Summary of “How to Orchestrate Change from the Bottom Up”

PCMH requires primary-care doctors to change their daily work practices by moving from reactive care to prevention and by using evidence-based guidelines to treat patients with chronic illnesses like diabetes.
I observed them as they engaged in activities such as “Huddling,” where doctors and medical assistants discussed the conditions and progress of patients coming in for office visits that day, and strategic planning meetings, in which managers, doctors, and medical assistants talked about how to best implement the reforms.
From an analysis of the data, I was able to identify the most significant factor: On the teams that were most successful, managers had enlisted the aid of medical assistants to help change the doctors’ behaviors.
Third, the medical assistants were central in the doctors’ peer network, enabling them to spread the word about those doctors who had adopted the new practices.
In the script, medical assistants would pose the change as something a doctor could do as a favor to them as opposed to being a policy imposed by management.
As one medical assistant recalled, “I told [doctor] that when patients are on the list, I need to keep managing them, and that takes time. Finally, she said she would do the to get those patients off the list for me.” In other words, the doctors viewed themselves as helping the medical assistants and, as one doctor noted, “We want to keep the MAs happy because we depend on them.” Doctors were willing to make changes to help their MAs, as long as these decisions did not run counter to their clinical judgment.
Importantly, the managers at the successful hospital freed up time for their MAs to engage in the new work associated with influencing the doctors.
While my study investigated two hospitals that were trying to change the work practices of its doctors, I believe the idea of leveraging the structural power of low level workers to push change from the bottom up has broader implications, especially for other organizations employing professionals.

The orginal article.