1. The
Adoption
Of
Palliative
Care:
The
Engineering
of
Organizational
Change
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Management
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2. The
Adoption
of
Palliative
Care:
The
Engineering
of
Organizational
Change
Overview
Imagine
that
you
have
just
been
named
to
the
faculty
of
a
distinguished
medical
institution.
Further
imagine
that
you
have
been
asked
by
the
Director
of
the
institution
to
“help
us
implement
palliative
care
in
our
institution.”
What
would
you
do?
How
would
you
do
it?
With
whom
would
you
work?
Whom
might
you
avoid?
What
missteps
would
you
want
to
avoid?
Hopefully
many
of
the
readers
of
this
case
will
be
asked
exactly
that
question;
“Can
you
help
us
implement
palliative
care?”
The
goal
of
this
white
paper
is
to
offer
a
framework
for
thinking
about
such
an
implementation
as
well
as
some
practical
tools
that
might
be
used
to
make
such
an
implementation
possible
in
a
relatively
short
period
of
time.
Elements
of
the
Framework
While
most
of
us
spend
our
time
inside
a
large
organization,
we
usually
don’t
spend
much
time
thinking
about
the
organization.
What
is
an
organization?
What
is
it
made
of?
What
do
we
mean
when
we
talk
about
“changing
the
organization?”
When
we
say
that
we
want
to
implement
palliative
care
in
an
organization,
what
does
that
mean?
The
following
three
subject
areas
can
form
a
framework
for
envisioning
and
then
changing
an
organization
and
how
it
operates:
1.
The
Organization
as
a
Mechanical
System.
A
large
organization
can
be
thought
of
as
a
mechanical
system
made
up
of
concrete
“moving
parts”
–
parts
that
can
be
“engineered”
(or
altered)
to
cause
the
organization
to
function
in
a
different
way,
like
delivering
a
new
service
such
as
palliative
care
to
the
institution’s
clients.
The
mechanical
parts
of
an
organization
that
must
be
engineered
for
change
are:
• Vision
...
the
organization’s
understanding
of
its
mission
and
future
• Processes
...
the
steps
that
allow
the
organization’s
work
to
be
done
(including
the
steps
associated
with
palliative
care)
• Plant/Tools
...
the
physical
assets
(including
software)
the
organization
uses
in
its
processes
• Performance
management
system
...
the
organization’s
way
of
attracting
and
retaining
people
to
work
the
organization’s
processes,
including
palliative
care
©
2011
Endeavor
Management.
All
Rights
Reserved.
Page
2

3. The
Adoption
of
Palliative
Care:
The
Engineering
of
Organizational
Change
2.
The
Diffusion
of
Innovation
within
a
Social
Organization.
Innovations
–
ideas
that
are
new
to
an
organization
–
diffuse
through
an
institution
in
a
patterned
way
over
time,
with
some
organization
members
far
more
inclined
to
adopt
an
innovation
like
pallia-­‐
tive
care
than
others.
Organization
members
might
be
described
in
“thirds:”
• first
third
...
those
clearly
eager
to
try
the
new
and
innovative
• third
third
...
those
clearly
reluctant
to
try
the
new
and
innovative
• second
third
...
those
“in
the
middle”
who
might
follow
either
the
first
or
third
third
3.
The
Role
of
Leadership
in
Creating
Change
in
an
Organization.
Leaders
cause
things
to
happen
in
an
organization.
Leaders
take
direct
actions
on
the
moving
parts
of
an
or-­‐
ganization;
they
influence
organization
members
to
enable
the
organization
to
make
changes
like
implementing
palliative
care
on
an
institutional
basis.
The
following
section
of
this
case
will
provide
both
understanding
as
well
as
action
steps
that
can
be
used
to
implement,
or
“engineer,”
an
innovation
like
palliative
care
into
an
institution
in
an
effective
and
efficient
way.
We
want
to
“pull
it
all
together”
to
illustrate
at
a
very
high
level
how
the
actions
can
be
used
for
the
real-­‐world
implementation
of
palliative
care.
Pulling
it
all
Together…
A
Palliative
Care
Success
Story
Take
for
example,
the
introduction
of
palliative
care
at
M
D
Anderson
Cancer
Center
in
Houston.
The
Chief
Executive
made
the
decision
to
move
toward
palliative
care
and
hired
a
leading
physician
to
come
to
Anderson
and
“run
the
show.”
Upon
arrival,
the
newly
ap-­‐
pointed
Palliative
Care
Department
Head
encountered
stiff
resistance
and
many
logistical
obstacles
that
were
almost
impossible
to
overcome.
At
the
end
of
the
first
18
months,
progress
in
gaining
acceptance
of
palliative
care
was
very
slow,
and
the
third-­‐third
popula-­‐
tion
of
resisters
had
made
themselves
heard.
The
situation
was
uncomfortable
enough
for
the
Department
Head
to
say
“that
he
felt
like
he
had
parachuted
in
behind
enemy
lines.”
In
an
effort
to
move
the
ball,
M
D
Anderson
retained
the
services
of
a
change
consultant
to
work
directly
with
the
Department
Head
and
his
palliative
care
team
of
department
member
physicians
and
administrators.
The
implementation
steps
taken
included
the
following:
• Instruction
of
and
consultation
with
the
palliative
care
team
in
the
change
concepts
that
are
described
in
this
paper.
The
Department
Head
stated
that
the
consultations
and
training
has
“opened
a
window
into
the
world
of
organizations”
that
allowed
them
to
better
see
and
understand
the
actions
that
he
and
his
team
needed
to
take.
©
2011
Endeavor
Management.
All
Rights
Reserved.
Page
3

4. The
Adoption
of
Palliative
Care:
The
Engineering
of
Organizational
Change
• Decision
of
the
palliative
care
team
to
“ignore
the
third-­‐third
detractors”
and
to
find
and
work
with
“first-­‐third”
professionals
only
(i.e.,
working
only
with
those
who
were
relatively
positive
and
eager
to
look
at
palliative
care
as
a
treatment
alternative).
• Formation
of
a
Palliative
Care
Steering
Team
made
up
of
volunteer
senior
physicians/faculty
members
(all
of
whom
were
first
third)
• Arranging
an
early
meeting/workshop
of
the
Steering
Committee
to
hear
directly
from
the
MDACC
Chief
Executive.
The
Chief
Executive
explained
to
the
steering
team
his
reason
for
moving
the
institution
toward
palliative
care,
his
reasons
for
selecting
the
Department
Head
and
his
vision
of
palliative
care
as
a
legitimate
and
important
treatment
modality
for
the
institution.
• These
key,
friendly
members
helped
establish
a
vision,
mission,
and
strategic
plan
of
action
and
not
only
provided
extremely
useful
feedback
but
by
the
same
process
they
were
sold
• This
strategic
plan
was
later
moved
upwards
in
the
administration
to
con-­‐
vince
remaining
senior
management,
and
a
process
of
continuous
monitoring
of
the
level
of
adoption
of
palliative
care
was
established.
• The
palliative
care
team
and
Steering
Team
worked
directly
with
administrative
officers
of
the
institution
to
ensure
that
processes
were
in
place
to
handle
business
and
scheduling
aspects
of
palliative
care.
• With
a
palliative
vision
and
strategic
in
place,
the
Department
was
able
to
launch
communication
and
public
relations
programs,
clinical
education
sessions,
as
well
as
consultations
inside
and
outside
the
institution.
The
focus
on
these
programs
was
initially
on
the
first-­‐third.
As
a
result
of
positive
acceptance
by
the
first-­‐third,
members
of
the
second
third
began
to
sign
up
...
and
before
long
the
first
two
thirds
were
chiding
members
of
the
third-­‐third
as
“being
behind
the
times.”
• The
result
of
this
implementation
approach
was
the
large
growth
in
referrals
to
the
palliative
care
program
that
have
succeeded
in
fully
establishing
it
as
a
viable
clinical
and
financial
program.
Note
the
rapid
rate
of
palliative
care
consultations
in
the
chart
below.
(insert
chart
entitled:
“The
Impact
of
Palliative
Care
Services
on
overall
hospital
mortality
in
a
comprehensive
cancer
care
center,
”by
Bruera,
et
al.)
• The
palliative
care
initiative
has
continued
to
increase
in
use
and
popularity,
with
©
2011
Endeavor
Management.
All
Rights
Reserved.
Page
4

5. The
Adoption
of
Palliative
Care:
The
Engineering
of
Organizational
Change
consultations
continuing
to
increase,
and
the
number
and
cost
of
deaths
in
intensive
care
continuing
to
decline.
Blending
the
messages
from
the
three
framework
elements
is
essential
to
effective
change.
The
essential
message
of
this
white
paper,
therefore,
is
for
leaders
to:
1.
take
strong,
aggressive,
visible
action
...
2.
with/through
the
“first-­‐third”
managers
and
professionals
...
3.
to
alter
the
mechanical
attributes
of
the
organization
that
will
enact
palliative
care.
In
summary,
key
to
the
success
of
the
effective
and
efficient
introduction
of
palliative
care
will
be
the
continuing
partnership
between
the
committed
chief
executive
and
leaders
in
the
management
cadre.
Dedicated
action
in
the
engineering
framework
described
in
this
chapter
...
along
with
huge
doses
of
“blood,
sweat,
and
tears”...
should
lead
to
another
palliative
care
success
story.
©
2011
Endeavor
Management.
All
Rights
Reserved.
Page
5

6. The
Adoption
of
Palliative
Care:
The
Engineering
of
Organizational
Change
About
Endeavor
Endeavor
Management,
is
an
international
management
consulting
firm
that
collaboratively
works
with
their
clients
to
achieve
greater
value
from
their
transformational
business
initiatives.
Endeavor
serves
as
a
catalyst
by
providing
pragmatic
methodologies
and
industry
expertise
in
Transformational
Strategies,
Operational
Excellence,
Organizational
Effectiveness,
and
Transformational
Leadership.
Our
clients
include
those
responsible
for:
•
Business
Strategy
•
Marketing
and
Brand
Strategy
•
Operations
•
Technology
Deployment
•
Strategic
Human
Capital
•
Corporate
Finance
The
firm’s
40
year
heritage
has
produced
a
substantial
portfolio
of
proven
methodologies,
deep
operational
insight
and
broad
industry
experience.
This
experience
enables
our
team
to
quickly
understand
the
dynamics
of
client
companies
and
markets.
Endeavor’s
clients
span
the
globe
and
are
typically
leaders
in
their
industry.
Gelb
Consulting
Group,
a
wholly
owned
subsidiary,
monitors
organizational
performance
and
designs
winning
marketing
strategies.
Gelb
helps
organizations
focus
their
marketing
initiatives
by
fully
understanding
customer
needs
through
proven
strategic
frameworks
to
guide
marketing
strategies,
build
trusted
brands,
deliver
exceptional
experiences
and
launch
new
products.
Our
websites:
www.endeavormgmt.com
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©
2011
Endeavor
Management.
All
Rights
Reserved.
Page
6