. And that is why the next step is focused on creating change champions.
[00:20:51] Stacey Richter: Let's talk about change champions.
[00:20:52] Ashleigh Gunter: This is the single biggest thing after creating great leadership that I think an organization can do to. to create success when making a change in their benefit plan. Bring in individual contributors or supervisors or, you know, folks who are on the front line who are vocal in the organization, maybe have some Influence in the organization in that other people listen to them, bring them into this conversation, help them to understand, you know, just like you've helped the leadership team to understand, okay, here's what's possible.
Let's talk about crafting a plan together. So bring them in early. Let them participate and let them be the advocates to their peers. It's in those situations that I see the trust being built. The message is coming from multiple places and it builds trust.
[00:21:54] Stacey Richter: Yes. And I think that's very well established.
I'm just recalling Geoffrey Moore, the old "Crossing the Chasm" book that where this is proven pretty endlessly that having peer champions who really understand this very well and can talk to their colleagues in the language of their colleagues, you can't say enough about that. And it's the stuff that lots of people forget.
It's the same thing. And I know we're going to get to this. later, but people, you know, stick something in the EHR and then wonder why nobody's using it, or there's an app and they wonder why. And then, you know, it's kind of like, well, how many doctors were on the committee? How many nurses were on the committee? How many patients were in that room when this was decided? And yeah. It's no surprise.
[00:22:42] Ashleigh Gunter: It's interesting though, because, you know, oftentimes when companies think about change, they don't apply a change management approach just because they think, oh, this is a simple change. Well, when you're talking about transformation and doing some bundled contracts or direct contracts or any of the things that you might undertake that lead toward value-based care, It's a real change and it should be treated just like any other major change in the organization.
[00:23:14] Stacey Richter: Well, I mean, not only is it a major change, but it's also healthcare. So like, there's that.
Over-Communicating for Success
Let's talk about step four then, which is over communicate.
[00:23:24] Ashleigh Gunter: My favorite statistic is from John Kotter, who is, you know, the expert on change and is a professor at Harvard Business School. He says that most executives underestimate the need for communication by a factor of 10.
And it's, it's so interesting to me because I see this in my own company, right? I communicate something and I think I've done this really good job of, I told a group of people, I told the leaders, I had them cascade, I sent out a message and, you know, I put it in the company Slack channel and I find people who have no idea, you know, what I've communicated.
And it's simply because there's so much communication that happens. in any given organization, that the messaging just gets diluted. And so as a leader who is undertaking a major change, it's something you have to focus on over and over and over again. And, and you probably get sick of, you know, I'm saying it, but that's the way that you get to the point that the employees hear the message. And so communicate, communicate, communicate.
[00:24:33] Stacey Richter: Yeah. And it's the same sort of thing in marketing. Like there's an often cited marketing trope or truism that you have to communicate a marketing message nine times before someone remembers it. And, again, although this is very well established, the whole nine times thing, not many people manage it when rolling out internal initiatives. I mean, maybe they're pressed for time, maybe it's boring to say the same thing nine times.
[00:25:00] Ashleigh Gunter: They get bored, but, but also what happens is people think. I'm belittling them because I've already told them this, they don't need to hear it again. So it's interesting the number of rationales that I hear from people. The reality is you just got to say it 10 times.
[00:25:15] Stacey Richter: Well, I think also, especially if something is complicated and there's a lot of nuances, The number of communications could help layer on additional understanding or aspects of it. It's not like they go from zero to 100 on the 10th time, is that every single time they hear it, they understand a little bit more.
[00:25:39] Ashleigh Gunter: That's absolutely right. We start with those kind of pieces of information that help an employee population get their hands around, like, what's the scope of this problem? And then we begin to move into, and, and fixes exist, right? So there are ways for us to impact this problem. There are ways for us as a population to be well and to, save money and to compensate our doctors appropriately.
And then from there, we start to move into specifics around, okay, so what does that mean here in our organization? And then where do you get support? And who can you call for help? Building from that sort of general of what are we even talking about here through to, okay, I understand, I know who to call when I need help and I feel empowered.
[00:26:29] Stacey Richter: It sounds like you start with the why, you get into the what, like what we're doing here, but then we can't lose track of the how. Which I think is the very, very frustrating when someone finds themselves at loose ends because they know there's a new process, but they don't know what it is or how to go about it.
Measuring and Celebrating Success
Exactly. Okay. So let's move into step five in which we measure.
[00:26:51] Ashleigh Gunter: Yeah, so it's really important. One, that we're getting feedback. How did that go? What would have made it easier? Because you can learn, but you also want to measure the success, and then we're sharing that information back, not only with the executive team, but on the whole to say, so here are the wins that we're achieving.
We know this was a hard road. We know it required change. We know it was a little bit bumpy at times because it will be, but here are the results that we're seeing. So sharing great stories about a particular person or whatever the story is that's relevant to that particular organization.
[00:27:28] Stacey Richter: So it sounds like that last step there not only includes measuring, but then also communicating the successes.
[00:27:35] Ashleigh Gunter: Absolutely. Celebrating those wins is a way to cement that we've made this change. It was the right change. Kind of prevents buyer's remorse that occurs sometimes when you hit a bump in the road. Oh yeah, no, this is why we're doing this. Here's the benefit for us and isn't that great?
Conclusion and Contact Information
[00:27:53] Stacey Richter: Obviously, change management, it's a thing. It's a whole discipline. If someone is interested in the work that you are doing over at Translucent Healthcare Consulting, where would you direct them for more info? What's your web URL?
[00:28:08] Ashleigh Gunter: It's translucenthc.com.
[00:28:11] Stacey Richter: Ashleigh Gunther, thank you so much for being on Relentless Health Value today.
[00:28:16] Ashleigh Gunter: Thank you for the time. I really enjoyed it.
[00:28:18] Rob Marty: Hi, this is Rob Marty. The Relentless Health Tribe has had a positive impact on my life since I first started listening two years ago. Support this tribe by leaving a review, subscribing to the newsletter, and, most importantly, inviting others to join the tribe by sharing the podcast with them. Go ahead! Forward it before you tackle that next project. Chances are the person you share it with will thank you.