How to Change an Organization Without Blowing It Up

Too often, conventional approaches to organizational transformation resemble the Big Bang theory. Change occurs all at once, on a large scale and often in response to crisis. These approaches assume that people need to be jolted out of complacency to embrace new ideas and practices. To make that happen, senior management creates a sense of urgency or takes dramatic action to trigger change. Frequently, the jolt comes from a new CEO eager to put his or her stamp on the organization. Yet we know from a great deal of experience that Big Bang transformation attempts often fail, fostering employee discontent and producing mediocre solutions with little lasting impact.1

But meaningful change need not happen this way. Instead of undertaking a risky, large-scale makeover, organizations can seed transformation by collectively uncovering “everyday disconnects” — the disparities between our expectations about how work is carried out and how it actually is. The discovery of such disconnects encourages people to think about how the work might be done differently. Continuously pursuing these smaller-scale changes — and then weaving them together — offers a practical middle path between large-scale transformation and small-scale pilot projects that run the risk of producing too little too late.

Researchers tend to overlook this option because few managers have employed it until recently, assuming they needed to take an all (Big Bang) or small (pilot projects sequestered away from the dominant organizational culture) approach to organization change. That may have been more true in the past when organization boundaries were less malleable, communication more difficult and people less mobile. However, today’s complex and connected global environment makes step-by-step transformation by managers inside most organizations a real possibility, if senior leaders recognize and help cultivate their employees’ collective capability to discover everyday disconnects. Organizations can practice uncovering these disconnects on a scale extensive enough to make a real difference, yet at a rate that keeps the effort focused and manageable within budgetary and time constraints.

My research has found that organizations take three approaches to discovery that are particularly effective both for uncovering everyday disconnects in their work and for seeding transformation from the bottom up. (See “About the Research.”) These techniques can be used together, in any combination, or individually. All three techniques share a common trait: They take rigid, prescriptive activities like work design, best practices or training; strip them of their chief assumptions; and turn them into powerful instruments for finding new and better ways of getting things done.

The three techniques are:

1. Work discovery: Instead of assuming that you know how work is designed, examine it firsthand as it is actually conducted. Determine how to turn the (inevitable) surprises you uncover into assets.

2. Better practices: Instead of simply adopting other organizations’ best practices, screen the way work gets done in your organization through those best practices in order to generate new ideas. In other words, use best practices to generate even better practices.

3. Test training: Instead of locking down standard operating procedures during training, experiment with other, potentially better possibilities for changing the way the work will get done. Use training for testing these possibilities.

Each technique strips away assumptions and gains additional power by pairing something unfamiliar with something familiar. Work discovery pairs the familiar territory of managers’ offices with the less familiar territory of frontline operations. A focus on better practices imports the unfamiliar into the organization via others’ practices and pairs them with the (familiar) way work is currently being done. Test training pairs new standard operating procedures with possible new procedures that emerge during training. Such pairings prompt people to look beyond familiar expectations and see the actual work in light of the possible instead of just the prescribed or presumed. By using these techniques, people throughout an organization can collectively surface everyday disconnects, see new possibilities in deeply familiar contexts and generate new ways of working. As a result, improvement multiplies methodically, reliably and continuously, and you can achieve continuous, sustainable change in the organization without having to blow it up and then reassemble the pieces.

The Three Discovery Techniques

Generating new possibilities for organizational change requires a collective capacity to see beyond what is currently done. Yet moving past what we expect to see and identifying new possibilities is not a capability that has been cultivated widely, either by individuals or by organizations. Absorbed in our everyday work, we overlook possibilities right in front of us. That’s a problem. After all, renowned management thinker Peter Drucker once explained his ability to generate insights by saying simply, “I just look out the window and see what’s visible — but not yet seen.”2 As Drucker suggested, the ability to see past what is currently seen — and, in the workplace, currently done — is essential for transformation. Fostering this capability begins with implementing discovery techniques.

Work Discovery: Examine Firsthand the Work Where It Is Actually Conducted

Seeing the organization’s work as it is conducted by people on the front lines takes senior managers and others out of their familiar habitats and enables them to compare close-up observations of the work with their expectations, uncovering disconnects in the process. Consider, for example, how people in ThedaCare Inc., a medium-sized community health system in Wisconsin, created a new model of inpatient care. Known as collaborative care, the model has garnered national visibility for its exceptional quality and safety, as well as patient and clinician satisfaction. This model is designed around the patient, pulling care to the bedside whenever needed and enabling staff to focus on getting patients well.

For Kathryn Correia, senior vice president of ThedaCare at the time, the origins of the innovative collaborative care model began in 2003. Seeing her job as bringing out the best of the organization, she looked around the hospital, searching for possible answers to questions such as: “What is it that has to be right? What is the most important thing a hospital actually contributes to the delivery of high-quality patient care, versus the many things that we do in little clusters such as radiology, lab, outpatient surgery, respiratory therapy?” Early conversations ensued with managers and clinicians (including nurses, physicians and pharmacists) around these questions. To look more closely at the hospital’s emergency, inpatient and outpatient flows of care delivery, Correia brought together a broad group of clinicians and managers from across the system. Because each clinician knew only part of the flow of patient care and the managers weren’t in constant contact with direct patient care, the group decided to map the current care delivery flows from the viewpoint of patients.

They could have taken a different approach, of course. For example, they could have sat down with a flow chart and figured out inefficiencies; they could have identified how medical/surgical units are organized in other systems; or they could have searched the literature for ideas that had worked at other organizations. Instead, acting as if they were patients, the group members followed the paths typical patients take in receiving care. Those following an inpatient’s path experienced the flow from admission to discharge. Those following an outpatient’s path experienced the flow from visiting specialty physicians’ offices to getting tests done and returning to the physicians’ offices.

The managers and clinicians soon noticed that once patients made contact with ThedaCare’s system and were admitted, the care flow was anything but clear. Patients went off in different directions depending on what tests were ordered or why the patients had been admitted.

When the clinicians and managers came back together, they realized there was no way to map the care flow. While they could see how patients got into the hospital through the admission process, they had no clear idea of how patients got out. There was no obvious pattern for how patients moved through the system to get well and be discharged.

Having uncovered the disconnect between their expectation (that there was a clear patient flow) and the reality (that there wasn’t), the team wondered if they might benefit from walking alongside real patients in order to get a deeper understanding of patients’ actual experiences of the care flow. Members of the team were assigned to individual patients and asked them to describe what was going on for them during each step of their experience. Convening afterward, the group agreed that the results were eye-opening. They had seen for the first time how much the outpatient and inpatient flows were interfering with each other and with getting patients well. For example, if it was midafternoon and inpatients needed tests in radiology to determine if they could go home, they had to wait until they could be squeezed in between previously scheduled appointments — often causing hours of delay.

Above all, the team members noticed how much of what went on actually got in the way of care and created negative experiences for patients. A particularly revealing example was the long distances outpatients had to walk to get to labs so they could undergo tests that doctors had prescribed for them. Walking with the patients, the team members observed that some — for example, the elderly, pulmonary patients (who have trouble breathing) and others who were seriously ill or severely out of shape — were out of breath by the time they reached the blood-work lab. They saw patients struggling and worrying about being late as they tried to find their way through the seemingly endless corridors. No one had noticed this before. The system was placing undue burdens on these patients. The clinicians and managers had not expected that, and they knew it was definitely not how they wanted to treat patients. As one manager later said, “It was a big ‘aha.’ And it helped make visible that we were doing neither inpatient nor outpatient care as well as we would like.”

This “aha” moment brought quick agreement to focus first on redesigning inpatient care. And it helped the team members realize that while they wanted to deliver the best care, their hospital’s current efforts were vague at best and chaotic at worst. Extraordinary efforts were often required to advance patients through the system. For example, nurses would need to make repeated “hurry-up” calls to obtain overdue lab results needed to determine what antibiotics the patient should receive. The prevalence of these efforts pointed to the critical role of nurses in providing ongoing, high-quality care. By the end of the initial stage, the team members all had vivid, firsthand experience of critical disconnects, and they were beginning to generate alternative possibilities for how work could be done differently.

Embracing the need to change inpatient care delivery, hospital clinical staff and managers, in conversation with ThedaCare leadership, undertook the building of a new model. A new, smaller design group again followed the flow with patients, this time creating a highly detailed chart of the current inpatient care process and paying close attention to how this process kept patients in the hospital, with little work consistently directed toward helping them get out. This approach contrasted with a common hospital practice of hiring utilization review nurses (“care managers”), who assemble documentation focused on justifying to insurance companies why patients are admitted and need to stay longer.

The vice president of nursing described how the team “realized at a different and deeper level that the old process was oriented to justifying patient stays. We needed a different process — one that focused on optimal recovery and on pulling the patient through the hospital system.” In the ensuing months, the organization’s leadership supported the team’s efforts to build a new model. For example, the team noticed that nurses lacked important information about why physicians pursued specific treatment plans. Having that understanding of care was not only useful in answering patient questions but also critical in identifying potential errors, such as improper treatment sequencing. To address this and other concerns, all clinicians were given access to the context and rationale of a specific treatment plan as part of the care process redesign, and a clinical trio, comprised of a nurse, physician and pharmacist, was created. The trio met together with the patient and family to determine a single plan of care.

The new model of general acute care the organization created, which ThedaCare calls collaborative care, enables staff to think about patient stays with an emphasis on getting patients well. In contrast to models organized around medical condition, the collaborative care model is designed to help advance all patients similarly through the system, regardless of medical diagnosis, while also accommodating each patient’s unique needs.

The scope of change in process was extensive. The doctor, nurse and pharmacist trio would collectively meet with the patient and family within 90 minutes of admission. The electronic medical records were redesigned to reflect a single plan of care. The typical centralized nursing unit was replaced with multiple nursing alcoves located just outside patient rooms. And patient rooms were designed for safety, privacy and easy interaction with the care team. Designed during 2005 and 2006 and first implemented in February 2007 in one medical-surgical unit, this care model has subsequently spread to all medical-surgical and many specialty units with dramatic results. When patients in the initial collaborative care units were compared with like patients on non-collaborative care units, the team found that average length of stay decreased by at least 10% with the new model, and direct costs decreased on average 20% to 25%. Nurse productivity increased by 11%, and the percentage of patients who were satisfied with their care increased to 95%, up from 68% prior to implementation of the new model.3

Although the implementation of collaborative care at first glance looks similar to a traditional pilot project in that it involved the use of a design team and was first rolled out in one unit, it was conceived as part of a larger exploration of what care delivery in the broader system at its best might become. The initial unit design and rollout was always connected to this larger possibility, even though the possibility itself was in the process of becoming defined.

The care process redesign did not start by trying to improve unit functioning and then scaling up. Rather, the team began by exploring care delivery through mapping inpatient, outpatient and emergency care flows. Only after examining actual patient experiences and learning how their system burdened patients were the team members able to settle on inpatient care as a starting point and to imagine real possibilities for designing a fully patient-centric care model.

Finally, while implementing the new model in the first unit, staff and leadership examined and identified the specific units next in line for the new model. This examination prompted consideration about what parts of the collaborative care model were essential to retain and what could be altered in spreading the model to subsequent units. Those involved in the first unit rollout had come to understand that the relational aspect of the model was most important to retain. It mattered that the nurse, physician and pharmacist trusted each other and interacted well with each other and with the patient and family. While other parts of the model might be altered, the collaborative clinical trio would remain.

Better Practices: Instead of Adopting the Best Practices of Others, Screen Your Work Through Those Best Practices in Order to Generate New Ideas

Organizations often devise new ways of working by simply adopting best practices used elsewhere. But such best practices can be more effectively used as a discovery technique, enabling people to go beyond replication and discover new possibilities for meaningful change.

Using others’ best practices as a discovery technique asks people to compare their expectations of how work is currently done with what might be offered by the best practice. This discovery tool imports the unfamiliar in the form of others’ best practices and pairs them with the familiar. Exploring this pairing enables people to move beyond their expectations and tease out new possibilities that are suggested by best practices elsewhere. Overlaying your current practices with someone else’s best practices in this way generates better practices — better than best because they are relevant in highly specific ways to your organization’s work.

Consider the checklist, a well-publicized best practice. It was originally created to reduce errors and standardize the behavior of airline pilots, and it has since been widely adopted in other contexts. To reduce errors in surgical settings, for example, the use of a checklist prompts members of the surgical team to identify aloud their names and the name of the patient, the procedure type to be undertaken and an itemized list of the instruments and equipment at hand. In exploring the use of the checklist, surgical unit staff members of an academic medical center were asked to use role-play as a way of experiencing what this best practice might offer for their own work.

In the role-play debriefing, staff members were asked two questions. The first question was, What would you do differently in your work as a result of practicing with the checklist, and what things do you want to incorporate as unit practice? The responses identified items that had been on the standard checklist as well as some additional ones, such as: Be sure the patient’s ID tag is visible; mark with a red pen or bright highlighter any patient requests or conditions requiring extra attention during or after surgery.

The second question was: What didn’t the checklist cover that you wished it had, and/or what didn’t you know how to address in its use? Instead of merely generating a list of items, this question prompted an exploration of different possible clinical relationships. The group considered not only who was responsible for a given activity, which was a question they had identified before starting the role-play, but why that particular person was responsible and whether only one person actually was or should be responsible. And they went further and asked: What would it take for doctors and nurses to work in full partnership? How might all clinical members work to their fullest scope? By considering what they didn’t know in addition to what they had learned in exploring what the checklist might offer, the staff could step back from their usual absorption in their day-to-day work and generate new possibilities for enhancing how they related with each other in delivering patient care.

Benchmarking, itself a best practice that identifies others’ best practices, can also be used to spur people to think about how the conduct of their work could be organized differently. In attempting to improve performance, organizations often compare their work processes, strategy and performance metrics to those of competitors. Such benchmarking tells you how your organization stacks up against best-in-class organizations and enables you to take action to close the gaps with them.

But benchmarking deployed in this way results in imitation. Granted, it is imitation of an organization believed to be the “best,” but using benchmarking to follow the leaders limits the usefulness of this technique for discovery by overlooking its potential as something unfamiliar that can be paired with the familiar to generate new ideas.

A university task force on curriculum redesign used benchmarking for discovery when it expanded the typical comparison group from competitor universities and their curricula to include the teaching conducted in corporate, military and nonprofit organizations. Widening the focus enabled unfamiliar organizations to be paired with the familiar content and sequence of the university’s teaching in its current curriculum. In exploring what the best practices in the more unfamiliar organizations might offer, task force members uncovered a disconnect — not in content, but in pedagogy. A prime example was the difference between the current university curriculum’s heavy use of teacher-focused lecture and in-class sessions versus the other organizations’ emphasis on learner-focused experiences. Incorporating ideas such as technology-enabled classrooms or student-generated content altered how traditional teaching occurred and broadened the notion of a course. As a result, task force members were able to step back from the usual gap analyses that benchmarking produces and not just consider the curriculum but also develop a more engaging model for teaching students that included learning beyond the classroom.

Test Training: Use Training to Experiment With Emergent Possibilities for the Way Work Will Be Done

Organizations typically test inventive solutions that are in final development in order to identify adjustments or refinements prior to full implementation. The benefits of this approach are well documented. Mistakes are identified and more readily corrected, opportunities for improvement are found and can be incorporated and the product or model is optimized and verified before full deployment.

In contrast to refining and establishing proof of concept, test training focuses on uncovering disconnects between people’s expectations for how proposed solutions might operate and the actual experience of the solution in experimental settings such as training or trials. This enables people to see and come to understand what they don’t know about the solution as well as to continue to shape it for implementation, often in significant ways.

Consider an example from ThedaCare’s design of its collaborative care model. To prepare for implementation of the new model, nurses from the unit were taken away from their normal duties for six weeks, and physicians and pharmacists joined them for intensive periods. Using volunteers as “patients,” clinicians trained together in a mocked-up collaborative care unit that matched the newly designed ones, with private rooms for all patients; newly designed supply servers outside the patient room yet accessible to clinicians inside the room; and, in place of the nursing station, a central area visible from all rooms. Part of the training was designed to inculcate new practices like getting accustomed to what would be stored in the new private rooms, using the new drug dispenser and using revised electronic medical records to assure reconciliation of medication.

A central feature of the new model was the creation of a trio of physician, nurse and pharmacist who would deliver care at the patient bedside. To be effective, the trio required its members to work as a clinical team, asking questions of each other in front of the patient and addressing patient questions as a team. So a second part of the training was designed to help clinicians see beyond their current expectations of how they should relate to one another and entertain possibilities for greater collaboration.

Organization development specialists on staff worked with nurses to help them see beyond their existing role, which involved nurses taking direction from doctors with little opportunity to give input, and instead become partners with physicians and pharmacists. As one specialist observed, “This is a different challenge for nursing staff — to be able to give to and receive feedback from other members of that professional team, especially if something is not going well.”

Conversely, organization development staff worked with pharmacists and physicians to help them let go of the expectation that they would perform all the important tasks. As one pharmacist said, “We were holding onto a lot of things that nurses were already double-checking and that the doctors were double-checking, so we needed to build more trust that it was being covered.” The line manager responsible for physician engagement noted that trial made “the biggest difference” in helping physicians accept being in a team with nurses and pharmacists in the patient’s room. They realized, she said, that they truly were in a team and that the pharmacist and nurse had something to add and contribute and challenge them on, in a more collaborative way. “The physicians now speak about the learning that they’ve received because a pharmacist or nurse is there,” the line manager said.

Takeaways About Designing Discovery Techniques

All three types of discovery techniques share characteristics that differentiate them from more conventional change practices. Building on organizations’ experiences implementing them, I have derived a set of key principles leaders can keep in mind when encouraging the design and use of discovery techniques within their own companies:

• Everyday disconnects should prompt collective reconsideration (discovery) of expectations or understanding of how work is conducted and the entertaining of new possibilities.

• Discovery techniques generate insights and possibilities for change because they help people come to see what they don’t know rather than confirming what they do know and maintaining the status quo.

• Discovery techniques operate by pairing something familiar with something unfamiliar to uncover everyday disconnects that illuminate people’s
expectations for work, and prompt consideration of how it might be done otherwise.

• Discovery techniques are deployed in the midst of, or close to, the doing of the organization’s regular work. When disconnects are uncovered, it is this close proximity that brings home the significance and impact of what is not being done, as well as the opportunity to generate new solutions.

• Instead of simply dismissing the current way of doing things as out-of-date, discovery techniques relate and draw upon the present, as seen in light of comparing expectations and actual conduct of work, in order to see future possibilities.

• Although individuals in some of the examples did separately notice everyday disconnects, discovery techniques work for seeding transformation because they connect such efforts and/or foster the collective uncovering and engaging of disconnects. By designing and adopting discovery tools that uncover everyday disconnects, organizations can:

1. Achieve the benefits of transformation without risking wholesale disruption of operations.

2. Build a culture of continuous improvement that is embraced by leadership and employees throughout the organization.

3. Avoid the often exorbitant costs of Big Bang transformation associated with wholesale replacement of employees.

4. Leverage existing employee knowledge and experience for transformation.

5. Cultivate collective, not just individual, capacity in surfacing disconnects and generating new insights and ideas that seed transformation.

Most importantly, organizations that cultivate the uncovering of everyday disconnects and explore possibilities for meaningful change will find themselves no longer caught between the equally unattractive possibilities of Big Bang transformation or remaining in a steady state.