by Carey Gallagher

What’s in the Way? Working with Resistance

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 to help them reduce readmissions – when patients return to the hospital and are readmitted with the same ailment within 30 days of being discharged. This is not only a priority for providing excellent patient care, it’s 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 from the hospital 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 spread throughout their flagship hospital. 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 that was already following up with patients over the phone. How did they do it?

No one unit had a perfect solution, but 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 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 patients.

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 put together 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? What was going on?

When we met with the leadership team, we too were surprised. But in our experience with change initiatives, we see a lot of resistance to new behaviors at first. Resistance can feel like running head first into a brick wall, but that impact is full of potential energy. If you view resistance to an initiative like a kind of jiu jitsu, the energy within the opposition can 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 it.

We thought there must be more to the story. We suggested that the executives go back out to the units and talk with the nurse managers about the phone call initiative. And in fact, there was more going on. When a nurse on duty would call recently discharged patients, 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 didn’t know how to 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 follow-up appointments 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 useful ideas inside. By listening to workers at the front lines, understanding the sources of their resistance to the change, and working with that resistance, leaders came up with a better solution.

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