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By Jeff Olivet
Coleman Associates

Some people love change. You know the type: they were the first ones to use email when the rest of us thought it was a crazy idea. They were the first to buy the hybrid car when it came off the line. They are constantly introducing us to new music and movies, the latest restaurant in town, or the newest little technological gadget. These people thrive in environments that are ever-changing. They embrace change and run with it.

These people are not generally drawn to healthcare.

In most of the healthcare settings in which Coleman Associates works, we find people who care about patients, enjoy their work, and hate change. Absolutely hate it. I do not mean to imply that everyone in healthcare is resistant to change, but it is a reality that many healthcare professionals become entrenched over the years in their way of doing things. They have become very skilled at doing things their own way. They are convinced they have tried every other possible way and it has failed. Trying to get these people to do anything in a new way—e.g. to redesign clinic work processes—can prove to be a very challenging task indeed.

When clinics undertake the work of patient visit redesign—in order to improve patient flow, decrease patient wait time, and create a more patient-centered visit—redesign teams and managers inevitably meet with resistance. This resistance comes in many forms, including anger and accusation, passive unwillingness to learn new ways of working, and active undermining of new approaches to serving patients. It also comes from all quarters—doctors, nurses, managers, administrators, and support staff.

When they encounter such resistance, patient visit redesign teams and managers must be shrewd, tactical, and creative in deciding how to deal with it. Here are two key strategies:

• Understand where the resistance is coming from.
• Tailor the response to the person.

Thinking like a Psychologist

In order to improve the patient visit process, leaders in clinic redesign must think like psychologists. Overcoming resistance requires understanding individuals one at a time—uncovering what makes them tick and what it is they're actually resisting. Here are the questions a leader should be asking:

• What is this person resistant to?
• Why is he/she resistant?
• What will it take to break through the resistance?

In each case, the answers to these questions will be different. For example, some people will be resistant to the idea of change because they fear it will mean more work. Others have an underlying insecurity they will not be able to function well in the new system—a fear of failure, really. Still others, often managers, will be worried that their jobs will become obsolete as patient care teams become more autonomous.

Some resistance is superficial and melts away as soon as people see the benefits of the redesign. They come around as soon as they see the value in improving patient visit cycle time—and realize the value extends to both patients and staff. A provider who was initially resistant to working as part of a team comes to value the close support and efficiency the team affords. A lack of trust among colleagues transforms into a healthy respect and reliance on one another's skills.

But this is not always the case. Some resistance is deep. Some people are not willing to change in order to adapt to new work processes. Some people choose to leave. Some are fired.

What do redesign leaders do when resistance seems insurmountable?

Tailoring the Response to the Resistance

Patient visit redesign teams and managers leading a redesign effort should approach resistance with a whole toolbox full of strategies. Any toolbox worth its salt won't contain just a hammer, or just a screwdriver. It'll have a variety of tools in different sizes with different uses for different problems.

The same is true for dealing with resistance. A manager cannot simply do the equivalent of leaving the toolbox in the basement saying, "let's just be patient—so-and-so will come around eventually." This will only create an atmosphere of permissiveness in which no one can be required to change. Nor can the only approach be that of the chainsaw: "Whoever doesn't do things this way starting now, they're toast." This only creates a fearful, demoralized atmosphere.

You've got a toolbox, but it does you no good if you don't use the tools inside it.

Leaders must be equipped and willing to employ a wide range of approaches depending on the individual and the source of the resistance. Here are some tools for your anti-resistance toolbox:

• Roll with resistance. Some people just need time. Keep trying to show and convince, but be patient while people come around. WARNING: This approach should be used sparingly, and only when there has been a judgment that it will be the most effective method.

• Reward appropriate behavior frequently and consistently. Reward publicly. Make it genuine. Make it mean something. You can never reward too much—reward has a profound impact on both those being recognized and those not being recognized. See A Carrot a Day: Reward to Retain the Best Staff for some specific ideas.
• Blast the person—chastise in private. While you should reward publicly, you should be conscious about chastising in public. Here's a good rule of thumb: if the behavior takes place in private, then chastise privately, but if the behavior takes place in public, then chastise publicly. When "blasting someone," you've got a variety of approaches you can use—direct confrontation, questioning the person as to why they are behaving in a certain way, threatening disciplinary action, and many others. A good resource for private confrontation is Getting to Yes: Heal Thyself.
• Blast the person—chastise in public. Do not be afraid of confrontation. Do not be walked on. You as the leader of this redesign effort are responsible for the patient care at your site—do whatever you have to do to ensure that it's of the highest quality. This means at times confronting people who will push back and not take kindly to being confronted. See Crucial Confrontations: A Review to help develop skills for healthy confrontation.
• Use a time box. Do not let bad behavior go on and on. Use time limits and enforce consequences if the behavior does not change within those time limits. Just like watching the clock wind down at the end of a basketball game inspires the players to make heroic efforts, a deadline is great motivation for behavioral change.

	Set goals and expectations, then do a performance review. Get formal. Write out goals for performance improvement. Make them specific and measurable, then sit down after a week, two weeks, a month, to evaluate whether job performance has improved. If performance has not improved, then immediately begin the process of formal reprimand and steps toward firing.
	Be willing to go all the way—FIRE WHEN NECESSARY.
	Sometimes the best thing a manager can do is fire someone. It is best for the patients, the rest of the clinic staff, and often even for the person being fired. WARNING: This approach should be used judiciously, but without fear or hesitation when warranted.

While this is just a sampling of tactics to be used in dealing with resistance, our hope is that it gives managers and patient visit redesign teams some skills and courage to confront resistance, work to understand it, and tailor effective responses to resistance as expressed by different individuals. If redesign leaders are committed to transforming the patient experience—to creating a system of care that is truly patient-centered—they will work to achieve those results by any means necessary. And a big piece of that work is breaking through resistance.

Breaking through resistance takes courage, focus on results, and a real creativity to tailor responses to the nuanced forms that resistance takes. It requires leaders who have a clear vision of great patient care and the willingness to make it happen.

For further reading, see also: Setting Goals for Redesign in Seven Steps: A Simple Method for Effective Leaders in the Techniques section of this website.