Tag Archives: Patient safety

Leading Sustainable Change: Top Down or Bottom-Up?


bottom upI was meeting with a VP in a large, well-regarded, health care organization this past week.  The company has 36 facilities spread over 21 states.  He was in charge of something called patient safety (meaning working to reduce the number of incidents throughout the system where patients could be harmed due to an error or oversight).   This mission has to do with developing and improving quality systems, changing culture, and changing processes.

As seems logical, the company created a system wide committee to study this problem and then develop a national “solution” to it.  They were already anticipating the need for a change acceleration process to overcome expected resistance to change when moving to roll out the “answer”.

Now I am sure that the people on this task force are highly competent, dedicated, and knowledgeable.  Let’s also assume that after they complete their data collection, assessment, and internal discussions, that they would come up with an awesome solution to the problem.   The next question is whether or not they can successfully execute (implement) the solution across the entire network?

I have my doubts.

There is no question that people have been successful with both top-down and bottom-driven strategies for implementing change.   There are certainly pros and cons, but I believe there are some strategies that help sustainability.

The problem.  

Here is a basic problem with the top-down method.   You take a group of smart people who comprise the “task force”.   They spend 2, 4 or 6 months together, researching, collecting data, sharing, discussing, debating, developing, improving, and summarizing a set of ideas.   By the time they are done, they have completed a masterpiece.  They now have a brilliant strategy that was well thought through, and logical.     Every word in their final report has deep meaning to all the task force members who labored so hard to produce it.   It resonates with them, because they shared the context for the exercise, they learned together, they know why they made certain choices, and not others, and why several good ideas were abandoned along the way in favor of others.

When we roll out the solution to the masses, they will often fail to comprehend, believe in, and support the proposed solution to the same degree as those who championed it.   Implementation enthusiasm is lower than desired, and people will “bend” the execution rules in ways that suit them.

You see, the most important benefit of a problem solving (or strategic planning) effort is the process itself.  By working together, the team gradually leaves behind their own individual biases, forming instead a new solution based on their newly formed common understandings and insights.

People support more fully that which they had a hand in shaping.    

One change leadership premise I now hold (though didn’t always practice) is that people will execute with far more passion and commitment ideas when they feel are their own.  In fact, I have observed many cases where even mediocre ideas were successfully executed when the people responsible WANTED to make it work.  Don’t discount passion and will power.   They can often trump intellect.

Re-think what needs central control.

I know it is logical to think there are some large system-wide issues that need to solved on a global basis.   I think it is worth challenging your assumptions about what really needs to be done so in a centralized fashion.   IT and business systems problems may be one example where central decision-making makes sense because the cost of maintaining 36 independent accounting or server systems may be prohibitive.   But what about the topic of patient safety?

Why should we conclude there is only one “right” answer to that problem?   It seems to me our job as executives is to decide whether or not an issue like patient safety is important enough to be on the top of someone’s priority list.   Senior leaders can decide that this matters, and needs to be solved.   But why not allow the people in each location to decide on what is the best way?   You might find that some units were far better, more creative, and more innovative in their solutions.  In fact, one of your local teams might have discovered some ideas that even your blue-ribbon task force would not have thought of.

As people start to attack the problem, why not simply provide a vehicle for success sharing among the units.  This could be done electronically by some internal company blog, a shared electronic “knowledge base” or by some system-wide conference where we bring together people to share their unique solutions, and to recognize the units with the best performance improvements or most innovative solutions.  From there, everyone can learn from each other and bring back new ideas to apply.

Solutions need to be aligned with local cultures.  

Most MBA and executive groups I have taught would agree that culture is a big deal.  In fact, culture drives behavior even more than do directives, policies or procedures.   So for solutions to work, they must be compatible with local behaviors and attitudes.   In one hospital, physicians may have a tradition of being in command of everything, and a top-down autocratic approach may work there.   In a different hospital, there may more of a collaborative tradition, so having nurses and administrative staff involved in different aspects of decision-making may be perfectly natural.   Imposing one solution on the other group would be an up-hill fight.

I learned this lesson in my business trying to harmonize design approaches between R&D centers in Michigan, Germany, and Japan.   I imagined great synergies, a single global design, and lots of efficiency and quality improvements.  The problem was that the cultural differences were too great among the three design teams.  They all had very different definitions about what QUALITY was, and about what constituted an elegant design.   The Japanese, for example valued simple, compact, and inexpensive solutions.   The Germans, on the other hand valued high technology, and robustness.   Getting them to think alike was nigh on impossible.  And, I was wrong for thinking they should.   Their different views were driven by the fact that their local customer bases also shared different philosophies which is what drove the design thinking in our various research centers.  Making them standardize would not have served our customers.

In the end, we did find some value in sharing ideas, but each team knew best their home situation and constraints.  They needed the freedom to adapt ideas to fit their local situation.

And so. . .

It is sometimes nice to be asked to join the global task force to solve the big problem for the organization.  But a strategy of informing and enabling local solutions can sometimes yield the best results.

Other resources:

Driving Top Down Change from the Bottom Up, by Kristen Etheredge and Damon Beyer, AT Kearney.

Combining top-down and bottom-up change management strategies in implementation of ACP: the My Wishes program in South West Sydney, Australia;  by C Shanley1, L Johnston2 and  A Walker, BMJ Supportive and Palliative care.

Advantages and disadvantages of the top-down and bottom-up implementation approaches , IBM white paper.

Implementing Scrum: Top Down and Bottom Up Approach Part 1 and Part 2, by Sean Mchugh, the Agile Zone

Advertisements

Leave a comment

Filed under Uncategorized