Strategies Health Care Leaders Use to Implement
Strategic Change Initiatives Successfully
Section 1: Foundation of the Study
Business and corporate strategic plans have little value without
implementation (Greer, Lusch, & Hitt, 2017). Strategic change is necessary
for organizational growth and business success (Issel, 2016). Leaders must
integrate strategic change initiatives into the work of frontline staff to realize
competitive advantage (Ukil & Akkas, 2017). The misalignment between
strategic goals and operational activities results in failures that are
disruptive, costly, and threaten the economic viability of companies globally
(Fedato, Pires, & Trez, 2017). The purpose of this study was to explore
strategies health care leaders use to implement strategic change initiatives
successfully.
Background of the Problem
Strategic change implementation is critical for business success (Issel,
2016). In health care, strategic change implementation is necessary to stem
the rising health care cost, address disparity and access issues, mitigate
supply and demand concerns, improve poor patient outcomes, adopt new
technologies, and conform to regulatory mandates (Chin et al., 2018; Keehan
et al., 2017; Naranjo-Gil, 2015). Health care leaders must understand the
positive and negative impact of strategic change implementation on staff,
workflows, and organizational processes (Mork, Krupp, Hankwitz, & Malec,
2018; Sarnikar & Deokar, 2016). Failure to successfully implement strategic
change initiatives can worsen the already high health care cost and increase
patient safety concerns (Mtebe & Nakaka, 2018; Palmer et al., 2018). Before
embarking on strategic change implementation initiatives, leaders must
assess organizational readiness and ability to sustain the change and mitigate
high-risk conditions to prevent failure (Timmings et al., 2016).
Most strategic change initiatives fail at implementation (Greer et al.,
2017; Ukil & Akkas, 2017). According to Sull, Homkes, and Sull (2015),
strategic change initiatives fail due to a lack of collaboration and
coordination of activities among all members of the organization. Systems
issues, staff reaction, and the intervention itself are barriers or facilitators of
successful strategic change initiatives (Geerligs, Ranklin, Shepherd, &
Butow, 2018). The management of system factors like environmental
context, culture, organizational inertia, communication processes,
leadership, and technology determine strategic change success (Bashir &
Verma, 2019). Leaders must consider employees’ attitude, behavior, and
readiness for the change and employ strategies to mitigate adverse reactions
that threaten successful implementation (Thakur & Srivastava, 2018).
The ease of integration and presence of organizational support can
facilitate or inhibit change success (Geerligs et al., 2018). Leaders should
help employees make sense of the change and identify strategies to integrate
the change in current practice (Kraft, Sparr, & Peus, 2018). Tailoring change
to match the intended context is critical for success (Boyd, Powell, Endicott,
& Lewis, 2018). In addition to context, leaders must evaluate the relevance
of content, process, and leadership style on strategic change success (Ahmad
& Cheng, 2018). The objective of the current study was to explore the
strategies health care leaders use to implement strategic change initiatives
successfully.
Problem Statement
Health care organizations lose a significant competitive edge when
leaders fail to align strategic change initiatives with necessary operational
activities (Tang & Liu, 2016). Seventy percent of strategic change initiatives
fail because of poor strategy execution (Ngan & Chung, 2017). The general
business problem is some health care leaders are unable to implement
strategic change. The specific business problem is some health care leaders
lack strategies to implement strategic change initiatives successfully.
Purpose Statement
The purpose of this qualitative multiple case study was to explore
strategies health care leaders use to implement strategic change initiatives
successfully. The target population consisted of four leaders from two health
care organizations in Manhattan, New York who have successfully
implemented strategic change initiatives. The implications for positive social
change include the ability to improve the social and human conditions of
members of the community. Patients and health care recipients may benefit
from access to safe health care, leading to fewer medical errors, treatment
disparities, and premature deaths. Communities may benefit from more
employment opportunities, improvement of the standard of living for
residents, more cost-effective health care services, and having a healthy local
workforce.
Nature of the Study
Qualitative, quantitative, and mixed-methods research are standard
methods used by researchers when conducting a study (S. Turner, Kane, &
Jackson, 2015). The qualitative method is appropriate to understand the
meaning of a social phenomenon through the interpretive process of
analyzing data collected during semistructured interviews (Saunders, Lewis,
& Thornhill, 2016). For this study, I selected the qualitative method to
understand the strategies health care leaders use to execute strategic change
successfully in the real-life setting of their organizations. Researchers use
the quantitative method to examine relationships or differences between
variables (Counsell, Cribbie, & Harlow, 2016). The quantitative method was
not ideal for this study because the purpose was not to test hypotheses or
examine variables’ relationships or groups’ differences. Turner, Cardinal,
and Burton (2017) described mixed-methods research as the combination of
both qualitative and quantitative methodologies into one study to provide a
broader perspective and overcome the limitations of each approach to an
inquiry. The mixed-methods approach was not appropriate because
statistical testing was not necessary to achieve the purpose of this study.
Five designs in qualitative methodology are ethnography, grounded
theory, phenomenological, narrative research, and case study (Saunders et
al., 2016). The ethnographic design allows researchers to study cultural
groups in their natural setting over a prolonged period (Davies, 2015). The
study of cultural groups was not necessary to answer the research question in
the current study. The grounded theory design enables the researcher to
develop an abstract theory of a process or phenomenon grounded in the
views of a group of participants (Corley, 2015). The grounded theory
approach was inappropriate for the current study because the development of
a theory was not required to achieve the purpose of the study. Researchers
using the phenomenological design conduct semistructured interviews and
prolonged engagement to understand the meanings of lived experiences of
the study participants about an event or phenomenon (Marshall & Rossman,
2016). The phenomenological approach was inappropriate for the current
study because understanding the meanings of the lived experiences of
participants was not the purpose of the study. The narrative design that
includes person-to-person storytelling is used by researchers to understand
participants’ life experiences through folklore, drama, and oral history
(Parker, Dickens, & Herlihy, 2019; Saunders et al., 2016), which was not
appropriate for the current study. Researchers use the case study design to
explore a phenomenon within an existing context and use diverse data
sources to gain a holistic understanding (Larrinaga, 2017; Yin, 2018). The
case study design was appropriate for the current study because I explored
the strategies health care leaders use to implement strategic change
initiatives successfully.
Research Question
The central research question for this study was the following: What
strategies do health care leaders use to implement strategic change initiatives
successfully?
Interview Questions
1. What strategies do you apply to implement strategic change
initiatives?
2. What processes, techniques, or approaches do you use when
implementing strategic change initiatives in your organization?
3. What strategies do you use to ensure that strategic change
initiatives align with operational activities?
4. What execution strategies failed to result in the successful
implementation of strategic change initiatives?
5. What were the key types of challenges you experienced when
implementing strategic change initiatives?
6. What additional information regarding the strategies used to
implement strategic change initiatives within your health care
organization would you like to share?
Conceptual Framework
Pettigrew and Whipp’s (1992) content, process, and context model of
strategic change management and the Hoshin Kanri (HK) program
deployment model (Akao, 1991) constituted the composite conceptual
framework for this study. Pettigrew (1990) disagreed with the linear
approach to strategic change management and emphasized the need to
describe and analyze processes of change as dynamic and context based. The
components of Pettigrew and Whipp’s strategic framework are context,
content, and process. Successful change is a result of the interplay among the
content (or what) of change, the process (or how) of change, and the context
(or where or why) of the change (Stetler, Richie, Rycroft-Malone, Schultz,
& Charns, 2007). The content of change is the substance or the aspect of the
organization undergoing the change (Nelson, 2003). The context of change
is divided into the inner and outer context. According to Pettigrew (1987),
the inner context of change describes the organizational elements that
influence the change process, and the outer context refers to the social,
political, economic, and competitive environment in which the change
occurs. The process of change relates to the actions, interactions, and series
of events necessary for change to happen (E. Hage, Roo, van Offenbeek, &
Boonstra, 2013).
HK is a planning, implementation, and review framework that links
the business strategy to execution (Witcher & Butterworth, 1997).
According to Witcher and Chau (2007), HK is an integrative cross-
functional approach that provides firms with the capacity to sustain strategic
change through the management of priorities across all levels of the
organization. The components of the HK model are focus, alignment,
integration, and review (Da Silveira, De Lima, Da Costa, & Deschamps,
2017). Business leaders employing the HK guidelines use a process of goal
alignment and horizontal and vertical communication and deployment to
successfully implement change (Nicholas, 2016).
Operational Definitions
Catchball: Catchball is a two-way, top-down, bottom-up
communication process that facilitates the sharing and distribution of plans
and objectives within the organization (H. Ahmed, 2016).
Hoshin Kanri: Hoshin Kanri is a management approach that creates a
bridge between strategic goals and daily operational activities (Nicholas,
2016).
Organizational change readiness: Organizational change readiness is
the extent to which employees are prepared psychologically and
behaviorally for the implementation of a change (Zainun, Johari, & Adnan,
2018).
Organizational culture: Organizational culture is a set of values and
beliefs that dictates the behaviors and norms of employees (Mohelska &
Sokolova, 2018).
Strategic change: Strategic change is a radical organizational change
that is consciously initiated by top management, which creates a shift in
priorities, structure, and key activities that go beyond incremental changes
(Joshi & Jha, 2017).
Strategic change initiatives: Strategic change initiatives are
discretional projects designed to help an organization achieve targeted
performance (Ngan & Chung, 2017).
Strategy execution: Strategy execution is the translation of a chosen
strategy into organizational actions to implement the activities required to
achieve strategic goals and objectives (Dyer, Godfrey, Jensen, & Bryce,
2016).
Assumptions, Limitations, and Delimitations
Assumptions
Assumptions influence the value of the research (Noble & Smith,
2015). Assumptions are necessary assertions of the study that researchers
cannot confirm, and without them the study cannot exist (Leedy & Ormrod,
2016). I assumed that participants would answer questions honestly and
accurately, data collection techniques and instruments would be sufficient to
answer the research question, and participants would be available for
interviews and member-checking procedures. Based on my interactions with
the participants, I believed participants were honest in answering the
interview questions, the instrument was appropriate to get answers to the
research question, and participants were available for interview and member-
checking procedures.
Limitations
Limitations are inherent weaknesses in the study that the researcher
cannot control and may hinder generalizability of the outcomes (Leedy &
Ormrod, 2016; Morgado, Meireles, Neves, Amaral, & Ferreira, 2017).
Studies conducted using the case study design have limited generalizability.
Qualitative study findings are not generalizable, but the findings may be
transferable if the research is bounded and based in a specific context
(Marshall & Rossman, 2016). When using the case study design, the
researcher is both the instrument and the interpreter of the findings, exposing
the risk of personal bias threatening the quality of the research (Yin, 2018).
Awareness of personal prejudice and prejudgment is necessary before
beginning the interview process (Moustakas, 1994). During the study, I
bracketed activities for each phase of the research process. I exercised self-
awareness throughout the process, used several sources of data to confirm
findings, and included rich data description to increase objectivity. Netcoh
(2017) identified time as a limitation of studies that include the case study
design. The findings of this study were limited by the data collection period
because changing conditions within the same organization may have
produced a different result based on the collection time.
Delimitations
Delimitations are the characteristics that define the boundaries and
limit the scope of the study (Qiu & Gullett, 2017). Researchers have control
over delimitations of the study (Leedy & Ormrod, 2016). Delimiting factors
include the research problem, research questions, sample size, and
population selected (Yin, 2018). The purpose of this study was to explore
strategies health care leaders use to implement strategic change initiatives
successfully. Participants were leaders involved in successful strategic
change implementation at two health care organizations located in
Manhattan, New York. There may be leaders in different geographical
locations or industries who have successfully implemented strategic change,
but they were not within the scope of the current study.
Only leaders who are directly involved in the strategic change
implementation process at the selected health care organizations were
invited to participate in this study.
Significance of the Study
Health care leaders control cost and enhance health care quality by
implementing strategic change initiatives to improve efficiency and maintain
competitive advantage (Khalifa & Zabani, 2016; Seo, Park, & Lee, 2016).
The successful implementation of strategic change initiatives is necessary
for organizations’ growth and health (Gębczyńska, 2016; Naranjo-Gil,
2015). The results of this study may increase health care leaders’ awareness
of the ability to execute strategies that may result in the successful
implementation of strategic change initiatives.
Contribution to Business Practice
The findings of this study may contribute to business practice by
identifying strategies health care leaders employ to implement strategic
change initiatives successfully. Implementing strategic change initiatives
may cut costs incurred due to inefficient processes such as overtreatment,
billing failures, waste, and fraud and abuse (Anthony, 2017; Escobar-Perez,
Escobar-Rodriquez, & Bartual-Sopena, 2016). Successful implementation of
strategic change initiatives will reduce inefficiencies and lower health care
cost (Lyu et al., 2017).
Implications for Social Change
The social change implications of this study include raising awareness
of strategies that may be used to implement strategic change initiatives
successfully, deliver more efficient and cost-effective health care, decrease
medical errors and mortality rates, and provide opportunities for families to
improve social status through access to health care and increased
employment opportunities. Inefficiencies in the health care system lead to
health care access disparity and increase mortality rates of members of the
community (Kindig, Nobles, & Zidan, 2018; Peterson, Belakovskiy,
McGrath, & Yarrow, 2018). When health care cost is high, families may
need to choose between food, education, shelter, and addressing their health
care needs (Waal & Heijtel, 2017). Health care organizations that are
successful at implementing strategic change initiatives may provide more
employment opportunities for families in the social environment, improve
the social and physical well-being of consumers, and increase the
socioeconomic status of families. The social change implication for the
successful implementation of strategic change initiatives in health care may
have a positive impact on the health and well-being of health care
consumers, providers, families, and community members.
A Review of the Professional and Academic Literature
The intent of this qualitative multiple case study was to explore
strategies health care leaders use to implement strategic change initiatives
successfully. In the literature review, researchers synthesize existing
research on the topic and justify the need for additional studies about the
problem (Marshall & Rossman, 2016). In the current study, a literature
review was necessary to validate the problem, inform the research and
interview questions, and support data triangulation. Researchers recommend
a continuous literature review throughout the research process to maintain
awareness and relevance of the research question under study
(Onwuegbuzie, Frels, & Hwang, 2016; Onwuegbuzie & Weinbaum, 2016).
Pettigrew and Whipp’s (1992) content, process, and context strategic
change management model and the HK program deployment model
constituted the conceptual framework for this study. The practice of studying
strategic change as a linear, discrete entity within an organization without
consideration for context, history, and process is inadequate (Pettigrew,
1987). Leaders must adopt a holistic approach to the study of change within
organizations (Pettigrew & Whipp, 1992). The HK model provides a
feedback loop in the strategic management process that links strategy to the
operational level of the organization (Da Silveira et al., 2017).
Understanding how health care leaders align, communicate, and implement
successful strategic change initiatives may create awareness of how to
reduce the number of failed implementations. According to Ngan and Chung
(2017), 70% of strategic change initiatives fail within organizations. In this
section, I begin with a review of Pettigrew and Whipp’s (1992) strategic
change model and the HK program deployment model as the conceptual
framework for the current study. I also review alternative theories that were
considered. Then I examine the strategies leaders use to implement
successful strategic change initiatives. Subtopics included in the literature
review are health care overview, strategic change implementation, strategy
execution and alignment, facilitators and barriers to strategic change
implementation success, and sustaining strategic change.
Primary research databases I used for this research were
ABI/INFORM, Business Source Complete, EBSCO, Emerald Management
Journals, Google Scholar, and SAGE. I searched a collection of peer-
reviewed journals, dissertations, and textbooks to locate credible sources to
gain an understanding of the current body of knowledge available to support
or contest the topic. The key words included strategic change initiative,
Pettigrew and Whipp strategic change, Hoshin Kanri (HK) policy
deployment model, health care, and strategy alignment, change
management, and sustaining change. This study included 331 sources, of
which 292 (89%) were peer reviewed and 278 (95%) were published within
the last 5 years. A total of 184 sources are cited in the literature review, of
which 169 (97%) were peer reviewed.
Conceptual Framework
Pettigrew and Whipp strategic change theory. Pettigrew and
Whipp’s (1992) strategic change model was used to understand the context,
process, and content factors that contribute to the successful implementation
of strategic change within organizations (see Figure 1). Pettigrew and Whipp
(as cited in Koch & Friis, 2015; Panday, 2015) developed their strategic
change model to understand how to manage change for competitive success
within an organization. Traditional organizational change management
models describe change as an ordered and linear process of information
processing and rational choices (Bakari, Hunjra, & Niazi, 2017; Burnes &
Bargal, 2017). Pettigrew and Whipp’s strategic change model deviated from
traditional views and emphasized the need to understand how the presence
of conflicting interest, politics, and culture influence change success
(Sminia, 2016). According to Pettigrew (1987), organizational change is a
complex process that requires multilevel analysis over a prolonged period
and within a specific context.
Leaders must consider the internal (or microeconomic) and external
(or macroeconomic) factors that influence the change and explains the why
of change (Pettigrew & Whipp, 1992). The internal factors are the
organizational elements that impact the change, such as resources, skills and
capabilities, culture, and organizational politics (Pettigrew, 1987). The
external factors are elements within the broader environment whose
activities impact the change within an organization, such as politics and
economic conditions (Dyer et al., 2016). Successful change leaders consider
the internal capacity of the organization and climate of the external
environment when implementing strategic change initiatives (Bunea, Dinu,
& Popescu, 2016). During the implementation of strategic change initiatives,
leaders must ensure that the organization is ready and the environmental
conditions are suitable to influence success.
Content refers to the aspects of the organization affected by the
change, such as technology, human resources, product, or culture (Pettigrew,
1987). The content dimension of change addresses the what of change. The
content of change influences the choice of service, objectives, and
assumptions affiliated with the change (Pettigrew & Whipp, 1992).
According to Ahmad and Cheng (2018), the content of change may address
the impact of the change on the people of the organization. Employees are
affected by organizational change, and their actions and reactions determine
success (Hon & Lui, 2016). Employees’ openness to the content of change
influences acceptance and success of strategic change initiatives
(Augustsson, Richter, Hasson, & Schwarz, 2017). Employees’ behavior and
commitment are necessary for successful change implementation (Shah,
Irani, & Sharif, 2016; Thuy & Van, 2020). Change leaders must prepare
employees for the change and implement strategies to encourage acceptance.
The process of change describes the actions, reactions, and
interactions of stakeholders as they transform the organization from the
present state to the future state (Pettigrew, 1987). An analysis of the process
describes the how of change. Effective process management is necessary for
successfully deploying strategic change within an organization (Gębczyńska,
2016). According to Pettigrew and Whipp (1992), the process dimension of
change addresses issues like social, political, and cultural factors within the
macro- and microeconomic environment. When exploring the process of
change, leaders must also discuss the role of the change manager, models of
change, change formulation or implementation, and the pattern of change
through time (Dyer et al., 2016). In the current study, I examined the change
process from the implementation and deployment perspective to understand
the techniques, actions, and strategies health care leaders employ to ensure
the successful implementation of strategic change initiatives.
Hoshin Kanri policy deployment model. The HK policy deployment
model also provided a conceptual lens for this study. According to Akao
(1991), HK is a planning, implementation, and review framework for the
management of change. In the 1950s, the
Japanese Union of Scientists and Engineers invented HK based on the
teachings of Peter
Drucker (Da Silveira et al., 2017). HK became popular in Japan during the
1960s when Bridgestone Tire Institute used it as a management system
integrated with their total quality control methodology (Akao, 1991). The
first reported application of HK outside of Japan was in 1989 by the Florida
Power and Light Company in the United States (Paraschivescu & Bacovia,
2018). HK has since been adopted in several industries and processes such
as manufacturing, education, quality management and lean initiatives,
human resource management, health care, and corporate social responsibility
(H. Ahmed, 2016; Barnabe & Giorgino, 2017; Chiarini, 2016; Melander,
Lofving, Andersson, Elgh, & Thulin, 2016; Nicholas, 2016; Su & Yang,
2015). HK has also been successfully adapted by some well-known
multinational industries like Hewlett Packard, Fuji-Xerox, Texas
Instruments, A&T Lucent Technology, Rover Group, Tyco, Nissan, and
Toyota (Chiarini, 2016; Su & Yang, 2015).
Organizations that have adapted HK have reported several benefits
and success factors. Some benefits of HK are aligning stakeholders within
the organization to a few high-impact objectives, promoting organizational
learning through process improvement and root cause corrective action, and
providing standardized user reporting on projects (Nicholas, 2016; Su &
Yang, 2015). During the implementation of HK, successful leaders exhibit
flexibility and employ extensive scanning and engagement (Melander et al.,
2016). Leaders must balance flexibility and formalization with policy
deployment. When applied to corporate social responsibility, HK is more
flexible than balanced scorecard, and the catchball feature creates consensus
among managers and promotes staff involvement (Chiarini, 2016). In
addition to flexibility, leaders must develop and document policies to
support the change process (H. Ahmed, 2016).
When implementing strategic change, leaders must stay focused and
lead the organization through the change (Dyer et al., 2016). The HK
deployment model ensures that management and staff work together in the
same direction toward a common strategic goal through vertical and
horizontal alignment of the objectives and targets (H. Ahmed, 2016). HK
aligns corporate strategic objectives with plans and activities and with
middle management, teams, and the work completed by employees at the
operational level (Barnabe & Giorgino, 2017). The HK planning process is
successful because consensus is achieved by all members of the organization
around the high-priority initiatives before engaging in project completion
activities (Nicholas, 2016). In associating projects with high-priority
initiatives, leaders assign resources like staffing and equipment to
accomplish the change (S. Ahmed & Abdullahi, 2017).
Monitoring and evaluating are necessary for successful project
implementation (Abdi & Kisimbii, 2017). Leaders must implement a
rigorous review process to monitor alignment of strategic goals with project
activities and proactively identify conditions that threaten project success.
HK provides a systematic approach to integrate organizational strategy into
daily routine through the adequate deployment of policies at all levels of the
organization supported by a review process (Tortorella, Cauchick-Miguel, &
Gaiardelli, 2018).
There are several steps in the HK implementation process. Nicholas
(2016) identified common themes associated with HK: vision, strategy,
medium, and long-term goals; cascade goals and objectives, catchball and
cross-functional management, means, ends, and targets; objectives linked to
daily work, review, and control, and plan-docheck-act (PDCA). Leaders
implement HK in four phases: focus, alignment, integration, and review
(Ozkavukcu & Durmusoglu, 2016). Setting strategic goals is the first step in
the HK planning process and should be guided by the organization’s mission
and recycled annually (Da Silveira, De Lima, Deschamps, & Da Costa,
2018). Organizations should focus efforts by identifying three to five
breakthrough goals that account for the vision and long-term strategy of the
organization, and should allocate resources and set targets to achieve them
(Nicholas, 2016). Business leaders are encouraged to develop core
objectives from the breakthrough goals and deploy them to every department
to execute (Ozkavukcu & Durmusoglu, 2016).
Alignment is the phase in which the catchball method is used to
cascade deployment of objectives vertically and horizontally in the
organization (Da Silveira et al., 2018). H. Ahmed (2016) described catchball
as the two-way, top-down, bottom-up process that facilitates the sharing and
distribution of plans and objectives within the organization. The catchball
mechanism is used to cascade the deployment of policies and plans
throughout each level and department of the organization to foster
alignment, agreement, and commitment (Da Silveira et al., 2018). The
process of implementing goals, objectives, plans, targets, and controls
throughout all levels of the organization is called cascading (H. Ahmed,
2016; Nicholas, 2016). HK provides a cross-managed bridge between cross-
functional teams and daily management (Akao, 1991). In crossfunctional
management, high-level objectives that cross the boundaries of business
functions are effectively managed, which results in all departments moving
in the same direction with alignment of efforts around the few established
objectives (Da Silveira et al., 2018).
With HK, an integrated process is used to address goals, means, and
targets. Integration is the phase in which employees engage in daily
activities to accomplish the plan (Ozkavukcu & Durmusoglu, 2016). In the
HK model, the purpose of each organizational level is to establish the
actions or means necessary to accomplish the goals and targets set by the
level above (Nicholas, 2016). Horizontal and vertical communication is
facilitated in this process because managers interact with their supervisors
and subordinates in setting and deploying goals (Chiarini, 2016). Objectives
are also linked to daily work and operational activities and facilitate a closed
loop process that promotes continuous improvement and organizational
learning (Melander et al., 2016).
Reviews and controls ensure oversight of the HK process. The review
phase is the checking cycle in which annual diagnosis, reflection, and
learning occur (Nicholas, 2016). During the review cycle, plans are realigned
with targets, and lessons learned are incorporated in plans (Melander et al.,
2016). HK employs a rigorous review process that includes progress report
presentation and assessment of achieving targets versus plans, root cause
analysis of failures, and corrective action plans (H. Ahmed, 2016). The
review process comprises self-assessment and problem diagnosis by all
stakeholders, including unit leaders, department and division executives, and
the president (Akao, 1991). Reviews are data driven and conducted in a
reverse cascade process in which managers meet weekly, monthly, and
quarterly to assess performance, and the president prepares an annual
diagnosis report that is used to adjust plans and set breakthrough goals
(Nicholas, 2016; Su & Yang, 2015). According to Paraschivescu and
Bacovia (2018), HK employs process management and performance
measurement to ensure annual goal achievement.
Synthesis of Conceptual Framework
The conceptual framework for this study was a composite of Pettigrew
and Whipp’s (1992) content, context, and process of change model and the
HK policy deployment model. Adapting Pettigrew and Whipp’s perspectives
to strategic change management provides health care leaders with an
understanding of the drivers of change and the internal and external factors
that influence strategic decision-making (May, Johnson, & Finch, 2016).
Pettigrew and Whipp’s strategic change model allow for an understanding of
the impact of organizational culture, management styles, and leadership on
successful change implementation (Da Silveira et al., 2017). Although
Pettigrew and Whipp presented a dynamic model to view strategic change
from a holistic perspective, reported weaknesses are lack of focus,
concreteness, and implementation difficulty (Sminia, 2016). To circumvent
these weaknesses, I incorporated HK or policy deployment to understand the
actions necessary to implement strategic change at the operational level of
the organization. HK is a focused framework that outlines discrete steps in
the execution process that are essential to create a link between strategy and
daily operations (Da Silveira et al., 2017; Nicholas, 2016). In the current
study, Pettigrew and Whipp’s model was used to explain the contextual and
structural aspects of strategy management, and HK provided a focused
understanding of the process of converting strategic goals into operational
activities.
Alternative Theories
Kotter’s change management approach is used by organizational
leaders to lead people through strategic change initiatives. Kotter (1996)
described change as a social process where managers guide employees
through an 8-step method of creating a sense of urgency, building a guiding
coalition, developing a vision and strategy, communicating the vision,
empowering employees into action, generating short wins, consolidating the
change, producing more change, and anchoring the approach into the
culture. Researchers adopted Kotter’s change management model to
successfully implement strategic changes in health care (Baloh, Zhu, &
Ward, 2018; Casey et al., 2017; Small, Gist, Souza, Dalton, & Magny-
Normilus, 2016).
Although Kotter’s model is useful, scholars criticize it for the top-
down approach and inflexibility when applied to change implementation
(Bakari et al., 2017; Calegari, Sibley, & Turner, 2015). Implementing
change without conforming to the step by step approach outlined by Kotter
increase the risk of failure (Baloh et al., 2018). Because organizations are
complex systems, it is necessary to apply a holistic approach to implement
successful change (Pettigrew & Whipp, 1992). In adopting a holistic
approach to change implementation leaders must consider the influence of
environmental factors. Leaders who monitor the internal and external
environment during change adoption facilitates organizational learning and
promotes successful change (Felin, Foss, & Ployhart, 2015). It is essential to
lead people through change using a flexible process that is adaptable to the
environment.
The total quality management (TQM) theory also provided support for
the current study. TQM was developed by Deming in the 1950s and focused
on integrating quality at all levels of the organization (Deming, 1986). The
elements of the TQM framework are customer satisfaction, employee
empowerment, continuous improvement, visionary leadership, and creation
of value (Kar, 2017; Nahyan & All, 2017). Business leaders who adapt TQM
tools and techniques to processes, improve organizational performance by
eliminating inefficiencies (Cho, Jung, & Linderman, 2017; Yousef &
Yousef, 2017). Success of TQM results from the plan-do-study-act control
and feedback process (Park, Kim, Kwon, & Yu, 2017). When applied to
strategic change implementation in health care, TQM may increase success
by reducing variation in practice through standardization, employee
empowerment, department, and team integration, unified organizational
culture, and continuous learning (Ishanka & Gooneratne, 2018; Yousef &
Yousef, 2017).
Lean principles and tools which originated in the Toyota production
system are used to reduce waste and improve consumer value (Womack &
Jones, 1996). Lean is a systematic approach to strategy design,
implementation, and measurement (Calopa, Kokot, & Kokotec, 2020;
Stalberg & Fundin, 2018). According to Raja, Vijaya, and Raju (2018),
leaders use Lean strategies to improve operational efficiency, remove waste,
and non-value-added activities. Lean organizations enhance performance
among frontline staff through employees’ involvement and training (Bai,
Satir, & Sarkis, 2019). Leaders employ Lean principles like root cause
analysis to solve problems, ensure smooth flow of information throughout
the system, standardization work, and promote effective teamwork (Gupta,
Sharma, & Sunder, 2016).
Like HK and TQM, Lean leaders use a plethora of tools to implement
changes at the operational level of the organization (Nicholas, 2016). Tools
like value stream mapping, PDCA cycle, spaghetti, and cause-and-effect
diagrams are used to visualize and optimize activities (Kovacevic, Jovicic,
Djapan, & Zivanovic-Macuzic, 2016; Realyvasquez-Vargas, Arredondon-
Soto, Carrillo-Gutierrez, & Ravelo, 2018). Although some leaders employ
Lean successfully to improve processes and operational efficiency, there is a
high failure rate of these initiatives due to lack of commitment to change and
haphazard applications of the Lean principles and tools (Aij & Rapsaniotis,
2017; Chiarini & Baccarani, 2016; Coetzee, van der Merwe, & Van Dyk,
2016).
Additionally, the implementation of Lean principles increases
occupational stress among employees and threaten change success (Stimec
& Grima, 2019). Regardless of criticisms leaders have successfully
implemented Lean in health care to execute strategic change, support a
learning culture, reduce cost, and provide value to consumers (Goodridge,
Westhorp, Rotter, Dobson, & Bath, 2015). Implementing change initiatives
at the operational level of the organization is complicated, but business
leaders who employ dedicated policy deployment principles and utilize
performance measurement tools like Lean and HK may experience more
success with strategic change implementation (Barnabe & Giorgino, 2017).
Health Care Overview
The United States health care system is in crisis and needs
reformation. The rising cost of products and services is a significant driver
of strategic changes in health care. Health care spending increased by $933.3
billion between 1996 to 2013 with the price of services accounting for 50%
of this rise (Dieleman et al., 2017). The upward trend in health care spending
continues. In 2015, health care spending increased by 5.8% and reached $3.2
trillion costing $9,990 per person annually to receive care (Martin, Hartman,
Washington, & Catlin, 2017). Keehan et al. (2017) predicted this growth
would result in a rise in the health care share of the gross domestic product
from 17.8 percent in 2015 to 19.9 percent by 2025.
Even with the high cost of health care, U.S. citizens experience poor
quality of care and health outcomes. Americans spend more on health care
than any other country in the world, although they experience lower health
outcomes and shorter life expectancy (Squires & Anderson, 2015). While
health care spending is high, the positive impact on health outcomes is not
apparent, and this may be due to process inefficiencies. Thirty-five percent
of wasteful spending in health care is due to clinical waste, excessive prices,
and fraud and abuse (Sahni, Chigurupati, Kocher, & Cutler, 2015). Lyu et al.
(2017) conducted a study among medical doctors in the American Medical
Association database and found that clinicians reported that 30-45% of
medications prescribed, and tests and procedures done are unnecessary.
According to Joudaki et al. (2016), 10% of the annual health care
expenditure accounts for fraud and abuse violations. Health care fraud and
abuse manifest in charging excessively for services, misusing codes on
claims, making illegal referrals, soliciting or accepting remuneration for
services reimbursed by federal programs, and submitting false claims
(McWay & Kurian, 2017).
Strategic change is necessary for the U.S. health care system to remain
viable. The current health care infrastructure is not conducive to
transforming health care in the manner needed to maintain a competitive
advantage. The strategy to fix health care includes replacing the fragmented
health care system with an integrated delivery model, reimbursing for value,
not volume, and providing better system oversight (Porter & Lee, 2013).
Much of the increase in spending is due to the change in population size, the
aging population, disease prevalence, and incidence, cost of care, high
insurance premium, and technology (Dieleman et al., 2017; Hartman,
Martin, Espinosa, & Catlin, 2018; Nilsen, Seing, Ericsson, Birken, &
Schildmeijer, 2020). According to Santilli and Vogenberg (2016), macro
environmental issues like pricing pressures, educational gaps, and the
inefficient payment structure would continue to drive change in health care.
Researchers found that applying the recommendations of Porter and Lee
which includes a shift to integrated practice units adds value and improve
patient outcomes (Low et al., 2017). Leaders must change the current health
care delivery model to transform health care into a value-added industry.
Strategic Change Implementation
The implementation of strategic change is necessary for organizational
growth and competitiveness. Strategy implementation or execution is the
process of informing, translating, and executing activities needed to achieve
strategic goals (Dyer et al., 2016). Strategy implementation follows the
strategy formulation process (Lindsay, Jack, & Ambrosini, 2018). Chief
executive officers (CEOs) and board executives formulate strategies for the
organization to achieve success (O’Shannassy, 2016; Sarros, Sarros, Cooper,
Santora, & Baker, 2016). A strategy is only as good as its implementation.
Researchers found that only 10-30% of strategic change initiatives are
implemented successfully (Candido & Santos, 2015). The high failure rate of
strategic change initiatives may be due to the disconnection between strategy
formulation and implementation (Oskooee, 2017). Top executives formulate
strategies but fail to involve lower-level managers or provide guidance on
how to implement changes throughout the organization (Greer et al., 2017).
During strategy formulation, executives should consider resources and
provide the support necessary for employees to successfully implement the
strategy (Leonardi, 2015). Without successful strategy implementation, it is
difficult for organizations to maintain competitive advantage (Mukerjee,
2016). Leaders should establish clear links between strategy formulation and
implementation to reduce the failure rate of strategic change initiatives.
Continuous environmental changes create a sense of urgency for
organizations to implement strategic changes to remain viable (Andreeva &
Ritala, 2016). Leaders must choose the best strategic initiatives to increase
the chance of survival (Galpin, 2018). Leaders who are short-sighted when
selecting change initiatives and setting the strategic direction of the
organization experience higher failure rates (Sull, Turconi, Sull, & Yoder,
2018). Demands created from the external environment, forces change in the
internal environment which generates tension that either increase or decrease
change adoption (Dominguez, Galan-Gonzalez, & Barroso, 2015). Excessive
change occurs when the demand for the change is greater than resources and
will result in a negative reaction from employees (Johnson, 2016).
Successful leaders choose appropriate strategic change initiatives and create
an ideal implementation environment.
Health care leaders attempt to balance supply and demand limitations
by implementing multiple strategic change initiatives simultaneously.
Implementing multiple simultaneous change initiatives is stressful to the
organization and employees affected by the change (Aslam, Ilyas, Imran, &
Rahman, 2016). The implementation of strategic changes impacts the whole
organization, alters strategy, and affect the structure, process, and people
(Joshi & Jha, 2017). Consequently, the successful implementation of
strategic change requires mobilization and coordination of resources
controlled by managers at different levels of the organization (Dominguez et
al., 2015; Sull et al., 2015). Because of resource limitations and the
disruptive nature of change, organizations should implement no more than
three to five major strategic change initiatives simultaneously (Galpin,
2018). When implementing strategic change initiatives leaders must be
mindful of the impact of the change on the organization and employ
strategies to mitigate the risk of failure.
Leaders should stay focused but exhibit flexibility when implementing
strategic change initiatives. Maintaining the focus of the organization on the
strategy is important to achieve success (Tawse, Patrick, & Vera, 2019).
Effective leaders have the necessary focus and organizational skills to
execute the strategy (Friis, Holmgren, & Eskildsen, 2016). Regrettably,
organizations easily lose focus and take on other initiatives even before the
complete implementation of one strategy (Lindsay et al., 2018). Leaders who
focus the organization around a few specific strategic objectives are
successful at reducing distractions and inefficiencies in change processes
(Melander et al., 2016). Not all changes are necessary, and employees
become disgruntled and disinteresting when implementing unnecessary
changes (Lv & Zhang, 2017).
Strategy execution takes time and depletes the resources of the
organization (Lowy, 2015). Furthermore, strategic change initiatives trigger
the need for resource reevaluation and redistribution across the organization
which may result in unexpected consequences (Li & Xu, 2020; Wiedner,
Barrett, & Oborn, 2017). Strategic change initiatives fail because leaders
abandon implementation efforts too soon (Conbrere & Heorhiadi, 2017).
Leaders must be prepared for disruptions caused by strategic change
initiatives and should not quit strategy when unexpected events occur.
Strategy implementation is the process of making the strategy unfold
and successfully achieve the strategic objectives of the organization.
Features of strategy implementation are having an action plan, strategy,
leadership, and maintaining focus. The recipe for successful strategy
execution involves creating clear objectives for people to follow, finding
ways to measure performance, holding people accountable for their actions
accurately, and rewarding excellent performance (Dyer et al., 2016). During
implementation, leaders must decompose the strategy into activities and
cascade the change throughout the organization (Gębczyńska, 2016).
Leaders should reflect corporate strategy in specific plans and schedules,
assign them to different departments, processes, and individual working
positions for execution (Nicholas, 2016). Action plans should include a
timeline, responsible parties, and a review process with appropriate
corrective action (Friis et al., 2016). Leaders use key performance indicators
(KPIs) to measure progress toward the attainment of action plans and change
outcomes (Spackman et al., 2019). KPIs are necessary because they provide
management at various levels of the organization with useful feedback and
insight into the strategic change initiative (Kuhfahl, Sehlke, Sones, &
Howard, 2018). Successful leaders establish performance criteria for the
change and measure progress toward goal achievement.
Strategy Execution and Alignment
Alignment is a critical success factor in strategy execution. Alignment
is the degree to which design, strategy, and culture of an organization
cooperate to achieve a common or shared goal (Volk & Zerfass, 2018).
Implementing a new strategy requires alignment of resources and internal
capabilities to the organizational context (Fedato et al., 2017). To achieve
success, leaders employ techniques such as informing, involving, enhancing,
motivating, and evolving when aligning structures, processes, and behaviors
among individuals in an organization (Hilligoss, Song, & McAlearney,
2017). Strategy implementation involves widespread organizational changes
so leaders must utilize alignment strategies to increase success.
Alignment is the foundation of effective strategy execution. When
considering alignment, it is necessary to include business units, resource
commitment, policies, operations, structure, best practices, and culture
(Sushil, 2017). Alignment of strategy at the operational level occurs through
synchronization between staff activities, measurements of operational
factors, and the use of feedback and data from operations to optimize
processes (McAdam, Miller, & McSorley, 2019). Lack of alignment leads to
limited support for middle managers and staff who are critical to successful
change implementation (Engle et al., 2017). Effective alignment helps in
achieving consensus and better coordination among components of the
strategy execution process (Nicholas, 2016).
Effective alignment of strategy at different levels of the organization
such as structure, operations, and best practice assist in successful strategy
execution. Structure - strategy linkage is important for successful strategy
implementation (Sushil, 2017). Even when structural factors are considered
most companies struggle with strategy execution (Ivancic, Mencer, Jelenc, &
Dulcic, 2017). Although structure influences successful strategy
implementation, other alignment factors positively contribute to strategic
change success (Sushil, 2017). When implementing strategic change
initiatives leaders should take a holistic approach and consider alignment
from the perspective of the external environment, strategy, process,
structure, culture, and people (Volk & Zerfass, 2018). Leaders must conduct
frequent environmental scans and infuse findings into strategic change
initiatives because changes in the environment may influence success
(Ivancic et al., 2017). Alignment strategies that go beyond structural
concerns may result in more successful strategic change implementations.
Leaders who apply alignment and integration strategies across
departments and functions refocus the organization on primary
organizational priorities and are more successful when implementing change
initiatives (Alagaraja, Egan, & Woodman, 2017). Creating alignment
enhance team integration and purposeful allocation of organizational
resources (Recardo & Toterhi, 2015). Weak links between operations and
strategy results in unclear direction, conflicting priorities, and failed
initiatives (Sushil, 2017). Proper alignment of resources like financial and
human is necessary to ensure effective strategy execution (Ghinea &
Moroianu, 2016; Mugge, Abbu, Michaelis, Kwiatkowski, & Gudergan,
2020). Alignment facilitates effective communication which positively
influences employees’ acceptance of change (McAdam et al., 2019; Volk &
Zerfass, 2018). Strategic change initiatives are necessary to improve
organizational performance, but without adequate alignment strategies,
organizational goals are unattainable.
Facilitators and Barriers to Strategic Change Implementation Success
Health care leaders must adapt implementation strategies that may
better meet the growing and diverse needs of the changing health care
organization and enhance change success (Asrar-ul-Haq & Kuchinke, 2016).
Successful organizational change leaders are aware of the facilitators and
barriers to change success and implement strategies to mitigate failure and
promote success.
Organizational change readiness. Organizational readiness to
change is the prerequisite to successful change implementation in health care
(Al-Hussami, Hamad, Darawad, & Maharmeh, 2017). Organizational
readiness is the extent to which employees are prepared psychologically and
behaviorally for the implementation of a change (Zainun et al., 2018).
Leaders who understand organizational readiness to change develop more
effective and efficient change implementation strategies (Storkholm,
Mazzocato, Tessma, & Savage, 2018). Despite evidence demonstrating that
it is essential to assess organizational change readiness to promote
implementation success, researchers found that readiness is often not
assessed before strategy implementation (Timmings et al., 2016). Readiness
for change and actions undertaken in the implementation of change is critical
to the successful execution of strategic change initiatives (Engle et al.,
2017). With increase assessment of organizational readiness to change
leaders may achieve more success when implementing strategic change
initiatives.
Leaders must assess organizational readiness to change at various
levels of the organization. Organizational change readiness is multilevel and
is associated with staffing, leadership, and resources adequacy (Sharma et
al., 2018; Winters, CollinsCamargo, Antle, & Verbist, 2020). Leaders often
address change readiness from the individual perspective, but there are also
organizational level implications like communication, goal alignment,
coordination, and strategic leadership (Benzer, Charns, Hamdan, & Afable,
2017). Leadership competency and decision quality increase strategic
change implementation success (Al-Hussami et al., 2017). Leaders who
determine the organizations’ ability to adapt to change and readiness for
change experience more successful change implementations.
Change readiness increase the capacity of the organization to
implement successful change initiatives (Spaulding, Kash, Johnson, &
Gamm, 2017). According to Kotter (1996), many organizational change
initiatives fail because leaders neglect to create enough readiness for the
change. During change preparation leaders must mold employees’ attitude
and encourage commitment to the change (Adil, 2016). Employees’
commitment to change may be improved through formal and informal
communication (Appelbaum et al., 2017). Change leadership contributes to
employees’ commitment to change by providing high-quality change
communication and stimulating employee participation in the
implementation of change (der Voet, 2015; Holten, Hancock, & Bollingtoft,
2020). When assessing readiness, it is necessary to assess employees’ belief
system about the potential change; and their knowledge, skills, and ability to
perform after implementation (Timmings et al., 2016). Leaders must assess
employees’ commitment and readiness to accept change because employees
play a pivotal role in change success.
Organizational structure. Strategic change implementation is
difficult because it often requires changes in the formal structure of the
organization. Structural changes involve making changes to the goals,
purpose, and strategy of the organization (Lynch & Mors, 2018). Structure
determines information flow and decision making at different organizational
levels to achieve the mission and goals of the organization (Dyer et al.,
2016). Structure includes the assignment of tasks and resources to
accomplish the organizational goals (Burton & Obel, 2018). Structure
follows strategy. For successful implementation of strategic change
initiatives, leaders should adjust the structure of the organization to suit the
strategy (Karim, Carroll, & Long, 2016). Consequently, during a strategic
change, leaders must adjust operational activities to meet the changing needs
of the environment (Kral & Kralova, 2016). Leaders must understand the
impact of the change on organizational structure and employ strategies to
enhance employees’ ability to achieve the company’s mission and goals.
Change to the organizational structure affects employee networks. As
the formal structure of the organization changes employees’ ability to
maintain work-related networks are disrupted (Lynch & Mors, 2018). Work-
related networks are where employees access the resources and knowledge
necessary to complete operational tasks (Rogan & Mors, 2017).
Organizational structure determines the relation between team members at
different levels in the organization and describes the relationships between
supervisors and information flow (Koohborfardhaghighi, Lee, & Kim,
2016). Leaders must investigate organizational networks or work-related
relations between individual and organizational silos and build bridges
between functions and groups disrupted by strategic change (Rydzak &
Monus, 2018). Efficient information flow between crossfunctional teams and
employee networks increase successful implementation of strategic change
initiatives.
Structural obstacles influence organizational success. Structure
impacts the ability of the organization to survive (Renzi, Sancetta, &
Orlando, 2017). The nature of the organizational structure is a precursor to
the successful implementation of business strategies (Fedato et al., 2017).
Inflexible organizational structure is an obstacle to strategic change
implementation (Nazemi, Asadi, & Asadi, 2015). Consequently, the
organization’s ability to change determine its chance of survival (Renzi et
al., 2017). Strategic change initiatives are successful when leaders mitigate
obstacles and integrate the change within the organization.
Leadership. Leadership plays a pivotal role in the success or failure
of strategic change initiatives. Top executives determine the vision and
strategic direction of the organization (Greer et al., 2017). Lack of support
and feedback from senior executives, limited team involvement, and
communication failures negatively influence strategic change
implementation (Bernardo, Anholon, Novaski, Silva, & Quelhas, 2017).
Successful strategic change implementation requires commitment from
executives and senior managers (Narikae, Namada, & Katuse, 2017). The
leadership team champions change by improving communication and
promoting inclusiveness (Bates & Atkins, 2017). Executives may use
strategic communication to create alignment with the organizational
objectives and empower employees to accept change (Argenti, 2017).
Ineffective leadership leads to poor communication of the organizational
goals and strategic vision and increase uncertainty when implementing
strategic change initiatives.
Change management involves adopting strategies, procedures, and
technologies to address changes in the external and business environment
(De Lellis, Di Leva, & Sulis, 2018). Leaders must be aware of the
opportunities and threats in the changing internal and external environment
such as technological, demographic, economic, legal, social, and political
and appropriately exploit them to improve organizational success (Nazemi et
al., 2015; Wang, Li, & Qi, 2020). Strategic change initiatives affect all levels
of the organization, and leaders must employ a holistic approach to change
management to mitigate obstacles (Michel et al., 2016). Barriers encountered
during the implementation process account for the failure of strategic change
initiatives.
The change management literature revealed that leadership practices,
styles, and behaviors influence change success (Levene & Higgs, 2018).
Transformational, transactional, and laissez-faire leadership are common
leadership styles found in the literature (Raziq, Borini, Malik, Ahmad, &
Shabaz, 2018). Transformational leaders employ influence, charisma, and
emotional engagement to inspire followers to exhibit a positive attitude
towards change (Richter et al., 2016). In contrast, transactional leaders value
structure and use tactics like rewards and punishment to nudge subordinates
to accept change (Guy, 2018). The structure provided by leaders using the
transactional leadership style helps employees prepare for change and
support the implementation process (Von Treuer et al., 2018). Laissez-faire
is a leadership approach in which leaders provide minimal support or tools
and allow employees to make decisions independently without guidance
(Bligh, Kohles, & Yan, 2018). According to Yasir, Imran, Irshad, Mohamad,
and Khan (2016), laissez-faire leadership negatively influence change
capacity and implementation success. When preparing to implement
strategic change initiatives health care leaders must assess change readiness
and employ the most appropriate leadership style to promote success.
In health care, no one leadership style is appropriate for all situations.
Effective health care leaders must adopt the leadership style that is
appropriate for a given context or situation (Lacerenza, Marlow,
Tannenbaum, & Salas, 2018). Successful leaders utilize strategies like
encouragement, trust building, creating a shared vision, rewards and
incentives, and effective communication to create transparency and motivate
team to accept change (Reed, 2017). Commitment, communication,
coordination, and monitoring are organizational leadership factors that
influence successful strategic change implementation (Narikae et al., 2017).
The ideal leadership style for successful health care strategic change
implementation is one that is context specific and supportive of operational
activities.
Successful leaders help employees connect to a higher purpose and
build a positive team culture which is necessary to effect positive change
(Herd, Adams-Pope, Bowers, & Sims, 2016; Owens, Eggers, Keller, &
McDonald, 2017). Leaders must engage with stakeholders at all levels of the
organization to successfully implement strategic change initiatives (K.
Wilburn & R. Wilburn, 2017). Middle managers influence successful
strategic change by maintaining a relationship with top management,
embracing the strategy, and aligning roles and skills necessary to attain the
strategic objectives of the organization (Austin, Chreim, & Grudniewicz,
2020; Ukil & Akkas, 2017). Frontline leadership is critical to strategic
change success because of their influence on the daily activities of
operational staff and health outcomes (Joseph & Bogue, 2018; Mianda &
Voce, 2018). Leadership engagement throughout the organizational
hierarchy facilitates change success.
Leaders of health care change initiatives must understand the health
care landscape, develop a culture that embraces, and welcome change, and
empower teams to be successful (Herd et al., 2016; Sullivan, Ibrahim, Ellner,
& Giesen, 2016). Leaders should empower each team member to function
autonomously in completing job functions (Feldman, 2018). Health care
leaders must exhibit collaborative leadership to leverage the expertise of
multi-disciplinary teams while transcending structural and cultural barriers
which promote inefficiencies (Ward et al., 2018). The culture of the
organization determines staff satisfaction, sense of value, and organization
performance (Owens et al., 2017).
Organizational culture. Organizational culture influence employees’
behavior. Organizational culture is a set of values and believes that dictates
behaviors and norms of employees (Mohelska & Sokolova, 2018). Culture is
a collective agreement that distinguishes organizations (Dhingra & Punia,
2016). Within organizations, culture may manifest as language, shared
values and beliefs, symbols, legends, stories, and physical environment
(Arslangilay, 2018). Organizational culture creates a sense of identity and
commitment among employees which support stability and influence change
acceptance (Mehrtak et al., 2017). People are the reason strategy fails or
succeeds, and culture is stronger than strategy (Eaton & Kilby, 2015). As
organizations undergo strategic change, individuals are forced to participate
in various change initiatives (Zondi & Mutambara, 2016). Since people are
affected by an organizational change, leaders must be aware of how culture
impacts employees’ acceptance of the change as this may positively or
negatively influence change success.
Culture is a strong predictor of employees’ readiness to change.
Successful change leaders prepare employees for the change (Heine,
Beaujean, & Schmitt, 2016; Mugge et al., 2020). During strategic change
execution leaders are encouraged to exercise openness, involve employees
early, and embrace confrontation because these are strong predictors of
change readiness (Dhingra & Punia, 2016). Organizations characterized by a
culture of innovativeness and risk-taking are more flexible and respond
positively to change (Tavare, 2017). Additionally, a positive organizational
culture, senior management support, effective performance monitoring,
building and maintaining a skilled workforce, and cohesive interdisciplinary
teamwork influence successful strategic change implementation (Taylor,
Clay-Williams, Hogden, Braithwaite, & Groene, 2015). As leaders engage in
activities to ready the organization for a change, it is necessary to develop a
positive organizational culture through support and flexibility.
The success of strategic change initiatives is dependent on the leaders’
ability to integrate the change within the organization (Fedato et al., 2017).
Change leaders are encouraged to assess the fit between strategy and culture
because compatibility positively influences change success (Chen, Huang,
Liu, Min, & Zhou, 2018). The lack of fit between strategy and culture leads
to conflicts in values and norms which results in employees’ resistance to
change (Kotter, 1996). Leaders who address cultural issues before
embarking on strategic change initiatives are more likely to succeed (Heine
et al., 2016). Leaders must educate themselves about the culture and needs
of the organization before embarking on strategic change initiatives and
implement strategies to offset risks and facilitate success (Davis & Dolson,
2018). Organizational culture is effective when it supports the mission,
goals, and strategy of the organization (Mohelska & Sokolova, 2018). An
effective culture matches the business needs and aligns with employees’
norms and values (Mustafa-Elqadri, & Priyono, 2015). Culture change may
be necessary to promote strategic change success (Zondi & Mutambara,
2016). Dhingra and Punia (2016) advised leaders to make strategic changes
within the current context of the organization because culture change takes
many years. A culture that supports the organization’s strategy facilitates
successful strategic change implementation.
Communication. Communication is essential during strategic change
implementation. Success or failure of strategic change initiatives is
dependent on how leaders manage communication (Luo, Song, Gebert,
Zhang, & Feng, 2016). How, when, and how much leaders communicate the
change, vision, and strategy predicts change success (Jones-Schenk, 2017).
Communication involves activities that enable information creation,
distribution, receipt, acknowledgment, and understanding (Senaratne &
Ruwanpura, 2016). Communication is critical during strategic change
implementation because it facilitates the flow of messages through
interactions that occur using speech, gestures, texts, and discourses
(Cornelissen, Durand, Fiss, Lammers, & Vaara, 2015). According to
Eriksson and Fundin (2018), visualization is necessary to communicate
change as a process. Communication is essential because it is the tool used
for announcing, explaining, and preparing people for the change which may
positively impact health care leaders’ ability to implement successful change
initiatives.
Clear and effective communication is a critical success factor for
strategic change implementation. The quality of the communications and
employees’ ability to make sense of the change is necessary for success
(Fedato et al., 2017). Effective communication is a two-way process that
involves all levels of employees within the organization (White, 2016).
Effective communication inspires employee trust, encourages a collaborative
culture, and reduces resistance to change (Livesey, 2016; Sverdrup &
Stensaker, 2018). Effective communication facilitates stakeholder
engagement and participation in the change management process (Butt,
Naaranoja, & Savolainen, 2016). Leaders who use effective communication
strategies, when implementing strategic change initiatives, may help
employees accept and incorporate the change in daily operations.
Effective communication involves the alignment between the message
and the medium. The communication medium employed may impact user
perception, and the ability to decode and understand the message (Eriksson
& Fundin, 2018). Communication can be face-to-face, verbal, written or
nonwritten, or formal or informal (Kral & Kralova, 2016). Leaders
communicate using bulletins, suggestion box, letters, memos, emails, phone
calls, reports, meetings, handbooks, surveys, and hallway and dinner chats
(Butt et al., 2016). There are various modes of communication. The mode of
communication does not have to be elaborate, but it must be accurate,
complete, timely, and include appropriate stakeholders (Link, 2018).
Communication is a tool used to share messages and encourage employees
to accept change. Well-informed employees have a more positive attitude
towards change (den Heuvel, Schalk, & Van Assen, 2015). During the
change process, communication needs to increase, and leaders should
provide an opportunity for open communication to prevent distrust among
employees (Le, 2015). Communication is ineffective when it is inadequate.
When communication is inadequate rumors and misrepresentation of the
message ensues (Düren, 2016). Ineffective communication includes giving
information too late, not including the right stakeholders in the message, or
providing incomplete information (Düren & Ross, 2015). Leaders who
communicate change effectively promotes hope, provides support, increases
subordinate orientation, and increases employees’ commitment to change
(Luo et al., 2016).
Employee resistance. Employees have a natural propensity to resist
change (Okumus, Bilgihan, Ozturk, & Zhao, 2017). Employees resistance to
change may be due to habit, job’s security, economic factors, fear of the
unknown, increasing workload, and threats to interpersonal relations
(Kuzhda, 2016). Employees exhibit resistance to change by voicing their
concerns about the change (Cinite & Duxbury, 2018). To reduce resistance
leaders should educate employees about the rationale for the change and the
impact of change on job functions (Kuzhda, 2016). Leaders should also
involve employees in change decision making early as this will encourage
participation and inspire acceptance (Mathews & Linski, 2016). Leaders
should involve employees in preimplementation, planning, and
implementation stages and provide adequate training and support to promote
change acceptance (Okumus et al., 2017). Leaders can help employees
overcome resistance and accept change by involving them in the change
process.
Employees’ attitude towards change may determine change success.
Employees who do not understand the motivation for the change are
distrustful and will question the motive behind the change (Blanca &
Ramona, 2016). Trust is a necessary factor for change acceptance (Gigliotti,
Vardaman, Marshall, & Gonzalez, 2018). Employees who question the
motive of management for implementing the change is likely to exhibit
resistance (Blanca & Ramona, 2016). Because change is difficult, it is
imperative that leaders motivate employees through training and skills
development activities to increase change acceptance and readiness (Thakur
& Srivastava, 2018). Leaders can help employees develop a positive attitude
towards change by ensuring adequate preparation for the change.
The introduction of change is disruptive to employees and may elicit
various emotional response. To overcome emotional and behavioral
resistance from employees, leaders should utilize strategies to transform
from having a negative to a positive attitude toward change and innovation
(Hon & Lui, 2016; Li & Hsu, 2016). Leaders should be aware that
employees may not perceive their actions and reactions to change as
resistant and may excuse their behavior as having the best interest of the
organization (Kulkarni, 2016). Employees perception of the change
determine resistance or acceptance of a strategic change initiative (Afrianty,
2020; Will & Pies, 2018). Supportive leaders remove sources of change
resistance and initiate structures for work accomplishment (Jones & Van de
Ven, 2016).
The action of leaders influences employees’ response to change.
According to Balogun, Bartunek, and Do (2015), leaders sensemaking of
strategic change evolved as they dialogued with senior leaders, managers,
and employees. Leaders who understand the change are better able to share
the purpose of the change with employees. Leaders can also address
employee resistance to change through negotiations and agreement like
offering incentives (Kuzhda, 2016). Leaders must support employees during
change through the provision of organizational and emotional support
(Thakur & Srivastava, 2018). Some leaders also use coercion strategies to
encourage change acceptance. But leaders should use coercion as a last
resort to encourage employees to accept the change since this may lead to
distrust (Kuzhda, 2016). Over time, supportive leadership reduces change
resistance (Jones & Van de Ven, 2016). Leaders can help employees
overcome resistance and become more accepting of strategic change
initiatives by utilizing appropriate strategies.
Sustaining Strategic Change
Sustaining change is the final stage of the strategic change
implementation process (Dick et al., 2018). Willis et al. (2016) defined
sustained change as the long term and deeply embedded changes in values,
beliefs, and assumptions of employees within an organization. Sustaining
strategic change in an organization has two aspects: implementing the
change in all organizational units and groups and keeping the new behavior
ongoing even after initial implementation (Dick et al., 2018; Willis et al.,
2016). Researchers argued that the reported high failure rate of strategic
change initiatives might be erroneous because of the lack of a standard
measure and definition for change success and sustainability (Candido &
Santos, 2015; Moore, Mascarenhas, Bain, & Straus, 2017). Given the
complexity of the health care system, leaders must consider a comprehensive
sustainability model that address setting, context, intervention, and external
support factors when implementing strategic change initiatives (Colon-
Emeric et al., 2016).
Sustaining strategic change initiatives require making the change the
new way of doing business in the organization (Meissner, 2018). Leaders
must facilitate institutionalizing the change within the culture of the
organization by articulating how it positively impacts shared goals and
values (Dick et al., 2018). Permanent change takes time because employees
must acquire new skills and develop trust in the change (Dyer et al., 2016).
Hence, leaders should implement strategies to integrate new strategic
changes into the culture of the organization and avoid regression into the
pre-implementation stage.
Existing organizational structures may prevent the proper anchoring of
change in the organization (Clausen & Kragh, 2018). The guiding principles
for sustaining change are aligning change with vision and action, fostering
distributed leadership, promoting staff engagement, creating collaborative
relationships, and allowing for continuous learning (Canterino, Cirella,
Piccoli, & Shani, 2020; Willis et al., 2016). Continuous training and funding
are necessary for sustaining change in large health care systems (J. Hage &
Valadez, 2017). According to Green, Bell, and Mays (2017), senior
leadership support is essential to sustain strategic change.
Concise, continuous communication is necessary for sustaining
change. Dick et al. (2018) advised leaders to communicate change
consistently and in a series of smaller steps because it is less overwhelming
to employees and is more useful for sustaining change initiatives. Leaders
must integrate and communicate strategic change at all levels of the
organization to ensure sustainability (Gutberg & Berta, 2017). Oversight and
monitoring systems like audits, steering committee oversight, revising
policies and procedures, and encouraging leadership involvement are
necessary to sustain change (Higuchi, Davies, & Ploeg, 2017). Leaders could
monitor sustainability by using process control and performance boards
which are two visual management tools to track progress or identify
deviation from goal (Silver et al., 2016). Leaders should implement
strategies to sustain strategic change like aligning change with success
criteria metrics, incorporating the change in improvement huddles, standard
work, and employee’s performance incentive programs (Dick et al., 2018;
Green et al., 2017; Silver et al., 2016).
Transition
Section 1 consisted of a background of the study including the
problem and purpose statements, and the research question. I used Pettigrew
and Whipp’s (1992) context, content, and process strategic change model
and the HK or policy deployment (Akao, 1991) framework as the conceptual
lens to evaluate the problem under study and the associated research
question. Also included in this section were the significance of the study,
social change impact, and a review of the relevant literature.
In section 2, I presented a description of the project including an
overview of the role of the researcher, participants, the research method,
research design, and population. Additionally, I provided information about
research ethics, data collection instruments, techniques, and data
organization techniques. I concluded this section with a description of the
data analysis plan, and reliability, and validity considerations. Section 3 is
the final section of this study, and consisted of the presentation of the
findings, recommendations for action and future research, a reflection of my
experience, and conclusion.
Section 2: The Project
Section 2 includes a restatement of the purpose statement and a
description of the role of the researcher, participants, and research
methodology and design. The section also contains information about the
population and sampling method, ethical research, data collection
instruments and techniques, and data organization techniques. I conclude
this section with a discussion of data analysis, reliability, and validity.
Purpose Statement
The purpose of this qualitative multiple case study was to explore
strategies health care leaders use to implement strategic change initiatives
successfully. The targeted population consisted of four leaders from two
health care organizations in Manhattan, New York who have successfully
implemented strategic change initiatives. The implications for positive social
change include the ability to improve the social and human conditions of
members of the community. Patients and health care recipients may benefit
from having access to safe health care, leading to fewer medical errors,
treatment disparities, and premature deaths. Communities may benefit from
more employment opportunities, improvement of the standard of living for
residents, more cost-effective health care services, and having a healthy local
workforce.
Role of the Researcher
The primary function of the researcher in qualitative research is to
establish procedural thoroughness to support data collection, data
organization, data analysis, and presentation of findings (Marshall &
Rossman, 2016). In qualitative studies, researchers serve the role of the
primary data collection instrument (Farooq & de Villiers, 2017; Van den
Berg & Struwig, 2017). As the data collection instrument, the researcher
must be able to conduct thorough, unbiased interviews, as well as review
documents and exercise advanced observation skills to capture accurate and
reliable data (Denzin & Lincoln, 2018). In the current study, I employed a
multiple case study design and interacted with participants through
semistructured interviews and review of company documents and archival
records and gained an in-depth understanding of the strategies health care
leaders use to implement strategic change initiatives successfully.
As a registered nurse and project manager, I have over 25 years of
experience implementing strategic change initiatives in health care
organizations. My experience may have influenced the study because I am
aware of the issues faced during the implementation of strategic change
initiatives in health care. Given this knowledge, I brought my perspectives,
opinions, and personal biases to this study. The experience of the researcher
may provide valuable insights and challenges to the study (Greene, 2014).
To mitigate risks and develop awareness of bias, qualitative researchers
employ bracketing, interpretive thinking, and critical reflexivity (Wadams &
Park, 2018). Qualitative researchers who apply bias reduction strategies
during data collection, coding, and data analysis could eliminate personal
bias and increase trustworthiness (Clark & Veale, 2018).
To reduce the influence of personal bias on the findings of this study, I
applied procedures to ensure that the results were valid and reliable. Before
the interviewing process, I engaged in the process of bracketing in which I
examined and recorded my personal biases about the topic. Researchers
bracket their experience by acknowledging their personal biases before
conducting interviews (Moustakas, 1994). During data collection,
researchers must exercise active listening to deliberately engage with
participants and improve the quality of the interaction (Spataro & Bloch,
2018). I took notes during the interview and documented observations,
which increased rigor and validity. Researchers ground research in evidence
from the literature to reduce bias (Gog, 2015).
During the interview, I adhered to the interview protocol and refrained
from leading or guiding participants responses. Yin (2018) recommended the
use of an interview protocol to provide structure and maintain the integrity
of the qualitative case study. Castillo-Montoya (2016) supported this notion
and encouraged use of an interview protocol to adhere to research standards,
guide the interview process, mitigate bias, and allow for gaining insight into
the participant’s experience. An interview protocol replicates data collection
procedures and ensures a consistent process during each interview
(McGonagle, Brown, & Schoeni, 2015). The interview protocol allows for
the uniformity of questions for each participant.
I conducted the interviews in a private, quiet location to facilitate the
open sharing of personal experience and opinions. Researchers should create
an interview environment free from noise and distrations that is comfortable
to enhance acurate data collection (Dikko, 2016). During scheduling, I
allowed each participant to choose the location and time of the interview.
Interviewing is a necessary tool for collecting evidence to support case study
research (Yin, 2018). During the interviewing process, researchers must
maintain confidentiality and gain the trust of participants (Petrova, Dewing,
& Camilleri, 2016). I ensured confidentiality by allowing each participant to
choose the location and time of their interviews.
During each interview, with the permission of the participant, I took
notes and recorded the conversation to enhance recollection and facilitate
accurate data transcription. After the data reporting, I stored all recordings
and notes on a thumb drive in a locked box, which will be retained for 5
years. At the end of 5 years, I will destroy the thumb drive, notes, and any
physical company documents to protect the confidentiality of human
subjects as recommended in the Belmont Report (1979). Throughout the
data collection and data analysis phases, I engaged in the process of critical
reflection and double checking to reduce the potential for misinterpretation
of the participant’s responses (see Elo et al., 2014). Open coding of data was
used during analysis to capture common themes that emerged as I reviewed
the interview transcripts (see Elo et al., 2014). Also, data analysis involved
summarizing interview responses through the lens of the conceptual
framework selected for this study.
Researchers have an ethical obligation to participants. Researchers
must observe ethical standards when conducting studies involving human
subjects (Yin, 2018). Stichler (2014) affirmed the need to protect human
subjects who participate in research. The Belmont Report is a regulation that
protects human subjects who participate in research and includes special
consideration for vulnerable populations (Mclaughlin & AlfaroVelcamp,
2015). The Belmont Report (1979) outlined the minimum standards
researchers must follow during a study: acknowledging participants rights
for anonymity and confidentiality, voluntary participation, and beneficence
and justice. I applied the recommendations described in the Belmont Report
when conducting this study.
Marshall and Rossman (2016) advised researchers to maintain ethical
standards throughout the study. As the researcher, I informed participants of
their rights before conducting interviews and provided details about the
protection of confidentiality and the management, storage, and use of data
after the interviews. During the informed consent process, I informed
participants that they could withdraw from the study at any time even after
data collection without fear of consequences. After data collection, I used
memberchecking to increase research validity and mitigate bias.
Participants
The participants in this qualitative multiple case study were four
change leaders from two health care organizations in Manhattan, New York
who have experience with implementing successful strategic change
initiatives. Participant selection was nonrandom because I needed to
interview subjects who were knowledgeable and successful in implementing
strategic change within a health care organization. According to Leedy and
Ormrod (2016), qualitative researchers use a purposeful sample to select
participants who will provide relevant information about the research
question. Purposive sampling involves targeting research subjects from the
population with the ability to share experience about the phenomenon under
study (Benoot, Hannes, & Bilsen, 2016; Grafton, Reid, & Coyne, 2016;
Newton, 2017). Establishing inclusion and exclusion criteria is necessary to
create boundaries for the sample (Robinson, 2014). Inclusion criteria for this
study included health care leaders from the selected organizations who have
been instrumental in the successful implementation of strategic change
initiatives within the last 5 years. The exclusion criteria were leaders and
staff who were not involved in implementing strategic change initiatives
within health care organizations.
I selected participants because of their experience and knowledge of
the topic. To identify participants, I gathered a list of all health care
organizations in Manhattan, New York. I searched social media, LinkedIn,
and Google to make contact with prospective participants. Researchers can
use social media profiles of prospective participants to determine eligibility
(Dodge & Chapman, 2018). Establishing access through formal gatekeepers
is necessary to get approval to conduct interviews with staff of an
organization (Yin, 2018). After I received IRB approval from Walden
University, I established a working relationship through telephone
conversations and email communication with the gatekeeper and prospective
participants who met the eligibility criteria. Gatekeepers were asked to assist
in making introductions to other members of the selected organizations who
met the eligibility criteria. From these introductions, I recruited participants
for interviews and continued to interview until no new themes emerged.
Researchers must inform participants of their rights and obtain informed
consent from participants before data collection (Perrault & Keating, 2018;
Phillippi & Lauderdale, 2018). Before commencing the study, I emailed an
invitation to prospective participants requesting their time to engage with me
through interviews to facilitate the collection of data for this study.
Invitations included details about the objectives of the study, the reason for
participants’ selection, and the inform consent process.
Research Method and Design
Researchers use qualitative, quantitative, and mixed-methods
approaches in business and social science research. According to Saunders et
al. (2016), qualitative researchers search for patterns and meanings through a
process of inductive reasoning to understand the environment in which
participants live and work. The qualitative method is used to gain a rich
understanding of participants’ experiences and perceptions of a phenomenon
(Yin, 2018). Quantitative researchers approach research from a deductive
perspective, beginning with theory and examining relationships among
variables (Christenson & Gutierrez, 2016). In quantitative studies,
researchers deduce meanings from numerical data and apply statistical tests
to make predictions, identify patterns of behavior, and examine relationships
(Saunders et al., 2016). Some researchers argue there is no absolute truth, so
it is necessary to study phenomena from both a qualitative and quantitative
perspective to gain a comprehensive understanding (Leedy & Ormrod,
2016). The mixed-methods approach involves the combination of qualitative
and quantitative methods to study phenomena (Thiele, Pope, Singleton, &
Stanistreet, 2018).
Research Method
I selected the qualitative method for this study. Researchers who use
qualitative methodology conduct an in-depth review of a phenomenon in its
natural setting (Leedy & Ormrod, 2016). The qualitative approach is
appropriate to explore the nature of a phenomenon, gain new insight into an
issue that may lead to theory development, validate claims and assumptions
of a theory in a real-world context (Saunders et al., 2016). Qualitative
research is interpretive and focused on a specific context, which allows for
the holistic understanding of the participants’ experience with the
phenomenon under study (Marshall & Rossman, 2016). The qualitative
method provides for the exploration of the views of research participants
through the use of open-ended questions, review of company documents,
and observations (Leko, 2014; Yin, 2018). In the current study, I employed
the qualitative method to explore strategies used by health care leaders to
implement strategic change. Using the qualitative approach, I was able to
gain an indepth understanding of the experiences of participants who
implemented strategic change initiatives and the tools and techniques used to
enhance success.
Although the qualitative method was most appropriate for the current
study, I also considered other approaches. There are three standard
approaches to research inquiry: qualitative, quantitative, and mixed methods
(P. Turner et al., 2015). Whereas the qualitative method allows for open
exploration of the research topic, the quantitative method does not allow for
this flexibility. The quantitative method is theory driven and used to examine
the relationships among variables through numerical data and statistical
analysis (Saunders et al., 2016). Although there is value in numbers, in the
current study, employing the quantitative method would not have allowed
for the rich understanding of the strategies used by health care leaders to
implement strategic change initiatives successfully. I also considered the
mixed-methods approach because of the ability to explore a phenomenon
from both qualitative and quantitative perspectives. The mixedmethods
approach was not appropriate for this study because quantitative data were
not needed to answer the research question (see S. Turner et al., 2017). After
completing a review of the three methods of research inquiry, I determined
that the qualitative method was appropriate to answer the research question:
What strategies do health care leaders use to implement strategic change
initiatives successfully?
Research Design
The design of the study must align with the research method selected.
The research designs for qualitative studies are ethnography, grounded
theory, phenomenological, narrative, and case study (Marshall & Rossman,
2016). The ethnographic design involves immersion and prolonged exposure
in a cultural group to collect data about daily events and personal
experiences (Davies, 2015). The ethnographic design is ideal for the study of
cultural groups, which was not the focus of the current study. The grounded
theory design is focused on theory development and does not support the in-
depth exploration of the case of interest (Corley, 2015). The
phenomenological design allows for data collection of the lived experiences
and perceptions of participants through interviews (Gorichanaz, 2017). The
phenomenological design was not appropriate for this study because there
was no need for understanding of the lived experience of participants. The
narrative design involves studying the life of one individual to give a
chronological account of an event (Parker et al., 2019). This design did not
align with the purpose of my study.
The case study design allows for the exploration of a problem from
various perspectives (Larrinaga, 2017). The case study design is appropriate
to understand a phenomenon as it occurs in the real world (Yin, 2018). In
case study research, openended questions are used to allow participants to
describe the phenomenon under study (Tran, Porcher, Tran, & Ravaud,
2017). In qualitative studies, researchers read and reflect on the answers of
participants and derive meanings about the concept of interest. In the current
study, I employed a case study design to obtain a rich and holistic
understanding of the strategies used by health care leaders to implement
strategic change initiatives successfully. The case study design was
appropriate because it allowed for the in-depth examination of the problem
using different data sources (see Ridder, 2017). Researchers should continue
interviewing participants until data saturation (Saunders et al., 2016).
Researchers achieve data saturation when no new themes emerge during data
collection (Patton, 2015). Although interviews were the primary data
collection method for this study, I also conducted a review of appropriate
company documents and archival records relevant to the line of inquiry to
support data validation and determine data saturation.
Population and Sampling
Trochim, Donnelly, and Arora (2016) defined the study population as
the group to which the findings of the study is generalizable. Depending on
the problem statement the population may be too large, disperse, or
inaccessible to study. Researchers redefine the population into a more
manageable subset called target population (Saunders, et al., 2016). The
target population for this study were leaders from two health care
organizations in Manhattan, New York who have successfully implemented
strategic change initiatives in their organization.
Convenience and purposeful sampling are two nonprobability methods
researchers use to select participants for studies. In a convenience sample,
participants are chosen based on accessibility, and geographical proximity
(Etikan, Musa, & Alkassim, 2016). Convenience samples might lead to
findings that are not trustworthy or generalizable to the population of interest
(Leedy & Ormrod, 2016). In purposeful sampling, researchers use judgment
to select participants that will be able to provide answers to the research
question (Saunders et al., 2016). The purposeful snowball sampling
technique involves identifying people who meet established eligibility
criteria for participation in the study and those persons then recommend
others who meet the requirement to participate (Elo et al., 2014; Robinson,
2014). Purposeful snowball sample is appropriate when the population of
interest is hard to reach or inaccessible (Trochim et al., 2016). In this study,
purposeful snowball sampling was used to choose participants who possess
unique experiences and may share insights on a phenomenon under study.
The eligibility criteria for inclusion in the current study were being a health
care leader in Manhattan, New York, have implemented strategic change
initiatives successfully at the chosen organization, and have implemented
successful strategic change initiatives within the last five years.
For the current study, I interviewed four participants from two health
care organizations and continued data collection until there were no new
themes, codes, or data. The ideal sample size for qualitative studies is
dependent on the research question, objective, and method (Patton, 2015).
For example, quantitative researchers believe the larger the sample size, the
better the chance of having a representative sample especially with survey
research (Leedy & Ormrod, 2016). For qualitative studies, smaller samples
are acceptable because there is more interaction between the researcher and
participants which allow for extensive data collection (Elsawah, Guillaume,
Filatova, Rook, & Jakeman, 2015). Employing semistructured interviews, a
minimum of 5-25 participants is ideal (Saunders et al., 2016). Yin (2018)
supported this notion and recommended a minimum sample size of 3-5
participants for case study research. Researchers concluded that the focus of
qualitative studies is on data saturation and not sample size (Wakefield
& Blodgett, 2016).
Conversely, other researchers recommend that the depth of the data
should determine sample size in qualitative studies and purported that data
collection should continue until data saturation is reached (Fusch & Ness,
2015; Patton, 2015). I assumed data saturation when there were no new ideas
from any of the data collection sources. To verify data saturation, I asked
participants to provide explanations and clarify the meanings of statements
made during the interview. After the interview, I confirmed data saturation
through member-checking.
After gaining access, getting IRB approval from Walden University,
and informed consent from participants, I conducted interviews. In this
study, participants had the flexibility to choose between a telephone and
face-to-face interview. Traditionally, researchers use face-to-face interviews
in qualitative studies (Hilgert, Kroh, & Richter, 2016). With the increased
use of telecommunication technology and telecommuting within
organizations I provided an opportunity for participants to choose the most
convenient method. Zhang, Kuchinke, Woud, Velten, and Margraf (2017)
found no statistically significant difference between data collected by face-
to-face and telephone interviews. According to Leedy and Ormrod (2016),
regardless of the interview approach researchers must clarify answers and
seek more information about questions during data collection.
I conducted the interviews at a time and place selected by each
participant. Participants were asked to schedule the interview at a time when
they can dedicate 60 minutes protected time to engage in conversation. I was
prepared to break the interview into more than one session but this was not
necessary. Researchers must conduct interviews in a quiet, private location
that is free from noise, interruptions, or distraction (Yin, 2018). Participants
were given the flexibility to choose a location outside the work environment
to host the interview. However, participants preferred the office location so I
asked them to reframe from checking emails or taking phone calls during the
interview session. The interview environment should be comfortable to
stimulate natural conversation flow (Bredart, Marrel, Abetz-Webb, Lasch, &
Acquadro, 2014). To encourage natural conversation, I followed an
interview protocol, prepared and used open-ended questions to guide the
discussion, actively listened to participants, and used prompts to seek
clarification where necessary. With the permission of participants, during
each interview, I took notes and recorded conversations. I also requested
samples of company documents and archival records used in the planning,
and implementation of strategic change initiatives such as meeting notes,
memos, project and change management tools, and, policy and procedure
documents to use for data validation and triangulation.
Ethical Research
Researchers participating in research using human subjects must
conform to ethical guidelines. The Belmont Report (1979) outlined the
following guidelines for researchers to follow when conducting studies, and
these include: acknowledging participants as autonomous agents, ensuring
that the research will result in no harm or beneficence to participants; and
guaranteeing just and fair treatment of participants. In preparation for
conducting this study, I completed the National Institute of Health (NIH),
protecting human research courses to attain detailed knowledge about the
ethical guidelines for research. Institutional Review Boards (IRB) are
implemented by organizations to provide the oversight necessary to enforce
the ethical standard in research (Page & Nyeboer, 2017). Before conducting
the current study, I received IRB approval number 11-05-19-0133881 from
Walden University.
Ethical issues can occur during participant recruitment and selection,
data collection, maintenance of participant privacy, protection of
confidential data, and dissemination of information. Developing a trusting
relationship with participants influence the quality of data (Marshall &
Rossman, 2016). In developing a trusting environment, researchers must
exhibit transparency and disclose plans for protecting privacy,
confidentiality, and data use (Lohle & Terrell, 2014). I followed the research
best practices provided by Walden University and the Belmont Report to
ensure that I interact with participants in an ethical manner.
Consent Process
According to Perrault and Keating (2018), informed consent is the
process of informing participants of their rights, and potential risks of
participating in the study, and obtaining a participation agreement. Before
conducting interviews, participants read and attested to the terms and
conditions of the informed consent. During the informed consent process, I
explained the purpose of the study, the rights of participants, and the data
protection procedure. Each participant was required to reply ‘I consent’ via
email as an indication of an agreement to voluntarily participate in the study
and to respond to questions truthfully and honestly. Participants were also
told of their rights to withdraw from the study.
Research Withdrawal Process
In this study, participants could withdraw at any point before I publish
the research findings. I told participants that they may refuse to answer any
questions during the interview, and post-interview they could request that I
do not include their contribution in the final publication. Also, I informed
participants that their decision to withdraw will not have any negative
consequences on their job or physical well-being. Although, participants had
the option to withdraw from the study in person, by email, or telephone
communication with the researcher, no participants requested a withdrawal.
Incentives
Providing incentives can motivate participants to participate in the
research but may lead to ethical concerns of paying for participation.
Participant’s agreement to participate in the study must be of free will
(Marshall & Rossman, 2016). In this study, I provided no incentives and
participants were notified that participation is voluntary.
Data Security
In this study, I complied with Walden University IRB guidelines to
secure, retain, and destroy study materials. During the interview, I took
notes, recorded verbal exchange, and requested company documents and
archival records to support claims. After the study, I secured documents,
recordings, and associated transcriptions in a locked safe for five years. At
the end of the required five-year period, I will destroy thumb drive and study
materials. Researchers have an ethical obligation to protect study
participants. According to Leedy and Ormrod (2016), researchers should
present findings in a manner that de-identify participants. Saunders et al.
(2016) recommended assigning codes to each participant to ensure
anonymity. In this study, I protected the participant’s anonymity by
assigning pseudonyms or codes to label and identify organizations and
participants using the order O1P1, O1P2, or O2P1, O2P2. Assigned codes
aid in data management and participant identification.
Data Collection Instruments
The researcher is the primary data collection instrument in qualitative
research (Marshall & Rossman, 2016; Yin, 2018). As the researcher, I
collected data mainly through semistructured interviews guided by open-
ended questions. Using open-ended questions in interviews allowed
participants to express ideas and share experiences freely without the
constraints of structured choices (Leko, 2014). In the current study, I asked
health care leaders about their experience in implementing strategic change
initiatives. Using semistructured interviews, I obtained an in-depth
understanding of the tools and techniques used to implement strategic
change initiatives successfully. I used an interview protocol to maintain
consistency while asking questions to participants. An interview protocol
serves as a guide and allow for consistency and the fair and equitable
administration of interview questions (Schwab & Syed, 2015).
In addition to semistructured interviews, the case study design allows
for the collection of data from multiple sources like observation, archival
records, and company documents (Yin, 2018). For this study I requested
copies of project documents, policy and procedure documents, and a sample
of meeting agenda and minutes used in planning and executing strategic
change initiatives. Using more than one data collection sources enhanced
validity.
To enhance the reliability and validity of data, I conducted member-
checking. After completing data collection, I used member-checking to
verify whether my interpretation of participants’ response is accurate.
Member-checking is the process of having each participant review the
summary of the interview for accuracy (Marshall & Rossman, 2016).
Member-checking adds credibility to the findings of qualitative studies
(Harvey, 2015). Before using member-checking, researchers must have
strategies to address disagreements and be willing to conduct further analysis
(Birt, Scott, & Cavers, 2016). After each interview, I transcribed the
recorded data, reviewed archival data, and company documents, and present
a summary document to each participant within seven days, for review and
confirmation. I conducted member-checking procedures shortly after
interview and asked participants to validate the accuracy of the researcher’s
interpretation of the data. During member-checking one participant provided
written clarification to interview question responses and these changes were
accepted and included in the final study.
Data Collection Technique
In qualitative case study research, researchers use multiple data
sources to increase rigor and enhance the credibility of the findings (Yazan,
2015; Yin, 2018). In this study, I used the following sources for data
collection, semistructured interviews, archival document analysis, and
review of company records. Before data collection, I received IRB approval
from Walden University. I used social media LinkedIn and Google to
identify and contact prospective participants who met the eligibility criteria.
I stopped making social media contact when prospective participants from
two health care organizations provided approval for me to conduct the study
at their sites and shared email contact information of another prospective
participant. I contacted eligible participants via email and invited them to
participate in the study (see Appendix A). Each of the four prospective
participants contacted completed an interview. During this stage, I
established a working relationship with each participant by introducing
myself and sharing information about my background and research interest,
explaining the purpose of the study and their role, and discussing the
estimated time commitment and inclusion criteria.
Each participant introduced me to at least one other prospective
participant from the same organization who met the eligibility criteria. I then
sent an introductory email, which included an overview of the study and an
invitation to participate. All prospective participants contacted met eligibility
criteria and agreed to participate in the study. One participant requested a
meeting to clarify expectations. This participant agreed to participate in the
study after we had a 10 minutes telephone conversation about the purpose of
the study and the data protection plan. I emailed an informed consent form to
prospective participants who expressed willingness to participate in the
study. Participants were required to email ‘I consent’ to the researcher before
each interview. I informed participants of their right to withdraw from the
study at any time and that participation is voluntary with no incentives. I
received the ‘I consent’ email confirmation from each participant before
each interview and none of the participants withdrew from the study. I
scheduled interviews according to each participant’s preference at a
convenient time and location. Two participants from separate organizations
requested face-to-face interviews, and the remaining two participants
preferred telephone interviews.
Semistructured Interview
During each interview, I followed an interview protocol to maintain
consistency among participants (see Appendix B). Using an interview
protocol in semistructured interviews allow a researcher to collect data about
the topic of interest while allowing participants to openly share experiences
within the limitation of the area of focus (Schwab & Syed, 2015). I used
semistructured interviews to gain a rich understanding of participants’
experience in implementing strategic change initiatives. Through these
interviews, I gathered information about the techniques used to overcome
barriers and promote successful implementation. Semistructured interviews
allow participants to elaborate on questions asked and share details about
perception, and practices related to a real-life phenomenon (Yin, 2018).
Reported disadvantages of semistructured interviews are it is time-
consuming to schedule, transcribe interviews, and analyze voluminous data
(Marshall & Rossman, 2016). During each interview, I recorded the audio
exchange using an Apple iPhone recorder and took handwritten notes to aid
in accurate data transcription.
Review of Company Documents
A review of company documents allows for data triangulation because
the researcher can corroborate verbal responses with documents (Pacho,
2015). Company documents could provide background information
necessary to understand the context and rationale for decisions made
(Marshall & Rossman, 2016). Company documents are specific and allow
for repeated review but may be inaccessible due to privacy concerns (Yin,
2018). For this study, company documents included methodology templates,
project plan, policy and procedure documents, and other documents used in
communication. During each interview, as participants discussed the
materials used in their project planning and management process, I asked for
samples of these documents. I sent a follow-up email after each interview to
thank participants for their time and to remind them to email sample
documents (see Appendix C). Three out of the four participants shared
sample documents, which included project tracker, project plan, and mission
statement. These documents were reviewed, analyzed, and reported on as
part of the findings of this study.
Archival Document Analysis
Archival data analysis is another method used in data collection.
Archival data in this study were both publicly available or internal to the
company. According to Deller (2019), when relying on archival company
data, it is necessary to follow up with participants to reduce data delivery
time lag. In this study, I emailed participants the day after the interview to
follow up on the request for archival documents. Participants shared project
documents such as communication plans and implementation metrics, and
these were reviewed, and analyzed until I attained data saturation.
Member Checking
Member-checking is the process of following up with participants to
validate whether the researcher accurately interprets their responses to
interview questions (Thomas, 2017). Member-checking allows participants
to verify whether the researcher correctly described their answer to each
interview question (Marshall & Rossman, 2016). After data collection, I
paraphrased the interview responses in my own words and created a
summary document for member-checking. I emailed a summary document
to each participant to review and verify the accurate interpretation of
responses to the interview questions. All participants confirmed the accurate
interpretation of interview responses within the allotted 7 days’ timeframe.
One participant provided further clarification to responses, and I included
these changes during data analysis. Member-checking presents an
opportunity for participants to correct information, provide clarification, or
add more details (Fusch & Ness, 2015; Harvey, 2015).
Data Organization Technique
Data organization is necessary for data management, maintain
integrity, and aid in efficient analysis. In the current study, I collected data
from several participants using multiple sources. For proper management, I
established a labeling convention for files, interview scripts, documents, and
summary data to quickly identify participants. Qualitative researchers use
codes to hide participants’ identity and to reinforce the reliability and
validity of data analysis (Emmel, 2015; Stuckey, 2015; Yin, 2018). I used
the code OP to represent the organizations and participants, and I added 1, 2,
or 3 to identify the organization and the interview position of the
participants. I also use codes to identify the data source. For example, I
labeled the interview provided by the first participant and organization as
O1P1, and documents submitted labeled O1P1D1. I followed this labeling
protocol to organize data and maintain confidentiality.
Researchers encourage the use of technology in data collection,
organization, and storage to facilitate ease of analysis (Moylan, Derr, &
Lindhorst, 2015). In this research, I organized interview recordings,
handwritten notes, and company documents such as project tracker and
communication plan. The handwritten notes were used to register biases and
observations made during data collection which allowed for comprehensive
data analysis. I used an audio recorder to record the interviews and
transcribed data in the Microsoft Office software to manage and control data.
The data management strategy for these sources included the creation of
electronic folders for each organization and participant using the labels
O1P1, O1P2, and O2P1, using one folder to store data provided by each
participant. Within each folder, I created subfolders for interviews, and
documents. The interview subfolder contained the recording, transcribed
data, and a scanned copy of handwritten notes. The document subfolders
included electronic communication, consents, and sample company
documents provided by each participant.
I used a dedicated thumb drive to store any data collected for this study.
After data collection and organization, I uploaded electronic
documents into NVivo 12 for further organization, and analysis. NVivo is a
commercial software often used by qualitative researchers to identify themes
and patterns during data analysis (Sarma, 2015; Woods, Paulus, Atkins, &
Macklin, 2015). I will retain all research documents which includes
interview transcripts, notes, logs, and recordings for five years. Physical
documents and the thumb drive will be stored in a locked safe during this
period. After 5 years I will shred paper documents and physically destroy the
thumb drive making it permanently unreadable.
Data Analysis
Data analysis is the process of analyzing collected data (Vaughn &
Turner, 2016). Researchers employ triangulation techniques in data analysis
to converge data collected from various sources to decrease the deficiency of
a single strategy and increase the ability to interpret the findings (Lawlor,
Tilling, & Smith, 2016; S. Turner et al., 2017). Four types of triangulation
techniques are data triangulation, investigator triangulation, theory
triangulation, and methodological triangulation (Fusch, Fusch, & Ness,
2018). Researchers defined the different types of triangulation as data
correlates people, time and space; investigator compares the findings of
other researchers; theory relates multiple theoretical perspectives; and
methodological links multiple data collection methods (Joslin & Müller,
2016; Korstjens & Moser, 2018). I used methodology triangulation to
enhance the quality of the findings by analyzing data from interviews,
archival and company documents, and handwritten notes until data
saturation.
During data analysis researchers engage in the process of coding,
categorizing, and developing themes identified in the data collected through
the interview process (Marshall & Rossman, 2016). Yin (2018) described
thematic analysis as a five-step data analysis approach that comprises of data
compilation, deconstruction, reconstruction, analysis, and conclusion.
During data analysis researchers immerse in the data, offer interpretation
through analytic memos, and search for an alternative understanding
(Marshall & Rossman, 2016). After data collection, I compiled interview
notes, and recordings, and organized them in one related document into a
database. Then, I breakdown the data into categories, assign codes, and
identify common themes. Similar to other researchers, I engaged in the
process of open and focused coding until all interview and notes are coded
(Maher, Hadfield, Hutchings, & de Etyo, 2018). I used NVivo 12 to assist in
data analysis. According to Robins and Eisen (2017), NVivo allows for data
coding, theme identification, document review, and query. Researchers use
NVivo to index and categorize data making it ready for analysis (Woods et
al., 2015).
According to Onwuegbuzie et al. (2016), a continuous literature
review is necessary throughout the entire research process to ensure that the
problem is still relevant. During the thematic analysis, I compare and
contrast findings with existing literature, which include new studies
published since the initial search. I also correlated derived themes against the
conceptual framework to gain insight into the strategy’s health care leaders
uses to ensure the successful implementation of strategic change initiatives.
Pettigrew and Whipp’s (1992), context, process, and content, strategic
change, and HK or policy deployment models (1991) was the conceptual
framework for this study.
Reliability and Validity
Reliability
Reliability is the extent to which the measure is consistent, replicable,
or dependable (Trochim et al., 2016). Researchers ensure dependability by
describing the research process in sufficient details so another researcher can
replicate (Elo et al., 2014). An interview protocol outlines the procedures
and rules to collect data and increase the reliability of the research (Yin,
2018). I kept a detailed audit trail and followed the interview protocol to
facilitate replication and dependability.
Validity
Validity is the truth-power or the trustworthiness of the research
(Leedy & Ormrod, 2016). Researchers use member-checking to improve the
reliability and validity of the study (Birt et al., 2016). Trustworthiness
qualitative research must satisfy credibility, transferability, dependability,
and confirmability (Korstjens & Moser, 2018). Credibility ensures that the
study is a reflection of the problem or the measure aligns with the intention
(Maher et al., 2018). I enhanced credibility by incorporating
memberchecking, methodological triangulation, and using handwritten notes
about the study.
Transferability address the ability of the findings to be transferable to
other situations (Korstjens & Moser, 2018). Marshall and Rossman (2016)
advised researchers to leave transferability of the findings to the reader and
future researchers. Transferability confirms whether participants respond to
the same questions and allow for transferability to another setting (Patton,
2015). I ensured transferability by providing a thick description of the
problem under study and followed the interview protocol.
Qualitative researchers use confirmability to minimize investigator
bias by ensuring that the findings are reflective of the data (Korstjens &
Moser, 2018). Researchers use member-checking to enhance confirmability.
Member-checking is the process of providing data summary and
interpretation to participants to validate findings (Marshall & Rossman,
2016). Researchers use member-checking and detail record keeping to
ensure confirmability (Connelly, 2016). I ensured confirmability of the
findings by capturing detail notes and engaging in member-checking before
publishing the results of the study.
Data saturation during data collection is the point at which no new
information emerges (Tran et al., 2017). Determining data saturation is
difficult because researchers are limited only to the information found at a
point in time. According to Fusch and Ness (2015), failure to reach data
saturation impact the quality of the research. In qualitative research data
saturation and the decision to stop collecting data is dictated by the
researcher’s judgment and experience (Tran et al., 2017). Data saturation
occurs when there is enough information to replicate the study (Fusch &
Ness, 2015). In the current study, I assumed data saturation when no new
themes, codes, or data emerge on the topic from the sample population, and
there is enough information to replicate the study.
Transition and Summary
In Section 2, I addressed the role of the researcher, participant
selection, research method, data collection techniques, data organization
techniques, data analysis, and reliability and validity. I also included in
section 2 a discussion about research ethics and population. Section 3
comprised of the presentation of findings, application to professional
practices, the implication for social change, the recommendation for action,
and recommendations for future study. I conclude section 3 with reflections
and conclusion.
Section 3: Application to Professional Practice and Implications for Change
Introduction
The purpose of this qualitative multiple case study was to explore the
strategies health care leaders in Manhattan, New York use to implement
strategic change initiatives successfully. This final section includes the
presentation of findings, application of findings to practice, implications for
social change, recommendations for action, recommendations for further
research, and reflections. In the current study, I conducted semistructured
interviews with four health care leaders from two organizations who have
more than 5 years of experience with implementing strategic change
initiatives. I also reviewed company documents and archival records to
explore the strategic change implementation process.
To maintain participants’ confidentiality, I used codes (O1P1, O1P2,
O2P1, O2P2) to identify participants and their associated organization. Each
participant responded to the six interview questions (see Appendix D). The
duration of the interviews was 30-45 minutes. The interviews were audio
recorded, transcribed, and coded. Findings indicated that health care
strategic change leaders use various strategies to implement strategic change
initiatives successfully.
Presentation of the Findings
The research question for this study was the following: What
strategies do health care leaders use to implement strategic change initiatives
successfully? I used NVIVO 12 to aid in code assignment and theme
identification. After data analysis and coding, various keywords were
identified (see Table 1).
Table 1
Interview Questions and Keywords
# Interview questions Keywords
1 What strategies have you used to
successfully implement strategic
change initiatives?
Communication, frontline staff
involvement, demonstrate
organization values, provide
oversight, vision alignment,
leadership buy-in, stakeholder
awareness
2 What processes, techniques,
methods, or approaches did you
follow when implementing
strategic
change initiatives in your
Culture of improvement, standard
methodology and tools like Lean,
True North, A3, audit checks,
frontline staff support, coaching,
organization?
PDCA cycle, transparency, frequent
updates, measure progress towards
goals, communication, team
meetings, training, workshop,
pre/post surveys
3 What strategies do you use to
ensure that strategic change
initiatives align with operational
activities?
Leadership involvement, Gemba-
visit at work site, create process and
value stream maps, communication,
frontline staff awareness, clarify
impact of change on current work,
knowing both the current state and
the future state, staff engagement,
reinforcement, incentives
4 What execution strategies failed
to result in the successful
implementation of strategic
change initiatives?
Too many changes at once, lack of
executive support, not motiving or
energizing people, not helping staff
visualize personal benefits, unclear
communication, not understanding
the strategic landscape, inflexible
plan, lack of oversight and follow-
up, not trying
5 What were the key types of
challenges you experienced
when implementing strategic
change initiatives?
Multiple competing initiatives, lack
of time, regulatory and political
climate, culture, employee and
stakeholder resistance, incentive
structure, unclear communication,
lack of shared vision, limited
resources, sustaining the change
6 What additional information
regarding the strategies used to
implement strategic change
initiatives within your health
care organization would you
like to share?
Start simple, gain trust, nothing
worth doing is easy, engaged leader,
passionate people
The three primary themes that emerged from the data analysis were
situational awareness, communication, and leadership strategies (see Figure
2). The presentation of findings includes a detailed discussion of each theme
and alignment of results with the literature and the conceptual framework
used to inform this study.
Theme 1: Situational Awareness
One finding of the current study was situational awareness is
necessary for the successful implementation of strategic change initiatives in
health care. Situational awareness involves the perception and understanding
of the current context of change (Almeida et al., 2019). Participants in the
current study shared that numerous changes in the health care ecosystem
create a state of constant change in local organizations. Participants viewed
situational awareness from two perspectives: (a) understanding how changes
in the external environment create a need for local organizational changes
and (b) readying the local organization to adopt new change initiatives (see
Table 2). In this study, references to situational awareness occurred 23 times
and were categorized as subthemes external and internal environment
awareness.
Table 2
Situational Awareness References and Subthemes
Themes/subthemes
Organization 1
Organization 2
Participant O1P1 O1P2 O2P1 O2P2
Theme 1: Situational awareness
Subthemes:
Internal environment
X X
X
External environment X X X
External environment. Having situational awareness of the external
environment is essential to anticipate changes necessary to maintain a
competitive advantage (Pettigrew & Whipp, 1992). The climate of the
external environment, such as politics, technology, new knowledge, and
economic conditions, generates significant changes in health care
organizations (Bunea et al., 2016; Dyer et al., 2016). According to Gavil and
Koslov (2016), the frequency of change in a highly regulated health care
environment threatens implementation success. Participants in the current
study shared examples of external environmental changes that are
challenging to implement. O2P1 and O2P2 asserted that the current
regulatory health care environment, such as the move from volume- to
value-based pricing, issues around the opioid crisis, and the high maternal
death rate, create constant change in their organization. Changes imposed by
the external environment may not be operationally feasible for health care
organizations to implement (Dominguez et al., 2015). According to O2P2,
the move to value-based pricing in health care creates implementation
challenges for leaders because some providers are still using the volume-
based approach while adopting this change, so initially it is not cost-effective
to implement this change.
Political and economic environmental pressures give rise to an
increase in mergers and acquisitions in health care (Parikh, Haque, Miller, &
Dimick, 2019). Mergers and acquisitions are another external factor that is
generating many changes in health care organizations (Chesley, 2019). One
participant in the current study shared that being a product of a recent
merger and acquisition in the health care industry creates an opportunity for
the organization to increase population reach and expand programs, which is
a significant source of change in the resulting organization. Viewing mergers
and acquisitions in a positive light was an unusual finding in the current
study because previous researchers indicated the adverse effects of these
transactions. For example, Walia and Boudreaux (2019) found that mergers
and acquisitions hurt health care consumers because the associated
regulatory policies raise allocative efficiency, surplus, and overall cost.
The findings of the current study revealed that participants are aware
that changes in the external environment have both a negative and positive
impact on the internal organization. When discussing the effects of the
external environment on change implementation, O1P1 equated these
changes as “being in a state of constant pressure.” O2P1 expressed a sense of
being trapped and stated “being in an industry as regulated as health care,
although changes are needed, you do not have the flexibility and ease to
implement them.” Having situational awareness of the drivers and sources of
strategic health care changes is necessary to prepare the organization for
change implementation success.
Wambua and Omondi (2016) advised strategic change leaders to
employ environmental scanning to gain insight about trends and external
forces of change and develop an effective response to position for future
success. According to Amuna, Shobaki, and Naser (2017), without external
environment analysis, organizations will fail to survive the effects of
environmental factors that threaten viability. Although participants in the
current study did not provide details about specific steps taken to maintain
environmental awareness, they all agreed that their knowledge of the
external environment determines which strategic change initiative to
implement. In the current study, situational awareness allows leaders to
analyze and choose the actions needed to implement strategic change
initiatives to maintain a competitive advantage.
Internal environment. Having awareness of the external situation
does not guarantee the successful implementation of strategic change
initiatives in health care organizations (Felin et al., 2015). When considering
situational awareness in the context of change implementation, it is also
necessary to evaluate the impact of the change initiative on the internal
environment (Bunea et al., 2016). According to Fischer et al. (2017), there
are three levels of situational awareness: perception of the situational
elements, comprehension of elements in the situation, and projection of their
meaning in future situations. Having awareness of the organizational level
factors that may impact change implementation is important for success (Al-
Hussami et al., 2017). Internal environment analysis should include
organizational features such as resources, capability, culture, structure, and
management style (Dyer et al., 2016).
According to Fedato et al. (2017), leaders who consider the internal
environment when implementing change are more successful. In the current
study, O2P2 reinforced this assertion and stated “one critical component that
should not be missed is the perspective of the internal situation that
influences the strategic process to a great degree.” Awareness of the internal
situation is necessary to determine the best strategic change initiative to
implement (Fedato et al., 2017). Poor situational awareness harms strategic
change implementation success (May et al., 2016). Participants in the current
study confirmed that health care leaders consider the internal environment
when developing, planning, and implementing strategic initiatives to ensure
success. O2P2 stated “any change management process that does not include
the internal perspective is poised for failure.”
Situational awareness of the internal environment helps health care
leaders plan for successful change implementation. Participants (n=3) shared
that before implementing strategic change initiatives, it is crucial to
understand the problems in the organization. O1P2 mentioned that
conducting a culture survey before change implementation provided insight
into what changes would resonate with employees. O1P1 and O2P1 reported
that without understanding the culture and people of the organization, it is
challenging to implement and sustain change.
Employing situational awareness allows for comprehensive evaluation
and sound decision-making when implementing changes (Li, Huang, Wang,
& Li, 2019). Participants in the current study engage in various activities to
increase understanding of the work environment. In Organization 2,
participants explained that before embarking on strategic change initiatives,
they develop a current state analysis to get a good sense of the current
situation and assess change readiness. Before strategic change
implementation, participants in Organization 1 conduct a similar activity that
they called process mapping. O1P1 shared that before doing process
mapping, a visit to the physical work environment is necessary.
A visit to the worksite allows leaders to learn about the work and
observe the physical environment that will be impacted by the change.
Understanding the workflows and physical layout is necessary for successful
change implementation (Mork et al., 2018). Seeing the work environment
increases leaders’ awareness of change readiness from a physical perspective
and provides insight into how the change will impact the people and
workflows. The findings of the study confirm Burton and Obel’s (2018)
finding that leaders who understand organizational readiness for change
implement specific strategies to promote success. According to Engle et al.
(2017), the actions taken by leaders while preparing for the change
implementation impact success.
Theme 2: Communication
Communication is the process of relaying messages (Koschmann,
2016). Communication is necessary for strategic change implementation
success because it is the means of sharing information about the desired state
and the steps needed to get there (Luo et al., 2016). From the thematic
analysis of the interview responses and company documents in the current
study, communication was a common theme used to ensure successful
implementation of strategic change in health care organizations. The
communication theme was mentioned 22 times throughout the interviews
(see Table 3).
Table 3
Communication References
Themes
Organization 1
Organization 2
Participant O1P1 O1P2 O2P1 O2P2
Theme 2: Communication X X X X
Participants described communication as the two-way process of
sharing information between employees and executives in the organization.
O2P1 stated “I keep my leader regularly updated….and I filter information
as it goes back to my staff.” O2P2 added “we use communication to share
the vision for the change but also to receive feedback about the change.”
Two-way communication allows for the distribution and sharing of plans
required for successful strategic change implementation (H. Ahmed, 2016).
Purposeful use of communication by an organization aids in mission
fulfillment and provides alignment between the organization’s vision and
goals (Falkheimer et al., 2016; Volk & Zerfass, 2018). All participants in the
current study agreed that purposeful communication is necessary for
successful change implementation. O2P2 reported “to be successful in
change management, the one thing leaders must do is to be clear in
communicating what the vision is.” O1P2 asserted that communicating the
values of the organization and getting others to recognize these values in
others is necessary to promote change success. Through purposeful
communication, leaders help employees make sense of the change (Kraft et
al., 2018). According to O1P1, “before embarking on a change initiative it is
vital to understand the people and the work to develop a useful
communication plan.” O1P2 stated “we help employees make sense of the
change within their context.” O2P1 also described a strategy of simplifying
and presenting the change in terms that are meaningful to employees.
Effective communication inspires trust and increases employees’
commitment to change (Appelbaum et al., 2017; Sverdrup & Stensaker,
2018). According to O2P2, “I use communication to influence individuals
within the organization to participate in the vision and feel motivated to
pursue that vision. Communication promotes transparency.” O2P1
mentioned “communication encouraged openness and realized through
frequent updates with key stakeholders about the progress of the change
project.” Two participants (O1P2, O2P2) reported that resistance is a big
barrier to change acceptance; they use communication as a tool to keep staff
informed. Uninformed staff are more resistant to change adoption (Pomare,
Churruca, Long, Ellis, & Braithwaite, 2019). O2P2 used communication to
energize people and motivate them to view the change through the lens of
the opportunities afforded by the change. People are more likely to accept
change when they can visualize personal benefits (Kuzhda, 2016). O2P1 also
added that “frequent communication helps to maintain momentum and show
that the change implementation project is a priority.”
According to Falkheimer et al. (2016), effective communication is not
a one-time event but a process of moving messages throughout a medium.
Findings confirmed that when implementing strategic change,
communication is a process that includes consideration for timing and
activities. Participants from Organization 2 provided a detailed account of
when, how, and why to communicate when embarking on a strategic change
initiative implementation. O2P2 stated, “when implementing strategic
change an initial kickoff meeting with key stakeholders is used to set
expectations early and establish priorities.” Participants shared that after the
kickoff meeting, incremental communication facilitates maintaining contact
with stakeholders. O2P1 shared “if stakeholders do not hear anything about
the project for six weeks, a month, or three months they are no longer
motivated to keep it going.” Participants agreed that communication should
be frequent, accurate, and intentional.
According to Butt et al. (2016), the chosen communication medium
must be appropriate for the message. In the current study, participants shared
that they used a combination of emails, and biweekly, and monthly tracking
meetings to facilitate mutual communication about the change. O2P2 shared
that an initial kickoff meeting provided an opportunity for all project
stakeholders to be in the same room. O2P1 added, “biweekly face-to-face
meetings provided an environment for project-level updates about project
status.” For the frontline support staff, O1P2 stated,” although opportunities
for face to face communication is encouraged, sharing information via email
is necessary because these are used as reference guides when needed.”
According to McAdam et al (2019), during strategic change implementation,
leaders should provide the opportunity to get feedback from the worksite.
O1P1 opined that “daily debrief meeting after implementing the change was
used to get input about employees’ adoption experience and address
identified issues.” According to Jones-Schenk (2017), the frequency of
communication and the quality of the information communicated determine
the change success.
Various communication tools are used by health care organizations to
implement strategic change initiatives successfully. In Organization 1, tools
mentioned were True North, A3 form, E6, communication plans, PDCA
cycle document, and newsletter. According to O1P1, ‘True North’ is a
framework used to create alignment and get everyone working in the same
direction.’ O1P1 also shared that Gemma -walks, debriefing, and meetings
are used to monitor and communicate progress. For Organization 1, the
company documents reviewed were the True North, PDCA cycle document,
and the newsletter, and I found that they supported the information shared by
participants. For Organization 2, the ‘Values board,’ the project tracker, and
project plans were tools used to facilitate communication during the change.
I reviewed the ‘Values board’ and the project tracker in this study. During
my visit to both organizations, to conduct the interviews, the True North tool
and the Values board were visibly on display in several public areas. Having
these tools on display confirmed the findings of Eriksson and Fundin (2018)
that visualization is a useful tool to communicate process change.
Theme 3: Leadership Strategies
The process of implementing change management begins at the top,
the leadership’ (Greer et al., 2017). Leaders inspire trust, which is necessary
to reduce resistance and promote change acceptance (Gigliotti et al., 2018).
In the current study, the theme of leadership was mentioned 14 times in the
current study. All participants attributed their strategic change
implementation success to the guidance provided by executive leadership
(see Table 4).
Table 4
Leadership Strategies References and Subthemes
Themes/subthemes
Organization 1
Organization 2
Participant O1P1 O1P2 O2P1 O2P2
Theme 3: Leadership
strategies Subthemes:
Executive leadership X X X X
Employee engagement X X X X
Executive leadership: Leadership is the process of influencing the
activities of an organization towards goal achievement (Levene & Higgs,
2018). Leaders set the strategic direction of the organization, which is
necessary for strategic change success (Sull et al., 2018). The findings of the
current study confirmed that leaders promote strategic change
implementation success by creating the vision, helping employees make
sense of the change, and aligning and integrating the change at the
operational level of the organization. O2P2 stated, “at the outset leadership
should be at the forefront of any change because they set the change agenda
and direction.” In Organization 1, participants overwhelmingly attributed
their change implementation success to having a visionary executive leader.
O1P2 opined, “we have a very good and supportive president, and he allows
you to fail…he is one of the best things to have in this work.” O1P2 agreed
and stated “our president is open-minded and creates a mindset that failure is
just an opportunity to reflect on what is missing and learn from that
experience.”
Participants in the current study emphasized that leaders determine the
culture of the organization, which determines change success. According to
Wisdom (2019), lack of executive engagement negatively influences change
success because they promote commitment, accountability, and involvement
in the strategic change implementation. O1P1 mentioned that engaging
executives early before embarking on a strategic change initiative and
inspiring them to buy-in to the strategy is necessary for success. O2P2
opined that it critical to have all executives onboard before embarking on
any change initiatives because strategic change affect all departments in the
organization.
Participants agreed that getting leadership involved is necessary for
strategic change implementation success because they set priority about
issues and influence diffusion of the change across all levels of the
organization. Participants were mindful that the siloed nature of health care
makes it difficult to implement change initiatives. O2P1 commented, “the
siloed nature of health care makes it difficult to implement change.” O1P1
opined, “when implementing change, some leaders may be skeptical about
the change at first, so it is critical to get them on board.”
Leaders align and integrated change in health care organizations.
Leaders must integrate change in operations and daily work because
misalignment may lead to implementation failures (Fedato et al., 2017; Ukil
& Akkas, 2017). O2P1 commented, “sometimes there is just a tremendous
amount of resistance when change is not completely aligned.” O1P2
postulated “in ensuring alignment I make the change visible and meaningful
for employees.” Leaders should create opportunities for employees to see the
change in action (Canterino et al., 2020; Higuchi et al., 2017). O1P2
implemented a “value of the month newsletter and provided opportunities to
show employees what good looks like.” According to Da Silveira et al.
(2018), a critical function of leaders during change implementation is to
propel the change among cross-functional teams across all departments in
the organization. In the current study, participants shared that leaders allow
for change diffusion by fitting any new change within the current portfolio
of work and filtering new changes through the lens of whether the change
will advance the organization’s objectives and vision.
Leaders must provide support for successful change. Leaders provide
support through the establishment of standards (Nicholas, 2016). Having a
standardized measure to support the change process is necessary for success
(Moore et al., 2017). Dyer et al. (2016) advised leaders to maintain
accountability during strategy execution. Standards also allow for the
creation of alignment and synchronization of activities (McAdam et al.,
2019). The findings of the current study supported the creation of an
accountable environment and keeping stakeholders informed and aware of
their responsibilities during strategic change implementation as necessary.
O1P2 stated, “True North helps us with setting and determining priorities.”
O1P1 added, “having a standard support structure like True North helps to
hold team members accountable for their aspect of the work.” Although
participants from Organization 2 did not mention ‘True North,’ O2P1
described a process of team-based project review with critical milestones,
and progress towards goals as the process of maintaining and ensuring
stakeholder accountability. O1P1 and O1P2 mentioned that involving
frontline staff in the creation of the measurement of success for the project
informed by the high-level standards of the organization allowed for peer-
level oversight and change implementation success.
Successful change leaders provide a flexible structure to support
change implementation (Tavare, 2017). The findings of the current study
compared to that of Karim et al. (2016), who stated that leaders must adjust
the structure of the organization to suit the strategy. In the current study,
participants from both organizations expressed that structure allowed them
to experience change implementation success. The results of the current
study confirmed the findings of Sushil (2017) that strong links promoted
change success. All participants reported that strong ties between operations
and strategy enabled successful strategic change implementation. O2P1, said
“my team reports up to the chief medical officer who oversees anything
related to patient safety across the company. I keep my leader looped in and
regularly updated, and he brings those to his boss, who is the chief medical
officer.” O1P1 stated, “leaders practice active Hoskin Kanri, during the
yearly executive retreat informed by the report on the change initiatives of
the prior year and other factors, the executives determine which key strategic
change initiatives to focus on.”
Employee engagement: According to Bhatt and Sharma (2019),
employee engagement addresses the relationship between employee
experiences and shape work and behavior within the organization. Employee
engagement is multidimensional and should include emotional, physical, and
cognitive engagement in daily work (Jia, Yan, Liu, & Huang, 2019). The
findings of the current study aligned with Joseph and Bogue (2018) that
involving frontline employees in the change process is critical to success.
O2P2 focusing on employee engagement, reiterated “the frontline has to
participate in giving input into the development of the vision. If you do not
know the perspective of the frontline, the vision that you create would be
incomplete.” Both O1P1 and O2P1 mentioned that involving employees
early, providing an environment that promotes transparency, and having
good feedback loops about implementation progress are necessary to
encourage alignment.
Leaders must build employees and organizational capacity to change
(Dyer et al., 2016). Leaders can create capacity by developing employees’
skills, letting them know how they are doing, and coaching them on how to
improve. According to Okumus et al. (2017), training is necessary for
change acceptance and skills development. The findings of the current study
supported the assertion of Thakur and Srivastava (2018) that training allows
for skills development, which is required to reduce change resistance and
increase adoption. O1P1 stated “training is necessary for knowledge
transfer.” Even when not associated with a specific change initiative, leaders
in Organization 1 routinely trained employees on Lean methodologies -
green and black belt. OIP1 opined that the more staff who understand the
work, the more people will understand the methodology and the “less my
team has to do hand-holding.”
Mentorship and coaching are other strategies used by study
participants to engage employees and increase change implementation
success. Strategic change implementation disrupts employee work-related
networks and requires them to form new ones (Lynch & Mors, 2018; Rogan
& Mors, 2017). In the current study, mentorship was a method used to
reestablish networks. In Organization 1, leaders employed a formal
mentorship program to help frontline staff understand the strategic change
methodology. According to O1P1, in addition to training, her organization
provides coaching and mentorship. O1P1 commented, “when we first started
doing the work, we hung with the team for about three months after to work
closely with them. And now, we do a lot of coaching and mentorship. The
more we get other people who understand the methodology, the less my
team has to do hand-holding because they got it.” In the current study,
during the mentoring relationship, leaders provided resources that the
organization uses to implement successful change. O1P1 shared that during
implementation, tools, and resources like the standard of work template and
audit checklist are provided to staff to help them manage change projects.
Successful leaders help employees work across organizational
boundaries and ensure that the organization’s processes and systems are in
support of the change. According to Stinglhamber, Ohana, Caesens, and
Meyer (2020) perceived organizational support is the extent to which
employees believe the organization cares about their wellbeing and values.
The results of the current study confirmed that organizational support is
necessary for the successful implementation of strategic change in health
care organizations. The findings of the current study expanded those of
Zipfel et al. (2019) that organizational support is needed at the beginning of
the implementation plan and during execution. In the current study, I found
that support is also necessary to sustain the change after initial
implementation. According to Geerligs et al. (2018), training, audits, and
feedback, and end-user involvement are supportive components necessary
for strategic change success. The findings of Geerligs et al. were replicated
in the current study but included skills development, mentorship, standards,
and structure as additional factors that influence successful change
implementation in health care.
Reflecting on the feedback from the study participants, during the
implementation of strategies, change leaders held employees accountable for
specific tasks needed to complete the change. Participants (n=3) asserted that
employees, especially at the frontline, should be involved in planning,
oversight, and shepherding the work of implementing the change. O2P2
added that the amount of engagement depends on the type of change
initiative and the job function of the stakeholder. Involving employees in all
aspects of the change create motivation and reduces resistance (Afrianty,
2020). O2P1 remarked, “people are more likely to accept change when they
can visualize personal benefits.” Miech et al. (2018) mentioned that the use
of champions is one strategy health care organizations used to effect
successful change; in the current study, most participants shared this finding.
Although all participants agreed that employee engagement is necessary for
success, one participant (O1P2) indicated that the use of frontline based
champions was not successful because of limited resources to provide
support. Findings from the current study confirmed that executive leadership
support promoted change success. These findings are similar to that of Gupta
and Rous (2016) that change implementation gains momentum through
collaboration and employee engagement.
Findings From Company Documents and Archival Records Analysis
Much of the previous discussion was about the findings derived from
the interviews except for the communication section. However, a thorough
review of the company documents submitted by the participants revealed
that they also support the findings of the study. During the interviews,
participants from Organization 1 made multiple references to True North’. A
review of the True North metrics supported the finding that situational
awareness, communication, and leadership strategies are critical strategic
change implementation success factors. The True North metrics also
demonstrated the values of the organization and showed that the
organization realize its vision through the streams of safety and quality,
patient experience, financial stewardship, and flow. Strategic change leaders
in this health care organization use the tenets of True North to understand
the current situation and ensure that change initiatives are in alignment.
The PDCA worksheet, another document reviewed, provides an in-
depth understanding of how leaders plan and execute change and used data
to determine what actions to take. The ‘values newsletter’ was also
reviewed, and this demonstrated a strong focus on employee engagement.
The values newsletter contains excerpts from various categories of staff
about their experience and provides qualitative insight in how the
organization leaders and staff make sense of the change. In Organization 2,
the values board, the project tracker, and the company website were
company documents and archival records reviewed. Similar to the ‘True
North’ in Organization 1, the ‘Value board’ is used for strategic change
prioritization. In Organization 2, people formed the center of the value
statement with integrity, excellence, inspiration, and caring as significant
tenets of the organization’s values. The project tracker revealed details of the
project stakeholders, the tasks needed to achieve the change, and the
progress, goals, and challenges.
The review of company documents and archival records from both
organizations revealed leaders provided an organizational support structure
conducive for the successful implementation of strategic change initiatives.
According to Aarons, Ehrhart, Moullin, Torres, and Green (2017),
organizational support is necessary for strategic change implementation
success. The findings of the current study, which were supported by the
company documents and archival records, reinforced the importance of
situational awareness, communication, and leadership strategies as critical to
the successful implementation of strategic change.
Findings Alignment With Conceptual Framework
The conceptual framework for this study was the composite of
Pettigrew and Whipp’s content, context, and process of change and HK or
policy deployment models. The findings of this study aligned with the
conceptual framework. The situational awareness finding, closely aligned
with Pettigrew and Whipp’s strategic change model, which highlighted the
importance of understanding the impact of environmental factors on change
implementation success. The findings of the current study supported the
assertion that leaders who are aware of the forces in the external
environment and the opportunities and limitations within the internal
environment are employing strategies to successfully implement strategic
change initiatives (Dominguez et al., 2015; Galpin, 2018). After having a
good understanding of the situation, health care leaders must develop and
implement an effective communication plan, involving stakeholders and
leaders to disseminate the change initiative within the organization. Within
the organization, leaders must provide the needed resources necessary to
facilitate successful implementation.
The findings of the study also aligned with the HK principles of the
conceptual framework. The results of the current study supported having a
specific action plan, timeline, and a feedback loop that is necessary for
successful change implementation (Friis et al., 2016; Kuhfahl et al., 2018; Li
& Xu, 2020). In the current study, participants shared details about the tools
and techniques used to engage stakeholders and lead the organization
through successful change implementation. According to Nicholas (2016),
HK helps leaders maintain focus and align the change within the
organization. Participants from both organizations described a process of
leadership aligning the change and providing feedback to top leadership to
inform further change. The current study also supported the findings of Da
Silveira et al. (2017) that HK helps leaders maintain focus and identify
competing priorities that may threaten the success of strategic change
implementation.
Applications to Professional Practice
Even though the findings of this study are not generalizable, they may
provide health care leaders with an awareness of the strategies used by some
industry leaders to implement strategic change initiatives successfully.
Health care leaders can apply the findings of this study to inform decisions
that may result in more successful implementation of strategic change
initiatives. The findings of this study included three main themes: situational
awareness, communication, and leadership strategies.
Health care organizations undergo constant changes to improve
patient outcomes and care delivery (Moussa, Garcia-Cardenas, & Benrimoj,
2019). According to Galpin (2018), organizations must execute strategies
successfully to realize anticipated value. By incorporating the findings of the
current study in strategic change implementation plans, health care leaders
may achieve more successful change initiatives necessary to maintain a
competitive advantage. The results of this study expanded the change
management literature by emphasizing the need for a holistic approach to
change implementation. This study revealed that successful healthcare
change leaders consider the internal and external environmental situations
when implementing change and contemplate the impact of organizational
support, stakeholders, and leadership involvement during change execution.
The findings of this study also provided insight into how to
communicate and integrate the strategic change initiative into the practice
setting to promote success. The study participants provided details about
how they communicated and integrated each strategic change initiative at the
operational level of the organization. Leaders who employ effective
communication systems share the vision and incorporate the change into
practice effectively (Laureani & Antony, 2017; Narayanan & Adams, 2017).
Leaders may apply the findings of the current study to modify
implementation strategies which may lead to more successful change
initiatives execution.
Implications for Social Change
The findings of this study could help health care strategic change
leaders implement more successful strategic change initiatives necessary to
improve the health and wellbeing of community members. The results of this
study might contribute to positive social change by increasing health care
change leaders’ awareness of the strategies known to influence the
successful implementation of strategic change initiatives. Health care leaders
can use the findings of the current study to inform the development of
communication plans necessary to provide clarity of purpose to maintain
accountably and reduce unnecessary stress during strategic change
implementation. According to Aslam et al. (2016), change implementation is
a stressful process that may negatively affect employees’ behavior and
productivity.
Understanding that situational awareness is necessary to inform how
to communicate, prioritize, and oversight change, health care executives
must constantly surveil the internal and external environment and develop
strategies to mitigate risks proactively. Health care leaders can use the
findings of this study to reduce inefficiencies within the health care system
by implementing solutions to increase access to care, reduce health care
disparity, and increase employment opportunities for community members.
Recommendations for Action
The findings of the current study revealed that health care strategic
change leaders who are aware of the existing organizational and
environmental situation, employ communication and leadership strategies
that results in more successful change initiatives. According to Mtebe and
Nakaka (2018), successful strategic change implementation is necessary to
reduce health care costs and patient safety concerns. Previous researchers
highlighted communication and leadership involvement as essential for
successful change implementation (Bernardo et al., 2017; Greer et al., 2017).
The findings of the current study supported those assertions but added more
details about the frequency, content, and tools necessary for effective
communication. From the leadership involvement perspective, the findings
of this study revealed that the level of leadership involvement, such as
creating and disseminating the vision, helping stakeholders to understand the
vision, and aligning and integrating the activities needed to adopt the change
are all required for success. According to Higuchi et al. (2017), leadership
involvement is necessary to sustain change. Reflecting on the findings of the
current study I recommend that before embarking on strategic initiatives
leaders must examine their level of participation because creating and
sharing the vision is not enough to sustain change.
Situational awareness was a finding of the current study that was
resounding as critical for change implementation success. Without intimate
knowledge of the internal and external situation and how this impacts the
change, implementation failure will occur (Dyer et al., 2016). Health care
organizations are complex, having various stakeholders, motivators, and
structures, it is not ideal to use the same strategy for all strategic change
implementation (Colon-Emeric et al., 2016). In the current study,
participants discussed a range of strategies used to influence success. All
participants at Organization 1 emphasized that having a visionary, flexible,
and insightful senior executive was the recipe for successful strategic change
implementation. Health care leaders must realize that although they cannot
control all conditions that may influence success, having awareness, and
being flexible to adjust to the changing environment are foundational skills
needed when implementing strategic change. Being reactive will not prevent
implementation failures.
Leadership strategies which include executive leadership and
employee engagement are additional findings of the current study that health
care leaders cannot overlook. Previous studies address stakeholder
engagement from a single perspective. For example, Bakker and Albrecht
(2018) mentioned the need for an effective bottom-up strategy to engage
employees and improve work performance. Conversely, Richter et al. (2016)
focused on leadership as necessary for successful implementation efforts.
The findings of the current study illuminated the need to engage all
stakeholders that will be impacted by the change. Organizations are social
networks and any change will have upstream and downstream effects (Lynch
& Mors, 2018; Rogan & Mors, 2017). Health care leaders cannot continue to
implement change in silos (Rydzak & Monus, 2018). The findings of the
current study demonstrated that getting all stakeholders involved was
necessary to reduce resistance and increase implementation success.
Leadership support is necessary for success (Green et al., 2017). The
findings of the current study replicated that of previous studies that lack
support and commitment from executives’ limit change implementation
success (Bernardo et al., 2017; Narikae et al., 2017). The findings of the
current study revealed that health care leaders must support employees –
through training, mentorship, and skills development activities and promote
a structure that is amicable to change adoption and implementation.
I recommend that health care leaders involved in implementing
strategic change initiatives review the findings of the current study to
understand the strategies used to increase change implementation success. I
plan to distribute the results of this study at professional conferences,
seminars, and in scholarly journals. I also plan to present the results within
my local network, using presentations and workshops. With the knowledge
that 70% of change initiatives fail during implementation, it is necessary to
share the strategies some health care leaders found essential for success.
Recommendations for Further Research
The purpose of this qualitative multiple case study was to explore the
strategies health care leaders use to implement strategic change initiatives
successfully. Recommendations for future studies include replicating this
study in different geographical locations, applying different research
methods and collecting data at different time points, and conducting this
study among different categories of workers within health care
organizations.
The limitations of this study were that it was cross-sectional,
qualitative, and involved only two health care organizations in Manhattan,
New York. Although my findings were valuable, they are not generalizable.
According to Marshall and Rossman (2016), qualitative studies are not
generalizable, but when correctly done, the results are transferable. I
recommend that more research about the problem using larger sample size,
and in a different geographic location is necessary to understand the
strategies other health care leaders are using to implement strategic change.
According to Counsell et al. (2016), quantitative studies are ideal for
showing the relationship among variables. Due to the qualitative nature of
the current study, I am unable to hypothesize if some strategies are more
predictive of success, replicating this study using a quantitative method
would have provided that insight. Situational awareness was a major theme
found in this study. Because of the finding that the situational influences
change implementation success, I recommend further research to understand
the relationship between the current situation, strategy selection, and change
implementation success.
Replicating this study using a different qualitative method may have
yielded mixed results. In this study, I collected data at one-time point. I
recommend a longitudinal study to understand whether data collection time
would impact the study findings. Finally, the target population for this study
was health care leaders directly involved in the change implementation
process. I recommend that further research among other health care
stakeholders who were impacted by the change as this may reveal other
themes necessary for change implementation success.
Reflections
Being a registered nurse for over 20 years, I have a good
understanding of the opportunities and challenges within health care from
the perspectives of a clinical professional. According to Keehan et al.
(2017), without strategic change, health care costs will continue to rise.
Feeling helpless about the health care cost predictions and recognizing a
knowledge deficit about health care as a business, I decided to embark on
this program of study. During this journey, I gained extensive knowledge
about business concepts and how to apply them to solve health care
problems. The need for strategic change in health care resonated with me
throughout the program and formed the basis of my final research project.
During the DBA Doctoral Study process, my specific problem
statement changed several times. After several attempts at crafting the ideal
business problem statement, I zoomed in on strategic change
implementation, then absorbed myself in the literature to understand the
current trends. I knew that change projects sometimes fail but did not
understand the extent to which these failures occurred. During this study, I
gained indepth knowledge about the strategies successful health care leaders
are using to implement change.
Throughout this process, I developed personally and professionally. I
developed perseverance and tenacity, a skillset that will last a lifetime. On
this journey, I realized that I work best in the early morning hours before
daybreak and that feedbacks are necessary for growth and improvement.
Professionally, I learned that acknowledging personal biases, using
triangulation, and staying close to the data are ways to provide credible
evidence. I became aware that asking the right questions is necessary for
understanding the problem. My critical thinking skills and ability to examine
concepts from various perspectives also improved. As I aspire to become a
senior leader in health care, I will apply these new insights into my daily
practice to inform decision making.
Conclusion
Health care organizations must implement strategic change initiatives
to remain viable and competitive. The purpose of this multiple qualitative
case study was to understand the strategies health care leaders use to
implement strategic change initiatives successfully. The findings of this
study confirmed that implementing strategic change initiatives guided by the
composite of Pettigrew and Whipp’s content, content, and process of change
model and HK program deployment model may help health care leaders
implement more successful strategic change initiatives.
During data analysis, three themes emerged as necessary for change
implementation success in health care. These themes are situational
awareness, communication, and leadership strategies. The findings of this
study may help strategic change leaders select, prioritize, communicate,
implement, and monitor strategic change initiatives appropriately to increase
implementation success. Health care leaders who adopt specific strategies to
improve communication, engage employees, and provide an environment
supportive of the change are more successful at executing change initiatives
necessary to improve the living conditions of health care consumers.
