3.1 Introduction

Change is a constant social and health care service delivery feature that impacts on various aspects of culture (Drumm 2008). Change instigation is a task that is challenging and that necessitates careful management. Change framework and model use makes it possible for the organization to plan for their change initiatives carefully and to manage them (Cameron 2008). This chapter will review the rational for selecting the Health Service Executive (HSE) Change Model for this project instead of the Senior & Swailes Model, the methodology are going to be explained in details in a frame of assorted phases of the HSE model. The discussion will start by highlighting organizational culture and leadership.

3.2 Critical Review of Approaches to Organisational Development

——- (WRITE) —– 500 WORDS

PROVIDE A BRIEF REVIEW OF APPROACHES TO ORGANISATIONAL DEVELOPMENT/ CHANGE

(THE FOLLOWING –HIGHLIGHTED- IS NOT REQURED, OVER WRITING)

3.2 Culture

In the healthcare setting there are several competitive variables within the culture of an organization. The conflicting wants of patients, families, providers, regulators, etc. create several inconsistencies and mixed messages. Additionally to the problems of hierarchy mentioned earlier, there are few where each role and operates independently, whereas not understanding the total implications of its actions on others (Patientsafetyed.duhs.duke.edu, 2016).

The current concentrate on improving care by redesigning systems, tasks and workforce essentially emphasizes the multiple factors underpinning errors, depends on reporting systems for capturing errors, and advocates a “blame free” setting in order that staff can report their mistakes or near misses. This approach examines system factors as causes of errors instead of people.

3.3 Leadership

Leadership, in the broadest sense, implies authority. It is founded on objective factors, including managerial ability, and more subjective features that encompass leaders’ personal qualities (Tsai 2011). Leadership can be viewed as the art by which an organization is guided through structural change. Leading change has been cited as the most important function for today’s managers. A leader remains an important actor in the process of change. He/she is charged with the responsibility of making the process of change the smoothest possible (Rosén 2014). Organizational leaders’ behavior has a direct influence in work environment actions that enable change. Leaders are responsible for change strategy as well as implementation and monitoring of the change, thereby functioning as change agents. Consequently, the challenge of change management is one of the most enduring and fundamental roles of leaders. The rapidly increasing pace of change in organizations calls for effective leadership (Gilley, McMillan & Gilley 2009). Organizations that implement and support transformational and continuous change are likely to remain competitive. Researchers have argued that despite the escalation of numerous multistep approaches, models and theories, leaders still lack adequate knowledge of change, its effective processes, its antecedents and are still not able to engage members of the organization in change initiatives successfully (Cameron 2008).

Recent research demonstrates that it is rare for change programs to attain desired results and that lack of effective leadership is the primary reason why most change initiative fail (Gilley, McMillan & Gilley 2009). Some barriers to organizational change include lack of management skills, poor communication skills, lack of reward for workers, and the inability to motivate others to change (Cameron 2008). For successful organizational change to occur, leaders need to adopt certain goals, values, routines, frameworks, processes, and behaviours. Evidence shows that there is a link between leader behaviours and effectiveness in change implementation. For instance, skills on change management have been positively associated with successful organizational change and vice versa. Leadership behaviours and skills that have been positively linked to organizational change include building teams, rewarding, motivating, involving others, communicating, and coaching (Gilley, McMillan & Gilley 2009). To ensure effective change implementation in the multispecialty clinic, the leadership of the clinic needs to adopt and demonstrate the skills and behaviours that have been linked to positive organizational change as outlined above.

3.4 Project Change Models

Two change models have been selected for discussion in this paper, and they include the Health Services Executive (HSE) change model and the Action Research-Based Change Model by Senior and Swailes (2010).

3.4.1 The HSE Change Model

The HSE change model is a relatively new approach for organizational development that was developed to enhance service users’ and patients’ experiences, to promote team working among teams and staff to enhance services and to facilitate a constant change approach across the system. The focus of the HSE model is on people and cultural change aspects, based on that fact that organizational change management is primarily about managing people. This implies that organizations should not discount or ignore the perspectives of employees. A fundamental leaders’ function is the management of their own culture by understanding the feelings, thoughts and beliefs of individuals. The HSE change model builds and reflects upon explicit core principles that managers and leaders can apply (Uden, Hericko, & Ting 2015). The model describes a transformational journey that makes it possible for people to transition from their current situation to a future that is desired (Drumm 2008).

The HSE change model is founded primarily on four main stages of project management lifecycle, including initiation, planning, implementation, and mainstreaming.

Figure 1: HSE Change Model (2008)

All these stages are interrelated and influence each other (Uden, Hericko, & Ting 2015). The initiation stage sets the pace for the change process and entails preparations to lead the change. It is vital to address issues in this stage because successful change implementation depends on the energy spent on the initiation stage. This early preparation is intended to create a considered case and readiness for change, scope out a solid base for successful change, and build a sense of shared responsibility. This stage builds on core management and leadership responsibilities. It helps in grasping an early sense of the depth and breadth of the change effort. In addition, it involves that identification of the key people and groups who are needed to implement the change and who the change will directly impact (Drumm 2008).

The planning stage of the HSE change model is intended to determine the specific change details and create support for the process of change. The change process is likely to be easier if the support is broader (Uden, Hericko, & Ting 2015). This phase diverts the leaders’ orientation to starting an action that is more visible. The focus is on building organization-wide capacity, momentum and commitment to the change. It increases engagement and participation in the process of change, develops increased understanding of the intended accomplishments of the change, and promotes personal involvement. The planning stage involves three major steps, including building commitment, determining the change details, and developing the implementation plan (Drumm 2008).

The implementation stage of the HSE change model focuses on the implementation and monitoring of the project plan to ensure its purpose is met. It requires the discontinuation of inappropriate models of working and the implementation of new and agreed ways of working (Uden, Hericko, & Ting 2015). Even though implementation is likely to follow the main plan parameters, the change process aspects will inevitably be different from the plan. Leaders should permit the natural evolution of the implementation, revisit the sequence of implementation activities, learn from what takes place and influence it when appropriate. In addition, leaders should also maintain their responsibility of keeping the process of change on track in accordance with the available resources and the agreed vision for the change (Drumm 2008).

The mainstreaming stage of the HSE change model is intended to focus attention on the change effort successes and the integration and sustainability of the new ways of behaving and working (Uden, Hericko, & Ting 2015). It also focuses on approaches for evaluation and continuous improvement. The stage involves two major steps, including making it “the way we do our business” and evaluating and learning (Drumm 2008).

3.4.2 Action Research-Based Change Model

The action research-based change model was developed by Senior and Swailes (2010). This model acknowledges the importance of the change agent leading the change. The change agent is at the core of this change model. He/she is mandated to drive forward each change process aspect and is vital to the success or failure of the proposed change. It underscores that relevant research and efforts required prior to embarking on vision building and change initiation (Senior & Swailes 2010).

Stage 1a: Diagnoses Current Situation

This stage entails a comprehensive assessment of the internal workings and external environment of the organization. This environmental assessment is vital in evaluating the change initiative and in collecting of important data (Hashim 2014). To be able to gain a fully-rounded organizational picture, the model recommends the assessment of organizational goals and purposes; organizational culture and structure; leadership approaches and styles; recruitment practices; opportunities and career paths; individual motivation and commitment; reward practices and structures; group relationships; and learning and development (Senior & Swaile 2010).

Stage 1b: Develop a Vision for Change

This stage involves an imagination of the ideal situation for the organization. It is a creative process that should involve several people that the change is likely to impact. The stage may require changes to organizational processes, markets, services, and products as well as leadership and management practices (Senior & Swaile 2010). Ideas for change of the organizations’ vision are also likely to require the seeking of additional new information, which may then require further adjustments to the vision. Ultimately, stage 1 is concerned with determining the difference between the current state and the ideal state of the organization, both subjectively and objectively (Hashim 2014).

Stage 2: Gain Commitment to the Vision

This stage requires a strong communication network. It is important to involve people so that they are being heard and that they have a say. The change agent should understand the factors that motivate people to resist change and should employ various strategies to overcome change resistance. Understanding the major causes of resistance is likely to make it much easier for the change agent to negotiate a compromise that is acceptable to both parties, mitigate negative effects, or convince individuals of the advantages of the change. The completion of this stage is likely to be much easier if all organizational members have been engaged in the first stage (Senior & Swaile 2010)

Stage 3: Develop an Action Plan

This stage involves putting up a plan for the “who”, “what” and “where” of the change process. It requires the identification of who is likely to guide the planning as well as the implementation of the change. It also requires the specification of what should be changed for the vision to be realized and the level at which this should be done. In addition, it requires the identification of where the each intervention is likely to occur. According to Senior and Swaile (2010), a responsibility chart can be used to identify who is responsible for the needed actions, who will support the person, and whose authority it is to veto or approve the issue (Senior & Swaile 2010)

Stage 4: Implement the Change

Senior and Swaile (2010) contend that a successful implementation requires two things. The first requirement is the building on short-term wins that are likely to increase buy-in and support, and boost morale of members of the team and the organization and minimize resistance. The second requirement is ongoing stakeholder engagement during the process of implementation. The organization should demonstrate the willingness to hear from employees and must take their feedback seriously and assess them together with more quantifiable measures, including performance and finance. Reassessment should be done based on the feedback and any adjustments made as appropriate (Senior & Swaile 2010).

Stage 5: Assess and Reinforce Change

The stage entails assessing and evaluating the process of change to determine the extent to which the organization has realized the vision. The focus is to prevent the falling back into old behavior (Hashim 2014). Senior argues that assessing “Soft” change effort success is harder compared to “Hard” change. In general, Soft changes involve cultural norms, behaviours and attitudes, and are often difficult to quality. Change reinforcement aims at making the change permanent. Reinforcement can be more difficult with Soft changes. Middle managers are identified and the most important group to cultural change success because of their experience. Therefore, getting them committed to support the proposed change may be vital for the success and reinforcement of the change across all departments (Senior & Swailes 2010).

3.3 Rationale for Choosing the HSE for the Project

This project focuses on introducing an electronic prescription to an outpatient multispecialty clinic. The HSE change model was adopted to guide the change process for this project. The HSE change model is deemed the most appropriate model for this project because it meets the requirements of the proposed project and thus permits the flexibility to move back to prior stages. This model is also continually cyclical in nature, and this makes it suitable for the project. In addition, the model covers various issues of importance to this project, including the importance of decision making, communication, and engagement to promote continued organizational improvement (Uden, Hericko, & Ting, 2015). As this project focuses on introducing an electronic prescription to an outpatient multispecialty clinic, it is vital for the researcher to communicate and enhance learning and knowledge about electronic prescription among the multidisciplinary team using the right style for communication, which the HSE change model addresses.

3.4 The Change Process Based on HSE Model

3.4.1 Initiation

Step 1: Preparing to lead the change

Identify what is driving the need for change and the degree of urgency

Field force analysis was done to identify what is driving the need for the proposed change and the degree of urgency for the change (see appendix 2). Pre-study data was gathered and it was felt that the change was very important to improve patient care and minimize incidents of medication errors due to poor hand written prescriptions. The analysis of clinic health data revealed that medication errors are a major problem in the multispecialty clinic and that their incidence is on the rise. It also showed that prescription errors are the most common forms of medication errors in the facility. Of the prescription errors identified, poor physician handwriting was found to be the commonest contributing factor.

Medication errors are a common threat to patient safety and have been associated with patient harm due to adverse drug events (ADEs). Prescription errors have been found to be responsible to the largest proportion of ADEs. The high incidence of medication errors at the multispecialty clinic have contributed to poor patient outcomes and increased rates of ADE-related morbidity and mortality as well as increased medical costs to the patients and their families, the health facility, and the society at large (Dixon-Woods et al. 2013). If not addressed, these detrimental effects of medication errors are likely to extrapolate, resulting in further harm. It was deemed that introducing an electronic prescription in this facility would help reduce the incidence of medication errors, reduce the harm associated with these errors and ultimately improve patient safety and outcomes.

For the past four years incidents involving medications errors occurred in the organisation in which prescribing and dispensing errors were on the top of the list (see appendix 1), the reason of most incidents was due unclear handwritten prescriptions. In addition the increased demand from the local market to shift to an e-claim system monitored by local authorities gives more pressure on medical providers in Dubai to comply with their requirements.

Clarify leadership roles and identify the key influencers and stakeholders

Various stakeholders and influencers played a role in this project. The stakeholders included the leaders and managers of the clinic who will spearhead the proposed change. Other stakeholders include information technology team, physicians, pharmacists, nurses, and patients, other healthcare providers involved in patient care in the clinic, stakeholder Analysis was performed (see appendix 3 ). This project is likely to directly impact on these stakeholders, and therefore their involvement in the change process was imperative. A team, consisting of the senior managers, the physician, information technology expert, pharmacist and the advanced practice nurse was constituted to lead the change. Members of this team are role models to their subordinates and thus have the ability to influence and motivate the other employees to adopt the proposed change. They were the drivers of the change and were involved in designing the change management process for the proposed project. The leadership role of the team was communicated to the entire organization.

Assess readiness and capacity for change

The readiness and capacity for change was assessed to identify the most appropriate strategies that could be employed to support the people at the clinic through the change. Key leaders of the team were involved in creating the energy, support and the motivation for readiness for the change in the organization. All levels of organization commitment were sought to ensure adequate resourcing for the change. All the employees were educated about the change to ensure they have the relevant skills, information and knowledge required to take responsibility for action. The nature and scope of the change was shared with the team to secure agreeable mandate and to facilitate buy-in from these key stakeholders. This helped in clarifying early expectations and to secure the relevant resources needed for the change. There was continuous communication about the proposed change as well as support for effective team working to promote readiness and capacity for change.

Attend to organisational politics

The researcher sought to understand the power and political dynamics of the organization and the wider environment because these factors can impact the change process negatively or positively. The reality of internal politics was attended to by active involvement of each person in the process and taking into account their contributions. Organizational culture and relationships among people as all levels were used constructively to plan and monitor ongoing developments.

Identify the leverage points and opportunities for change

The change agent took into consideration how best to explore the possibilities and opportunities for change. Opportunities to build on openness to innovation, existing good relationships and strong alliances within the inter-professional team were maximized. The information technology department was particularly integrated into the project to support and facilitate the change process.

Perform an initial assessment of the impact of the change

An initial assessment of the likely impact of the change was conducted. Meetings were held with all the relevant individuals, including pharmacists, physicians, and nursing staff to gather information regarding their concerns and expectations of the upcoming implementation. Physicians were concerned that the process of electronic prescription would be time consuming. They expected that the current system would be linked to pharmacy stock to help them know if the medication prescribed is out of stock and the best available alternatives. The pharmacists were concerned that physicians would not comply with the new system. Their expectation were that less time will be consumed calling doctors for double check and that dispensing errors due to poor hand written prescriptions will be reduced. Nurses were mainly concerned that some doctors may shift responsibility to their nurses. They expected that less time will be spent between pharmacists of physicians to clarify drugs prescribed and at other times alternatives in pharmacy.

Outline the initial objectives and outcomes for the change

As aim and objectives were discussed earlier in chapter one, the writer as the change leader must discus them clearly with defined stakeholders. Type of Communication will depend on stakeholders’ interest. Effective project leadership is critically depends on effective project communication (Frank Cervone, 2014).

Agree initial resource requirements

Issues regarding initial resource requirements were agreed upon. The resources that were needed to support the change process included finances, human resources, time, technological resources and specialist/expert knowledge. A meeting was also held with the information technology team with a major focus on the design of the required e-prescription format. Following discussions with the physicians, it was decided that a readymade format designed for our main branch in Dubai where e-prescription was implemented four years ago will be used. In addition to the old format, our physicians had a request for additional options where they would get a reminder for a re-fill prescriptions. It took us three weeks to finalize the desired design with the IT team. The e-prescription was uploaded to our Healthcare Information system (HMIS)-PulseMedPlusSM. There was regular review of the required resources during the change process.

Outline the initial business case for change

An outline of the initial business case for change was developed. It included an updated summary of all the relevant data collected. It included a description of the vision for change, rationale, mandate and need for the change, roles of the change leaders, required resources, major stakeholders, change drivers, degree of urgency, objectives, purpose and outcomes, outline cots, possible timeframe, and plan for business case communication.

3.4.2 Planning

Step 2: Building Commitment

Build a shared vision

The details of the electronic prescription project and the vision of it minimizing the incidence of medication errors and improving patient safety and outcomes were shared with all the employees and their representatives as well as service users. This facilitated the understanding of the project and a shared vision for its future. The staff developed a greater sense of reality regarding the project.

Communicate the vision and the business case for change

The guiding vision and the business case for change were communicated to all the relevant stakeholders. The vision of the electronic prescribing change project was communicated in a manner that is meaningful and compelling to ensure that the whole organization understands the vision adequately and to secure support and commitment. Some of the concerns and fears of the physicians, nurses and pharmacists regarding time and shifting of responsibilities were addressed by reassuring that the change process for the project would be gradual and that adjustments were likely to be made in future depending on the outcome.

Increase readiness and capacity for change

The readiness and capacity for change was increased through education and training of employees to equip them with competencies, knowledge and skills required for the change process. The education and training created special opportunities for team and personal development. The leaders received the appropriate support and were able to model the new behaviours needed to effect the change. Training began in the second week of November for the first floor physicians (18 doctors), and was done for each doctor in their clinics. People who attended the training included the physician, IT, doctor’s assistant nurse and the researcher. Training session was booked on each physician’s schedule after first appointment with patients to ensure the presence of each doctor. Training of the physicians (13 physicians) on the second floor was done on the third week of November. All the staff demonstrated the readiness and capacity for change following this training.

Demonstrate that change is underway

There was need to demonstrate in meaningful and real ways that change was taking place in the organization. It was important to show that the old ways of handwritten prescriptions are changing. By the last week of November, all physicians started ordering electronic prescriptions to their patients. All manual prescription books were removed from clinics and one book was kept on each floor nurse station. The change leaders were responsible for scanning all the ongoing change activities to determine the fits and align the activities appropriately.

Step 3: Determining the detail of the change

Assessment of the current situation against the future vision for change

Most healthcare facilities like hospitals and clinics initially used traditional prescription where physicians relied on hand writing prescriptions for patients during their consultancy visits and hospital admission (Smith, 2006). This meant the patient that the physician transferred the responsibility of taking the prescription to the pharmacy or company for fulfillment. In addition, the prescription was often times written in illegible hand writing that was difficult to read, thus contributing to the pool of medication errors. It is evident, by principle, that paper-based systems took a lot of time in writing the prescription, tasking the patient to take it to the pharmacy where they were likely to meet long queues, as well as taking time to read through physicians’ scribbled hand writing.

To help reduce medication errors associated with paper-based prescriptions, this study sought to introduce an electronic prescribing system with the aim to increase medication accuracy, improve health service quality, and ultimately ensure safety of care (Hollingworth et al., 2007). By introducing e-prescription to the healthcare facility, the researcher seeks to achieve a reduction in the frequency of near-miss incidents associated with prescription. This is possible because e-prescription takes advantage of Web technology to link physicians and pharmacies with minimal to no impact on the workflow (Hollingworth et al., 2007, Moody, 2005). Doing so will ensure that the healthcare facility achieves a compliance rate of 95% and above.

Feedback this analysis to key stakeholders

An evaluation of the current and evidenced benefits of e-prescription indicates that healthcare providers assure patient safety (Ammenwerth et al., 2014). To attain this level of quality healthcare, healthcare professionals such as physicians and pharmacists need to have high levels of compliance and strictly adhere to use of e-prescriptions rather than backtracking to paper-based prescription. Even so, resistance is a normal response whenever a shift in processes is introduced.

Need for change

To effect change from paper-based prescription to e-prescription, the healthcare facility needs to enforce electronic prescription as a strategic policy meant to improve quality of healthcare (Kierkegaard, 2013). For this to happen, the healthcare facility established strict guidelines to ensure compliance with the new prescription system.

Step 4: Developing the implementation plan

Detail of the design of future state

The design of a state-of-the-art system is cardinal in the development of an efficient and effective e-prescription system anchored on increasing patient safety. Such a system includes training requirements and revised clinical practice aimed at eliminating unintended problems such as manual prescription (Redwood et al., 2011). This ensures high levels of compliance, hence reduced risks of reverting to old errors.

Impact of the detailed design

In using the new design, it was expected that physicians, pharmacists and other healthcare stakeholders would achieve a significant decrease in the number of near-miss incidents related to dispensing of medication (Moniz et al., 2011). This was one of the most important target areas of the project. In addition, it was expected that a decrease in dispensing near miss incidents would help healthcare professionals to attain high patient satisfaction levels. Last but not least, it was expected that majority of healthcare professionals would embrace the e-prescription and comply with it for the provision of quality health services and assurance of patient safety.

Outline and agree the plan for implementation

Many healthcare practitioners perceive lack of an implementation plan as the main barrier to the integration of e-prescription into clinical practice (Hor et al., 2010). In knowing this, this project came up with

Detailed Implementation/Project Plan

The project primarily used the HSE change model to provide guidance on e-prescription adoption. To make the transition seamless, physicians were trained on the use of approved credentials (username and password) to access the e-prescription system developed using the MedPulse software. To achieve compliance with the new system, strict policies were put in place to bar physicians from writing manual prescriptions. As such, pharmacy staff members were under strict instructions not to accept manual prescriptions. Physicians were required to send prescriptions using only the new electronic system

3.4.3 Implementation

Step 5: Implementing change

Implement the change

The project was implemented in accordance with the laid out actions. The focus was building upon teamwork and to offer opportunities for those involved in the process to spearhead the implementation. The change leaders openly acknowledged the personal change challenges and supported a culture of continuous learning and tolerance. The impact of electronic prescribing on staff and key service providers as well as service users was monitored closely during implementation, with seeking of appropriate feedback. Implementation of electronic prescription at the clinic started in the last week of November. Open communication among service users, staff and other relevant stakeholders was encouraged to help identify and address any issue that arose in the early implementation stages. The researcher worked closely with staff and the relevant stakeholders to monitor the impact of electronic prescribing at the clinic. Managers were readily available to provide support and address any issues that were likely to arise.

Sustain momentum

Strategies of sustaining the energy and momentum for the change over time and to modify actions should new ideas emerge were put in place. These strategies included peer support, action learning groups, partnership training, team and personal development opportunities, partnership and engagement processes, leadership development and review of performance.

3.4.4 Mainst