No one wants to think their workforce just doesn’t care. But what happens when it looks like that’s the case?
We’ve been working with an academic medical center for several years on their initiative to reduce readmissions, when patients come back to the hospital with the same ailment within 30 days of being discharged. This is not only a priority for providing excellent patient care, but also a financial imperative, as hospitals are now being penalized when these patients come back.
The initiative’s executive sponsors knew that patients often went to the ER within a few days after discharge if they were experiencing any kind of problem—because they just weren’t sure what to do. Research showed that having nurses make followup phone calls one to two days after discharge would lower readmissions. The executives asked us to formulate a plan with them to roll out across their flagship hospital. They also said that they knew of a few units that were already making these calls. We advised them to look across the hospital and talk to every unit following up with patients over the phone. How did they already do it?
No one unit had a perfect solution, but the executives found pieces of the solution across the hospital. For example, one unit had developed a script to make sure that no matter who was calling, every patient got the same information and was asked the same core questions. Others were notifying the health system’s home care agency that also called patients, so that they weren’t confusing patients by doubling up in the same day. Yet another had given an administrative assistant the task of following up with low-risk patients to maximize other use of clinicians’ time.
We helped the leadership team knit the pieces together to form a cohesive plan with elements they wouldn’t have thought of without the input of their workforce. Then they piloted the whole package on units with the most readmissions, places where patients suffered from chronic, debilitating illness. The executives thought there was no way this would fail — they’d taken good ideas from the “bottom up” instead of doing what often happens, mandating one set way to work without getting enough input from the frontline. They were giving nurses the go-ahead to spend time doing something that would not only improve readmissions, but directly help the patient.
But something funny happened. They began reviewing reports and realized that on a few units — places that had never done the calls — call logs were very low. The nurses weren’t making the calls. The executives were upset. They had invested time and energy in going around to the units to figure out how to set forth a call strategy that took people’s good ideas into account. And they thought a lot of their workforce. This was clearly in the best interest of the very patients that nurses had seen and cared for days earlier. Didn’t the nurses care? Were they just lazy? Or challenging authority? Or were they really not committed to improving patients’ experience of chronic illness? What was going on?
When we met with the executive team, we too were surprised by the lack of participation in the calls. But in our experience with change initiatives, we see a lot of resistance to new behaviors at first. Resistance can feel very tense, yet full of potential energy. If you view it like a kind of jiu jitsu, you see that resistance can block an initiative but can also be flipped to support it. The pushback can be hard to understand at first but we find that often, when you peel back the layers, there’s helpful information embedded in that resistance. Those resisting a change can actually make the new work more efficient and effective.
So we thought there must be more to the story. We suggested that the executives go back out to the units to have conversations with the nurse managers about the phone call initiative. And in fact, there was more going on. When the nurse on duty would call recently discharged patients, he or she would find one of three things: the patients were fine; they were having serious symptoms and needed to go to the emergency room; or they were having some mild difficulties. The nurses knew exactly what to do in the first and second case, but in the third case, which was most common, they didn’t have anything to offer. The nurses weren’t being lazy — they cared about the patients and they felt stuck because they couldn’t help.
The executives felt excitement and relief in equal parts—the nurses wanted to make the program work; they weren’t disengaged. And all the nurses were asking for were more ways to connect the patients to what they needed!
The executives set up a more direct way for the nurses to make a follow-up appointment with the patient’s doctor or send them to a nearby clinic. They got the word out that there was something new to help the mild cases. The resisting nurses changed course and call volumes started going up on the key units. Readmission rates dropped on the most challenging units, due in part to the power of working with resistance to get to the good ideas inside. An effective change took place by listening to workers at the front lines, understanding the sources of their resistance to the change, and working with that resistance to come up with a better solution.