The People Side of Change

Managing Expectations Early to Eliminate Workarounds Post

OccupancyInforming the transition process

Jennie Evans, RN, BS, EDAC, LEEP AP, Lean Six Sigma CE

Associate Principal and Sr. Vice President

HKS Architects

Adeleh Nejati, PhD, MArch, EDAC

Architect and Design Researcher

HKS Architects

Meredith Slosberg, MBA, FACHE, CSC Lean Six Sigma Green Belt

Deployment Leader

Organizational Effectiveness

Akron Children's Hospital

Acknowledgment: Center for Advanced Design Research and EvaluationPrincipal Investigator: Upali Nanda

1. Articulate the relationship between project planning and transition planning for people.

2. Identify opportunities to deploy change engagement directives during the project planning and implementation process.

3. Identify why change engagement is necessary, and effective, in all planning and design projects, based on systematically collected data.

4. Learn about three key talking points to begin conversations about implementation in your organization.

275,000 sf patient care tower

75 bed NICU

39 room emergency department

6-OR outpatient surgery center

High risk delivery area

Continuing to deliver on the promises that were written in 1890, our campus expansion will enhance the high quality, compassionate and family-centered care that we have delivered to the communities we serve for over 120 years.

Pre-Design Design Transition Occupancy

Visioning

Emerging Trends

Current to Future State

Site Visits

Site Visits

Dept. Mock Ups

Spaghetti Diagrams

Expectation

Check Survey

Ambassadors

Pulse points

Leadership Training

Ambassadors

Trials

Post Design Mock-up

Pulse Points

Expectation

Check Survey

Akron: Integrating Design and Change Management

Existing ED Future ED

39 Rooms

27,907 DGSF

26 Rooms

21,800 SF

Future NICUExisting NICU

59 Beds

27,843 SF63 Private / 6 Twin = 75 Beds

68,179 DGSF

• Preparedness must consider model of care and work flow differences in

• Team Collaboration

• Visibility

• Walking distances

• Care delivery processes

• Post-occupancies identify spaces are not always used as intended

• Communication pathways are not established• Team collaboration / Devices are under utilized

• Decentralized work stations are not used• Visibility of peers

• Nurse servers are not used• Walking Distances

Recent survey of healthcare administrators cites failure to create buy-in as one of the top 2 barriers to sustainable change.

• American College of Healthcare Executives, Journal of Healthcare Management

progress

productivity(effort)

project management timeline

human response to change

goal

change management area of impact

endings exploration

new beginnings

Source: Pritchett LLC

Pre-Design Design Transition Occupancy

Visioning

Emerging Trends

Current to Future State

Site Visits

Site Visits

Dept. Mock Ups

Spaghetti Diagrams

Expectation

Check Survey

Ambassadors

Pulse points

Leadership Training

Ambassadors

Trials

Post Design Mock-up

Pulse Points

Expectation Check

Survey

Akron: Integrating Design and Change Management

Survey 1

Survey 2

June 2013

Oct 2013

May 2014

ED Timeline

Survey 3

Survey 4

Jan 2015

June 2015

1. Leader Training Starts2. Trials Start3. Town Halls4. Pulse Points Start5. Trauma Room Mock up6. Ambassadors

Design Phase Complete

1. Leader Training Starts2. Focus Groups

Survey 1

Survey 2

Design Phase Complete

June 2013

Oct 2013

June 2014

NICU Timeline

Trials Start

Survey 3

Survey 4

Nov 2015

June 2015

• Awareness

• Language and storytelling

• Messaging

• On-going dialogue

• Values and Key Behaviors

• Pulse Points

Formalize it

Overt communicate

Venues

− Daily Huddles

− Staff meetings

− Department meetings

− Governance councils

− Town halls

− Focus groups

− Email and intranet

− Ambassadors

− Surveys

NICU Focus Groups, Focused Voice

Fears

• Loneliness

• Lack of help from fellow nurses

• Increased dependence on technology

• Looking incompetent for asking for help

Leadership Advocacy

• Communication technology

• Simulation time

• Parent/family expectations

Single room line of sight and patient safety

When town halls don’t work

Prn/evenings/week-ends/tight shifts

1:10 ratio

Flash drives or intranet

Consistent regular messaging from leadership to staff and back

Regular meetings for Ambassadors

• Respiratory

• Fast Track

• Distance to Transport

• Suture Cart

• Communication devices

• Pulse Ox

• Staffing Model

• Supply carts

Stake holder Issue Action

RN -Develop/implement new FT/triage process-Development of staffing model for new ED

-Develop education and communicationplan-Continue use of ambassadors, tours and behaviors/values role out

Physicians -Staffing-New roles/interactions with fellows-Room assignments-Even flow of patients through entire ED

-Develop education and communicationplan-Recruitment-Consider flow/teamwork when developing new FT/triage process

NPs

Registration/Secretaries

Respiratory Integrating Transport in ED operation -continue presence at huddles in ED-Global plan around integrating into services in new building

Mental Health Technicians -maintaining consistent processes with new and revolving staff

-developing guidebook for RN/MHT staff-scripting to communicate what to expect to families

MAs

Suture Staff -integrating suture staff in FT-geographic separation creates some challenges in communication/touchdown space-uncertainty around change at satellites

-continue to monitor, remind ED staff of where suture staff may reside

To do a regular check in with the staff to assess their perceptions, expectations and level of preparedness for the move

To use the survey results to inform specific change engagement initiatives

To analyze the survey to understand how involvement in the design of the new facility, and new processes, contributes to staff preparedness and adaptation for the new move

ED 1: N= 47ED 2: N= 88

14.9

51.1

31.9

4.34.59.1

68.2

18.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Leadership Medical staff Clinical staff Non-clinical staff

% o

f P

art

icip

an

ts

Job Role

ED 1 ED 2

12.8

6.4

48.9

10.68.5

2.1

10.69.111.4

42.0

9.1 8.010.2 9.1

0.0

10.0

20.0

30.0

40.0

50.0

60.0

< 6 mths < 1 yr 1-5 yrs 6-10 yrs 10-15 yrs 15-20 yrs > 20 yrs

% o

f P

art

icip

an

ts

Years of Experience

ED 1 ED 2

ED Survey Demographic

16.38.2

71.4

4.19.3

2.3

86.0

2.3

0.0

20.0

40.0

60.0

80.0

100.0

Leadership Medical staff Clinical staff Non-clinical staff

% o

f P

art

icip

an

ts

Job Role

NICU1 NICU2

8.26.1

30.6

6.1 6.18.2

34.7

2.3 2.3

46.5

9.3

2.34.7

32.6

0.0

10.0

20.0

30.0

40.0

50.0

< 6 mths < 1 yr 1-5 yrs 6-10 yrs 10-15 yrs 15-20 yrs > 20 yrs

% o

f P

art

icip

an

ts

Years of Experience

NICU1 NICU2

NICU 1: N= 49NICU 2: N= 43

NICU Survey Demographic

Level of Involvement and

Knowledge

Type of Involvement in the

Facility Design

Type of Involvement in the

Process Design

Perception of Preparedness

How prepared do you feel to work in the new environment?

Perception of Adaptation

To what extent do you feel your involvement in/ knowledge of design

will help you adapt to your new environment?

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state

3.4

1.4

1.81.6

2.2

2.5

3.7

0.9

1.7 1.6

2.6 2.6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Years ofExperience

Level ofInvolvement

Level of FacilityKnowledge

Level of ProcessKnowledge

Preparedness Adaptation

ED1

ED2

Summary Results for ED and NICU Surveys – Mean Comparison

T-test: Significantly different from Survey 1 to 2

NICU 1: N= 49NICU 2: N= 43

ED 1: N= 47ED 2: N= 88

4.6

1.4

2.0

1.4

1.9

2.6

4.5

1.4

2.2

1.5

2.1

2.7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Years ofExperience

Level ofInvolvement

Level of FacilityKnowledge

Level ofProcess

Knowledge

Preparedness Adaptation

NICU1

NICU2

Importance of involvement in design phase will be a recurring theme today

For ED, a range of activities informed preparedness including: 10 trials Ambassadors Leadership training Interactive mock-up of trauma room

Some leadership/staff trust issues were more pressing. Only a small core group involved. Leadership matters!

27.731.9

29.8

10.68.0

36.439.8

15.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Not at all A little bit Moderately so Very much so

% o

f P

art

icip

an

ts

ED1

ED2

32.7

44.9

18.4

4.1

14.0

65.1

16.3

2.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Not at all A little bit Moderately so Very much so

% o

f P

art

icip

an

ts

NICU1

NICU2

NICU 1: N= 49NICU 2: N= 43

ED 1: N= 47ED 2: N= 88

23.421.3

36.2

19.1

10.2

39.8

33.0

17.0

0.0

10.0

20.0

30.0

40.0

50.0

Not at all A little bit Moderately so Very much so

% o

f P

art

icip

an

ts

ED1

ED2

10.2

42.9

28.6

18.4

7.0

39.5

30.2

23.3

0.0

10.0

20.0

30.0

40.0

50.0

Not at all A little bit Moderately so Very much so

% o

f P

art

icip

an

ts

NICU1

NICU2

NICU 1: N= 49NICU 2: N= 43

ED 1: N= 47ED 2: N= 88

Level of involvement in the

facility design

Level of Knowledge of New Facility

Level of Knowledge of New Process

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state[S1, S2]

[S1]

ED Survey Result

Level of Involvement & Knowledge

[S1]

[S2]

CorrelationPredictionSurvey 1Survey 2

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state[S1, S2]

Level of Knowledge of New Facility

Level of Knowledge of New Process

Level of involvement in the

facility design

NICU Survey Result

Level of Involvement & Knowledge

[S1]

[S2]

CorrelationPredictionSurvey 1Survey 2

Level of involvement in the

facility design

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state

Level of Knowledge

Process

Facility

ED only

Summary Result

Level of Involvement & Knowledge

Being involved in facility design was key:

• To increase knowledge of process and knowledge of environment

• To increase ED’s perceptions of both preparedness and adaptation

• To increase NICU’s perception of adaptation but not preparedness

This points to how the future design configuration affectsthe current model of care. The new NICU design has a hugeimpact on current model of care. The new ED is a larger space but has less impact on the model of care. Preparedness and adaptation seem to be more closely aligned when the new model of care is similar to the old model of care.

Knowledge of facility and knowledge of process did not have the same impact on each group.

• Knowledge of process and facility increased NICU’s perception of their ability to be ready ahead of time.

• Knowledge of facility increased ED’s perception of their ability to adjust to the new space.

• Knowledge of process increased ED’s perception of their ability to be ready ahead of time.

Since our goal is to have our employees ready to utilize the space in a way that is congruent with intended use we need to pay attention to providing them with both types of information. However, one group may need a certain type of information more than the other and at different times in the transition process.

Pre-Design Design Transition Occupancy

Part of design team

Tour mock up

Patient care processes

Choosing design options

Workshop report outs

Regular communication

Part of design team

Tour mock up

Patient care processes

Choosing design options

Workshop report outs

Regular communication

Trialing new equip/ tech

Trial new equip/tech

Leadership training

Focus groups

Regular communication

Trial new equip/tech

Leadership training

Focus groups

Regular communication

13

23

96 7

27

7

20

49 11

69

0

10

20

30

40

50

60

70

80

Part of theDesign Team

Tour Mock-up Create PatientCare Processes

Choose DesignOptions

AttendWorkshopsreport outs

RegularCommunication

Nu

mb

er

of

Pa

rtic

ipa

nts

ED1

ED2

1013

10

16

8

38

5

13

7 63

39

0

10

20

30

40

50

60

70

80

Part of theDesign Team

Tour Mock-up Create PatientCare Processes

Choose DesignOptions

AttendWorkshopsreport outs

RegularCommunication

Nu

mb

er

of

Pa

rtic

ipa

nts

NICU1

NICU2

NICU 1: N= 49NICU 2: N= 43

ED 1: N= 47ED 2: N= 88

NICU 1: N= 49NICU 2: N= 43

ED 1: N= 47ED 2: N= 88

46.9

14.3

28.6

44.2

9.3

34.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Trial of NewEquipment &Technology

Leadership Training Focus Groups

% o

f P

arti

cip

ants

NICU1

NICU2

23.421.3

31.9

35.2

6.8

12.5

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Trial of New Equipment& Technology

Leadership Training Focus Groups

% o

f P

arti

cip

ants

ED1

ED2

Involved in trialing new equipment and technology

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state

Involved in leadership training

Involved in focus groups

Part of the design team

Toured the mock up

Involved in creating the patient care processes in the new department

Involved in choosing unit design options for the new department

Attended the workshop report outs either in person or via webex

Receive and read regular communication on your unit design

Ty

pe

of

Inv

olv

em

en

t in

F

ac

ility

De

sig

n

Ty

pe

of

Inv

olv

em

en

t in

P

roc

ess

De

sig

n

[S1]

[S1]

[S2]

PredictionSurvey 1Survey 2

ED Results

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state

[S2]

Involved in trialing new equipment and technology

Involved in leadership training

Involved in focus groups

Part of the design team

Toured the mock up

Involved in creating the patient care processes in the new department

Involved in choosing unit design options for the new department

Attended the workshop report outs either in person or via webex

Receive and read regular communication on your unit design

[S1]

[S2]

PredictionSurvey 1Survey 2

Ty

pe

of

Inv

olv

em

en

t in

F

ac

ility

De

sig

n

Ty

pe

of

Inv

olv

em

en

t in

P

roc

ess

De

sig

n

NICU Results

Part of the design team

PreparednessMake ready ahead

of time

AdaptationAdjust to a new

state

Touring the mock up Creating the patient

care processes Attending the

workshop report outs

ED

Trialing new equip/ tech

Leadership training Focus groupsNICU

ED & NICU

Summary Result

Type of Involvement

Process design involvement is more critical when the model of care changes

Key Learnings: Type of Involvement

• Being part of design team led to both more adaptation and preparedness for ED and NICU

• ED’s involvement in design activities led to more adaptation

• NICU’s involvement in process activities led to more preparedness

We’ve said this multiple times. Being actively involved in the design phase of the project matters when it comes to being prepared and adapting to a new space.

Type of involvement produces different results. Understanding the type of involvement that leads to either adaptation or preparedness help leaders selectthe best activities for change engagement.

Summary of ED Qualitative Results

ED1 and ED2 ED1 ED2

Excited about

Newness, clean environment, more space, better patient flow and processes.

Concerned aboutProximity to main hospital, adjusting to changes, staffing issues

Lack of involvement in design, not enough computers.

Communications

Facility designers Should have

Involved more staff, considered PICU and or locations, design issues.

Management/ senior leadership should have

Involved more staff, considered PICU and or locations

Design issues

CommentsLooking forward to prepare for move, see new building, staffing.

Summary of NICU Qualitative Results

NICU1 and NICU2 NICU1 NICU2

Excited about Private rooms, clean and new environment

Windows New equipment

Concerned about Staffing, patient safety Size of unit vis-à-vis response time, not able to see babies constantly, how to get help in emergent situations, not having enough time with babies (parent satisfaction), distance between patients and supplies

Nurse safety, staff morale, proximity of staff

Facility designers Should have

Involved more staff members

Designed private rooms and pods

Made rooms smaller

Management/ senior leadership should have

Considered staffing Involved more staff Be concerned about staff concerns

Comments Familiarize with space and processes before moving, tour facility, staffing

Have concerns addressed Discuss workflow and processes, practice on new communicationsystem

Pre-Design Design Transition Occupancy

Akron: Integrating Design and Change Management

Visioning

Emerging Trends

Current to Future State

Site Visits

Site Visits

Dept. Mock Ups

Spaghetti Diagrams

Expectation

Check Survey

Ambassadors

Pulse points

Leadership Training

Ambassadors

Trials

Post Design Mock-up

Pulse Points

Expectation Check

Survey

progress

productivity

(effort)

project management timeline

human response to change

GO

LIVE

endings exploration

new beginnings

human response to change

post go-live!

Source: Pritchett 2013 and Meredith Slosberg 2014

Design Team Recommend the need for pre-

design operational planning with cross-functional teams

Choose design team members who will serve as ambassadors

- Provide job descriptions

Implement initiatives to engage staff who are not at design table

- Collect responses to specific questions

- Post images / drawings

- Communicate

- Solicit constant feedback

Healthcare Leadership Integrate Change Engagement

concepts into the design/project plans

Create early dialogue with all staff and continue through post go-live

− go to the people

− use many modalities

Establish ambassador program

− how to get many voices while maintain a small decision-making group

Establish pulse point checks and continue three to six months post occupancy

• What interventions help staff prepare and adapt and when should they be implemented?

• What kind of ripple effect do these results (with the staff) have on the patient and family?

• What role does leadership play in the staff’s willingness to adapt and be prepared?

• What design process is the most effective for preparing staff for their new environment?