Rear Admiral Grace Hopper, a computer scientist who is perhaps best known for helping to develop the computer programming language, COBOL (an acronym for "common business-oriented language"). She is also known for being the first person to find a computer bug (the common term for an error, flaw, or glitch in a computer program). As the story goes, it was a warm, late summer day in 1947 (September 9, 1947 to be exact) when a team of engineers and computer scientists at Harvard University were working on the Mark II computer. The computer program kept delivering an error. According to legend, Hopper opened up the back of the computer to check one of the relays and found a dead moth. She carefully fished the moth out of the computer with a pair of tweezers, taped it into her logbook, and wrote the message, "first actual bug found." Hopper reportedly said afterwards, "From then on, when anything went wrong with a computer, we said it had bugs in it."
It's a great story, but I have another reason to admire Admiral Hopper that is more relevant to today's post. Admiral Hopper once said, "The most damaging phrase in the language is It's always been done that way." She actually said a lot about people's resistance to change - here are a few more quotes:
"I've always objected to doing anything over again if I had already done it once."
"Humans are allergic to change. They love to say, 'We've always done it this way.' I try to fight that. That's why I have a clock on my wall that runs counter-clockwise."
"A ship in port is safe, but that is not what ships are for. Sail out to sea and do new things."
I've posted a lot about "change" and "change management" in the past. I am by no means an expert in this area - there are countless articles and books on managing change that are much more valuable than anything that I have written in the past. However, I write about "change" because "change management" is one of the most difficult aspects of being a leader.
John Kotter developed an 8-step change model that is commonly cited and used today. The first step is to "create a sense of urgency," taking advantage of the fact that people often respond better to change when there is a crisis or so-called "burning platform." In my experience, it doesn't really matter if there is a "burning platform" or not, there will always be some individuals who will resist change and do everything in their power to fight it. These are the "active resisters" identified by Sanjay Saint and his colleagues in an excellent study on change management specific to hospital infection prevention and control practices ("How active resisters and organizational constipators affect health care-acquired infection prevention efforts").
Saint and colleagues surveyed 86 hospital executives, infection prevention specialists, nurse managers, hospital epidemiologists, and frontline physicians and nurses about barriers to the implementation of evidence-based practices around hospital-acquired infections (e.g., central line infections, surgical site infections, etc). "Active resisters" were those individuals who vigorously and openly opposed the various changes in infection prevention and control practices. In some cases, these individuals would counter the change with the "We've always done it this way" or "That's not how I was trained." In other cases, the resistance was more blatant and vehement. For example, in one hospital, a senior surgeon openly instructed the other members of the surgical team to be noncompliant with one of the changes in the surgical site infection prevention bundle.
There was another important category of individual who was just as detrimental to the success of the change initiative - the so-called "organizational constipator". These were the individuals who passively resisted any change effort, often by withholding resources (money and/or personnel) or pushing back important deadlines. Unfortunately, these individuals are often the most challenging group to address. While the "active resisters" are often vocal and open about their resistance to change, the "organizational constipators" are more covert. They may say the "right" things in public, but silently oppose the change.
Fortunately, there are ways to overcome both active resistance and organizational constipation. One of my former PICU colleagues, Dr. Maya Dewan, suggested a couple of strategies to overcome the "active resisters" and the "organizational constipators" - in my own attempt at tongue-in-cheek humor, what I call the "organizational enema"! Dr. Dewan suggests:
1. Follow the evidence! Use evidence-based guidelines and/or expert consensus statements whenever possible.
2. Show the data! Provide benchmarking data both within your own organization as well as peer organizations.
3. Recruit champions! Depending on the change initiative, both physician and nurse champions will frequently be necessary. Leverage their experience, expertise, and reputation to model and promote the change.
4. Bring the organizational constipators to the table! Engage these individuals early on in the planning process, even if it means developing work-around strategies.
5. Be a relentless pursuer of improvement! Don't give up. You will encounter both active and passive resistance. However, if you follow this model, data and evidence will be on your side.
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