Transformative change refers to the process of changing an organization or a work unit that has probably performed well enough to maintain the status quo, but now needs to reinvent or transform itself into an entity that is much better equipped to respond to the challenges of rapidly changing external environment (Carayon, 2007). At John Hopkins Hospital, transformative change may mean addressing serious system problems that undermine patient safety, redesigning systems of care that curtail deficiencies and disparities of quality, as well as restructuring the work environment of the personnel. Carayon (2007) explained that transformative change requires the hospital to address performance deficit resulting from staffing shortages, long work hours and unsafe practices, or establishing a health information technology infrastructure that ensures a higher standard of care and culture of safety.
Transformative change occurs in response to the external environment and involves some combination of factors associated with environment, leadership, mission and strategy, as well as John Hopkins Hospital’s organizational culture. According to Wolf, Hanson & Moir (2011), transformative change challenges the core assumptions and values, and, therefore, it is difficult to manage at JohnHopkins Hospital. Some scholars argue that transformative change cannot be managed, because it involves moving from a known present state to an unknown future state. Wolf, Hanson & Moir (2011) claim that the change process must be crafted, shaped and adapted as it unfolds. When completed, the outcome is a radically changed organization that then needs to revamp its internal systems to restore stability and improve efficiency and quality, which are often disrupted by the radical change process.
Wittenstein (2008) indicates that transformative change can often be regarded negatively, at least by everyone at JohnHopkinsHospital, with the exception of change drivers. It is, therefore, important to note that transformative change can only occur if the members of the hospital change. Wittenstein (2008) maintains that “transformative change can include the development of differences in the structures, systems, policies and procedures, boundaries, functions or state of John Hopkins Hospital over time” (p. 6). Transformative initiatives at JohnHopkinsHospital mean that employees are empowered to adapt successfully to change, and that immediate self-interest is transcended. According to Carayon (2007), higher-order values are the focal point, making everybody feel that they are personally involved in organizational learning and bringing about a higher standard of care.
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Factors Supporting Transformative Change at John Hopkins Hospital
JohnHopkinsHospital’s readiness for change is influenced by the employees’ belief that they are capable of implementing the proposed change, that the proposed change is appropriate for the organization, that the leaders are committed to the proposed change and that the proposed change is beneficial to the organizational members (York, 2009).
Recognizing the need for change at JohnHopkinsHospital is a major factor supporting transformative change. According to Carayon (2007), under these conditions, the major leadership challenge is to convince other key people in the organization of the seriousness of the problem and the need to make major changes, and not just incremental adjustments. The management of JohnHopkinsHospital must ensure that there is a clear picture of the costs and undesired consequences associated with not making changes, which will help foster a sense of urgency (Carayon, 2007).
The second factor that supports change at JohnHopkinsHospital is its vision. The hospital’s leadership have over time been able to energize their workforce with a vision of an attractive future that is sufficiently compelling to justify the costs and uncertainties of changing comfortable patterns of behavior (Carayon, 2007). The hospital’s clear and appealing vision has significant desirable properties. Firstly, they provide a new sense of direction, give new meaning of the work and collectively raise consciousness levels in terms of being part of a worthwhile hospital. Carayon (2007) further indicated that with JohnHopkinsHospital commonly shared vision everybody knows what is important and how to separate the trivial from the non-trivial.
Commitment and trust have continually supported transformative change at the hospital. Carayon (2007) underscores the importance of commitment and trust, since they are closely tied to the consistency of decisions, statements and actions of the hospital’s leadership. York (2009) indicates that “the leadership of John Hopkins Hospital communicates values, priorities, and what is important by simply what they attend to, what they respond to and what gets them excited” (p. 322). Youngberg & Hatlie (2004) say that the hospital’s management support transformative change by reducing complexity and increasing predictability in day-to-day activities. Wager, Lee & Glaser (2009) note that “the members of the organization must trust the integrity, intelligence, compassion and skill of JohnHopkinsHospital” (p. 392). The members of the hospital staff must trust their leaders, who have thoughtfully come to the conclusion that the difficult change has excellent reasons behind it and represents the best option for the hospital (Wager, Lee & Glaser, 2009).
It is important to note that chairs of clinical departments, chief medical officer, chief nursing officers, nursing unit managers, director of quality improvement and pharmacy director are some of the important stakeholders who manage and enable transformative change at JohnHopkinsHospital. Youngberg & Hatlie (2004) note that “since work units are necessarily multidisciplinary, coordination of functional department based intervention is crucial for success” (p. 61). Good work unit climate and individual motivation at JohnHopkinsHospital have played a key role in transformative change (York, 2009). Youngberg & Hatlie (2004) note that the hospital’s workforce possess the right skills for the required tasks, and are working in a resourceful work unit climate, which is possible due to supportive and open culture. Incentives, which may be monetary or in the form of professional recognition, can help sustain new behaviors that are consistent with a safety culture.
Incentives at JohnHopkinsHospital have enabled transformative change. Wager, Lee & Glaser (2009) note that organizational members at the hospital are motivated to support change. At times, excitement with the vision is a sufficient incentive. If JohnHopkinsHospital’s staff lose their jobs or have their roles changed significantly due to transformative change, education that prepares them for new roles and or new jobs must be offered (Wager, Lee & Glaser, 2009). The hospital offers bonuses to key individuals, according to the success of the change and each person’s contribution to the change.
The leadership examples at John Hopkins Hospital give us insights into what leaders of complex healthcare care delivery systems need to be and do to transform these organizations. Cohn & Hough (2008) mentioned that the leaders at JohnHopkinsHospital are change agents, who are guided by a deep commitment to service. Gopee (2010) notes that transformative changes tend to individuals who effect radical or revolutionary changes by merging the goals, desires and values of their followers with their own, stimulate growth and development, and discourage dependence. Transformative changes require the management of JohnHopkinsHospital to develop a vision for the service, acting as mediators and champions, and exerting control over complex change initiatives (Gopee, 2010).
Sare & Ogilvie (2010) note that in order to achieve transformative change in any aspect of a healthcare reform, the hospital continually uses OD processes to facilitate complex system change. In each case, leadership collaboration and teamwork across multiple stakeholder boundaries were enhanced by effective change management facilitation, strategy development, team development and organizational learning. Wolf, Hanson & Moir (2011) indicate that the OD processes were designed to minimize the barriers to transformative change and leverage opportunities to develop a new way to approach reforms at JohnHopkins Hospital. The hospital’s transformative change process embraced the whole system in a coordinated process focused on what was best for hospital stakeholders.
The complex adaptive system (CAS) framework within JohnHopkinsHospital seeks to identify those agents in a system that act and interact in the pursuit of the hospital’s collective objectives. Rhodes (2009) notes that by using the CAS framework the hospital is capable of incorporating feedback from the system’s environment, as well as from the outcomes created by the actions of the agents within the hospital itself (p. 10). JohnHopkinsHospital fosters an environment that facilitates the practice of research-based and professional nursing. Newhouse (2007) mentions the fact that the hospital uses qualitative and quantitative systematic methods, as well as and transformational leadership approach, directed towards the study and improvement of patient care, patient-care systems and patient outcomes.
Through the use of CAS framework, JohnHopkinsHospital supplies the infrastructure required to provide excellence in transformative change through mentors, skill-building programs, financial support, computer access and referral to research consultative services (Newhouse, 2007). External and internal environmental factors play an important role in transformative change within the hospital.
External factors include accreditation bodies, legislation, quality measures, regulations, and standards. Newhouse (2007) explains that accreditation plays an important role in transformative change, because it enables the hospital to achieve and maintain high standards of practice and quality. Legislative and regulatory bodies enact laws and regulations that are designed to enable transformation through protecting the public and promoting access to health care services (Newhouse, 2007). Quality measures provide by CAS framework and professional standards serve as yardsticks for evaluating current practice and identifying areas of needed improvement or change (Rhodes, 2009).
The internal factors within the CAS framework that enable transformative change include organizational culture, leadership support, resource allocations, patient services, hospital’s mission and priorities, availability of technology, library support, equipments and supplies, staffing and standards. Newhouse (2007) notes that in this context, enacting transformational changes requires:
- A culture that believes transformational changes will lead to optimal patient outcomes
- Strong leadership support at all levels with the necessary resource allocation to sustain the process
- Establish clear expectations by incorporating transformative changes into standards and job descriptions.
Newhouse (2007) further noted that knowledge and an evaluation of the patient population, the hospital organization, and the internal and external factors are paramount components for the successful implementation and perpetuation of transformative changes within John Hopkins Hospital. Meleis (2010) notes that the understanding of transformative change, expectations of events, level of knowledge about transformative change, resources available in the hospital internal and external environment, capacity to plan for change, and emotional and physical well-being - all have an impact on transformative change. According to Meleis (2010) transformation in JohnHopkinsHospital can be viewed as a process, during which suffering may be reduced or alleviated.
Factors Inhibiting Transformative Change at John Hopkins Hospital
The greatest barrier identified by those involved in transformative change is time. Newhouse (2007) noted that “time constraints are repeatedly cited as the barrier that prevents implementation of transformational change within the organization” (p. 159). Experience shows that staff members need time to think about and discuss the change (Newhouse, 2007). It is important to note that staff members at JohnHopkinsHospital need time to acquaint themselves with the latest evidence and appraise the validity, strength, and quality of the evidence.
Staff members themselves act as a significant barrier to implementing transformative change. Newhouse (2007) notes that the staff at JohnHopkinsHospital often lack the skills, knowledge, and confidence to read the results of research studies and translate them into practice. It is also common that some nurses resist transformative change through negative attitudes and skepticism toward research.
Lack of communication is a common barrier to the implementation of transformative change initiatives at JohnHopkinsHospital. Newhouse (2007) says that “this barrier can be prevented by using the strategy of designing of a communication plan” (p. 158). The staff values responsiveness and listening on the part of the leadership to concerns or questions as the change is implemented (Newhouse, 2007). Staff members take ownership of the change, if they sense that the leadership listens to them and makes necessary changes.
The final barrier is lack of incentives or rewards in the organization for support of transformational change environment. Newhouse (2007) argues that criticism and discussion arise over this barrier by those who think that staff members should not be rewarded for doing their job. Incentives can be dealt with in several areas, which include communication, education and mentoring, job descriptions and evaluation tools. However, according to Newhouse (2007), the leadership team should understand the need for staff incentives and plan for recognition and rewards that are part of the transformative change implementation process.
The need to create a supportive transformative change environment within John Hopkins Hospital is one of the most important factors. Essential to transformative changes at John Hopkins Hospital is the supportive leadership that establishes a culture transformation, develops the capacity to implement transformation, including the expansion of infrastructure and allocation of resources, such as time, money and people. The hospital must be able to sustain the change and overcome barriers and resistance to change. In conclusion, the key to the successful implementation of transformative change and overcoming numerous barriers and resistance to transformative changes is leadership and planning.
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