How to Move a "Giant": 7 Lessons Learned for Making a Change in a Large Organization



 

Eric Yahney, PhD1; Susan Ambrose, LISW-S1; Ryan Vega, MD, MSHA2

Perm J 2019;23:18.306 [Full Citation]

https://doi.org/10.7812/TPP/18.306
E-pub: 08/08/2019

ABSTRACT

Bringing about change in a large organization can be a herculean task, similar to tales of old with the hero overcoming the slow and powerful giant. In this article, we discuss some of the lessons learned from our own journey: 1) Don’t present your ideas in a whisper because you are afraid of feedback; share your project with a megaphone, because feedback can only result in a better product; 2) Be enthusiastic; every discussion about your practice is an opportunity to engage others; 3) Focus on those who are willing to participate in your vision; don’t spend too much time and energy on naysayers; 4) Use the language of your audience. You do not need to become an expert in every subject matter, but you must be able to verbalize your project in a way that matches their terminology and priorities; 5) Streamline your facts and present enough information to remove the frightening unknown, but not so much that the details distract from the purpose; 6) Share your results, successes, and struggles; your authentic efforts will affect your audience far more than promises or predictions; and 7) Couple the fires of passion with the cold determination of commitment; the combination will help you persevere and achieve success.

INTRODUCTION

In fairy tales, a giant is the ultimate challenge for the hero. The brave adventurer must battle the powerful, larger, seemingly unmovable opponent to achieve victory. Similarly, large organizations are intimidating and slow to divert from their path. Achieving meaningful change in a large organization can be daunting, time-consuming, and difficult. But, the David and Goliath metaphor (little shepherd, sturdy slingshot, good aim, long odds, slays a giant, wins the day) has been around for thousands of years for a good reason. Making a change in a large organization can certainly be accomplished, even without a slingshot and pinpoint accuracy. In this article, we present 7 key lessons that we learned from our recent experience moving a “giant”: Implementing a new approach for veteran suicide prevention at a medical center in the Department of Veterans Affairs (VA), the largest integrated health care system in the US.

OUR STORY

Our story began with the goal of reducing the risk of suicide for veterans undergoing treatment for substance use disorders. Although suicide is the leading cause of death for people with an addictive disorder,1,2 very little guidance is available in the literature that addresses suicide prevention in a group therapy format. Consequently, we developed the Suicide Prevention-Addiction Recovery Care (SPARC) Group Therapy Module, a creative, original, group therapy intervention. We implemented the project in 2016 at the Louis Stokes Cleveland VA Medical Center in Cleveland, OH. Our group module was constructed using cognitive-behavioral techniques, which are supported in the literature as an effective approach to reducing the risk of suicide.3

The traditional approach to suicide prevention in mental health treatment is reactive and conducted solely in an individual therapy format. To initiate enhanced care services to reduce the risk of suicide, a veteran would need to self-disclose suicidal ideation, a clinician would need to recognize warning signs for elevated risk of self-directed violence, or friends or family would need to notify the clinician of their concerns.4

Furthermore, before 2018, suicide risk assessment and prevention were addressed by separate, independent disciplines within the VA system. Mental health practitioners often evaluate or treat risk of suicide with little to no coordination with specialists in treating substance use disorders. Our project involved a major cultural change: Focusing on integrating interventions and resources across treatment specialists to assist members of this vulnerable population.

The SPARC Group practice incorporates a proactive approach, as recommended by experts in the field,5 through an additional group therapy-based intervention. During the session, mental health clinicians educate veterans on risk factors and warning signs for suicide6 and substance use relapse as well as help participants recognize the correlation between substance use and suicide,7 group members create personalized safety plans,8 develop coping strategies, and identify individuals to serve as a support system.

With the encouragement of our administrators, we submitted our project to the VA Diffusion of Excellence Initiative, a program that identifies best practices for some of the VA’s most difficult challenges and assists with implementation at facilities across the nation. That submission process led all the way to the national stage in Washington, DC, and the program was chosen as a Gold Status Practice to be implemented at another facility, the Tuscaloosa VA Medical Center in Alabama. Along that journey, we learned many valuable lessons regarding how to implement change in a giant organization.

SEVEN LESSONS LEARNED FOR SUCCESSFULLY MAKING CHANGE IN A LARGE ORGANIZATION

As a caveat, this article will not review commonly understood notions of the process of change (eg, time management, resource allocation). The literature on implementing change is rich with well-known theories and models. The lessons learned that we list here reinforce specific concepts from our experience.

1. Feedback Can Only Make Your Project Stronger

Presenting a practice that is near to your heart to a nonreceptive or hostile audience can stop even the most passionate innovators in their tracks. It is helpful to remember that feedback will result in improvement. Feedback can be distilled into 3 categories:

  • Positive feedback is the easiest to hear, and it increases motivation, instills you with confidence, and encourages others to listen to your words.
  • Accurate critical feedback highlights shortcomings in the project. It may not be easy to hear but can be more valuable in the long run. You can use this information to evolve your project and resolve problems early.
  • Inaccurate critical feedback can be the most frustrating to receive. After some reflection, you may find that it can be as valuable as the rest. You may gain a better understanding of how your practice (or even your intentions) might be misperceived. Inaccurate critical feedback can serve as an alert of unknown oppositional forces. Think of it as a bobber on a fishing line; you might not know that the current below the river’s surface is turbulent and dangerous without that initial cast.

After presenting our practice, some glowing feedback made us wonder why we ever hesitated to share our ideas. Other feedback was harsh, inaccurate, and left us feeling rejected. Ultimately, all feedback was beneficial, even when painful. After review, it became apparent that some providers misperceived our practice as mandatory. Consequently, we clarified that the practice was voluntary, was an opportunity for growth, and was not a threat to their clinical judgment or autonomy. Future presentations emphasized the voluntary nature of the practice to avoid this misunderstanding.

Taking a practice from a small-scale operation to public review can be intimidating. Being mindful that feedback can only make your practice stronger may allow you to move forward and achieve victory, even without the courage of a legendary hero.

2. Enthusiasm Is Key to Engagement

Ideally, any audience that you present your project to will be thoughtful, attentive, and understanding. In reality, professionals are often tired and overworked and will be listening with only half of their attention. Stakeholders may not remember all the details from your presentation, but they will likely remember your enthusiasm. During any public discussion of your project, make sure to exude how rewarding, fulfilling, and meaningful the experience has been.

For example, we presented our practice on multiple occasions to nonclinicians, and it was clear that the subtle nuances of therapeutic interventions were unfamiliar territory. But, almost universally, our audiences commented on the dedication, fulfillment, and passion that we communicated during our presentations. These same audience members later contacted us to ask for our assistance in helping to implement the SPARC Group practice at their own facilities.

Remember, long after the specifics of your project have faded from your audience’s memory, the attendees will remember your enthusiasm and stay motivated by your inspirational “tale.”

3. Focus on Willing Participants of the Grand Design

Change can be difficult, and when you encounter staunch opposition, focus on those who are open to the possibility of change. That is not to say ignore those who are not in agreement—just don’t spend too much time banging on a locked door that is unlikely to ever open. In addition, some participants involved in implementation may not be enamored with their role. This is not a problem; when someone believes in the greater purpose of the project, they can be willing to fulfill their duties, even if their own part is not glamourous or inherently rewarding.

When we started the SPARC Group practice in Cleveland, OH, we encountered practitioners who wanted no part of it for a variety of reasons. Some clinicians had alternative interventions they preferred to employ, others felt they were already overworked and underappreciated with no room for additional responsibilities, and still others resented the prospect of their clinical judgment being superseded. Initially, we tried to convert the naysayers; however, we found that we lost momentum when we focused too much effort on converting the skeptics and instead realized that our energies were better spent focusing on those who were willing to come aboard.

4. Speak the “Language” of Your Audience

To drive organizational change, you must communicate with a diverse group of stakeholders (eg, administrators, supervisors, directors, committees), many of whom use different terminology, are motivated by different rewards, and hold unique beliefs and prejudices. To maximize your chances for success, learn the culture and language of the stakeholders you are trying to enlist. What motivates them? What do they believe is important? What does your terminology mean to them? Communicating change in language that is accessible to your audience, even if it involves terms that are not comfortable to you, is crucial to the success of your practice.

For example, during our journey implementing the SPARC Group in Cleveland, OH, we presented to fellow clinicians, administrators, service chiefs, and researchers. When we spoke with clinicians, discussing the impact our intervention had on improving quality of care was a major selling point. Those were easy presentations because we used the same language, often held similar viewpoints, and valued the same outcomes. With administrators, however, the language needed to shift to outcomes statistics, the efficiency of the intervention, and the number of patients treated.

Encouraging people to change in a giant organization is difficult enough without the additional barrier of ineffective communication. You will be far more likely to engage a receptive audience if you speak their “language.”

5. Pull Back the Curtain of Mystery—The Unknown Is a Barrier

The unknown can be a source of anxiety and may reduce willingness to participate in change. Having the right amount of detailed information in your presentation falls under the Goldilocks Principle. With too little information, your audience may “fill in the blanks” with their own worst fears and hesitate to consider innovative ideas. However, too much information can overwhelm stakeholders, derail your momentum, and potentially lead to needless debate on inconsequential points. Strike a balance. Seek to provide just enough information and data so that your audience can make an informed decision.

6. Promises Attract a Crowd, but Results Build Relationships

Conceptual benefits and prediction-based outcomes without proof may be enough to get people initially interested in your practice but are not enough for those same people to dedicate resources to make your vision a reality. To gain respect for your expertise and build your reputation as an innovative problem solver, you need to share your authentic experiences: Your results, your successes, and your struggles.

We found that sharing successes and struggles increased the acceptance of our practice. Our practice involves a frank and earnest discussion of suicidal thoughts, and, naturally, emergent situations can develop. We quickly learned not to schedule our module near the facility’s closing time or when only skeletal support staff was available. To convince others of the merits of your practice, sharing your successes, struggles, and results gathered over time will inspire others. After all, change is evident only through the accumulation of experience over time.

7. Commitment Plus Passion Can Change the Landscape

When one sets out to run a marathon, getting to the finish line is no small task. It involves perseverance, conditioning, and commitment. Although a marathon may appear impossible at first, training can transform it into a manageable, enjoyable, and fulfilling journey. The same can be said for implementing change across an organization.

Commitment is carving the time out of your schedule with a willingness to keep moving forward because of the project’s importance. Passion is the other side of that coin. It is the drive to make a difference, to work long hours, and to exert great effort based on the feeling of the moment. Passion inspires, motivates, and draws others to your project, even before the benefits of commitment are apparent. Plenty of projects begin in a burst of inspiration but do not result in meaningful change once those moments of passion dissipate because of a lack of commitment. Commitment keeps you engaged even when motivation falters. The combination of passion and commitment is what is needed to bring about change in a large organization.

CONCLUSION

Bringing about change in a large organization can be a herculean task, similar to tales of old with the hero overcoming the slow and powerful giant. In this article, we discussed some of the lessons learned from our own journey: 1) Don’t present your ideas in a whisper because you are afraid of feedback; share your project with a megaphone, because feedback can only result in a better product; 2) Be enthusiastic; every discussion about your practice is an opportunity to engage others; 3) Focus on those who are willing to participate in your vision; don’t spend too much time and energy on naysayers; 4) Use the language of your audience. You do not need to become an expert in every subject matter, but you must be able to verbalize your project in a way that matches their terminology and priorities; 5) Streamline your facts and present enough information to remove the frightening unknown, but not so much that the details distract from the purpose; 6) Share your results, successes, and struggles; your authentic efforts will affect your audience far more than promises or predictions; and 7) Couple the fires of passion with the cold determination of commitment; the combination will help you persevere and achieve success.

When all is said and done, the process of change always starts with you, your vision, and the courage to move giants.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

How to Cite this Article

Yahney E, Ambrose S, Vega R. How to move a “giant”: 7 lessons learned for making a change in a large organization. Perm J 2019;23:18.306. DOI://https://doi.org/10.7812/TPP/18.306

Author Affiliations

1 Louis Stokes Cleveland VA Medical Center, OH

2 Office of Disclosure, Education, and Affiliate Networks, Veterans Health Administration, Richmond, VA

Corresponding Author

Ryan Vega, MD, MSHA (ryan.vega@va.gov)

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Keywords: change management, innovations in group practice, suicide risk assessment, suicide risk in veterans

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