As part of our operational effectiveness program, the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital created quarterly performance and quality improvement workshops. These workshops morphed into best practice sharing sessions between our hospital and more than a dozen additional hospitals in our health system to engage suppliers in sharing their best practices with us. One was General Electric (GE), which provided an overview of their Change Acceleration Process (CAP) with our managers and executive staff. This process improvement method was identified as a best practice for the health system, and thus was chosen by our chief information office to be utilized in the development and deployment of our EHR initiative.

Our facility, located within the city’s Oakland neighborhood, is an adult, medical-surgical referral hospital and a site of ongoing research, in conjunction with the University of Pittsburgh School of Medicine. A renowned center for organ transplantation, our hospital also is a recognized leader in cardiology, cardiothoracic surgery, critical care medicine, and neurosurgery; in addition, UPMC is a designated Level I regional resource trauma center.

To fully understand what would be required for the EHR project to progress seamlessly, project leadership invited 90 hospital managers and executives to a three-day design session to help them better understand the scope of this enterprise initiative. As we had previously been using paper health records, converting to an EHR required significant planning and oversight. This robust brainstorming/education session was a critical part of our process, as one of our main goals was to engage leadership in evaluating the required steps and determining the best option for deploying the EHR. Our main consideration was whether to deploy the new application hospital by hospital or throughout the entire health system at one time. Another goal was to provide the leadership with an understanding as to which applications were in and out of scope. To evaluate this, we needed to create an understanding of the needs of each organization within the health system and the associated issues of keeping legacy applications running. At the end of that three-day meeting, we had mobilized commitment for moving forward with the EHR project.

Initiating the Change Process
The GE CAP model is a flexible, nonlinear method that can be used with any institutional change process. It is a strategy for influencing staff choices and behaviors, intended to facilitate commitment and behavioral changes through team dialogue and action. The process of leading change starts with having a champion for the project, who creates a shared need by demonstrating and sharing the reason for change, followed by shaping a vision, mobilizing commitment, making change last, monitoring progress, and changing systems and structures.

Changing staff beliefs from the assumption that the old, familiar methods are preferable to new ideas—and helping them believe in the effectiveness of the new process—is the most important element of implementing any effective modification to existing processes. One way to understand this approach is to visualize the bookends on either side of a book shelf; the left bookend is leadership, and the right bookend is the changing of the organization’s systems and structures to reinforce the behaviors that are needed to support the achievement of the project’s objectives. In between these bookends are the progressive stages for maintaining the gains of your initiative and for preventing staff members from reverting back to the old way of doing business. In addition, these stages also contain all the tools and techniques necessary for engaging the heads and hearts of the project’s key stakeholders, as well as staff members. 

This requires both a process and a collection of change management tools and techniques. Our health system found several tools and techniques to be useful:

• Facilitate conversation around the understanding of short-term versus long-term goals and the benefits of creating a shared understanding of the need to change
• Use a picture frame and have staff affix paper notes to record what they believe is within the scope of the project (within the frame) and out of scope (outside of the frame)
• Use white boards for the participants to describe their vision—what they expect to see, hear, and feel as a result of a successful project implementation
• Engineer early wins and integrate their performance and quality improvements with other initiatives
• Create a dashboard to monitor success

The availability of a wide cache of tools, as well as the ability to choose from the most effective ones to achieve your goals, will best ensure success. Not every tool or technique must or should be employed for every project, and accurately gauging which tools to employ is vital to an effective transition from one process to another. 

Overcoming Resistance to Change
Staff resistance to change is oftentimes one of the most pervasive problems encountered when implementing a new system or workflow adjustment. Many project managers fail to realize just how vital effective leadership is when motivating staff from the past way of thinking to the future state. Convincing staff not only of the quality of the new solution, but also helping them comprehend the need for the change, is the crux of any successful automation implementation orproject (see Sidebar). 

Many staff members’ initial reaction is denial that change is necessary, followed by resistance to the change, either passively or actively. As a leader, a significant job responsibility is not allowing your staff to wallow in this resistance. Encourage them to visualize the benefits of the future state for themselves. The next milestone is to see your staff express their commitment to the future state and the organization’s new way of doing business. If this transition is not properly managed, initiatives can turn into fads, and any benefits received will not last in the long-term. 

Benefits of Implementing EHR 
EHR applications advanced the quality of patient care in several ways. The EHR replaced paper charts, which can be misplaced or damaged. In addition, the need to maintain a paper trail of vital signs, prescriptions, and test results was eliminated. Physicians and other caregivers can now view x-rays, review test results and lists of current medications, and electronically send prescriptions to the pharmacy without utilizing an error-prone manual process.

Conclusion
With any process shift, staff resistance will be encountered and this skepticism is oftentimes the most significant obstacle to ensuring a successful project. Helping the key stakeholders understand both the causes and the magnitude of the cultural, economic, and political sources of this opposition is critical. Once understood, then you can start to develop approaches to eliminate or mitigate these challenges. 

By engaging our vendor, we were able to leverage a best practice to reduce resistance to change and mobilize commitment moving forward. This initiative ultimately resulted in increased communication among caregivers and improved patient outcomes.

Brian J. Sesack, RPh, MBA, is a unit-based pharmacist with the UPMC Presbyterian Hospital’s department of pharmacy and a member of the adjunct faculty with Duquesne University’s School of Leadership. In addition to his clinical duties, Brian is responsible for the Pharmacy Practice Resident’s Strength Based Leadership program and the pharmacy department’s Performance and Quality Improvement experiential learning rotations. He received his BS in pharmacy from Duquesne University and his masters in business administration from Fordham University.

Suggested Reading List 

• Bennis W. On Becoming a Leader. 4th ed. New York, NY: Basic Books; 2009.
• Bridges W. Managing Transitions: Making the Most of Change. 2nd ed. New York, NY: Da Capo Press; 2003.
• Jaffe DT, Scott CD. Mastering the Change Curve. 2nd ed. King of Prussia, PA: HRDQ; 2003.
• Johnson S. Who Moved My Cheese: An Amazing Way to Deal with Change in Your Work and in Your Life. New York, NY: Simon & Schuster; 1998.
• Kotter JP. A Force for Change: How Leadership Differs from Management. New York, NY: Free Press; 1990.
• Noer DM. Breaking Free: A Prescription for Personal and Organizational Change. Hoboken, NJ: Jossey-Bass; 1996.
• Sesack B, Pexton C. Accelerating Change at UPMC Health System. San Ramon, CA: GE Medical Systems; 2002.

Workflow Considerations for Carousel Implementations
A change management program can assist in automation implementations of all types; for example, if an organization is planning to implement medication carousels, utilizing this method can help pharmacy leadership gain a full understanding of staff’s perceived barriers to an effective implementation that rolls out on time and within budget. This approach also can provide managers with the opportunity to gain an understanding of their staff’s training needs, since new skills, knowledge, and abilities may need to be developed to ensure success.

While each hospital implementing carousels will have different requirements, central to every organization’s success is the creation of a flexible and resilient workforce, as this provides a vehicle for meaningful dialogue between staff and management and thus facilitates a culture of project ownership among staff.

Funding
Be sure to evaluate the available budget to determine the likelihood and timing of funds. Will adequate funds be available to purchase a sufficient number of carousels for all required areas in the hospital? Will any additional FTEs be required, and if so, will these funds be available? 

Implementation and Testing
Plan to build, load, and test the carousel on less demanding shifts; alternatively, temporarily change the dispensing and distribution schedules to create this window of opportunity. Creating capacity will likely be hospital-specific. It might be possible to outsource certain activities or substitute premixes for IV products that need to be compounded. In addition, it may be prudent to hire temporary staff or schedule overtime for your current staff.

Staff Engagement
The size of the hospital, as well as the number of carousels being implemented, will determine staffing requirements. Engage staff from the outset of the project to evaluate how the initiative will impact their duties and workflow. It may be valuable to use white boards or poster paper to provide staff the opportunity to describe their vision, in both words and pictures, for a successful implementation project and to identify any perceived barriers. In addition, organize them in small work groups or teams during your design sessions and have them report out their findings to each other, which is an effective method of encouraging creative thinking. 

Training
Encourage staff to identify the desired types of training they prefer (eg, just-in-time, classroom, video, podcasts) versus training they find less valuable. Ensure that training occurs in three phases: before, during, and after implementation. Prior to implementation, conduct walk-throughs or model what the new work steps will be; during the implementation phase, use intra-shift huddles to uncover practices that are working and those that are less effective; and post-implementation, recap results and lessons learned.

Drug Distribution
Utilizing a change management program can help determine a plan for drug distribution during the transition to using the carousels. Carousel technology provides additional medication safety benefits compared with a manual process, but it is imperative to also develop a backup plan in the event the technology is down, as well as to ensure drug distribution throughout the implementation. Using parallel processes during the carousel implementation is a prudent approach. 

In addition, when automated technologies are not functioning, this situation provides a useful opportunity to reevaluate existing processes. For example, if a carousel goes down, consider this an opportunity to reevaluate what is dispensed from the pharmacy operation and what is kept on the patient units as floor stock.

Adopting a backup plan is a sensible approach because every project has at least two unknowns: the known-unknown (you know that you are unaware of the answer to an identified problem), and the unknown-unknown (you are unaware that there may be a problem). The availability of a backup plan during the implementation phase best ensures timely drug distribution, even when unknown variables are uncovered.