Book of Change

Diagnostic Methods. There are numerous diagnostic methodologies. I researched countless pages in an academic literature review that analyzed various methodologies. Let us just say, I came to realize that selecting a diagnostic method was as difficult as selecting the correct OCM modeling process. What I found were models that were not rigorous enough and did not systematically lead to a conclusion. The processes I found were very obtuse and often fond of describing elemental relationships with no systematic conclusion.

      What you want is a diagnostic method that clearly allows you to take your qualitative and quantitative data, create the final problem statement, design the intervention, and implement change. What I found was a lot of diagnostic models that resulted in some very interesting bubble diagrams with some very interesting components, that delivered nothing useful. They were for the most part black box models. The product of black box models is a little like delivering mystery meat. It is like the quotation attributed to Germany’s first chancellor Otto von Bismarck: “If you like laws and sausages, you should never watch either one being made.”

      I was also leery of the predetermined bubble diagram labels. It was like being told to look at the heart, liver, lungs, etc. and their relationships. That seemed dangerous to me. It was telling me what the solution was before it was diagnosed. However, in medicine the diagnosis is not so prescribed as it is organic in detecting the symptoms first. It is the confluence of symptoms that lead to the discovery of the diseased organ.

      What I wanted and finally selected was a diagnostic method that clearly delineated the steps and process of creating a defensible set of implementation actions. My research is based on the findings and conclusions found in Improving Diagnosis in Healthcare, (National Academy Press, 2015). This publication was the result of a collaboration between the National Academy of Sciences, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention.

            The Diagnostic Method. In my field of doctorate research, organizational psychology, there is always the organization as individual metaphor. In other words, the organization is made up of individuals so there are psychological corollaries. So, I started to wonder if the same were true for the diagnosis. Are there also medical diagnostic corollaries? What if we diagnosed the organization in the same manner as the individual physiologically? How would the medical diagnosis look if the change agent were in the medical doctor role? 

      The medical diagnostic process is “A complex, patient-centered, collaborative activity that involves information gathering and clinical reasoning with the goal of determining a patient’s health problem” (Balogh, Miller, Ball, 2015). Substitute the word organization for “patient” and it reads quite well.

      Think of yourself, the change agent, as the medical practitioner examining the organization. In medicine, the diagnostic process theory is used. The patient comes in with a complaint about an ailment. There are requisite tests to make in the initial screening (e.g., temperature, blood pressure, weight, height). And then it is important to actively listen to the patient’s description of the ailment symptoms. A common maxim in medicine attributed to William Osler is: “Just listen to your patient, he is telling you the diagnosis” (Gandhi, 2000, p. 1087).

 

The diagnostic process is a complex, organization-centered, collaborative activity of the change management system that involves information gathering and critical reasoning with the goal of determining, addressing, and improving the organization’s health. The diagnostic model has several defined stages.

​

​

​

 

 

 

 

 

 

 

 

 

               

 

 

 

 

 

 

 

Figure 5.0. Improving Diagnosis in Healthcare, National Academy Press, Washington, D.C. (2015)

 

The Diagnostic Process

The diagnostic process is as follows: The organization experiences a health problem. The leadership, line staff, or vendors are likely the first people to consider symptoms and may choose at this to engage the change management system. Once someone engages the change management system, there is an iterative process of information gathering, information integration and interpretation, and determining a working diagnosis. Performing an organizational history and interviews, conducting an organizational assessment, performing diagnostic testing, and referring or consulting with other subject matter experts are all ways of accumulating information that may be relevant to understanding the organization’s health problem. The continuous process of information gathering, integration, and interpretation involves hypothesis generation and updating prior probabilities as more information is learned. Communication among subject matter experts, the internal employees, and the external organization stakeholders is critical in this cycle of information gathering, integration, and interpretation (National Academy Press, Washington, D.C. 2015).

 

1. Patient/Organization Identifies a Problem

2. Patient/Organization Engages Change Management System (Change Agent/Team)        

3. Information Gathering. At the center of the medical model there are four central pre-diagnosis activities:

      3a. Clinical history and interview (Data Collection 3.0/Stakeholder Feedback 4.0)

      3b. Physical exam consists of observation and review of internal and external factors that may be affecting the overall organizational health.

      Internal Change Impacts. There are six types of internal change impacts on the individual and the organization. They are the physical layout/assets, organizational culture, rules/procedures/processes, technology and tools, employee resources, and financial resources. I have created the acronym for them.

                       

PORTEF

• Physical Layout/Assets (buildings, offices spaces, parking, satellite offices)

• Organizational Culture

• Rules/Procedures/Processes

• Technologies and tools

• Employee resources

• Financial resources

     

      External Change impacts. There are six types of external change impacts on the individual, the organization, and on humanity. They are socio-cultural, technology, economic, political, pandemic, and environment. I have created the acronym for them.

 

STEPPE

• Socio-cultural (gender, race, nationality)

• Technological (artificial intelligence, technological advances, pharmaceutical, medical)

• Economic (recession, depression, trade wars, monetary devaluations, economic systems)

• Political (elections, coup d'état, regulatory/legislative)

• Pandemic (global diseases such as COVID-19, AIDS, Ebola, Zika, H1N1, SARS)

• Environmental (volcanic, tsunami, weather, flooding, earthquakes, climate change)

     

      3c. Diagnostic Testing (i.e., consultant evaluations such as 3.2 document review, 3.3 performance measurement, 3.4 cultural assessment)

      3d. Referral and consultation (Outside consultation with respective subject matter experts)

 

      The corollary here is that you as the medical doctor are the change agent. You have listened to the patient/organization describe what they think is the problem (preliminary problem statement) and you have done your due diligence by reviewing the four pre-diagnosis criteria.

      4. Information Integration and Interpretation. Involves hypothesis generation, updating prior probabilities, communication among all levels (i.e., internal and external stakeholders).

      Clinical Reasoning. This is the “cognitive process that is necessary to evaluate and manage the patient’s [organization’s] medical [curative] problem” (Barrows, 1980, p. 19). Clinical reasoning occurs within the clinician’s mind and facilitated by the clinician’s work system. This is called hypothetico-deductivism which is an analytical reasoning model that describes clinical reasoning as hypothesis testing. The steps involved in hypothesis testing are:

        4a. Acquisition. Change agent obtains contextual information by taking history, performing organizational examination, administering diagnostic tests, or consulting with other subject matter experts (SMEs).

       4b. Working diagnosis. Change agent formulate alternative diagnostic possibilities through ideation creation (see 5.3 Ideation Creation).

       4c. Interpretation (diagnostic modification and interpretation). Change agent interpret the consistency of information with each of the alternative hypothesis under consideration.

      4d. Hypothesis evaluation (diagnostic verification). The data are weighed and combined to evaluate whether one working diagnosis can be confirmed. If not, then further information gathering, hypothesis generation, interpretation, and evaluation is conducted until verification is achieved (Balogh, Miller, Ball 2015).

5.   Working Diagnosis. You begin by creating a single Working Diagnosis based on the Information Gathering, and Information Integration and Interpretation. Throughout the diagnostic process, there is an ongoing assessment of whether sufficient information has been collected. If the diagnostic team members are not satisfied that the necessary information has been collected to explain the organization's health problem or that the information available is not consistent with a diagnosis, then the process of information gathering, information integration and interpretation, and developing a working diagnosis continues. When the change agent/team judge that they have arrived at an accurate and timely explanation of the organization’s problem, they communicate that explanation to the organization’s leadership as the Final Diagnosis. In the medical model you are now ready to prescribe the intervention or therapy.

6. Communication of the Final Diagnosis. This is accomplished in Step 1.0 First Step, 1.5 Communication Plan. Use the same venues and techniques to update your employees. You are not ready to communicate the intervention strategies, but you can set the stage by talking about the issues that need resolution. 

7. Treatment (Implementation). This is accomplished in Step 7. Implementation.

8. Outcomes. This is accomplished in Step 10. Maintain, 10.1 Monitoring Performance.