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Gaining, Using & Sustaining Influence

January 16, 2014

Barbara R. Medvec, RN, MSA, MSN, NEA-BC

About to Oakwood

Oakwood Hospital & Medical Center

Oakwood Annapolis Hospital Oakwood Heritage Hospital

Oakwood Southshore Medical Center

Oakwood Common Retirement Community

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“The key to successful leadership is influence, not authority.”― Kenneth H. Blanchard

Objectives

• Appreciate definitions of influence and change management

• Review processes for using influence to create and sustain change within nursing practice

• Outline outcomes and opportunities in practice that can be achieved through using influence and change management

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in·flu·ence Noun

• 1. the capacity to have an effect on the character, development, or behavior of someone or something, or the effect itself. synonyms: effect, impact; More control, sway, hold, power, authority,

Verb

• 1. have an influence on."social forces influencing criminal behavior"

change - CHānj/ • Verb

• 1. make or become different. "a proposal to change the law” alter, make/become different, adjust, adapt, amend, modify, revise, refine; transform,

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Compelling Reasons for Understanding Change & Exerting Influence

Nursing: Scope and Standards of Practice

To Err is Human

Crossing the Quality Chasm

Keeping Patients Safe: Transforming the Work Environment of Nurses

The Future of Nursing: Leading Change, Advancing Health

Affordable Care and Accountability Act

Healthcare Reform & the Triple Aim

Reduce Cost Increase Quality Improve Safety

Safety First Patient Safety

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Challenging Healthcare Profitability

Evaluate All Core

Business for Efficiency

and Performance of

Results/Outcomes.

Assess Financial Value

Impact of Increased

Volume of Patients

Receiving Care and Rate

Reductions.

Define Strategies to

Integrate with

Physicians/Physician

Groups to Management

Bundled Payments and

Incentives

Create New Care Delivery

Models that Manage

Chronic Disease and

Leverage Technology.

• Prepare and enable nurses to lead change to advance health

Nurses should be full partners, with physicians and

other health care professionals, in

redesigning health care systems in the

United States

RECOMMENDATION NO. 7:

Future of Nursing

Foster Leadership Skills and

Competencies

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We are creatures of community. Those individuals, societies, and cultures who learned to take care of each other, to

love each other, and to nurture relationships with each other during the

past several hundred thousand years were more likely to survive than those

who did not. Dean Ornish, MD

Success

Opportunity

Approaches

Nursing Science

For

Transforming

Nursing Excellence

Research Priorities

Practice

Education

Leadership

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Vision First

• Define a clear vision

• Everyone visualizes it

• Have details that bring it to life

• Provide picture of what practice will look like

• Written in present

• Measurable elements

The key to sustaining any new vision for change is persistent focus,

dogged determination, resiliency, continuity, and the integration of the

individual efforts that specifically advance that vision.

Jayne Felgen

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The Facts of Change

• Each change that occurs causes more change to occur. • Change is the eventual outcome of problem solving

activities. • The Nursing Process is an excellent tool for assessing

and implementing change. • Change must be supported by objective data. • Successful change requires accessibility to resources. • Incremental change receives less resistance than

complex change. • It is more difficult to change an entire groups behavior

than one person.

Change Success

• For the change agent(s), the change must be compatible with their own personal values and not in conflict with policies and regulations of the organizational values.

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Understanding Values

• Values reflect the beliefs, attitudes & expectations which direct the priorities people live by; they are the language of a collective culture.

• Every organization has a set of core values that guide the Mission/Vision/Goals of the institution, and also establish the parameters of its workplace culture.

Understanding Values

• While executive leaders play a large role in defining organizational culture by their actions & leadership, all employees contribute to the culture within their own unit or department.

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Understanding Your Values

• Values are developmental

• Values are reflection of your conscious awareness

• Values can be learned, mentored, and transformative

Impact of Values on Influencing Change

A values-based culture holds the key to employee loyalty & commitment. Lack

of congruence between personal & work-place values decreases satisfaction

& effectiveness, leading to burnout, turnover & poor performance.

Joellen Koerner

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Reflection on Change Methods

• Lewin’s Change Theory

• Transformational Leadership

• 12E2

• Appreciative Inquiry

Kurt Lewin’s Three Stages of Change

• Phase/Stage I - Unfreezing

– Recognized need for change

• Expectations are not being met

• Discomfort or guilt arises because of an action or lack of an action

• An obstacle to change has been removed

ACNL/CINHC 2011

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Kurt Lewin’s Three Stages of Change

• Goal for Phase/Stage I – Clarify what is and facilitate the staff’s need to change

– Facilitate the staff’s commitment to the change process

• Nurse Leader Strategies – Raise Questions with staff

– Explore feelings and attitudes

– Allow the staff to feel the need for change before proposing options

– Help the staff explore options

– Explore the evidence

ACNL/CINHC 2011

Lewin’s Second Stage of Change

• Stage II – Moving

–Change begins to be implemented

–This phase is contingent on how well staff moved through Stage I

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Kurt Lewin’s Three Stages of Change

– Goal for Phase/Stage II • Successful implementation of the planned change

– Nurse Leader Strategies • Empirical-Rational

– People will change if shown rationally and what the benefit is to them

• Normative – Reeducative – Change not only behavior but attitudes, values and norms

• Power – Coercive – Legitimate power to force compliance with change

ACNL/CINHC 2011

Kurt Lewin’s Three Stages of Change

• Stage/Phase III – Refreezing

– The new knowledge, attitude or behavior is learned/integrated into practice/actions

– Staff consistently demonstrates the new attitude or behavior

– Acceptance

ACNL/CINHC 2011

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Kurt Lewin’s Three Stages of Change

• Goal for Phase/Stage III • Successful adoption of change • Integration of the Change

• Nurse Leader Strategies

– Taking actions that will help legitimate the change – Providing feedback to reinforce the behavior/attitude – Collect data on outcomes of change – Sharing articles/stories where others successfully

implemented the desired change – Evaluate for continued adherence to change

ACNL/CINHC 2011

Resistance Acceptance Continuum

Active Passive Passive Active

Resistance Resistance Apathy Acceptance Acceptance

ACNL/CINHC 2011

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Staff who Respond to Change • Innovators - enjoy change but can be complex as their

action may reveal the need for more change • Early Adopters – respected by peers, support and

facilitate change • Early Majority – accept idea after careful thought, they

have a desire to maintain stability • Late Majority – only accept after most have already

accepted • Laggards – side step change – may distrust process • Rejecters – may conceal and then undermine all

aspects

• Consistently, Against, Virtually, Everything

Transformational Leadership

“is a leadership style where one or more persons engage with others in such a way

that leaders and followers raise one another to higher levels of motivation

and morality.”

Burns, JM Leadership, Harper-Collins, 1978

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Transformational Leadership

• When people are aware of the importance of a task they will be motivated

• Focusing on the team or organizational goals produces better work

Bass, B.M. (1985) Leadership and Performance Beyond Expectations. New York, NY: The

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Begin Where You Are

• Having the capacity to see and accept reality and to lead from this point forward

• Look at the possibilities given our current realities

• What could be possible tomorrow

Lead with Purpose

• Understand your purpose as a health care team

• What does the purpose mean to each role on the team

• Identify the common outcome that all team members will strive for

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Creating Awareness

• Engage staff members in meaningful conversations about their practice and what is important to them

• Ask questions that help people connect with the power and importance of their work

Creating Awareness

• Consciously use meetings as a means for engaging my team, reflecting on and appreciating successes, and inspiring energy to overcome challenges

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Go With the Energy

• Seek out, support, and develop people who have positive energy and take ownership for their practice

• Resist draining my energy by worrying about people who do not rise to expected standards; as necessary, I take action to help them develop or make other choices

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Go With the Energy

• Seek out, support, and develop people who have positive energy and take ownership for their practice

• Resist draining my energy by worrying about people who do not rise to expected standards; as necessary, I take action to help them develop or make other choices

• Consistently, Against, Virtually, Everything

Go With the Energy

• Intentionality about caring for my own energy; this includes establishing effective boundaries and being conscious about my relationship with time

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Inspire a Shared Vision

• Ignites our passion

• Creates new energy

• Helps everyone see that their unique talents are valuable contributors to change

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Inspire a Shared Vision

• Encourage people to speak from their hearts about what is important to them in their work and I listen

Inspire a Shared Vision

• We help individuals see that the new vision is a vision they’ve already held

• Bring new vision in alignment with previous core beliefs

• Reconnect health care team members with their original “core of caring”

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How to Inspire

• Inspiration and Appreciation go hand in hand

“In order for people to be inspired to excellence, they must have a sense that their work contains elements of truth,

beauty, goodness, and unity” (four foundations of business and personal

excellence) Tom Morris

How to Inspire

We inspire most effectively when:

We help individuals see that the

new vision is a vision they’ve

already held

Bring new vision in alignment with

previous core beliefs

Reconnect health care team

members with their original “core of

caring”

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Learn by Doing and Reflecting

• Words and plans are placed into action

• Take risk

• Have the courage to pursue what is valued

• Change happens one person at a time

• Small changes can have big impacts

• Stimulate a culture of learning and shared leadership

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I2E2

• Inspiration

• Infrastructure

• Education

• Evidence

I 2 E 2

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I2E2

A formula for designing,

implementing and sustaining

comprehensive integrated

cultural change (blueprint for

change).

I2E2 encourages engagement

of everyone in the

organization.

It is cyclical in nature.

Appreciative Inquiry: An affirmative process in creating a Relationship-Based culture

www.chcm.com

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Guiding Principles of AI

• Make every inquiry “Appreciative”

• We Have Influence

• Experience Exuberance

• Believe in Your Abundance

• Be Clear

• Embody the Change

• We Get What We Pay Attention To

• Patients and Families Come First

Summary of Successful Change Agent Strategies

• Communication and Education

• Participation and Involvement

• Facilitation and Support

• Negotiation and Agreement

• Cooperation

• Little to do with Manipulation or Coercion

ACNL/CINHC 2011

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Lessons Learned

• With best minds available

• Best minds are NOT “like” minds

Solve Complex

Issues

• Movement

• Responsiveness

• Nimbleness

Process Matters

• Listen for principle(s)

• Do not take literally

• Some have the gift of argument

Extreme Viewpoints

• Be patient & interactive

• Reframe the message at critical times

• Listen sharply & differently

Use Your Voice

“When dealing with tough situations, there are three things

you must remember

Vision

Partnering

Courage”. Marla Salmon, PhD, RN, FAAN

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Barbara R. Medvec,

Senior Vice President &

CNO

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Nursing at Oakwood “A visible community of nurses, engaged in

guiding the delivery of care, inspired to positively impact our patient’s experience”

Oakwood Nursing Operating Vision

Compassion

Respect

Excellence

Diversity

Ownership

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Stimulating New Ways of Thinking

•Emerging

•Curious

•Risk

•Positive presentation

•Relationships

Relationship Oriented Care (ROC)

ROC is a philosophy of care and a method of delivering care that combines: – Patient and Family-Centered Communication – High Impact Team Practices – Outcomes Focused Care – Critical Thinking & Problem Solving – Supervision and Team Collaboration ROC means we are living our values: “Patients come first!”

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Three Elements of ROC

First Element: Fundamental Relationship with Professionals and Patients/Families to discover their preferred results.

Second Element: Critical Thinking and Problem Solving to get to preferred outcomes.

Third Element: Interdisciplinary Teamwork based on the Patient and Family’s 4 P’s.

The Oakwood Journey 2006:

ROC Facilitators Trained

Performance Improvement in Shift Reporting, Rounds

2007:

Manager and Staff Training

Hardwired Report Process & Handoff Tool

2008:

Staff Competencies, Practice Measures

2009:

Safety & Hourly Rounding Integration

Role Redesign Competencies

2010:

Non-Negotiable Expectations

Delegation & Team Design

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Courage to Change – Oakwood’s Relationship Oriented Care (ROC)

Champions at the Frontline

Innovative Thinking

• Risk

• Relationships

• Accountability

• Innovation

• Performance Measures

New RN Residency Results Turnover

Success

44%

22%

9%

20%

10%

5%2%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2008 2009 2010

6 Months 1 Year 2 Year

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Staff Nurse Retention & Education

Success

78%85%

89.90% 90.10% 91.20%94.60% 94.80%

30%

43% 45%50%

55%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<2000 2001 2007 2008 2009 2010 2011 YTD

% Retention % BSN1289 RN's 1732 RN's

Motivation, Job Satisfaction and Effectiveness

1. Meaningfulness: the importance of the work I do

2. Autonomy: my responsibility and accountability for outcomes

3. Feedback: how well am I doing?

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OSMC OHMC OAH OHH U of MSt. Joe

Ann Arbor

HF Wyand

HF W. Bloom

HF Det HarperMercy Mem

Monroe

St. John Det

Providence

Wm Beau R.O.

St. Mary Liv

Wm. Beau Troy

BotsfordSinai-Grace

Garden Cty

Det RecSt. John Macomb

% Always 81 80 80 80 79 79 79 78 77 77 77 76 76 76 75 75 74 72 72 72 70

Nat Average 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77 77

State Average 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78

0

10

20

30

40

50

60

70

80

90

100

CM

S P

erce

nt A

lwa

ys

CMS HCAHPS Data - October 1, 2010 thru September 30, 2011"How often did nurses communicate well with patients"

75th %tile

80 79 7981

75th to

90th %tile

OHH OSMC OHMC OAHSt. Joe

Ann ArborSt. John

DetHF Det

HF W. Bloom

Sinai-Grace

U of MMercy Mem

MonroeHarper

Wm. Beau Troy

HF WyandSt. Mary

LivWm Beau

R.O.Providenc

eDet Rec Botsford

Garden Cty

St. John Macomb

% Always 75 74 73 72 72 71 69 69 69 69 68 68 68 68 67 67 67 66 65 65 64

Nat Average 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70

State Average 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71 71

0

10

20

30

40

50

60

70

80

90

100

CM

S P

erce

nt A

lwa

ys

CMS HCAHPS Data - October 1, 2010 thru September 30, 2011"How often was patients pain well controlled"

75th to 90th

%tile

75th %tile

50th to

75th %tile

73 74 72 71

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OHH OSMC OHMCHF W. Bloom

St. Joe Ann

ArborOAH HF Det

HF Wyand

HarperWm. Beau Troy

Det Rec U of MProvidenc

e

Mercy Mem

Monroe

St. John Det

Wm Beau R.O.

St. Mary Liv

BotsfordSt. John Macomb

Sinai-Grace

Garden Cty

% Always 72 68 66 66 65 64 64 64 63 63 63 62 62 61 60 60 59 59 58 57 57

Nat Average 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65 65

State Average 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68 68

0

10

20

30

40

50

60

70

80

90

100

CM

S P

erce

nt A

lwa

ys

CMS HCAHPS Data - October 1, 2010 thru September 30, 2011"How often did patients receive help quickly from hospital staff"

75th to 90th%tile

50th %tile

50th to 75th

%tile

68 68 66 64

58 Score previous reporting period

HF W. Bloom

Harper OSMCSinai-Grace

St. John Det

St. Joe Ann

Arbor

Providence

Det Rec OHH HF Det OAHWm Beau

R.O.OHMC

HF Wyand

Wm. Beau Troy

U of MMercy Mem

Monroe

Garden Cty

BotsfordSt. John Macomb

St. Mary Liv

% Always 73 62 59 58 57 56 56 55 54 54 51 48 46 46 45 45 44 44 44 42 39

Nat Average 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59

State Average 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57 57

0

10

20

30

40

50

60

70

80

90

100

CM

S P

erc

en

t A

lwa

ys

CMS HCAHPS Data - October 1, 2010 thru September 30, 2011"How often was the area around patients rooms kept quiet at night"

50th to 75th %tile

25th to 50th %tile

10th to

25th %tile

10th %tile

58 54 49 48

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Inspiring Innovation

Defined:

Innovation is a change in the thought process for doing something, or the useful application of new inventions or discoveries. Innovation may refer to incremental, emergent or radical and revolutionary changes in thinking, products, processes, or organizations.

Wikipedia, 10/17/2010

“Leadership is about stretching oneself professionally and making those uncomfortable areas comfortable. Seek experiences outside your comfort zone and watch yourself ultimately master the

challenge”.- Shirley Chater, PhD, RN, FAAN

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Nursing Clinical Inquiry and Innovation • Evidence Based Practice (M. Titler, PhD)

• Frontline Staff in 18 month fellowship

• Individual/Group Inquiry

• Multi-disciplinary education

• 27 EBP Projects

• 10 EBP Projects Spread in 2013 System Level – Falls, Restraint, Noise Reduction

– Surgical Complications & End of Life Plans of Care

– Communication, Fatigue and Engagement

• Prepare and enable nurses to lead change to advance health

Nurses should be full partners, with physicians and

other health care professionals, in

redesigning health care systems in the

United States

RECOMMENDATION NO. 7:

Future of Nursing

Foster Leadership Skills and

Competencies

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38

• “A true leader is a person whose influence inspires people to do what is expected of them to do. You cease to be a leader when you manipulate with your egos instead of convincing by your inspirations.” - Israelmore Ayivor

“Inspiration helps others to see that the benefits of change outweigh the risks of upsetting the status quo.”

Jane Felgen

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