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A reflection on John P. Kotter's "Leading Change: Why Transformation Efforts Fail"

By Angela Skaff posted 09-20-2014 02:17


The Doctor of Pharmacy curriculum has prepared pharmacists to provide front-line, patient-centered care since its inception in 1950. Sixty-four years later, the Social Security Act still does not include pharmacists as providers under Medicare Part B, and thus does not recognize pharmacists as providers including those licensed by a state where pharmacists are providing patient care services and working within the laws and regulations that govern the practice of pharmacy in that state. Pharmacists and pharmacy organizations had neglected to make provider status a priority. John P. Kotter, a leadership professor of Harvard Business School and international best-selling author, introduced an eight-step process on change management. The article “Leading Change: Why Transformation Efforts Fail” pin points critical mistakes made by leaders at each step, of which in this reflection I will relate and reflect on current examples in pharmacy practice where errors have been made and/or overcome in transformation efforts; specifically, federal and state provider status for pharmacists, and implementing advanced pharmacy practice within a health-system.


Step 1: Establishing a Sense of Urgency

While many leaders in pharmacy have made great strides in promoting pharmacy services in individual academic medical centers, it has now become clear that a nationwide transformation in health system practice models to involve pharmacists on patient care teams will not be realized unless pharmacists are written into the law as providers. Unfortunately, convincing people that there is a need for change is not easy. Kotter states that transformation errors frequently occur when leaders are unable to establish a great enough sense of urgency, and are “paralyzed” by the resistance from the individuals within their scope of management. This is why the change often comes too late, after a crisis occurs – e.g. harmful medication error, net losses, job cuts. For preventative transformation efforts, Kotter states that the urgency rate is only high enough when about 75% of a company’s management is convinced that business as usual is totally unacceptable, and together can provide a powerful enough guiding coalition for change.


Step 2: Forming a Powerful Guiding Coalition

In January of 2014, the Patient Access to Pharmacists’ Care Coalition formed, comprised of over 20 national pharmacy societies and trade organizations in a variety of specialties. Kotter supports the notion that the heads of organizations must actively support the change that is to be promoted by its members. Furthermore, in cases of successful transformation efforts, the leadership coalition must grow over time. Currently, the PAPC Coalition is working towards gaining the support of stakeholders in medicine, nursing, and other groups who advocate for patient care. Equipped with a high sense of urgency, Kotter advises the members of the coalition to hold off-site retreats and systematically work towards a vision. The American Society of Health System Pharmacists (ASHP) hosts Policy Week, including a Legislative Day, where leaders in the profession meet to write professional policy and reach a consensus on important current issues affecting the profession, to guide the advocacy efforts of membership in their outreach to members of Congress and other stakeholders.



Step 3: Creating a Vision

In 2010, the ASHP and ASHP Research and Education Foundation’s vision was described as the Pharmacy Practice Model Initiative (PPMI) through the work of a PPMI summit. The vision is to increase pharmacist participation on patient care teams as the professional responsible for the patients’ medication related outcomes. A series of recommendations were created to allow for improved health-care team integration, leveraging pharmacy technicians, promoting pharmacist credentialing and training, and encouraging the use of automation and informatics.


Step 4: Communicating the Vision

Four years later, the vision set out by the PPMI has not yet reached all directors of pharmacy. This was evident by the disatisfying number of directors of pharmacy within each state that had yet to take the first step in using the Hospital Self Assessment Tool to determine the hospitals conformity with the recommendations; a step required prior to developing an action plan to advance the pharmacy practice model of the organization. Even after the introduction of the PPMI research grants, and provision of the State Affiliate Tool Kit, many pharmacists, pharmacy technicians and pharmacy students remain unable to tell you what PPMI stands for, let alone the meaning of provider status and the significance of HR4190.


Step 5: Empowering Others to Act on the Vision

Due to the significant insufficiencies in step 4, practice model transformations and advocacy efforts have failed. Kotter states “transformation is impossible unless hundreds or thousands of people are willing to help, often to the point of making short-term sacrifices.” In the case of advocacy efforts, unless we have at least half of the ASHP membership donating to Political Action Committees (PAC), our PAC dollars will never compare to that of nursing, physician assistant or physician groups; thus, pharmacists have remained omitted on the list of “providers” under the social security, evident by the fact that HR4190 to amend this clause only emerged earlier this year. 


Step 6: Planning for and Creating Short-Term Wins

While HR4190 will amend the social security act to include pharmacists as providers, it is important to note that this particular legislation will only allow Medicare Part B to cover services for medically underserved communities. If passed, it is a good start but a “short-term win,” as it only increases access to pharmacy services to a small percent of the population.


Step 7: Consolidating Improvements and Producing Still More Change

Kotter points out, however, that “while celebrating a win is fine, declaring the war won can be catastrophic.” Should HR4190 pass, it should serve simply as reassurance that advocacy efforts are effective, and motivate planning for when the next piece of legislation is on the table, that everyone quickly read up on the bill, write to congress, fund the PAC and ensure that the bill is co-sponsored to be enacted into law.


Step 8: Institutionalizing New Approaches

In the final analysis, Kott­­er states that change sticks when it becomes “the way we do things around here.” If we do achieve provider status for pharmacists, the question becomes whether or not the practice models in our individual health systems are prepared for it. This is why regardless of the federal and state laws where provider status has not yet been achieved, pharmacy leadership must prioritize the advancement of the practice model now, so that when pharmacists are classified as providers, the health-system will have a payment model and resources in place, that support the deployment of pharmacists to the front-lines of care.



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