Organisational Change - Book Summary - English literature, Summaries of English Literature

Download Organisational Change - Book Summary - English literature and more Summaries English Literature in PDF only on Docsity!

Organisational

Change

A REVIEW FOR HEALTH CARE MANAGERS, PROFESSIONALS AND RESEARCHERS

Managing

Change

in the NHS

Valerie Iles and Kim Sutherland

Managing

Change

in the NHS

Organisational

Change

A REVIEW FOR HEALTH CARE MANAGERS, PROFESSIONALS AND RESEARCHERS

Valerie Iles and Kim Sutherland

Managing

Change

in the NHS

Part 3

Reflections

on evidence

Appendices

References

2.5 How can we make change happen? 60

Organisational development (OD) 60 Organisational learning and the Learning Organisation 63 Action research 66 Project management 68

3.1 Assistance with using available evidence 74 3.2 Developing an evidence base 75 3.3 Developing evidence for local action 78 3.4 Areas for future research 79

Appendix 1 Search strategy 84

Appendix 2 Summary of empirical 85 research on effectiveness of change models in health care organisations 1990 –

Appendix 3 What is systems thinking? 89

Appendix 4 Development of a change 91 management resource

Appendix 5 Participants at the change 92 management workshop and seminar

Purpose of this review

This review aims to provide a resource and reference tool to help readers find their way around the literature on change management and consider the evidence available about different approaches to change.

Authors Valerie Iles, Really Learning and London School of Hygiene & Tropical Medicine, University of London Kim Sutherland, Judge Institute of Management Studies, University of Cambridge

Project sponsors Maureen Dalziel, Director NCCSDO Naomi Fulop, Deputy Director NCCSDO

Professor Sir John Pattison, Director, NHS SDO R & D Programme

Steering group Maureen Dalziel, NCCSDO (Chair) Sandra Dawson, Judge Institute of Management Studies, University of Cambridge Ewan Ferlie, Management School, Imperial College of Science, Technology and Medicine, University of London Naomi Fulop, NCCSDO Valerie Iles, Really Learning and London School of Hygiene & Tropical Medicine, University of London

Project management (NCCSDO) Helena Ward, Gráinne Kavanagh and Pamela Timms

Project communication and editorial consultants Marsaili Cameron, Steve Cranfield (managing editor – Review), Margaret Mellor and Jud Stone. Design by Sign.

Further copies Kate Thomas, Co-ordinator NCCSDO London School of Hygiene & Tropical Medicine 99 Gower Street London WC1E 6AZ

Tel: +44 (0) 20 7612 7980 Fax: + 44 (0) 20 7612 7979 Email: sdo@lshtm.ac.uk Web: www.sdo.lshtm.ac.uk

Date of issue: May 2001

The need for change in the health service is now widely recognised – by public, by professions and by government. The NHS Plan, issued last year, requires a fundamental change in thinking, practice and delivery of health care over the next decade.

The challenges for those working towards meeting the Plan’s ambitious change agenda are clear. We know that practising managers and professionals are keen to meet these challenges, to improve services by learning from the research literature and to base their decisions in evidence where possible. Many people in the NHS, however, are not familiar with the thinking about management of change which has come out of schools of management, psychology, sociology, and economics, over the last fifty years. Many who are aware of some of the concepts do not appreciate the contexts in which they were developed, nor the purposes to which they may be put in the process of managing change. Important insights and guidance which the literature offers are thus not being used to maximum effect.

This document is one of two SDO publications on change management – the second is a booklet summarising key lessons – designed with the needs of different audiences in mind but with the single aim of helping people to bridge this gap between the commitment to change and action. Drawing upon expertise from the Judge Institute of Management Studies, University of Cambridge, and benefiting from the advice of other academic colleagues, and colleagues in the NHS and other sectors, we have produced in this publication what we hope is a succinct and user-friendly review of the literature and evidence on change that the whole NHS can draw on.

We trust that significant lessons for change will be drawn from this review and its sister publication and that they will stimulate further debate and inquiry in this important area.

Professor Sir John Pattison Director NHS SDO R & D Programme

Foreword

Managing

Change

in the NHS

Introduction Background

In the White Paper, A First Class Service (DOH, 1998) the NCCSDO was commissioned to undertake a review of the evidence in the field of change management, as follows (Section 5.14):

Change may be an imprecise science, but evidence is available on what works and what does not, and the NHS must make use of this. The [NCCSDO] will review existing research findings of relevance to change management and quality improvement in the NHS. It will also commission new studies to improve the knowledge base. This work will be made available in a user-friendly format for the whole NHS to draw on.

During the autumn of 1999, the SDO programme carried out a national listening exercise which brought together those who make use of and those who deliver health care services (Fulop and Allen, 2000).

Participants were asked: What are the most important issues, for those delivering and organising services and for those making use of those services? Why is there so often a gap between research evidence and implementation at policy and local levels? What can be done to help promote research as a lever for change in the NHS? One area of common concern was the implementation and management of change.

In response two initial publications have been prepared, under the title ‘Managing Change in the NHS’.

• Organisational Change: a review for health care managers, professionals and researchers is a resource and reference tool designed to help readers find their way around the literature on change management and consider the evidence available about different approaches to change.
• Making Informed Decisions on Change: key points for health care managers and professionals is a booklet summarising the key lessons and points for action to be drawn from theory and practice.

Aims of the review

Organisational Change: a review for health care managers and professionals and researchers sets out to:

• describe relevant approaches and concepts which have been developed in schools of management, psychology, sociology, economics and other fields over the last fifty years
• discuss the context in which these approaches and concepts were developed, and the uses to which they may be put in the process of managing change
• consider the evidence that is available about the efficacy of these approaches
• begin a discussion about the nature of evidence in this field and the differences between evidence that is useful for clinical and for managerial interventions.

Managing

Change

in the NHS

Approach and method

In order to explore this large and complex field a multi-method approach was used.

First, a list of key theories and concepts was defined after reference to general management texts and review articles addressing change management, as well as through consultation and discussion with academics, management consultants and NHS managers. Desk research was accompanied by further discussions with fellow academics and practitioners over which tools, models and approaches they deemed most and least important, and which concepts were most commonly discussed by practitioners.

These tools, models and approaches were then subjected to a systematic literature review, carried out by:

• searching the major computerised databases – Proquest/ABI Inform, Social Science Citation Index (BIDS), and Medline
• identifying key books and reports by seeking advice from academics and practitioners, and by reviewing published articles looking for influences and references
• conducting more specific searches as described in Appendix 1.

Analysis and discussion of findings were subject to peer review and supplementary literature searches on two further tools and models were carried out. A number of other tools did not warrant a comprehensive literature search but were included because they were found to be useful in practice. Both the searched and the non- searched models and tools are clearly distinguished as such in the publication.

Criteria used for assessing the rigour of empirical studies were: clarity of methodology, peer review, use of multiple case studies, and external evaluation.

The literature

on change

management

Managing

Change

in the NHS

P A R T 1 : T H E L I T E R A T U R E O N C H A N G E M A N A G E M E N T

Many readers will be seeking an answer to the question ‘Does it work?’ in relation to individual models of change management. This review aims to help answer that question as far as the literature allows. But before proceeding it is important to appreciate that neither the question nor the answer will be simple or straightforward.

There are problems associated with gathering and reviewing evidence about the efficacy of change programmes. These include the following.

1. For all but the very simplest of changes the impact is multidimensional. The measures of the effectiveness of any change intervention must capture all these dimensions or the picture presented will be incomplete.
2. Change programmes involve analysing the causes of the presenting problem, designing the change programme, implementing and evaluating it. Often this is an iterative process, with information gained during the implementation phase informing a review of the analysis and/or of the design. In addition, a valuable tool may be applied in a situation for which it is not appropriate, or it may be applied suboptimally. Distinguishing between the outcomes of the different stages, and also between the skilfulness of the application and the underlying value of a tool, requires the development of a sensitive set of measures.
3. Different people involved in the change programme will have different views of the precipitating event, of the underlying causes of the problem, and of the desirable outcomes of the programme. They will therefore measure different outcomes, and measure them differently. The evidence must consider whose measures are to be used.

Perhaps because of these difficulties, the literature is dominated by descriptions of the various models and approaches, prescriptive advice and anecdotal accounts of organisational change. A major problem in this field has been the dominance of gurus who prescribe courses of action without any basis in evidence. The recourse to such prescriptions should be seen as part of the problem, not the solution. Articles based on empirical research are, however, relatively rare and are predominantly single-site case reports, often conducted by a member of the target organisation. Many of the most useful studies are well-conducted qualitative studies (see Appendix 2).

It cannot be emphasised strongly enough that the nature of evidence in the field of change management may differ from that which is relevant and useful in the clinical arena. We consider further some of the salient research and methodological issues in Part 3 after discussion of the available evidence in Part 2.

What kind of

evidence does

it provide?

Managing

Change

in the NHS

What is meant

by ‘change’?

This document describes and reviews a range of approaches, models and tools which managers and practitioners may be interested to learn more about as part of understanding and managing change. To begin the exploration, readers are introduced to some of the key terms and concepts in the literature. These will demonstrate the diversity of thinking and activity encompassed by the single term ‘change’.

Planned versus emergent change

Sometimes change is deliberate, a product of conscious reasoning and actions. This type of change is called planned change. In contrast, change sometimes unfolds in an apparently spontaneous and unplanned way. This type of change is known as emergent change.

Change can be emergent rather than planned in two ways.

1. Managers make a number of decisions apparently unrelated to the change that emerges. The change is therefore not planned. However, these decisions may be based on unspoken, and sometimes unconscious, assumptions about the organisation, its environment and the future (Mintzberg, 1989) and are, therefore, not as unrelated as they first seem. Such implicit assumptions dictate the direction of the seemingly disparate and unrelated decisions, thereby shaping the change process by ‘drift’ rather than by design.
2. External factors (such as the economy, competitors’ behaviour, and political climate) or internal features (such as the relative power of different interest groups, distribution of knowledge, and uncertainty) influence the change in directions outside the control of managers. Even the most carefully planned and executed change programme will have some emergent impacts.

This highlights two important aspects of managing change.

1. The need to identify, explore and if necessary challenge the assumptions that underlie managerial decisions.
2. Understanding that organisational change is a process that can be facilitated by perceptive and insightful planning and analysis and well crafted, sensitive implementation phases, while acknowledging that it can never be fully isolated from the effects of serendipity, uncertainty and chance (Dawson, 1996).

An important (arguably the central) message of recent high-quality management of change literature is that organisation-level change is not fixed or linear in nature but contains an important emergent element.

Episodic versus continuous change

Another distinction is between episodic and continuous change. Episodic change, according to Weick and Quinn (1999), is ‘infrequent, discontinuous and intentional’. Sometimes termed ‘radical’ or ‘second order’ change, episodic change often involves replacement of one strategy or programme with another. Continuous change, in contrast, is ‘ongoing, evolving and cumulative’ (Weick and Quinn, 1999). Also referred to as ‘first order’ or ‘incremental’ change,

3. Transformational change is radical or second order in nature. It requires a shift in assumptions made by the organisation and its members. Transformation can result in an organisation that differs significantly in terms of structure, processes, culture and strategy. It may, therefore, result in the creation of an organisation that operates in developmental mode – one that continuously learns, adapts and improves.

Systems thinking and change

Many of the approaches to organisational change found in the literature give the impression that change is (or can be) a rational, controlled, and orderly process. In practice, however, organisational change is chaotic, often involving shifting goals, discontinuous activities, surprising events, and unexpected combinations of changes and outcomes (Cummings et al. , 1985; Dawson, 1996). Accordingly, change can be understood in relation to the complex dynamic systems within which change takes place.

Systems thinking originated in the 1920s within several disciplines, notably biology and engineering, and grew out of the observation that there were many aspects which scientific analysis could not explore. Whereas scientific method – summarised by Popper (1972) as the three Rs: reduction, repeatability and refutation – increases our knowledge and understanding by breaking things

Managing

Change

in the NHS

Figure 1: Perspectives on change Adapted from Ackerman (1997)

STATEOLD^ TRANSITION

performance

time

birth

growth

plateau

chaos

death

re-emergence

NEW STATE

➤

Developmental change Improvement of existing situation

Transitional change Implementation of a known new state; management of the interim transition state over a controlled period of time

Transformational change Emergence of a new state, unknown until it takes shape, out of the remains of the chaotic death of the old state; time period not easily controlled

P A R T 1 : T H E L I T E R A T U R E O N C H A N G E M A N A G E M E N T

down into their constituent parts and exploring the properties of these parts, systems thinking explores the properties which exist once the parts have been combined into a whole. (For further background on systems thinking, see Appendix 3.)

A system is a set of elements connected together which form a whole, thereby possessing properties of the whole rather than of its component parts (Checkland, 1981). Activity within a system is the result of the influence of one element on another. This influence is called feedback and can be positive (amplifying) or negative (balancing) in nature. Systems are not chains of linear cause-and-effect relationships but complex networks of interrelationships (Senge, 1990).

Systems are described as closed or open. Closed systems are completely autonomous and independent of what is going on around them. Open systems exchange materials, energy and information with their environment. The systems of interest in managing change can all be characterised as open systems.

In terms of understanding organisations, systems thinking suggests that issues, events, forces and incidents should not be viewed as isolated phenomena but seen as interconnected, interdependent components of a complex entity. Applied to change management, systems theory highlights the following points.

• A system is made up of related and interdependent parts, so that any system must be viewed as a whole.
• A system cannot be considered in isolation from its environment.
• A system which is in equilibrium will change only if some type of energy is applied.
• Players within a system have a view of that system’s function and purpose and players’ views may be very different from each other.

Within the NHS the term whole systems thinking is now routinely used by managers and clinicians. This widespread usage reflects an increase in:

• awareness of the multifactorial issues involved in health care, which mean that complex health and social problems lie beyond the ability of any one practitioner, team or agency to ‘fix’
• interest in designing, planning and managing organisations as living, interdependent systems committed to providing ‘seamless care’ for patients
• recognition of the need to develop shared values, purposes and practices within the organisation and between organisations
• use of large group interventions to bring together the perspectives of a wide range of stakeholders across a wider system.

Largely for these reasons we have drawn on insights from systems thinking – as well as on other concepts discussed in this section – to help organise the groupings of change management models in Part 2 and to highlight the inter- relationships between these.

P A R T 1 : T H E L I T E R A T U R E O N C H A N G E M A N A G E M E N T

The scale of change is another important consideration when drawing lessons from other sectors. Small, focused interventions may have an equal potential for success in most contexts while more ambitious change initiatives are challenged, diverted and deflected by the inherent complexity, traditions and power dynamics of public sector organisations.

Challenges and opportunities for the NHS

Meeting organisational change in the NHS, therefore, involves working with:

• changing pressures in the environment
• multiple stakeholders within and outside the organisation
• changing technologies available to those stakeholders
• complex organisations in which individuals and teams are interdependent
  • that is, they can only achieve their objectives by relying on other people seeking to achieve different objectives
• people who have experience of change interventions which have had unforeseen or unintended consequences.

It is also important to remember that cause and effect relationships may not be easily apparent, and that an intervention in any part of a health care organisation will have outcomes in many others, not all of them anticipated, and not all of them desirable. The fact that change can lead to unanticipated, and indeed dysfunctional, consequences has been highlighted by, for example, Smith’s work (1995a; 1995b) on responses to performance indicators in the public sector.

For all these reasons change in the NHS is never likely to be straightforward and linear. Proposed change needs to offer benefits of interest to frontline staff and the approach needs to be interactive and to relate research clearly to current practice (Ywye and McClenahan, 2000).

Ambitious goals such as the achievement of the NHS Plan will require that the NHS becomes an organisation able to embrace continuous, emergent change (see page 14) , and will depend on people in the NHS becoming more skilled in handling change in a complex environment with multiple stakeholders, conflicting objectives and considerable constraints.

In Part 2 we look at models for diagnosing these organisational situations and consider which are likely to be most useful for understanding and intervening in particular circumstances.

No single method, strategy or tool will fit all problems or situations that arise. Managers in the NHS need to be adept at diagnosing organisational situations and skilled at choosing those tools that are best suited to the particular circumstances that confront them.

Managing

Change

in the NHS