09-Handouts-Case Studies in

Objectives
Pharmacist Objectives:
1. Explain ADKAR model in relation to creating

Case Studies in Change change
Management: Applied ADKAR 2. Discuss change management assumptions
3. Apply change management principles to a
Jason Glowczewski, Pharm.D., MBA situation at your own workplace
Director of Pharmacy
UH Community Hospitals
Jason.Glowczewski@UHhospitals.org
Objectives Need for Change
Technician Objectives:
1. Discuss why change management is

necessary
2. Describe how you can use ADKAR at your
institution
Available at: http://www.ashpfoundation.org/PharmacyForecast2014PDF
Need for Change Need for Change
Themes from the Pharmacy Forecast: Question:
1. Health care reform When implementing a new pharmacy program,

2. Pharmacy role in patient centered medical what is the biggest barrier to change?
homes and accountable care organizations A: Finances
3. Reform traditional pharmacy practice model B: Senior level leadership support
4. Evaluate outpatient pharmacies, improving C: Staff willingness to change
compliance, and sterile compounding
1
ADKAR ADKAR
The ADKAR Model Awareness
Introduced in 1998
Reinforcement Desire
Change management
Ability Knowledge
ADKAR Application of ADKAR
Tools: LEAN project for cart fill streamlining

Goal: change cart fill time and process
A: Staff meetings and changes in healthcare
D: Goals, evaluations, competition, participation
K: Training, education, CEs, shadowing
A: Coordination of time and documentation
R: Visible progress tracking, frequent follow up,
rewards and recognition
Application of ADKAR Application of ADKAR
Attempt #1 (pharmacy student) Attempt #2:
Awareness none Awareness Multiple meetings, focus groups

Desire Jason said we need to do it Desire Goal of saving everyone time
Knowledge Lets try something new Knowledge Written processes and timelines
Ability Yes Ability Modified schedule to change overlap
Reinforcement Didnt get that far! Reinforcement Collected data to prove time
savings (26 min/day = 158 hours/yr)
2
CHF Patient Counseling CHF Patient Counseling
Pharmacy resident led project Awareness

Education and auditing done by residents External changes health care reform
Residents as change agents Readmission CMS penalties
Opportunity for pharmacy to help
Department performance improvement project
Desire Knowledge
$25 gift card to pharmacist that counsels most 1 hour CE on heart failure pathophysiology and
patients how to implement the plan
Part of annual evaluation and goal CHF counseling booklet for patient
Frequent feedback on performance One page discussion guide for pharmacist
Competition between pharmacists See one, do one, teach one approach
Ability Reinforcement
Night shift helps with patient identification Visible and frequent recognition of top
Technicians engaged with follow up phone calls performing tech and pharmacist
Hours of pharmacist overlap targeted for best $25 gift card awards
free time to do counseling Built into evaluation process
No new FTEs were added Sharing of progress with outcomes
Training other facilities
3
Application of ADKAR ADKAR Summary
UH Geauga Medical Center
CHF Patient Counseling Results: Teaching ADKAR to students and residents
Goal of reducing resistance to change
Metric: CHF readmission rates
Using ADKAR for PPMI related changes
2012: 28% Residency development
COPD and other discharge counseling
42% Medication histories in the emergency
2013 16% room
The Arthur G. James Cancer Hospital

and Richard J. Solove Research Institute
National Cancer Institute
Leading Change: Comprehensive Cancer Center
Pharmacist Cross-training 228-bed academic and
Ben Lopez, PharmD, MS, MHA research institution
5 infusion pharmacies and
clinic locations
2-James
Comprehensive Breast Center
Martha Morehouse Medical Plaza
JamesCare East
Mill Run
2
The Ohio State University Comprehensive Cancer Center
Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 22
James Pharmacy Practice Model Pharmacist Roles
Ambulatory Infusion Pharmacists Work in ambulatory infusion pharmacies

Receive and verify orders, check and dispense final product
Inpatient Generalists Ambulatory
Provide supportive care interventions
infusion Provide medication information and patient education
Specialists pharmacist Precept students and residents
Inpatient Post-graduate training not required (some staff have PGY1)
Outpatient
Work on inpatient units (decentralized)
Inpatient Receive and verify inpatient orders
Provide supportive care interventions
generalist Provide medication information and patient education
pharmacist Precept students and residents
Post-graduate training not required (some staff have PGY1)
The Ohio State University Comprehensive Cancer Center The Ohio State University Comprehensive Cancer Center
Arthur G. James Cancer Hospital and Richard J. Solove Arthur G. James Cancer Hospital and Richard J. Solove
Research Institute 23 Research Institute 24
4
Identifying what Needs to Change Identifying what Needs to Change
Changing healthcare landscape Aligned with organizational goals

Reduce costs and improve care quality Better prepare for hospital expansion
Potential for reduced reimbursement
Schedule flexibility
ASHP PPMI
Expand pharmacists roles
Increase continuity across care settings
We needed to better match our labor
resources to workload demand
Change Goal Starting Small: Pilot
Cross-train our generalist and ambulatory infusion Started with gynecologic oncology service
pharmacists to work in both settings
One pair of pharmacists rotated
Pilot occurred over 6 months
Deemed successful based on:
Pharmacist feedback
Minor improvements in schedule flexibility
Expanding the Change Expanding the Change
Engaged stakeholders In < 1 year, cross-trained 83% (19/24) of ambulatory

Formed subgroup infusion pharmacists
Discussed training and expectations Evaluated training, divided pharmacists into two
Cross-trained about half of pharmacists over 6 groups:
months Comprehensive (4/19)
Supportive (15/19)
Reconvened the subgroup
Verify inpatient orders remotely
Identified gaps in training
Cover inpatient orders during weekend shifts
Clarified expectations
5
Results Key Principles of Leading Change
More efficient distribution of labor resources You: as the champion of the initiative
Better use of downtime People, not process
Improved schedule flexibility One size doesn't fit all
Accepting the Challenge Knowing your Stakeholders
Are you the right person to lead a change? Identifying the people who will influence the change
Is the need for change real? Calculate their likelihood of support
Is the proposed solution the correct one?
Are you willing to prioritize this initiative?
Image adapted from: The Advisory Board Company. https://advisory.blackboard.com/. Accessed 3/21/14.
Mobilizing Stakeholders Conclusions
Adopt a different Improved schedule flexibility

strategy for each Still refining some training materials
type of
stakeholder Wide variety of supporters, undedecideds, and
dissenters
WIFM - "What's in Staff feedback and engagement was key!
it for me?"
Image adapted from: The Advisory Board Company. https://advisory.blackboard.com/. Accessed 3/21/14.
6
Questions?
The Ohio State University Comprehensive Cancer Center

TheArthur
OhioG.
State University
James CancerComprehensive CancerJ.Center
Hospital and Richard Solove
Arthur G. James
Research Cancer Hospital and Richard J. Solove Research Institute
Institute 38
Huddling: Next step in LEAN Sample Huddle Agenda

Operating System
Standard Work and daily problem resolution to support quicker changes
Helps define targets, actions, and metrics for staff. (Daily, Weekly,
Monthly through display board)
Daily continuous improvements: Develop staff to solve problems and
improve performance (ENGAGEMENT)
Daily midnight hospital census vs. budget predictions
IT related issues
Medication Safety items
Drug shortages/Formulary changes
Dept. Policy/process reminders
Staffing (call offs, reduced time, training)
Hospital Happenings
Huddle Rules Huddle Whiteboard
Limit to 10 minutes or less

Hold the huddle in a central location (main pharmacy
work area)
Start with 1 huddle a day. Keep this time consistent.
(1400)
Start with a designated manager to lead
Seek input from all staff
Always end with a celebration
7
Employee Opportunities for Monthly Scorecard
Engagement
Performance
Improvement Activities
Just Do It vs. Evaluation of project by Pharmacy related to staff
Leadership Council. Staff bring up day to day issues. involvement.
Eg. Patient Satisfaction scores
regarding Communication of meds
End Huddle with Celebration/ Fun facts to share:
Personal or Work related celebration Know your Numbers !!
National Day of _______ (www.checkiday.com)
Fun fact of the day (uselessfacts.net)
Huddle Playbook Charge on Administration

Change: Using the Huddle
Process to improve change
Huddle updates posted daily to a shared
pharmacy drive.
Email of huddle minutes to staff every
Monday morning.
Case Studies in Change Management
Charge on Administration Charge on Administration

(COA) Considerations (COA) Considerations
What ADS cabinets would remain Charge on What medications may be problematic?
Dispense?---those that do not document on Insulin Bulk products
MAR (Cath Lab, Surgery, Radiology)
Inhalers Preop orders
How are continuous IVs charted to capture
new bag charges? What about home medications being
used?
What is financial impact to institution?
8
Staff Engagement Questions Employee Engagement
during Huddles
Are home meds charged appropriately if pharmacy Front-line staff feel more engaged with overall
changes to home med after dose given? operations and decision making ability
How do the front-line staff know if item already
Operational and Clinical goals known and in
charged?
front of staff on a daily basis.
What should be done when sending item to surgery.
(charge on dispense location)? Some enjoy the limelight, others prefer to let a
Do we need to charge for items in the chest pain manager bring up their topic.
box?
Moving to Charge on
Administration
Thank You.
Reduced technician time in crediting has
allowed for expanded technician opportunities:
Technician Admission Meds Rec in ED
Narcotics technician: monitors proper narcotic
documentation
Inventory technician: monitors high-cost drug charge
documentation to ensure charges accounted
Title of Presentation Arial Regular 22pt

Case Studies in Change Management: Decreases in
Single line spacing
census as the imperative for change
Up to 3 lines long
MAKING THE CASE FOR A

Date 20pts
Author Name 20pts
Author Title 20pts Rebecca A. Taylor, Pharm.D., MBA, BCPS
STAFFING MODEL CHANGE
Pharmacy Manager, Cleveland Clinic Marymount
taylorr3@ccf.org
OSHP Change Management l April 2014 l 2
9
Staffing Modeldecentral services in pink
Budgeted census decreased by 20%
2013ADC = 180 2014ADC = 160
N: 2100-0700 N: 2100-0700 Made healthcare reform real-life for the team
O: 0630-1500 O: 0630-1500 Heightened awareness for transitions of care and presence
in the ED
M: 1130-2000 M: 1230-2100 Expanded patient counseling on weekends, moved 1
daytime weekend pharmacist to floors
E: 1200-2200 E: 1330-2200 (ED)
Added 24/7 code response
C1-4: 0700-1530 C1-4: 0700-1530
Changes had to be implemented quickly for Jan 1
(variable) (variable)one in ED
Created hybrid model for med histories (tech, RPh,
A: 0700-1530 (variable) A: 0900-1730 (flex)
APPE students) in August 2013
Pharmacist: Patient Ratio = 1:30 Pharmacist: Patient Ratio = 1:25*
OSHP Change Management l April 2014 l 3 OSHP Change Management l April 2014 l 4
Manifestations of Resistance Which group do you think raised the most resistance?
Central pharmacy is too busy
How do we prioritize? A. Pharmacy Technicians
Some weekends 0 counseling
I can take better care of

patients from my computer B. Clinical Specialists
I cant get to all the patients
Rule inventions: creating arbitrary cut-off times, migration
back into central, frequent breaks C. Staff Pharmacists
Which group do you think raised the most resistance? Models for Change
Make the Surpass Personal
ADKAR undesirable Your
A. Pharmacy Technicians desirable
Limits
Influencer: The Power to
Find
Change Anything Social Harness Strength
Peer
Choose the vital behavior Pressure
in
Numbers
B. Clinical Specialists Hold each other accountable to
new practice model
Design
Spend 60% of shift at bedside Rewards and Change the
Demand environment Structural
Accountability
C. Staff Pharmacists
10
Appealing to personal reasons for change Appealing to social support for change
MotivationMake the AbilitySurpass Your MotivationHarness Peer AbilityFind Strength in
Undesirable Desirable Limits Pressure Numbers
How can you get people to In order to change the vital Approval and disapproval Align the team to help
do things they find boring behavior, people need to of a peer group is key to each other
or profoundly different? feel comfortable with it change efforts
Complex change requires
Immerse them in the Some employees need Engage the early adopters heightened teamwork
activity: try it, youll like it more practice after training (13%)
Discussion of process
Engage them/build trust Reinforcement/Education Discuss change openly, handoff
invite healthy dialogue
Set the bar, allow them to Pair with a mentor to Hold each other
make game plan to get provide feedback accountable
there
Create structural framework to make it stick

MotivationDesign Rewards AbilityChange the Celebrate Successes Examples of Data Reinforcement
and Accountability Environment 2013-2014 Pharmacy Capture Medication Admission
Histories
Optimize rewards, How do buildings, layout, 1200
1103
bonuses, salaries or space contribute to 1050 1072 1061
1005 1015 1018
993
corrective action change? 1000 940 949
920
Rewards are never first Make data visible, 800

678 691
616
measure often
Tie to vital behaviors 600
Doesnt have to be large See the invisiblewhat 400

294
381
obstacles are preventing 188 180
If all else fails, utilize

200
the goal? 92
37
disciplinary process
Support the change
0
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb
Admissions Medication Histories
Celebrate Successes Examples of Data Reinforcement Provide Accountability Data Reinforcement

2013-2014 Pharmacy Capture Patient Counseling vs. Discharge (Mental Health
Excluded) Pharmacy Counseling on Weekends 2014 (randomized)
1000 What will your number be?
900 845 856 863
831 815 817 7
800 779 766 765
756
6
700
635
579 5
600 558 571
532
511 498
478 472 477 490 471 490 4
500 442 457
400 380
307 317
3
6
300 2
200 3
100
1
2 2
0
0
0
Weekend A Weekend B
0
Weekend C Weekend D
0
Weekend E Weekend F Weekend G
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb
Discharges Patient Counseling
11
What did we do well?
The decrease in census provided the business case
for the change
Provided phones for each floor-based pharmacist with
clear schedule/support/break and lunch coverage
Streamlined operations (cartless) to minimize time in
central pharmacy
Provided 8 hours of training for medication histories for
LESSONS LEARNED each pharmacist
Moving clinical specialists to evenings allowed for
feedback and accountability for the staff
What improvements could be made based on change Change is a work in progress

models?
Timing didnt allow for enough intrinsic motivation, but SUCCESS SUCCESS
this is discussed at annual reviews, during IDP, and at
staff meetings
This group doesnt have an early adopter, most are
highly resistant
Discussed issues openly, but not early enough
Considering developing shared governance model for
department
As a last resort, will start to monitor # med histories &
patient counseling and use discipline process What people think it looks What it REALLY looks like
like
12

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Objectives

1. Explain ADKAR model in relation to creating

Objectives Need for Change

1. Discuss why change management is

Available at: http://www.ashpfoundation.org/PharmacyForecast2014PDF

Need for Change Need for Change

Themes from the Pharmacy Forecast: Question:

1. Health care reform When implementing a new pharmacy program,

The ADKAR Model Awareness

ADKAR Application of ADKAR

Tools: LEAN project for cart fill streamlining

Application of ADKAR Application of ADKAR

Attempt #1 (pharmacy student) Attempt #2:

Awareness none Awareness Multiple meetings, focus groups

CHF Patient Counseling CHF Patient Counseling

Pharmacy resident led project Awareness

Application of ADKAR Application of ADKAR

CHF Patient Counseling CHF Patient Counseling

Application of ADKAR Application of ADKAR

CHF Patient Counseling CHF Patient Counseling

The Arthur G. James Cancer Hospital

James Pharmacy Practice Model Pharmacist Roles

Ambulatory Infusion Pharmacists Work in ambulatory infusion pharmacies

Changing healthcare landscape Aligned with organizational goals

Change Goal Starting Small: Pilot

Expanding the Change Expanding the Change

Engaged stakeholders In < 1 year, cross-trained 83% (19/24) of ambulatory

Accepting the Challenge Knowing your Stakeholders

Mobilizing Stakeholders Conclusions

Adopt a different Improved schedule flexibility

The Ohio State University Comprehensive Cancer Center

Huddling: Next step in LEAN Sample Huddle Agenda

Huddle Rules Huddle Whiteboard

Limit to 10 minutes or less

Huddle Playbook Charge on Administration

Case Studies in Change Management

Charge on Administration Charge on Administration

Title of Presentation Arial Regular 22pt

MAKING THE CASE FOR A

I can take better care of

Create structural framework to make it stick

Rewards are never first Make data visible, 800

Doesnt have to be large See the invisiblewhat 400

obstacles are preventing 188 180

If all else fails, utilize

Admissions Medication Histories

Celebrate Successes Examples of Data Reinforcement Provide Accountability Data Reinforcement

Discharges Patient Counseling

What improvements could be made based on change Change is a work in progress

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