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PROFESSIONAL ISSUES

Effective design, implementation and management of change in healthcare NS861 Allen B (2016) Effective design, implementation and management of change in healthcare. Nursing Standard. 31, 3, 58-68. Date of submission: 30 November 2015; date of acceptance: 11 May 2016. doi:10.7748/ns.2016.e10375

Belinda Allen Honorary fellow, The University of Melbourne, Melbourne, Australia

Correspondence [email protected]

Conflict of interest None declared

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Abstract Changes in healthcare organisations are common, and their implementation is often complex and challenging. Change is often implemented suboptimally, and can have several negative effects on staff turnover, patient care and budget targets. To minimise and avoid negative outcomes, a systematic three-stage change process that comprises preparing for change, implementing change, and evaluating and sustaining change can be followed. In the first stage, before commencing any change activities, time and attention should be given to conducting detailed analyses and preparatory work to establish the foundation for the implementation phase. In the second stage, a clear set of multiple implementation tactics are used to ensure the change process is effective. In the final stage, an evaluation of the success of the change is undertaken and measures are put in place to ensure it is sustained over time. It is only by following a methodical change process such as this that changes can be implemented effectively in healthcare organisations.

Keywords change, change management, change process, implementing change, professional issues, project planning

Aims and intended learning outcomes This article is intended for healthcare professionals who are asked to lead a change project or are involved in suggesting changes that could be beneficial. A systematic three-stage process to optimise the implementation of change is outlined. The article focuses on the first preparatory or ‘unfreezing’ stage because of its importance in the effectiveness of a change project. The second stage of implementation or ‘changing’ and the third stage of evaluation and institutionalisation or ‘refreezing’ are covered in less detail. After reading this article and completing the time out activities you should be able to: » Outline each of the stages in the three-stage change process.

» Identify the information that should be collected as part of situation, stakeholder

and resource analyses for a change project.

» Understand the business case development process in relation to organisational change.

» Describe the concept of readiness for change and discuss its importance for effective change implementation.

» Explain effective strategies to ensure that organisational change is sustained.

Introduction Managing change is a challenge that most organisations experience. The implementation of change often involves overseeing multiple competing priorities, as well as handling demands from external sources and employees who are resistant to the proposed changes and view them as a source of stress (Kerber and Buono 2005). Therefore, effective implementation of change in organisations

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is often perceived to be challenging, and organisations frequently do not manage change projects successfully (Daft and Armstrong 2009). Research has indicated that organisations often have difficulty in motivating employees to change, communicating the need for change effectively and sustaining any improvements that the change has achieved over time (Martin et al 2012). Evidence also suggests that changes that are managed suboptimally can have several negative effects on employees, including: increased resistance to future changes, higher levels of hostility and bullying, low morale and higher staff turnover (Tvedt et al 2009).

The healthcare sector often experiences the challenges associated with implementing change effectively, and the complexity of these organisations can make this process difficult (Tucker and Edmondson 2003). Healthcare organisations are also facing increasing pressure to implement change. The UK has an ageing population; people are living longer and increasingly living with complex health conditions such as kidney and heart disease and diabetes, which require ongoing treatment and specialist care (Christensen et al 2009). Lifestyle factors, such as a suboptimal diet and inactivity, place additional demands on the NHS (Wang et al 2011). Public expectations of healthcare services have also increased, and the focus of the NHS is no longer considered to be primarily treating disease. Instead, the public expect the NHS to deliver a range of services aimed at preventing illness, for example nutrition programmes to reduce obesity. This is at a time when service delivery costs have been increasing and funding is being cut, placing significant economic pressures on the NHS (Lafond 2015).

These ongoing demands have resulted in significant pressure on the NHS to undergo radical change to ensure its sustainability in the future (NHS England 2014). It is evident that such changes have the potential to affect the nature of nursing practice and clinical environments substantially. Indeed, it is often nurses who

are responsible for the implementation of change. Knowledge of theories and models of change may help nurses to cope with change and can increase the likelihood that organisational change will be effective (Price 2008, Mitchell 2013).

Change process model There have been a multitude of theories relating to the stages or steps that can be used in the implementation of organisational change. It is beyond the scope of this article to discuss these theories; however, further information is available from Jick and Peiperl (2003). Most contemporary theories and models are adaptations of the seminal work of Kurt Lewin (1947); in particular his three- stage change model (Burnes 2004). The three stages of Lewin’s (1947) model are unfreezing, changing and refreezing.

Lewin (1947) asserted that any change project should begin with a process of unfreezing, designed to assess the current situation and acquire the resources and support required for the change to be implemented. Only when this first stage has been completed should the implementation process commence, which Lewin referred to as the ‘changing’ stage. In the final stage of the change process model, it is essential to ensure measures are taken to institutionalise the change, so that it is sustained over time and the resources, time and energy that have been committed to the change are not wasted. Lewin referred to this stage as refreezing.

Some have criticised Lewin’s work, suggesting the relevance of his three-stage model is limited to small-scale changes in stable conditions, and not suitable for the large-scale ongoing nature of change in many contemporary organisations (Garvin 1993, Dawson 1994). Burnes (2004) suggested that some of these criticisms are based on a misinterpretation of the terminology Lewin used to describe the stages in his three-stage model; in particular, the terms unfreezing and refreezing.

The unfreezing stage of Lewin’s (1947) model has been criticised as too simplistic and not suitable for large-scale change,

KEY POINT

‘Lewin (1947) asserted that any change project should

begin with a process of unfreezing, designed to

assess the current situation and acquire the resources

and support required for the change to be implemented. Only when this first stage

has been completed should the implementation process

commence, which Lewin referred to as the ‘changing’

stage’

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which has to take place quickly (Pettigrew 1990). Lewin (1947) acknowledged that the unfreezing process may not be easy or quick, particularly for large-scale changes, and that the same approach to unfreezing may not necessarily be applied in all situations. However, Lewin considered unfreezing to be a necessary process, including in situations where it is important to implement change quickly. Research has since shown that attempting to implement change without first ‘unfreezing’ the current situation to attempt to speed up the change can be short-sighted and may cause significant problems (Sweeney and Whitaker 1994, Backer 1997, Levesque et al 2001, Narine and Persaud 2003). Lewin’s (1947) final stage of refreezing has also been misinterpreted as meaning that changes are permanent and fixed (Burnes 2004). However, Lewin viewed change as an iterative, complex process and not simply as a planned movement from one stable state to another. Therefore, for Lewin, refreezing implied a quasi-stationary state rather than a permanently fixed state.

Despite the potential problems with the terminology used in Lewin’s (1947) model of change, it still has merit in providing a framework for planning change in organisations. This article details the main elements of each of the three stages in Lewin’s (1947) model, focusing on the first stage and how it can be used to implement change effectively in healthcare organisations.

Preparing for change: unfreezing Since the establishment of Lewin’s (1947) model for change, numerous authors have provided further detail about the main elements to be undertaken to ‘unfreeze’ effectively and prepare for change (Kotter 1995, Cummings and Worley 1997, Kettinger et al 1997, Caldwell et al 2008). This article focuses on eight elements that have been derived from the literature and the author’s experience in implementing change in organisations. 1. Situation analysis. 2. Stakeholder analysis. 3. Resource analysis.

4. Developing a business case. 5. Securing senior management support. 6. Forming an implementation team. 7. Ensuring readiness for change. 8. Developing a communication plan.

Situation analysis An important aspect of preparing for change is developing a clear understanding of the current situation or a baseline measure of the problem that will be the focus of the change project (Kettinger et al 1997). This information provides an awareness of the status of the problem – ‘where you are at now’ – and is critical in the later stages of the change project, because it enables assessment of the nature and extent of the effects of the change. Situation analysis typically focuses on what is problematic, for example waiting times in emergency departments, what is needed or desirable, for example meeting a 4-hour target for reducing waiting times, or what will be required to ensure the service meets current or future requirements. Performing a situation analysis should clarify why change is desirable in terms of minimising costs or maximising benefits.

There are several ways information can be generated to inform a situation analysis, including process mapping (for example of the patient journey), observing current processes and employee or patient questionnaires. Analysing any existing data in relation to the problem that will be the focus of the change is also important to understand if complete data exists and if the data recommends a particular action. Additional data gathering may be required, especially if the change involves a significant investment of time and money. The situation analysis should also help to identify potential barriers, as well as the potential facilitators or drivers for the proposed change. Box 1 lists questions to answer as part of the situational analysis.

TIME OUT 1 Consider a change that is about to be implemented in your organisation, or a change you would like to be introduced. Use this example of a change to complete the

KEY POINT

‘Situation analysis typically focuses on

what is problematic, for example waiting times

in emergency departments, what is needed or desirable, for example meeting

a 4-hour target for reducing waiting

times, or what will be required to ensure the service meets current

or future requirements. Performing a situation analysis should clarify

why change is desirable in terms of minimising

costs or maximising benefits’

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time out activities in this article. Answer the questions in Box 1 to identify the rationale, drivers, importance and scope of your chosen change.

Stakeholder analysis As part of the first preparatory stage of the change process, it is important to perform a stakeholder analysis. Stakeholders for a change project could include clinicians, patients, administrative staff, senior management and nurses. A stakeholder analysis is designed to identity the varying levels of influence or power the different stakeholders have over the change planning and implementation process (Finn 1995, Bryson 2004). For example, stakeholders with high levels of influence may have the capacity to persuade or compel others to take or not take action in relation to the change. Stakeholders with high levels of influence may also be able to facilitate or hinder the implementation of the change. The level of influence a stakeholder has may derive from their position in the organisation’s hierarchy or informal sources such as their personal connections (Finn 1995). A stakeholder analysis is also designed to help determine the level of importance the planned change has for different stakeholder groups. Importance signifies the extent a stakeholder will be positively or negatively affected by the planned change (Finn 1995).

Combining the level of influence and importance for each stakeholder enables a stakeholder matrix to be produced (Figure 1). This involves organising stakeholder groups into four categories and identifying their required level of attention and participation (Bryson 2004). Mapping the different stakeholder groups involved in the change project on the matrix can help to identify the relative risk each of these groups may present and where there may be potential alliances of support for the change project (Bryson 2004). For example, the greatest risks to the success of a change project are usually presented by stakeholders in the box labelled ‘C’ (Figure 1) (Finn 1995). These stakeholders have high levels of influence or power, but their interests are not necessarily aligned with those of the change project. These stakeholders may be able

to hinder or obstruct the change project; therefore, this group should be managed and monitored carefully.

Completing a stakeholder matrix can also be helpful in deciding how, and to what extent, different stakeholders should be included in the change process. For example, critical stakeholders who have

(Adapted from Bryson 2004, Ackermann and Eden 2011)

Figure 1. Stakeholder matrix

A These stakeholders should be

adequately informed to ensure their interests are being addressed and no

major issues are arising. This group can provide information to plan the change

project.

KEEP INFORMED

B These stakeholders should be fully engaged with the project and it is important to develop an effective

working relationship with this group.

MANAGE CLOSELY (maximum effort)

D These stakeholders need minimal

involvement and are of relatively low priority.

MONITOR (minimum effort)

C These stakeholders are a potential source of risk so enough attention

should be given to keep them satisfied. There should be ongoing careful

monitoring and management.

KEEP SATISFIED

High

High Level of influence

Le ve

l o f im

po rta

nc e

Low

Low

BOX 1. Situational analysis questions

Drivers and rationale for change » What is the problem that the proposed change project will seek to target? » What does existing data and information indicate in relation to the current magnitude,

extent and seriousness of the problem? » How long has the problem existed? What has prompted the drive for change to address the

problem and who views the change as necessary? » How powerful are these drivers? Is there an urgency to change? » Where is the drive for change coming from? This may be particular groups or departments

in the organisation, professional bodies, senior organisational members, the government or the general public.

» Who will potentially be opposed to the change and why? » What factors might impede the proposed change project?

Importance and scope of the change » How does the proposed change fit in with the existing performance objectives for the

organisation? » What priority level should be given to the change? » Who will take responsibility for the change implementation? » How substantial or significant is the necessary change?

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high levels of importance and influence are likely to provide the basis for a supporting alliance for the project and should be given increased involvement in the planning and implementation process (Bryson 2004). Conversely, stakeholders high in influence but low in importance can simply be informed and consulted about the change and its implementation (Bryson 2004).

As part of the stakeholder analysis, it is important to identify what the changes will mean to stakeholders, and in particular how it will affect them. It is important to ascertain what the stakeholders will like and dislike. To gather this information, representatives of each of the stakeholder groups can be invited to learn about the change project and provide feedback. The change project is likely to be perceived differently by each stakeholder group. Therefore, gaining the perspectives of the various stakeholder groups can assist in understanding likely areas of support for the change and the potential barriers to the change project (Cummings and Worley 1997). Conducting a thorough stakeholder analysis is essential to increase the likelihood the objectives of a change project will be achieved and the change will be sustained over time (Bryson and Bromiley 1993).

Table 1 shows a form that can be used as part of a stakeholder analysis. An example is provided in relation to a change project aiming to improve the skin integrity of older people.

TIME OUT 2 Reflecting on the change project you identified in Time out 1, construct a stakeholder matrix, categorising the stakeholders associated with the change based on their importance and influence. Complete the stakeholder analysis form in Table 1 for your proposed change.

Resource analysis The final type of analysis that should be undertaken as part of the first stage of the change process is a resource analysis. If a resource analysis is not performed, it is likely to result in inadequate resources for the change project, thereby hindering its implementation (Ackerman Anderson and Anderson 2010). The types of resources required will vary depending on the nature of the change project, but may include time for employees to attend training sessions about the change, information technology support and new equipment (Cummings and Worley 1997). A resource analysis checklist (Table 2) can be produced to identify the change project’s resource needs, while considering the resources that are already in place. Often, additional financial support and resources for the change project will not be available, so it is also important to consider existing resources and how these could be used effectively to implement the change. Initially, the list of resources will likely be broad and should be refined as the change progresses (Ackerman Anderson and Anderson 2010).

TABLE 1. Stakeholder analysis form to improve skin integrity in older people

Stakeholder Interest in the change project and importance for its success

Project requirements from the stakeholder

Stakeholder’s perceived attitudes and risks Actions

Technology manager

The technology manager governs access to the electronic medical records (EMR) system and is responsible for implementing changes to this system. However, they are not necessarily interested in the change project.

The change project may need to alter aspects of the EMR that relate to skin assessment, preventive measures and skin care.

They may be resistant to making changes until other aspects of the change are underway, or other changes have been implemented.

Obtain information about the process for requesting or making changes. Find out how this stakeholder fits in the overall organisational structure and the nature of their existing relationship with project leaders and champions.

(Adapted from Finn 1995)

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TIME OUT 3 Complete the checklist in Table 2 to identify the resources that are available and those that are required for the change you identified in Time out 1. These resources will include personnel, time, money and equipment.

Developing a business case As part of the first unfreezing stage of the change project, it is important to develop a business case, which outlines the potential benefits and drawbacks of the change project (Beer and Nohria 2000). The business case should detail milestones and responsibilities in relation to different elements of the change project (Phelan 2010). Acquiring the necessary information to complete the business case may require consultations with other departments in the organisation, such as finance and human resources, as well as organisational reports, such as previous budgets. Information collected as part of the situation, stakeholder and resource analyses can be helpful in compiling the business case. It is beyond the scope of this article to discuss calculating operational costs associated with a change project as part of developing a business case; however, further information is available (Voehl et al 2015).

A business case form may be used for this element of the change project, which outlines (Voehl et al 2015): » Project background. » General aims. » Initial risks. » Expected outcomes. » Benefits of implementing the project. » Initial estimates of cost and time.

Substantial change projects that require additional resources and/or the redeployment of resources may need to be costed operationally and require consultation with a finance officer in the organisation. However, before this, it may be beneficial to complete the business case form to ensure there is tangible information to discuss. There may be some hidden costs involved in the change project, for example the duties and tasks a nurse is not able to perform while undertaking training as part of the implementation process. Consultation with a financial

officer should identify these hidden costs. A well-developed business case for the proposed change can assist in the next element of the first stage in the change process: securing senior management support.

TIME OUT 4 Complete a business case form for the change project you identified in Time out 1.

Securing senior management support Ensuring there is management and senior management support for the planned change is essential (Kotter 1995, Ackerman Anderson and Anderson 2010). If senior leaders in the organisation do not support the change project, it will be necessary to compile a case in support of the change, which can be assisted by a well-developed business case (Phelan 2010). Depending on the specific management group, it may be important to focus on the financial benefits of the change, for example shorter patient stays in hospital, or to emphasise the clinical benefits of the change such as reduced medication errors (Phelan 2010). The information from the stakeholder analysis will also be useful, since this will provide an understanding of the different

TABLE 2. Resource analysis checklist

Resources Currently available: yes/no Notes on what is needed

Funds

Staff education programmes

Information technology support

Specific products, tools and equipment

Facilities and supplies, for example meeting rooms

Printing and copying

Non-clinical time for team meetings and activities

Other

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stakeholder groups, their concerns and priorities.

TIME OUT 5 Consider the potential level of support from management for the change you identified in Time out 1. Answer the following questions:

» Who are the managers and senior managers whose support you will require?

» Are the managers you have identified supportive of the change? If not, what actions will you need to take to gain their support? Review your stakeholder analysis form and your business case to develop a plan of action.

Forming an implementation team In addition to the support of management and senior management, change projects require a team of individuals who are committed to the project’s goals and responsible for its implementation (Kotter 1995, Ackerman Anderson and Anderson 2010). The implementation team may include managers and senior managers, clinical experts, opinion leaders in the organisation, and stakeholders of high importance and influence. These individuals should be perceived as credible by other employees, and may need to come from a range of disciplines, depending on the stakeholders the change is likely to affect (Bamford and Daniel 2005). The implementation team should act as a guiding alliance for the change, emphasising why the current situation is not sustainable and energising other employees in relation to the change project (Kotter 1995, Ackerman Anderson and Anderson 2010).

TIME OUT 6 Answer the following questions to identify individuals who could be members of the change implementation team for the change you identified in Time out 1:

» In your organisation, who are the potential advocates for the change you are planning?

» Which individuals care about the problem that will be the focus of the change?

» Which individuals is it important to involve in the implementation process?

» Which individuals would be willing to take responsibility for elements of the change project?

Ensuring readiness for change Holt et al (2007) stated that readiness ‘reflects the extent to which an individual or individuals are cognitively and emotionally inclined to accept, embrace, and adopt a particular plan to purposefully alter the status quo’. Failure to assess an organisation’s readiness for change can lead to unanticipated problems in implementation, or failure of the change project (Caldwell et al 2008). Armenakis et al (1993) stated that readiness is one of the most important elements in influencing individuals’ support for change projects.

The readiness for change checklist in Table 3 can be used to monitor progress through the preparatory steps and is a useful measure to ensure essential steps have not been missed. The checklist is a helpful tool for gauging the organisation’s level of readiness for the change. Any deficiencies identified by completing the checklist can be targeted as part of the change preparation plans, thus supporting change implementation.

TIME OUT 7 Complete the checklist in Table 3 to assess the level of readiness for the change you identified in Time out 1.

If the checklist indicates low levels of readiness, it is essential that this is enhanced before the change project commences (Caldwell et al 2008). Some ways to develop readiness include (Armenakis et al 1993): » Implementing the change in a single receptive exemplar unit to demonstrate success and provide evidence for the change being implemented successfully in other areas of the organisation.

» Holding one-to-one meetings with informal leaders to present information about the need for change and discuss the potential benefits of the change project.

» Collecting and sharing data, perhaps as part of an employee awareness campaign, on the problem that is the focus of the change. This will establish the relevance and urgency of the change.

KEY POINT

‘In addition to the support of management and senior

management, change projects require a team of individuals who are

committed to the project’s goals and responsible for its implementation (Kotter 1995, Ackerman Anderson and Anderson 2010). The

implementation team may include managers and

senior managers, clinical experts, opinion leaders in the organisation, and

stakeholders of high importance and influence’

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TABLE 3. Readiness for change checklist

What is the scope of the change, why is it needed and what are the potential impediments to the change?

» Specific reasons for the change have been identified. » Potential barriers to the change have been identified. » Urgency and scope of the change are known.

Is there an understanding of the stakeholders for the change?

» All stakeholders, their attitudes and interests in relation to the change and their required involvement in the project have been analysed.

What resources are needed?

» A preliminary list of the resources needed for the change has been developed. » Commitments from senior management to provide these resources have been

obtained.

Is there a business case for the change?

» A business case has been compiled which provides information in relation to important aspects of the change project.

Is there senior management support for the change?

» Level of senior management support for the change has been assessed. » If support is lacking, efforts are underway to generate support.

Is the change implementation team in place?

» Appropriate members for the change implementation team have been selected.

» Team members have commenced working collaboratively to design the implementation process.

(Adapted from Armenakis et al 1993, Holt et al 2007)

» Identifying and recruiting allies for the change who can disseminate information about the change project.

An important aspect of readiness is employee motivation to change (Armenakis et al 1993). The motivation of employees is likely to be strong and enduring if they have a clear understanding of the necessary changes and the reasons for them (Armenakis et al 1993). Therefore, effective communication is crucial in promoting readiness for change (Holt et al 2007). However, this can be challenging because the change project can be perceived differently by different groups or individuals in an organisation (Isabella 1990).

Perceptions in relation to change are formed as a result of individuals’ preferences, past experiences and professional values, which will influence their attitude towards the change (Isabella 1990, Dibella 2007). As a result, individuals and different professional groups in an organisation may have varying attitudes towards the change project. Therefore, developing a communication plan that acknowledges these differences and aims to ensure the change is perceived as beneficial is essential (Smollan 2006).

Developing a communication plan A communication plan should be developed outlining the main messages that need to be conveyed regarding the change. This should include information about the reasons for the change (Bingham and Main 2010). It is important to use the information gathered during the stakeholder analysis to identify the aspects of the problem the change is seeking to address that are likely to be most important for each stakeholder group. The messages communicated should be tailored to the different stakeholder groups to optimise their effectiveness (Klein 1996).

Communication of change should provide employees with an idea of the potential effects of future changes (Allen et al 2007), which will help make the changes tangible and easier to understand. It is also important to communicate how the changes will be implemented and when different elements

of the change implementation process will occur (Allen et al 2007). In addition, the people who will be involved in the change and how individuals will be specifically affected by the change should be discussed (Klein 1996). It is important to be open and honest about the aspects of the change that individuals may dislike; this will help those implementing the change to develop respect and credibility (Allen et al 2007). A variety of communication methods should be used to ensure that the main messages in relation to the change are received. Since individuals absorb information at different times and in different ways, it is also important to plan to reiterate the main messages (Klein 1996).

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The first stage of the change process – preparing for change or unfreezing – is critical since it establishes the foundation for the change project. Taking shortcuts during this stage will undermine the implementation of the change and will probably result in it being unsuccessful.

Change implementation: changing The second stage in Lewin’s (1947) model is change implementation, which involves executing all of the processes and activities to actualise change. During this stage, it is important that appropriate training is provided for employees to equip them with the knowledge and resources necessary to accommodate the change (Cummings and Worley 1997). In addition, it is important to empower stakeholders by keeping them informed of the progress of the change and any short- term successes, since this may reduce resistance to change (Phelan 2010).

Implementing change is a complex process; therefore, the specific techniques used will depend on the nature and circumstances of the change and the organisation. However, successful implementation of change has at least two main features: dedicated support structures and the use of multiple tactics to implement the change (Grol and Grimshaw 2003). Support structures should include a dedicated organisational team that is responsible for implementing the change (Ackerman Anderson and Anderson 2010). Members of the implementation team should be given time away from their usual tasks to focus on the change (Bamford and Daniel 2005).

The use of multiple tactics to implement change has been shown to increase its effectiveness. For example, if a hospital wanted to implement a change targeted at reducing medication errors, it would not be sufficient to review medication error reports more frequently alone. Sole use of a single tactic is unlikely to be effective (Bingham and Main 2010). Instead, it is necessary to combine this with other tactics, such as the introduction of an intranet-based reporting system, encouraging conversations about

medication errors among clinical staff, and facilitating communication between members of different healthcare professions to prevent and resolve problems related to medication errors. The more tactics used to achieve the target for the change, the more likely the change project is to be successful (Grol and Grimshaw 2003).

Evaluating and sustaining change: refreezing The third and final stage in Lewin’s (1947) change model involves evaluating the change project and ensuring the implemented changes are sustained over time. All change projects should be evaluated to determine the extent to which they have affected the problem being addressed (Aiken et al 1997). After completing the situation analysis as part of the first change stage, a pre and post- change comparison should be conducted as part of this final stage of the change process. In evaluating the effectiveness of the change project, the following questions are useful: » Did the action achieve the desired result or outcome?

» Is the improvement sustainable over time?

» Is there any more that can be done for this change project? Is it complete?

» Are employees aware of the outcomes of the change project?

This stage of the change process also involves ensuring the change is sustained in the long term. The sustainability of change can be gauged by the extent to which the new processes, procedures, behaviours and attitudes associated with the change endure over time (Martin et al 2012). Martin et al (2012) stated that the ‘improvement evaporation effect’ may occur, whereby the benefits initially reaped from the change diminish over time because of a lack of institutionalisation.

Institutionalising change requires a formal, long-term plan that employs multiple clear and interrelated strategies (Beer et al 1990). One strategy is to ensure the necessary structural changes have taken place to reinforce the change (Beer et al 1990). For example, if the goal

KEY POINT

‘Implementing change is a complex process; therefore,

the specific techniques used will depend on the

nature and circumstances of the change and the organisation. However,

successful implementation of change has at least two main features: dedicated

support structures and the use of multiple tactics to implement the change’

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of the change is to improve interactions between members of different healthcare professions in the organisation, this may require the introduction of multidisciplinary teams who jointly review patient cases on a daily basis. Without such accompanying structural changes, the modified behaviours are left to choice or chance and are therefore less likely to be sustained over time. Job roles may also need to be redesigned to ensure they are suitable and support any changes to processes and procedures (Cummings and Worley 1997). This may also mean that employees require further training to enable them to perform effectively in the redesigned roles.

Conclusion Change is increasingly common in healthcare organisations. However, it is often implemented suboptimally, leading to a range of adverse outcomes such as negative employee attitudes, additional costs and a failure to realise planned improvements. These issues can be minimised and avoided by following a systematic change implementation model. Lewin’s (1947) model places significant emphasis on the first, preparatory stage of the change process. Ensuring there is a clear understanding of the status quo, the importance of the change, its scope and drivers are all essential. It is also important

to have a detailed understanding of the main stakeholders for the change and the resources that will be required for successful implementation. All proposed changes should also have a well-developed business case and senior management support before implementation. Establishing an implementation team consisting of individuals who are credible and responsible for guiding the change through the implementation process is also beneficial.

Taking shortcuts in these preparatory steps or rushing through the first stage of the change process will undermine the second stage of implementation, and will likely lead to the change being ineffective. The second stage of the change process requires the use of multiple tactics and dedicated support structures. The third and final stage of the change process ensures that the change has been evaluated systematically and that there are measures in place to sustain the change over time. Given the money, time and effort committed to change implementation and the extent of the negative outcomes if change is not implemented effectively, it is vital that systematic approaches to change are used by healthcare organisations.

TIME OUT 8 Now that you have completed the article, you might like to write a reflective account as part of your revalidation.

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How to complete this assessment This self-assessment questionnaire will help you to test your knowledge. It comprises ten multiple choice questions that are broadly linked to the article starting on page 58. There is one correct answer to each question. » You can test your subject knowledge by attempting the questions before reading the article, and then go back over them to see if you would answer any differently.

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1. When implementing change, organisations often have difficulty:

a) Motivating employees to change c

b) Communicating effectively the need for change c) Sustaining any improvements the change

has made c

d) All of the above c

2. Which of the following is a potential effect of implementing change suboptimally?

a) Decreased resistance to future changes c

b) Higher staff turnover c

c) High morale among employees c

d) Lower levels of hostility and bullying c

3. What are the three stages of Lewin’s (1947) model of change?

a) Analysis, development, evaluation c

b) General aims, initial risks, expected outcomes c

c) Unfreezing, changing, refreezing c

d) Situation analysis, stakeholder analysis, resource analysis c

4. What might be involved in developing a business case for the change?

a) Completing a readiness-for-change checklist c

b) Detailing milestones and responsibilities for the change c

c) Gaining the perspectives of different stakeholder groups c

d) Forming an implementation team for the change c

5. In a stakeholder analysis, which stakeholders can be just kept informed of the change?

a) Those with high importance and high influence c b) Those with low importance and high influence c

c) Those with high importance and low influence c

d) Those with low importance and low influence c

6. Which of the following should a resources analysis consider?

a) The senior management support available c

b) The products, tools and equipment available for the change c

c) How the change will affect stakeholders c

d) The potential benefits and drawbacks of the change c

7. A communication plan: a) Should outline the main messages in relation to

the change c

b) Should not be tailored to the different stakeholder groups c

c) Should not involve discussing the potential effects of future changes with employees c

d) Is not a necessary part of the change c

8. The use of multiple tactics to implement change: a) Increases its effectiveness c

b) Decreases its effectiveness c

c) Is as effective as use of a single tactic c

d) Is less effective than use of a single tactic c

9. Which of the following is not a useful question to ask when evaluating the effectiveness of a change?

a) Did the action achieve the desired result? c

b) Was the improvement achieved quickly? c

c) Is the improvement sustainable over time? c

d) Are the employees aware of the outcomes? c

10. The ‘improvement evaporation effect’ is defined as:

a) A formal long-term plan to institutionalise change c

b) Structural changes to modify behaviour c

c) When the benefits initially gained by the change diminish over time because of a lack of institutionalisation c

d) A short-term strategy to institutionalise change c

This self-assessment questionnaire was compiled by Henrietta Cole

The answers to this questionnaire will be published on 28 September

The answers to SAQ 859 on Managing sepsis, which appeared in the 31 August issue, are:

1. d 2. d 3. a 4. b 5. b 6. a 7. b 8. d 9. d 10. c

Implementing change TEST YOUR KNOWLEDGE BY COMPLETING SELF-ASSESSMENT QUESTIONNAIRE 861