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A comparative study on 2015 and 2023 chennai flooding: a multifactorial perspective.

1. Introduction

2. study area, 3. materials and methods, 3.1. materials, 3.2. methodology, 4.1. rainfall analysis, 4.2. spatial mapping of flood, 4.3. integrated reservoir study for flood events, 4.4. study of cyclone activities and tidal wave heights during the flood event, 4.5. effects of enso/iod on northeast monsoon, 5. discussion, 6. conclusions, supplementary materials, author contributions, data availability statement, conflicts of interest.

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Radhakrishnan, S.; Duraisamy Rajasekaran, S.K.; Sujatha, E.R.; Neelakantan, T.R. A Comparative Study on 2015 and 2023 Chennai Flooding: A Multifactorial Perspective. Water 2024 , 16 , 2477. https://doi.org/10.3390/w16172477

Radhakrishnan S, Duraisamy Rajasekaran SK, Sujatha ER, Neelakantan TR. A Comparative Study on 2015 and 2023 Chennai Flooding: A Multifactorial Perspective. Water . 2024; 16(17):2477. https://doi.org/10.3390/w16172477

Radhakrishnan, Selvakumar, Sakthi Kiran Duraisamy Rajasekaran, Evangelin Ramani Sujatha, and T. R. Neelakantan. 2024. "A Comparative Study on 2015 and 2023 Chennai Flooding: A Multifactorial Perspective" Water 16, no. 17: 2477. https://doi.org/10.3390/w16172477

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Change Management: From Theory to Practice

Jeffrey phillips.

1 University Libraries, Florida State University, 116 Honors Way, Tallahassee, FL 32306 USA

James D. Klein

2 Department of Educational Psychology & Learning Systems, College of Education, Florida State University, Stone Building-3205F, Tallahassee, FL 32306-4453 USA

This article presents a set of change management strategies found across several models and frameworks and identifies how frequently change management practitioners implement these strategies in practice. We searched the literature to identify 15 common strategies found in 16 different change management models and frameworks. We also created a questionnaire based on the literature and distributed it to change management practitioners. Findings suggest that strategies related to communication, stakeholder involvement, encouragement, organizational culture, vision, and mission should be used when implementing organizational change.

Organizations must change to survive. There are many approaches to influence change; these differences require change managers to consider various strategies that increase acceptance and reduce barriers. A change manager is responsible for planning, developing, leading, evaluating, assessing, supporting, and sustaining a change implementation. Change management consists of models and strategies to help employees accept new organizational developments.

Change management practitioners and academic researchers view organizational change differently (Hughes, 2007 ; Pollack & Pollack, 2015 ). Saka ( 2003 ) states, “there is a gap between what the rational-linear change management approach prescribes and what change agents do” (p. 483). This disconnect may make it difficult to determine the suitability and appropriateness of using different techniques to promote change (Pollack & Pollack, 2015 ). Hughes ( 2007 ) thinks that practitioners and academics may have trouble communicating because they use different terms. Whereas academics use the terms, models, theories, and concepts, practitioners use tools and techniques. A tool is a stand-alone application, and a technique is an integrated approach (Dale & McQuater, 1998 ). Hughes ( 2007 ) expresses that classifying change management tools and techniques can help academics identify what practitioners do in the field and evaluate the effectiveness of practitioners’ implementations.

There is little empirical evidence that supports a preferred change management model (Hallencreutz & Turner, 2011 ). However, there are many similar strategies found across change management models (Raineri, 2011 ). Bamford and Forrester’s ( 2003 ) case study showed that “[change] managers in a company generally ignored the popular change literature” (p. 560). The authors followed Pettigrew’s ( 1987 ) suggestions that change managers should not use abstract theories; instead, they should relate change theories to the context of the change. Neves’ ( 2009 ) exploratory factor analysis of employees experiencing the implementation of a new performance appraisal system at a public university suggested that (a) change appropriateness (if the employee felt the change was beneficial to the organization) was positively related with affective commitment (how much the employee liked their job), and (b) affective commitment mediated the relationship between change appropriateness and individual change (how much the employee shifted to the new system). It is unlikely that there is a universal change management approach that works in all settings (Saka, 2003 ). Because change is chaotic, one specific model or framework may not be useful in multiple contexts (Buchanan & Boddy, 1992 ; Pettigrew & Whipp, 1991 ). This requires change managers to consider various approaches for different implementations (Pettigrew, 1987 ). Change managers may face uncertainties that cannot be addressed by a planned sequence of steps (Carnall, 2007 ; Pettigrew & Whipp, 1991 ). Different stakeholders within an organization may complete steps at different times (Pollack & Pollack, 2015 ). Although there may not be one perspective change management approach, many models and frameworks consist of similar change management strategies.

Anderson and Ackerman Anderson ( 2001 ) discuss the differences between change frameworks and change process models. They state that a change framework identifies topics that are relevant to the change and explains the procedures that organizations should acknowledge during the change. However, the framework does not provide details about how to accomplish the steps of the change or the sequence in which the change manager should perform the steps. Additionally, Anderson and Ackerman Anderson ( 2001 ) explain that change process models describe what actions are necessary to accomplish the change and the order in which to facilitate the actions. Whereas frameworks may identify variables or theories required to promote change, models focus on the specific processes that lead to change. Based on the literature, we define a change strategy as a process or action from a model or framework. Multiple models and frameworks contain similar strategies. Change managers use models and frameworks contextually; some change management strategies may be used across numerous models and frameworks.

The purpose of this article is to present a common set of change management strategies found across numerous models and frameworks and identify how frequently change management practitioners implement these common strategies in practice. We also compare current practice with models and frameworks from the literature. Some change management models and frameworks have been around for decades and others are more recent. This comparison may assist practitioners and theorists to consider different strategies that fall outside a specific model.

Common Strategies in the Change Management Literature

We examined highly-cited publications ( n  > 1000 citations) from the last 20 years, business websites, and university websites to select organizational change management models and frameworks. First, we searched two indexes—Google Scholar and Web of Science’s Social Science Citation Index. We used the following keywords in both indexes: “change management” OR “organizational change” OR “organizational development” AND (models or frameworks). Additionally, we used the same search terms in a Google search to identify models mentioned on university and business websites. This helped us identify change management models that had less presence in popular research. We only included models and frameworks from our search results that were mentioned on multiple websites. We reached saturation when multiple publications stopped identifying new models and frameworks.

After we identified the models and frameworks, we analyzed the original publications by the authors to identify observable strategies included in the models and frameworks. We coded the strategies by comparing new strategies with our previously coded strategies, and we combined similar strategies or created a new strategy. Our list of strategies was not exhaustive, but we included the most common strategies found in the publications. Finally, we omitted publications that did not provide details about the change management strategies. Although many of these publications were highly cited and identified change implementation processes or phases, the authors did not identify a specific strategy.

Table ​ Table1 1 shows the 16 models and frameworks that we analyzed and the 15 common strategies that we identified from this analysis. Ackerman-Anderson and Anderson ( 2001 ) believe that it is important for process models to consider organizational imperatives as well as human dynamics and needs. Therefore, the list of strategies considers organizational imperatives such as create a vision for the change that aligns with the organization’s mission and strategies regarding human dynamics and needs such as listen to employees’ concerns about the change. We have presented the strategies in order of how frequently the strategies appear in the models and frameworks. Table ​ Table1 1 only includes strategies found in at least six of the models or frameworks.

Common strategies in the change management literature

A = ADKAR (Hiatt, 2006 ); AA = Ackerman Anderson and Anderson ( 2001 ); B = Bridges ( 1991 ); BB = Buchanan and Boddy ( 1992 ); BH = Beckhard and Harris ( 1987 ); C = Carnall ( 2007 ); CW = Cummings and Worley ( 1993 ); FB = French and Bell ( 1999 ); GE = GE CAP model (Neri et al., 2008 ; Polk, 2011 ); K = Kotter ( 2012 ); KSJ = Kanter et al. ( 1992 ); L = Lewin’s Three-step model (Bakari et al., 2017 ; Lewin, 1951 ); LK = Luecke ( 2003 ); M = McKinsey’s 7-S framework (Cox et al., 2019 ; Waterman et al., 1980 ); N = Nadler and Tushman ( 1997 ); PW = Pettigrew and Whipp (1993)

Strategies Used by Change Managers

We developed an online questionnaire to determine how frequently change managers used the strategies identified in our review of the literature. The Qualtrics-hosted survey consisted of 28 questions including sliding-scale, multiple-choice, and Likert-type items. Demographic questions focused on (a) how long the participant had been involved in the practice of change management, (b) how many change projects the participant had led, (c) the types of industries in which the participant led change implementations, (d) what percentage of job responsibilities involved working as a change manager and a project manager, and (e) where the participant learned to conduct change management. Twenty-one Likert-type items asked how often the participant used the strategies identified by our review of common change management models and frameworks. Participants could select never, sometimes, most of the time, and always. The Cronbach’s Alpha of the Likert-scale questions was 0.86.

The procedures for the questionnaire followed the steps suggested by Gall et al. ( 2003 ). The first steps were to define the research objectives, select the sample, and design the questionnaire format. The fourth step was to pretest the questionnaire. We conducted cognitive laboratory interviews by sending the questionnaire and interview questions to one person who was in the field of change management, one person who was in the field of performance improvement, and one person who was in the field of survey development (Fowler, 2014 ). We met with the reviewers through Zoom to evaluate the questionnaire by asking them to read the directions and each item for clarity. Then, reviewers were directed to point out mistakes or areas of confusion. Having multiple people review the survey instruments improved the reliability of the responses (Fowler, 2014 ).

We used purposeful sampling to distribute the online questionnaire throughout the following organizations: the Association for Talent Development (ATD), Change Management Institute (CMI), and the International Society for Performance Improvement (ISPI). We also launched a call for participation to department chairs of United States universities who had Instructional Systems Design graduate programs with a focus on Performance Improvement. We used snowball sampling to gain participants by requesting that the department chairs forward the questionnaire to practitioners who had led at least one organizational change.

Table ​ Table2 2 provides a summary of the characteristics of the 49 participants who completed the questionnaire. Most had over ten years of experience practicing change management ( n  = 37) and had completed over ten change projects ( n  = 32). The participants learned how to conduct change management on-the-job ( n  = 47), through books ( n  = 31), through academic journal articles ( n  = 22), and from college or university courses ( n  = 20). The participants had worked in 13 different industries.

Characteristics of participants

( n  = 49)

Table ​ Table3 3 shows how frequently participants indicated that they used the change management strategies included on the questionnaire. Forty or more participants said they used the following strategies most often or always: (1) Asked members of senior leadership to support the change; (2) Listened to managers’ concerns about the change; (3) Aligned an intended change with an organization’s mission; (4) Listened to employees’ concerns about the change; (5) Aligned an intended change with an organization’s vision; (6) Created measurable short-term goals; (7) Asked managers for feedback to improve the change, and (8) Focused on organizational culture.

Strategies used by change managers

Table ​ Table4 4 identifies how frequently the strategies appeared in the models and frameworks and the rate at which practitioners indicated they used the strategies most often or always. The strategies found in the top 25% of both ( n  > 36 for practitioner use and n  > 11 in models and frameworks) focused on communication, including senior leadership and the employees in change decisions, aligning the change with the vision and mission of the organization, and focusing on organizational culture. Practitioners used several strategies more commonly than the literature suggested, especially concerning the topic of middle management. Practitioners focused on listening to middle managers’ concerns about the change, asking managers for feedback to improve the change, and ensuring that managers were trained to promote the change. Meanwhile, practitioners did not engage in the following strategies as often as the models and frameworks suggested that they should: provide all members of the organization with clear communication about the change, distinguish the differences between leadership and management, reward new behavior, and include employees in change decisions.

A comparison of the strategies used by practitioners to the strategies found in the literature

Common Strategies Used by Practitioners and Found in the Literature

The purpose of this article was to present a common set of change management strategies found across numerous models and frameworks and to identify how frequently change management practitioners implement these common strategies in practice. The five common change management strategies were the following: communicate about the change, involve stakeholders at all levels of the organization, focus on organizational culture, consider the organization’s mission and vision, and provide encouragement and incentives to change. Below we discuss our findings with an eye toward presenting a few key recommendations for change management.

Communicate About the Change

Communication is an umbrella term that can include messaging, networking, and negotiating (Buchanan & Boddy, 1992 ). Our findings revealed that communication is essential for change management. All the models and frameworks we examined suggested that change managers should provide members of the organization with clear communication about the change. It is interesting that approximately 33% of questionnaire respondents indicated that they sometimes, rather than always or most of the time, notified all members of the organization about the change. This may be the result of change managers communicating through organizational leaders. Instead of communicating directly with everyone in the organization, some participants may have used senior leadership, middle management, or subgroups to communicate the change. Messages sent to employees from leaders can effectively promote change. Regardless of who is responsible for communication, someone in the organization should explain why the change is happening (Connor et al., 2003 ; Doyle & Brady, 2018 ; Hiatt, 2006 ; Kotter, 2012 ) and provide clear communication throughout the entire change implementation (McKinsey & Company, 2008 ; Mento et al., 2002 ).

Involve Stakeholders at All Levels of the Organization

Our results indicate that change managers should involve senior leaders, managers, as well as employees during a change initiative. The items on the questionnaire were based on a review of common change management models and frameworks and many related to some form of stakeholder involvement. Of these strategies, over half were used often by 50% or more respondents. They focused on actions like gaining support from leaders, listening to and getting feedback from managers and employees, and adjusting strategies based on stakeholder input.

Whereas the models and frameworks often identified strategies regarding senior leadership and employees, it is interesting that questionnaire respondents indicated that they often implemented strategies involving middle management in a change implementation. This aligns with Bamford and Forrester’s ( 2003 ) research describing how middle managers are important communicators of change and provide an organization with the direction for the change. However, the participants did not develop managers into leaders as often as the literature proposed. Burnes and By ( 2012 ) expressed that leadership is essential to promote change and mention how the change management field has failed to focus on leadership as much as it should.

Focus on Organizational Culture

All but one of the models and frameworks we analyzed indicated that change managers should focus on changing the culture of an organization and more than 75% of questionnaire respondents revealed that they implemented this strategy always or most of the time. Organizational culture affects the acceptance of change. Changing the organizational culture can prevent employees from returning to the previous status quo (Bullock & Batten, 1985 ; Kotter, 2012 ; Mento et al., 2002 ). Some authors have different views on how to change an organization’s culture. For example, Burnes ( 2000 ) thinks that change managers should focus on employees who were resistant to the change while Hiatt ( 2006 ) suggests that change managers should replicate what strategies they used in the past to change the culture. Change managers require open support and commitment from managers to lead a culture change (Phillips, 2021 ).

In addition, Pless and Maak ( 2004 ) describe the importance of creating a culture of inclusion where diverse viewpoints help an organization reach its organizational objectives. Yet less than half of the participants indicated that they often focused on diversity, equity, and inclusion (DEI). Change managers should consider diverse viewpoints when implementing change, especially for organizations whose vision promotes a diverse and inclusive workforce.

Consider the Organization’s Mission and Vision

Several of the models and frameworks we examined mentioned that change managers should consider the mission and vision of the organization (Cummings & Worley, 1993 ; Hiatt, 2006 ; Kotter, 2012 ; Polk, 2011 ). Furthermore, aligning the change with the organization’s mission and vision were among the strategies most often implemented by participants. This was the second most common strategy both used by participants and found in the models and frameworks. A mission of an organization may include its beliefs, values, priorities, strengths, and desired public image (Cummings & Worley, 1993 ). Leaders are expected to adhere to a company’s values and mission (Strebel, 1996 ).

Provide Encouragement and Incentives to Change

Most of the change management models and frameworks suggested that organizations should reward new behavior, yet most respondents said they did not provide incentives to change. About 75% of participants did indicate that they frequently gave encouragement to employees about the change. The questionnaire may have confused participants by suggesting that they provide incentives before the change occurs. Additionally, respondents may have associated incentives with monetary compensation. Employee training can be considered an incentive, and many participants confirmed that they provided employees and managers with training. More information is needed to determine why the participants did not provide incentives and what the participants defined as rewards.

Future Conversations Between Practitioners and Researchers

Table ​ Table4 4 identified five strategies that practitioners used more often than the models and frameworks suggested and four strategies that were suggested more often by the models and frameworks than used by practitioners. One strategy that showed the largest difference was provided employees with incentives to implement the change. Although 81% of the selected models and frameworks suggested that practitioners should provide employees with incentives, only 25% of the practitioners identified that they provided incentives always and most of the time. Conversations between theorists and practitioners could determine if these differences occur because each group uses different terms (Hughes, 2007 ) or if practitioners just implement change differently than theorists suggest (Saka, 2003 ).

Additionally, conversations between theorists and practitioners may help promote improvements in the field of change management. For example, practitioners were split on how often they promoted DEI, and the selected models and frameworks did not focus on DEI in change implementations. Conversations between the two groups would help theorists understand what practitioners are doing to advance the field of change management. These conversations may encourage theorists to modify their models and frameworks to include modern approaches to change.

Limitations

The models and frameworks included in this systematic review were found through academic research and websites on the topic of change management. We did not include strategies contained on websites from change management organizations. Therefore, the identified strategies could skew towards approaches favored by theorists instead of practitioners. Additionally, we used specific publications to identify the strategies found in the models and frameworks. Any amendments to the cited models or frameworks found in future publications could not be included in this research.

We distributed this questionnaire in August 2020. Several participants mentioned that they were not currently conducting change management implementations because of global lockdowns due to the COVID-19 pandemic. Because it can take years to complete a change management implementation (Phillips, 2021 ), this research does not describe how COVID-19 altered the strategies used by the participants. Furthermore, participants were not provided with definitions of the strategies. Their interpretations of the strategies may differ from the definitions found in the academic literature.

Future Research

Future research should expand upon what strategies the practitioners use to determine (a) how the practitioners use the strategies, and (b) the reasons why practitioners use certain strategies. Participants identified several strategies that they did not use as often as the literature suggested (e.g., provide employees with incentives and adjust the change implementation because of reactions from employees). Future research should investigate why practitioners are not implementing these strategies often.

Additionally, the COVID-19 pandemic may have changed how practitioners implemented change management strategies. Future research should investigate if practitioners have added new strategies or changed the frequency in which they identified using the strategies found in this research.

Our aim was to identify a common set of change management strategies found across several models and frameworks and to identify how frequently change management practitioners implement these strategies in practice. While our findings relate to specific models, frameworks, and strategies, we caution readers to consider the environment and situation where the change will occur. Therefore, strategies should not be selected for implementation based on their inclusion in highly cited models and frameworks. Our study identified strategies found in the literature and used by change managers, but it does not predict that specific strategies are more likely to promote a successful organizational change. Although we have presented several strategies, we do not suggest combining these strategies to create a new framework. Instead, these strategies should be used to promote conversation between practitioners and theorists. Additionally, we do not suggest that one model or framework is superior to others because it contains more strategies currently used by practitioners. Evaluating the effectiveness of a model or framework by how many common strategies it contains gives an advantage to models and frameworks that contain the most strategies. Instead, this research identifies what practitioners are doing in the field to steer change management literature towards the strategies that are most used to promote change.

Declarations

This research does not represent conflicting interests or competing interests. The research was not funded by an outside agency and does not represent the interests of an outside party.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Jeffrey Phillips, Email: ude.usf@spillihpbj .

James D. Klein, Email: ude.usf@nielkj .

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A Change Management Case Study for Safe Opioid Prescribing and Opioid Use Disorder Treatment

Affiliations.

• 1 From Tufts University School of Medicine, Boston, MA (RS, AFS); Department of Psychiatry, Harvard Medical School, Boston, MA (ZS-O); Harvard Medical School, Boston, MA (MB); Malden Family Medicine Center, Cambridge Health Alliance, Malden, MA (LS, RS, AFS).
• 2 From Tufts University School of Medicine, Boston, MA (RS, AFS); Department of Psychiatry, Harvard Medical School, Boston, MA (ZS-O); Harvard Medical School, Boston, MA (MB); Malden Family Medicine Center, Cambridge Health Alliance, Malden, MA (LS, RS, AFS). [email protected].
• PMID: 31907254
• DOI: 10.3122/jabfm.2020.01.190223

Background: Given that prescribing practices have contributed to the current opioid epidemic and that primary care clinicians are the largest prescribers of opioids, family physicians must consider the twin goals of safely prescribing opioids for patients with chronic pain while effectively identifying and treating those who have developed opioid use disorder (OUD). However, family physicians may feel constrained by a culture and systems in their offices that do not support achieving these twin goals.

Methods: In a family medicine clinic within a larger academic institution that cares for an underserved, multicultural patient population in the greater Boston area, we provide a case study that illustrates the twin goals of safe opioid prescribing and treating OUD. We used 2 models of change management-Lewin's Three-Step Change Theory and the McKinsey 7S Model of Change-as a framework to describe our 5-year process of using cultural and structural elements to support these efforts.

Results: Deliberate use of change management theory to support both safe opioid prescribing and treating patients with OUD over the past 5 years resulted in changes to the practices, people, skills, and infrastructure within our clinic. These changes have demonstrated a sense of stability and sustainability and hence now represent our clinic's current culture.

Conclusion: The Lewin and 7S models of change can be helpful guides to creating and maintaining a foundation of office-wide culture and structural support to meet the twin goals of safe opioid prescribing and treating patients with OUD.

Keywords: Addictive Behavior; Boston; Chronic Pain; Family Physicians; Opioid-Related Disorders; Opioids; Pain Management; Patient-Centered Care; Primary Health Care; Quality Improvement.

© Copyright 2020 by the American Board of Family Medicine.

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Conflict of interest statement

Conflict of interest: none declared.

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Case study: examining failure in change management

Journal of Organizational Change Management

ISSN : 0953-4814

Article publication date: 21 February 2020

Issue publication date: 22 April 2020

This case study aims to shed light on what went wrong with the introduction of new surgical suture in a Dutch hospital operating theatre following a tender. Transition to working with new surgical suture was organized in accordance with legal and contractual provisions, and basic principles of change management were applied, but resistance from surgeons led to cancellation of supplies of the new suture.

Design/methodology/approach

Researchers had access to all documents relevant to the tendering procedure and crucial correspondence between stakeholders. Seventeen in-depth, 1 h interviews were conducted with key informants who were targeted through maximum variation sampling. Patients were not interviewed. The interviews were recorded, transcribed and analysed by discourse analysis. A trial session and workshop were participatively observed. A cultural psychological perspective was adopted to gain an understanding of why certain practices appear to be resistant to change.

For the cardiothoracic surgeons, suture was more than just stitching material. Suture as a tactile element in their day-to-day work environment is embedded within a social arrangement that ties elements of professional accountability, risk avoidance and direct patient care together in a way that makes sense and feels secure. This arrangement is not to be fumbled with by outsiders.

Practical implications

By understanding the practical and emotional stakes that medical professionals have in their work, lessons can be learned to prevent failure of future change initiatives.

Originality/value

The cultural psychological perspective adopted in this study has never been applied to understanding failed change in a hospital setting.

• Operating theatre
• Cultural psychological perspective
• Failed change
• Surgical suture

Graamans, E. , Aij, K. , Vonk, A. and ten Have, W. (2020), "Case study: examining failure in change management", Journal of Organizational Change Management , Vol. 33 No. 2, pp. 319-330. https://doi.org/10.1108/JOCM-06-2019-0204

Emerald Publishing Limited

Copyright © 2020, Ernst Graamans, Kjeld Aij, Alexander Vonk and Wouter ten Have

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode .

Introduction

In the Netherlands, and more broadly in Europe, the cost of health care is rising and is expected to continue to rise ( Jenkner and Leive, 2010 ; Mot et al. , 2016 ). In light of this development, the challenge for those managing healthcare institutions is to spend smartly and cut costs where possible, while at the same time meeting changing patient demands (e.g. Dent and Pahor, 2015 ; Thistlethwaite and Spencer, 2008 ). The fact that managing the work and practices of medical professionals has always been difficult (e.g. Andri and Kyriakidou, 2014 ; Kennerley, 1993 ; Kirkpatrick et al. , 2005 ) adds to the complexity of meeting this challenge. Furthermore, health workers increasingly are held accountable for and are expected to be transparent about the outcomes of their work (e.g. Exworthy et al. , 2019 ; Genovese et al. , 2017 ). Although this trend is generally expected to lead to improved results, for medical professionals it also creates a sense of being under constant scrutiny. The emotions and feelings that are triggered in these kinds of processes have a substantial impact, which is acknowledged by both management practitioners and social scientists working in health care (e.g. Kent, 2006 ; Mark, 2005 ; Sebrant, 2014 ). In this case study, emotions and feelings are addressed by adopting a specific cultural psychological perspective. Cultural psychologists Paul Voestermans and Theo Verheggen (2013) call for more detailed psychological investigations into how people acquire embodied skills and mannerisms that are in line with professional demands, preferences and tastes. When emotions and feelings are felt or displayed, this is seen as an indication that something “real” is at stake that deeply involves professionals into their group, department or speciality. This paper demonstrates that this deep involvement can affect the success or failure of a change initiative, in this case the introduction of new surgical suture material in the operating theatre. This affective aspect may be underestimated in change management or only addressed in rather abstract fashion; by prematurely explaining resistance to change with the help of notions as professional autonomy, entitlement, stubbornness, culture and so on. The epistemological problem of discursively turning a descriptive label into an explanation or operational determinant of behaviour has been addressed particularly by discursive psychologists (e.g. Potter and Wetherell, 1987 , 1995a ) and cultural psychologists (e.g. Valsiner, 2014 ; Verheggen, 2005 ; Verheggen and Baerveldt, 2007 ). Although the concerns in this paper are practical and empirical, they can be traced back to the same problem. In management practice, and especially in the management of medical professionals, certain abstract characterizations of behaviour and change resistance can become problematic when they are no longer just employed as general, imprecise descriptions, but are reified and employed as stopgaps. As such, they preclude deeper and more detailed investigations into what is at stake for the people behind these abstractions. The added value of the approach adopted in this case study is that it does not need the reification and superimposition of notions such as shared values, culture or even professional autonomy, but allows for more holistic, or contextualized investigations into the social patterning of behaviour within professional groups or specialities. Truly delving into the tenacity of certain medical professional practices goes further than positing professional autonomy or entitlement as a cause, for instance. Earlier, this particular cultural psychological approach has successfully been adopted to describe psychological dynamics within the boardroom of a large healthcare organization ( Graamans et al. , 2014 ) and, more recently, to better understand and contribute to more effective interventions against the culturally embedded practice of female circumcision ( Graamans et al. , 2019a , 2019b ).

The case: resistance to new surgical suture in the operating theatre of a Dutch hospital

At the end of 2014, a large university hospital in the Netherlands launched a procurement tender exercise for surgical suture material. The rationale for hospital management to initiate this procedure was cost-cutting and standardization. The award criteria were focussed on the most economically advantageous tender. There were different suppliers on the market that were able to produce and deliver high-quality surgical suture material for a lower price than was currently being paid. Consequently, the tender was awarded to a new supplier. The top managers and purchasing manager who initiated the tender trod carefully and implemented this relatively small-scale change initiative according to some basic change management principles (e.g. Kotter, 2012 ): they built a guiding coalition that incorporated renowned medical specialists, they consulted department heads and they communicated the change to surgeons through different channels. Furthermore, it was recorded in the tender that the new supplier should provide value-adding services such as e-learning modules for surgeons, facilitate lengthy trial-use periods and offer workshops and support to the operating theatre. Hospital management conceived this first initiative as a test case for more extensive cost-cutting operations that were to follow. This project was supposed to be relatively easy, both in scale and in complexity. However, in the preparations ahead of the trial phase, a concern was raised by the cardiac surgeons to one part of the tender package involving sutures specifically used for cardiac surgery. Nevertheless, surgeons were forced to participate in testing the products supplied in the whole tender, including those products used in their specific specialities. Meanwhile, the initiators of the project felt that careful preparations of the testing phase had been made.

So, what went wrong? In mid-2015 – when this research project started – hospital management eventually met with fierce resistance from some of the hospital's cardiothoracic surgeons. They adamantly refused to work with the new suture material. The resistance took the form of surgeons expressing anger at management, stockpiling their own supplies of surgical suture, refusing to operate, holding managers accountable for patient deaths that could arise from use of the new suture and threatening to go to the press if such a thing indeed were to happen. Hospital management had anticipated some resistance, but not of this intensity. The end result was that the contract was eventually cancelled for sutures specifically used in cardiac surgery.

This research paper sets out to answer the following question: why are some medical professional practices so difficult to change, and what can we learn from this failed test case?

Theoretical background

As mentioned earlier, to better understand the entrenched nature of professional practices and the emotional stakes involved, we adopted a particular cultural psychological perspective. Following Voestermans' and Verheggen's approach ( 2013 ), we explicitly take the position that people are embodied and expressive beings who over time attune their emotions, feelings, preferences and tastes to the groups they belong to. People naturally feel more compelled to act in accordance with these preferences than to act upon abstract ideas, rules and protocols superimposed upon them from outside their group. Evidently, medical professionals are not exempt from feeling more compelled to act in accordance with these preferences just because they are a highly educated group of people. To the contrary, as a result of being members of their professional group for so long – through medical school, surgical residency, PhD studies and so on – they have learned to coordinate their actions on the basis of complex sets of agreements, conventions and arrangements that characterize their professional group.

Whereas agreements are easy to articulate, such as taking an oath, Voestermans and Verheggen (2013) reserve the term “arrangement” for the way members of exclusive and often elite groups coordinate their behaviour almost automatically within their own specifically cultivated environments, following deeply embodied patterns. These patterns and practices are group-typical due to the mutual attunement of emotions, feelings, preferences and taste that has taken place over time. The resulting automaticity makes that they do not need articulation, whereas practices based on agreements do. Evidently, medical professionals have practices founded on highly specialized scholarship and evidence-based research. But it is a mistake to think of their work as a purely cognitive, rather mechanistic affair. These practices are enacted and reenacted in the minutest interactions on an ongoing basis, and get more refined over time, until at one point they are felt and experienced more than that they are talked about . It is predicted that groups formed on the basis of such arrangements are particularly difficult to change. The apprehension that is triggered by attempts to change even the smallest element of such an arrangement is immediately felt.

Data collection

Data collection took place in a year starting from mid-2015. In total, 17 in-depth interviews were conducted that each lasted approximately 1 h. The respondents were targeted through maximum variation sampling until saturation was achieved and are listed in Table I . Patients were excluded beforehand. The interviews were audio-recorded after verbal consent was given. All but one interviewee agreed to be audio-recorded. This interviewee was comfortable, though, with the interviewer (EG) taking notes. The interviews were transcribed and anonymized. Apart from formal interviewing, extensive informal conversations on the topic took place with surgeons from different medical specialities.

Field notes were made on the observations of a trial session and a workshop facilitated by the new supplier. These notes were divided into four categories: observational notes, theoretical notes, methodological notes and reflective notes ( Baarda et al. , 2013 ).

Data analysis

To gain an understanding of the different positions people can take up in relation to the introduction of new surgical suture and underlying social arrangements, the interview transcripts were analysed by means of discourse analysis following the example and guidelines of critical psychologist Carla Willig (1998 , 2008) . Her particular approach to discourse analysis was chosen because it allows for a discursive psychological reading of the interview transcripts whereby interviewees as active agents justify, blame, excuse, request or obfuscate to achieve some objective: the “action orientation” of talking ( Edwards and Potter, 1992 , 2001 ; Potter and Wetherell, 1995b ). Her approach also allows for a more Foucauldian, or post-structuralist reading whereby inferences are made on how the discourses interviewees draw upon delimit and facilitate behavioural opportunities and experience ( Davies and Harré, 1990 , 1999 ; Henriques et al. , 1984 ; Parker, 1992 ). The latter approach assumes that discourses, on the one hand, and practices, on the other, are closely tied and reinforce each other. Discourse from this perspective is not so much a matter of talking about things, but is conceived as an expressive practice in itself. Conceptualized as such discourses can hint at underlying social arrangements in which certain practices, such as operating with tangible surgical suture material, are performed. To come to such a conclusion with a greater amount of certainty, we contend, the inferences made on the basis of discourse analysis must always be triangulated with data from participant observations and cross-checked with key informants.

In October 2017, the findings were tentatively fed back to the management board in a plenary session and to department heads in several individual conversations. Extensive peer debriefing sessions within our multi-disciplinary research team in which both the medical professional and managerial perspectives were represented by its members took place to help with cross-checking and interpreting the data.

Conducting discourse analysis ( Willig, 2008 ) on the interview transcripts revealed several discourses that interviewees drew upon when they talked about the transition to working with the new surgical suture and surgical suture more generally. The main constructions, discourses and implications in relation to the interviewees themselves – in discourse analytic terms called “subject positions” – are summarized in Table II .

Economic/managerial discourse

We are confronted with an enormous challenge. We have to drastically cut costs. This was an important test case, because more and bigger cuts are pending. This appeared to us as an easy win. However, … [1] . (Head of operating theatres)

Not only with surgical suture, but in general medical specialists resist change. That is because these suppliers have a powerful and very effective sales force. It is what we call vendor lock-in . (Purchasing manager)

I get that those boys [cardiothoracic surgeons] … what they are doing is very precise and technical. And surgical suture and needles are of crucial importance. On the other hand, there are always these sentiments. I mean, there are many medical centres, also abroad, where cardiothoracic surgeons suture with XXX [brand name of new supplier] and it is not turned into a complicated affair. But you cannot take away these sentiments just like that. We took note of these feelings, and nudged our staff to give it [the new surgical suture] a try and comply as much as possible. But to be honest, according to me at cardiac surgery there is a lot of emotion involved surrounding suture, … and it is not working for me. (Department head, surgery)

The initiator – the manager that came up with the idea to supposedly cut costs – does not know that suture curls and curls more-or-less depending on the brand. He does not know whether needles are round or angular. And he doesn't care. But for my work this is very relevant. It has nothing to do with professional autonomy. (Cardiothoracic surgeon)

One might argue with this cardiothoracic surgeon that this is exactly what the notion of professional autonomy refers to; in this case, the autonomy to decide for yourself, as a medical professional, which materials to work with. But that is not the point this cardiothoracic surgeon is making per se . Apparently, in the daily jargon of healthcare managers, the notion of professional autonomy is employed as a stopgap explanation for resistance so often that this surgeon anticipated its negative connotation related to changing surgical suture and change more general. For him at least, the superimposition of professional autonomy as an explanation does not do justice to how he relates to the issue of changing surgical suture. For him it is not an abstract affair, but genuinely felt, both in a tactile and in an emotional sense. Also note that academic definitions of professional autonomy (conceptual) do not always correspond to how such notions are employed in daily usage (performative). The cardiothoracic surgeons spoken to frequently drew upon a competitive/professional discourse in relation to surgical suture, enriched with examples and in far less abstract manner than those that posited professional autonomy as the main cause of change resistance.

Competitive/professional discourse

He [Roger Federer] goes down in the history books as the best professional tennis player ever. And that is because he has spent endless hours on the court practising and refining his skills. His tennis racket has become a natural extension of his arm. His tennis racket is his instrument. My instrument is my suture … suture and needles. (Cardiothoracic surgeon)

I didn't just go to medical school. After that I have done my residency, with a Ph.D., et cetera . All in all an extra 10 years. Everything that you are supposed to do, I did that, to become the best possible professional and to be able to deliver the best possible care for the patient. This is not some quick course. This is really … six years of medical school and then postgraduate for another six years. That isn't nothing. You have to be motivated, driven and persistent. And you hope to end up working for an institution that enables you to profess your passion. (Cardiothoracic surgeon)

It is important to note that the cardiothoracic surgeons quoted here did not exclusively drew upon this competitive/professional discourse that implies sacrifice, persistence and drive. But when they did, they challenged the economic/managerial discourse without actually talking about finances. In a way, to put it bluntly, money from this perspective should not be an object, or, at least, it should never be a priority.

Discourse on patient care

Let's say … I am going to operate your father with XXX [brand name of new supplier], but I am not used to working with that suture. It curls more and the needles go blunt quicker and the needles are square and therefore more difficult to position in the needle holder. So I need to focus more and I need to stress … I need to work [with the utmost precision]. Well, I am curious whether that manager would let me operate on his father. (Cardiothoracic surgeon)

Surgical suture was constructed as a lifeline on which the cardiothoracic surgeon relies on behalf of the patient. Replacing surgical suture is perceived as an unacceptable potential cause of failure. So whereas the competitive/professional discourse places the concerns and aspirations of the medical professional front and centre, this discourse on patient care places the concerns of the patient front and centre by means of the medical professional as his advocate. Implicit in both discourses, though, is that money should not be an object. As such, these discourses are counter-discourses to the economic/managerial discourse that legitimizes replacing surgical suture by that of a cheaper brand.

Discourse on safety and quality

So many things can go wrong. So changing surgical suture presents an additional risk. We prefer to operate a patient's heart only once and then never again. (Cardiothoracic surgeon)

If medical specialists use the argument of safety, patient safety, then you are finished. As an executive it is over. You start thinking, what if he is right; and I force him to work with this suture and something goes horribly wrong. He only has to say: “I told you it wasn't safe!” And then you, as an executive, are gone. Of course, you have to challenge and not be naive, but ultimately it is a show stopper … that safety argument. Another factor was, that my colleague in the Executive Board and I are not [cardiothoracic] surgeons. So we could not weigh in from our own experience. (Chairman of the Board)

The best of the best: being part of an elite professional group

Those boys [cardiothoracic surgeons] – or men I should say – are so bloody good in what they do. And you [as a nurse operating theatre] also want to be part of that, to pass cum laude . They stand for their profession, each time they give it a hundred and ten percent. And they perform procedures that no one else dares to perform. For us it is a joy to assist them. You share in the pride and get into that special workflow. (Nurse, operating theatre)

Well, our group of cardiac surgeons consists of individuals with a unique history at this hospital. They are not known to be particularly dynamic or flexible. Let's keep it at that. So, to get them on board with our plans requires some extra effort on our part. (Chairman of the Board)

I have studied and practiced endlessly. And we [other cardiothoracic specialists] frequently consult one another. But sometimes when I have to decide fast, during a very complex operation, medicine is almost more like an art-form. I feel when something might go wrong and I anticipate what to do. And when someone later asks me: “Why did you do this or that?”, of course I will formulate an answer, but in reality I acted upon the experience I have and on what I have learned from my mentors. In these moments everyone in my team knows what to do. I do not even have to tell them. However, I cannot accept that someone who has no idea what we are doing, decides that I have to work with that suture. (Cardiothoracic surgeon)

The prediction that deeply embodied practices that are learned over time through mentorship, explicit instruction and implicit attunement of the senses are not to be changed by outsiders in a pick-and-choose manner (e.g. Voestermans and Verheggen, 2013 ) is confirmed by this surgeon.

As Willig noted: “It is important to examine the relationship between a source's and a recipient's discursive frames in order to understand the impact of a message” ( 1998 , p. 385). This paper is not intended as a reproach to either hospital management or those working within the cardiac surgery department. On the one hand, hospital management was faced with the challenge of cutting costs and making the provision of good health care sustainable. On the other hand, cardiothoracic surgeons were trying to keep the environment of the operation room as controlled and predictable as possible. They do not want any additional risks, especially if they feel that the risks have been imposed upon them. Just the fact that the new surgical suture had slightly different qualities – on which everyone agreed – made it an unacceptable change for the surgeons. Both perspectives make sense and, surprisingly, almost all research participants were able to eloquently elaborate on the opposing perspectives. However, it appeared as if the emotions and feelings that were immediately triggered within particular arrangements prevented the research participants from acting upon those insights. The result was a power struggle, and eventually management gave in to the cardiac surgeons by accepting a different supplier.

The failure described probably could have been prevented if those who initiated the change and implemented the transition had accounted for the particular social arrangements in which surgeons from different specialities operate. It could probably also have been prevented if the emotions and feelings that were expressed were acted upon in a timely manner, instead of being dismissed by implicitly juxtaposing emotional expression against rational decision-making. Cardiothoracic surgeons constitute a group with a distinct history and responsibility and to whom surgical suture is a crucial tool. Suture as a tactile element in their day-to-day work environment is embedded within a complex social arrangement that ties elements of risk avoidance, professional accountability and direct patient care together in a way that feels secure. The feelings triggered within this arrangement are genuinely felt and, therefore, are as real as the financial cost of surgical suture and evidence-based standards of its quality. These feelings need to be accounted for with the same managerial fervour. For hospital management this means that in planning a consistent overall approach to change in their institution, they must consider exceptions to that approach. It might be an uncomfortable message, but managers here to some extent reached the limits of changeability; the thinnest of sutures used to operate on people's hearts are beyond their reach, so to speak.

There are other aspects that need to be accounted for, that fall beyond the immediate scope of this research, but which nonetheless need to be mentioned to give a more complete picture. First, the main channel by which hospital management communicated about the tendering procedure, the verification process, the actual introduction, trial sessions and workshops was by email. One surgeon confided that he was too busy to systematically go through his emails and, due to a recent reorganization, had lost his personal secretary. The annoyances arising from different cost-cutting operations were thus accumulating. Secondly, although hospital management assumed that it had adequately communicated about and during the transition to new suture, some surgeons felt being presented with a fait accompli . Management had failed to ensure that the surgeons had received the necessary communications, and the surgeons did not acknowledge that they had indeed received them. This led to miscommunication and to further polarization. This was especially relevant because cardiothoracic surgeons had previously mentioned their concerns about the use of specific cardiac surgical sutures and were nevertheless then confronted with the new suture. The surgeons felt overpowered and had the impression of not being listened to. This resulted in some cardiothoracic surgeons deciding to present hospital management with a fait accompli in return by framing suture as a life-or-death matter and making the management responsible for the possibility of bad results that could be related to the sutures. Lastly, because of this escalation, emotions ran even higher, and interviewees on both sides frequently blamed each other for not having their facts straight. Change practitioners would do well to acknowledge these emotions and feelings, without dismissing them or juxtaposing them against reason and facts. It is a big mistake to view addressing feelings and emotions as simply the “soft” side of change management (see also: Steigenberger, 2015 ) or to superimpose labels on them too quickly.

In conclusion, we have demonstrated that even if all basic principles of change management have been applied in the usual way, procedures may escalate to an emotional level, eventually leading to a counterproductive deadlock. These emotions and feelings should be anticipated by thorough communication between all parties involved. Should they still arise, these emotions need to be accounted for and acted upon bilaterally in a non-judgemental and empathic manner to make informed decisions about pushing forward with a change initiative and, if so, guide its further implementation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Respondents targeted through maximum variation sampling

Summary discursive constructions, discourses and subject positions

The quotations are translated as the interviews were conducted in Dutch.

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Acknowledgements

We thank all research subjects, on both sides of the aisle, for their participation in this case study on a topic that involves them deeply into their professional groups. Also, we thank the anonymous reviewers for their insightful feedback on an earlier draft.

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Change Management: From Theory to Practice

• Original Paper
• Published: 09 September 2022
• Volume 67 , pages 189–197, ( 2023 )

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• Jeffrey Phillips   ORCID: orcid.org/0000-0003-0708-6460 1 &
• James D. Klein 2  

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This article presents a set of change management strategies found across several models and frameworks and identifies how frequently change management practitioners implement these strategies in practice. We searched the literature to identify 15 common strategies found in 16 different change management models and frameworks. We also created a questionnaire based on the literature and distributed it to change management practitioners. Findings suggest that strategies related to communication, stakeholder involvement, encouragement, organizational culture, vision, and mission should be used when implementing organizational change.

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Organizations must change to survive. There are many approaches to influence change; these differences require change managers to consider various strategies that increase acceptance and reduce barriers. A change manager is responsible for planning, developing, leading, evaluating, assessing, supporting, and sustaining a change implementation. Change management consists of models and strategies to help employees accept new organizational developments.

Change management practitioners and academic researchers view organizational change differently (Hughes, 2007 ; Pollack & Pollack, 2015 ). Saka ( 2003 ) states, “there is a gap between what the rational-linear change management approach prescribes and what change agents do” (p. 483). This disconnect may make it difficult to determine the suitability and appropriateness of using different techniques to promote change (Pollack & Pollack, 2015 ). Hughes ( 2007 ) thinks that practitioners and academics may have trouble communicating because they use different terms. Whereas academics use the terms, models, theories, and concepts, practitioners use tools and techniques. A tool is a stand-alone application, and a technique is an integrated approach (Dale & McQuater, 1998 ). Hughes ( 2007 ) expresses that classifying change management tools and techniques can help academics identify what practitioners do in the field and evaluate the effectiveness of practitioners’ implementations.

There is little empirical evidence that supports a preferred change management model (Hallencreutz & Turner, 2011 ). However, there are many similar strategies found across change management models (Raineri, 2011 ). Bamford and Forrester’s ( 2003 ) case study showed that “[change] managers in a company generally ignored the popular change literature” (p. 560). The authors followed Pettigrew’s ( 1987 ) suggestions that change managers should not use abstract theories; instead, they should relate change theories to the context of the change. Neves’ ( 2009 ) exploratory factor analysis of employees experiencing the implementation of a new performance appraisal system at a public university suggested that (a) change appropriateness (if the employee felt the change was beneficial to the organization) was positively related with affective commitment (how much the employee liked their job), and (b) affective commitment mediated the relationship between change appropriateness and individual change (how much the employee shifted to the new system). It is unlikely that there is a universal change management approach that works in all settings (Saka, 2003 ). Because change is chaotic, one specific model or framework may not be useful in multiple contexts (Buchanan & Boddy, 1992 ; Pettigrew & Whipp, 1991 ). This requires change managers to consider various approaches for different implementations (Pettigrew, 1987 ). Change managers may face uncertainties that cannot be addressed by a planned sequence of steps (Carnall, 2007 ; Pettigrew & Whipp, 1991 ). Different stakeholders within an organization may complete steps at different times (Pollack & Pollack, 2015 ). Although there may not be one perspective change management approach, many models and frameworks consist of similar change management strategies.

Anderson and Ackerman Anderson ( 2001 ) discuss the differences between change frameworks and change process models. They state that a change framework identifies topics that are relevant to the change and explains the procedures that organizations should acknowledge during the change. However, the framework does not provide details about how to accomplish the steps of the change or the sequence in which the change manager should perform the steps. Additionally, Anderson and Ackerman Anderson ( 2001 ) explain that change process models describe what actions are necessary to accomplish the change and the order in which to facilitate the actions. Whereas frameworks may identify variables or theories required to promote change, models focus on the specific processes that lead to change. Based on the literature, we define a change strategy as a process or action from a model or framework. Multiple models and frameworks contain similar strategies. Change managers use models and frameworks contextually; some change management strategies may be used across numerous models and frameworks.

The purpose of this article is to present a common set of change management strategies found across numerous models and frameworks and identify how frequently change management practitioners implement these common strategies in practice. We also compare current practice with models and frameworks from the literature. Some change management models and frameworks have been around for decades and others are more recent. This comparison may assist practitioners and theorists to consider different strategies that fall outside a specific model.

Common Strategies in the Change Management Literature

We examined highly-cited publications ( n  > 1000 citations) from the last 20 years, business websites, and university websites to select organizational change management models and frameworks. First, we searched two indexes—Google Scholar and Web of Science’s Social Science Citation Index. We used the following keywords in both indexes: “change management” OR “organizational change” OR “organizational development” AND (models or frameworks). Additionally, we used the same search terms in a Google search to identify models mentioned on university and business websites. This helped us identify change management models that had less presence in popular research. We only included models and frameworks from our search results that were mentioned on multiple websites. We reached saturation when multiple publications stopped identifying new models and frameworks.

After we identified the models and frameworks, we analyzed the original publications by the authors to identify observable strategies included in the models and frameworks. We coded the strategies by comparing new strategies with our previously coded strategies, and we combined similar strategies or created a new strategy. Our list of strategies was not exhaustive, but we included the most common strategies found in the publications. Finally, we omitted publications that did not provide details about the change management strategies. Although many of these publications were highly cited and identified change implementation processes or phases, the authors did not identify a specific strategy.

Table 1 shows the 16 models and frameworks that we analyzed and the 15 common strategies that we identified from this analysis. Ackerman-Anderson and Anderson ( 2001 ) believe that it is important for process models to consider organizational imperatives as well as human dynamics and needs. Therefore, the list of strategies considers organizational imperatives such as create a vision for the change that aligns with the organization’s mission and strategies regarding human dynamics and needs such as listen to employees’ concerns about the change. We have presented the strategies in order of how frequently the strategies appear in the models and frameworks. Table 1 only includes strategies found in at least six of the models or frameworks.

Strategies Used by Change Managers

We developed an online questionnaire to determine how frequently change managers used the strategies identified in our review of the literature. The Qualtrics-hosted survey consisted of 28 questions including sliding-scale, multiple-choice, and Likert-type items. Demographic questions focused on (a) how long the participant had been involved in the practice of change management, (b) how many change projects the participant had led, (c) the types of industries in which the participant led change implementations, (d) what percentage of job responsibilities involved working as a change manager and a project manager, and (e) where the participant learned to conduct change management. Twenty-one Likert-type items asked how often the participant used the strategies identified by our review of common change management models and frameworks. Participants could select never, sometimes, most of the time, and always. The Cronbach’s Alpha of the Likert-scale questions was 0.86.

The procedures for the questionnaire followed the steps suggested by Gall et al. ( 2003 ). The first steps were to define the research objectives, select the sample, and design the questionnaire format. The fourth step was to pretest the questionnaire. We conducted cognitive laboratory interviews by sending the questionnaire and interview questions to one person who was in the field of change management, one person who was in the field of performance improvement, and one person who was in the field of survey development (Fowler, 2014 ). We met with the reviewers through Zoom to evaluate the questionnaire by asking them to read the directions and each item for clarity. Then, reviewers were directed to point out mistakes or areas of confusion. Having multiple people review the survey instruments improved the reliability of the responses (Fowler, 2014 ).

We used purposeful sampling to distribute the online questionnaire throughout the following organizations: the Association for Talent Development (ATD), Change Management Institute (CMI), and the International Society for Performance Improvement (ISPI). We also launched a call for participation to department chairs of United States universities who had Instructional Systems Design graduate programs with a focus on Performance Improvement. We used snowball sampling to gain participants by requesting that the department chairs forward the questionnaire to practitioners who had led at least one organizational change.

Table 2 provides a summary of the characteristics of the 49 participants who completed the questionnaire. Most had over ten years of experience practicing change management ( n  = 37) and had completed over ten change projects ( n  = 32). The participants learned how to conduct change management on-the-job ( n  = 47), through books ( n  = 31), through academic journal articles ( n  = 22), and from college or university courses ( n  = 20). The participants had worked in 13 different industries.

Table 3 shows how frequently participants indicated that they used the change management strategies included on the questionnaire. Forty or more participants said they used the following strategies most often or always: (1) Asked members of senior leadership to support the change; (2) Listened to managers’ concerns about the change; (3) Aligned an intended change with an organization’s mission; (4) Listened to employees’ concerns about the change; (5) Aligned an intended change with an organization’s vision; (6) Created measurable short-term goals; (7) Asked managers for feedback to improve the change, and (8) Focused on organizational culture.

Table 4 identifies how frequently the strategies appeared in the models and frameworks and the rate at which practitioners indicated they used the strategies most often or always. The strategies found in the top 25% of both ( n  > 36 for practitioner use and n  > 11 in models and frameworks) focused on communication, including senior leadership and the employees in change decisions, aligning the change with the vision and mission of the organization, and focusing on organizational culture. Practitioners used several strategies more commonly than the literature suggested, especially concerning the topic of middle management. Practitioners focused on listening to middle managers’ concerns about the change, asking managers for feedback to improve the change, and ensuring that managers were trained to promote the change. Meanwhile, practitioners did not engage in the following strategies as often as the models and frameworks suggested that they should: provide all members of the organization with clear communication about the change, distinguish the differences between leadership and management, reward new behavior, and include employees in change decisions.

Common Strategies Used by Practitioners and Found in the Literature

The purpose of this article was to present a common set of change management strategies found across numerous models and frameworks and to identify how frequently change management practitioners implement these common strategies in practice. The five common change management strategies were the following: communicate about the change, involve stakeholders at all levels of the organization, focus on organizational culture, consider the organization’s mission and vision, and provide encouragement and incentives to change. Below we discuss our findings with an eye toward presenting a few key recommendations for change management.

Communicate About the Change

Communication is an umbrella term that can include messaging, networking, and negotiating (Buchanan & Boddy, 1992 ). Our findings revealed that communication is essential for change management. All the models and frameworks we examined suggested that change managers should provide members of the organization with clear communication about the change. It is interesting that approximately 33% of questionnaire respondents indicated that they sometimes, rather than always or most of the time, notified all members of the organization about the change. This may be the result of change managers communicating through organizational leaders. Instead of communicating directly with everyone in the organization, some participants may have used senior leadership, middle management, or subgroups to communicate the change. Messages sent to employees from leaders can effectively promote change. Regardless of who is responsible for communication, someone in the organization should explain why the change is happening (Connor et al., 2003 ; Doyle & Brady, 2018 ; Hiatt, 2006 ; Kotter, 2012 ) and provide clear communication throughout the entire change implementation (McKinsey & Company, 2008 ; Mento et al., 2002 ).

Involve Stakeholders at All Levels of the Organization

Our results indicate that change managers should involve senior leaders, managers, as well as employees during a change initiative. The items on the questionnaire were based on a review of common change management models and frameworks and many related to some form of stakeholder involvement. Of these strategies, over half were used often by 50% or more respondents. They focused on actions like gaining support from leaders, listening to and getting feedback from managers and employees, and adjusting strategies based on stakeholder input.

Whereas the models and frameworks often identified strategies regarding senior leadership and employees, it is interesting that questionnaire respondents indicated that they often implemented strategies involving middle management in a change implementation. This aligns with Bamford and Forrester’s ( 2003 ) research describing how middle managers are important communicators of change and provide an organization with the direction for the change. However, the participants did not develop managers into leaders as often as the literature proposed. Burnes and By ( 2012 ) expressed that leadership is essential to promote change and mention how the change management field has failed to focus on leadership as much as it should.

Focus on Organizational Culture

All but one of the models and frameworks we analyzed indicated that change managers should focus on changing the culture of an organization and more than 75% of questionnaire respondents revealed that they implemented this strategy always or most of the time. Organizational culture affects the acceptance of change. Changing the organizational culture can prevent employees from returning to the previous status quo (Bullock & Batten, 1985 ; Kotter, 2012 ; Mento et al., 2002 ). Some authors have different views on how to change an organization’s culture. For example, Burnes ( 2000 ) thinks that change managers should focus on employees who were resistant to the change while Hiatt ( 2006 ) suggests that change managers should replicate what strategies they used in the past to change the culture. Change managers require open support and commitment from managers to lead a culture change (Phillips, 2021 ).

In addition, Pless and Maak ( 2004 ) describe the importance of creating a culture of inclusion where diverse viewpoints help an organization reach its organizational objectives. Yet less than half of the participants indicated that they often focused on diversity, equity, and inclusion (DEI). Change managers should consider diverse viewpoints when implementing change, especially for organizations whose vision promotes a diverse and inclusive workforce.

Consider the Organization’s Mission and Vision

Several of the models and frameworks we examined mentioned that change managers should consider the mission and vision of the organization (Cummings & Worley, 1993 ; Hiatt, 2006 ; Kotter, 2012 ; Polk, 2011 ). Furthermore, aligning the change with the organization’s mission and vision were among the strategies most often implemented by participants. This was the second most common strategy both used by participants and found in the models and frameworks. A mission of an organization may include its beliefs, values, priorities, strengths, and desired public image (Cummings & Worley, 1993 ). Leaders are expected to adhere to a company’s values and mission (Strebel, 1996 ).

Provide Encouragement and Incentives to Change

Most of the change management models and frameworks suggested that organizations should reward new behavior, yet most respondents said they did not provide incentives to change. About 75% of participants did indicate that they frequently gave encouragement to employees about the change. The questionnaire may have confused participants by suggesting that they provide incentives before the change occurs. Additionally, respondents may have associated incentives with monetary compensation. Employee training can be considered an incentive, and many participants confirmed that they provided employees and managers with training. More information is needed to determine why the participants did not provide incentives and what the participants defined as rewards.

Future Conversations Between Practitioners and Researchers

Table 4 identified five strategies that practitioners used more often than the models and frameworks suggested and four strategies that were suggested more often by the models and frameworks than used by practitioners. One strategy that showed the largest difference was provided employees with incentives to implement the change. Although 81% of the selected models and frameworks suggested that practitioners should provide employees with incentives, only 25% of the practitioners identified that they provided incentives always and most of the time. Conversations between theorists and practitioners could determine if these differences occur because each group uses different terms (Hughes, 2007 ) or if practitioners just implement change differently than theorists suggest (Saka, 2003 ).

Additionally, conversations between theorists and practitioners may help promote improvements in the field of change management. For example, practitioners were split on how often they promoted DEI, and the selected models and frameworks did not focus on DEI in change implementations. Conversations between the two groups would help theorists understand what practitioners are doing to advance the field of change management. These conversations may encourage theorists to modify their models and frameworks to include modern approaches to change.

Limitations

The models and frameworks included in this systematic review were found through academic research and websites on the topic of change management. We did not include strategies contained on websites from change management organizations. Therefore, the identified strategies could skew towards approaches favored by theorists instead of practitioners. Additionally, we used specific publications to identify the strategies found in the models and frameworks. Any amendments to the cited models or frameworks found in future publications could not be included in this research.

We distributed this questionnaire in August 2020. Several participants mentioned that they were not currently conducting change management implementations because of global lockdowns due to the COVID-19 pandemic. Because it can take years to complete a change management implementation (Phillips, 2021 ), this research does not describe how COVID-19 altered the strategies used by the participants. Furthermore, participants were not provided with definitions of the strategies. Their interpretations of the strategies may differ from the definitions found in the academic literature.

Future Research

Future research should expand upon what strategies the practitioners use to determine (a) how the practitioners use the strategies, and (b) the reasons why practitioners use certain strategies. Participants identified several strategies that they did not use as often as the literature suggested (e.g., provide employees with incentives and adjust the change implementation because of reactions from employees). Future research should investigate why practitioners are not implementing these strategies often.

Additionally, the COVID-19 pandemic may have changed how practitioners implemented change management strategies. Future research should investigate if practitioners have added new strategies or changed the frequency in which they identified using the strategies found in this research.

Our aim was to identify a common set of change management strategies found across several models and frameworks and to identify how frequently change management practitioners implement these strategies in practice. While our findings relate to specific models, frameworks, and strategies, we caution readers to consider the environment and situation where the change will occur. Therefore, strategies should not be selected for implementation based on their inclusion in highly cited models and frameworks. Our study identified strategies found in the literature and used by change managers, but it does not predict that specific strategies are more likely to promote a successful organizational change. Although we have presented several strategies, we do not suggest combining these strategies to create a new framework. Instead, these strategies should be used to promote conversation between practitioners and theorists. Additionally, we do not suggest that one model or framework is superior to others because it contains more strategies currently used by practitioners. Evaluating the effectiveness of a model or framework by how many common strategies it contains gives an advantage to models and frameworks that contain the most strategies. Instead, this research identifies what practitioners are doing in the field to steer change management literature towards the strategies that are most used to promote change.

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Phillips, J., Klein, J.D. Change Management: From Theory to Practice. TechTrends 67 , 189–197 (2023). https://doi.org/10.1007/s11528-022-00775-0

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5 Critical Steps in the Change Management Process

• 19 Mar 2020

Businesses must constantly evolve and adapt to meet a variety of challenges—from changes in technology, to the rise of new competitors, to a shift in laws, regulations, or underlying economic trends. Failure to do so could lead to stagnation or, worse, failure.

Approximately 50 percent of all organizational change initiatives are unsuccessful, highlighting why knowing how to plan for, coordinate, and carry out change is a valuable skill for managers and business leaders alike.

Have you been tasked with managing a significant change initiative for your organization? Would you like to demonstrate that you’re capable of spearheading such an initiative the next time one arises? Here’s an overview of what change management is, the key steps in the process, and actions you can take to develop your managerial skills and become more effective in your role.

Access your free e-book today.

What is Change Management?

Organizational change refers broadly to the actions a business takes to change or adjust a significant component of its organization. This may include company culture, internal processes, underlying technology or infrastructure, corporate hierarchy, or another critical aspect.

Organizational change can be either adaptive or transformational:

• Adaptive changes are small, gradual, iterative changes that an organization undertakes to evolve its products, processes, workflows, and strategies over time. Hiring a new team member to address increased demand or implementing a new work-from-home policy to attract more qualified job applicants are both examples of adaptive changes.
• Transformational changes are larger in scale and scope and often signify a dramatic and, occasionally sudden, departure from the status quo. Launching a new product or business division, or deciding to expand internationally, are examples of transformational change.

Change management is the process of guiding organizational change to fruition, from the earliest stages of conception and preparation, through implementation and, finally, to resolution.

As a leader, it’s essential to understand the change management process to ensure your entire organization can navigate transitions smoothly. Doing so can determine the potential impact of any organizational changes and prepare your teams accordingly. When your team is prepared, you can ensure everyone is on the same page, create a safe environment, and engage the entire team toward a common goal.

Change processes have a set of starting conditions (point A) and a functional endpoint (point B). The process in between is dynamic and unfolds in stages. Here’s a summary of the key steps in the change management process.

Check out our video on the change management process below, and subscribe to our YouTube channel for more explainer content!

5 Steps in the Change Management Process

1. prepare the organization for change.

For an organization to successfully pursue and implement change, it must be prepared both logistically and culturally. Before delving into logistics, cultural preparation must first take place to achieve the best business outcome.

In the preparation phase, the manager is focused on helping employees recognize and understand the need for change. They raise awareness of the various challenges or problems facing the organization that are acting as forces of change and generating dissatisfaction with the status quo. Gaining this initial buy-in from employees who will help implement the change can remove friction and resistance later on.

2. Craft a Vision and Plan for Change

Once the organization is ready to embrace change, managers must develop a thorough, realistic, and strategic plan for bringing it about.

The plan should detail:

• Strategic goals: What goals does this change help the organization work toward?
• Key performance indicators: How will success be measured? What metrics need to be moved? What’s the baseline for how things currently stand?
• Project stakeholders and team: Who will oversee the task of implementing change? Who needs to sign off at each critical stage? Who will be responsible for implementation?
• Project scope: What discrete steps and actions will the project include? What falls outside of the project scope?

While it’s important to have a structured approach, the plan should also account for any unknowns or roadblocks that could arise during the implementation process and would require agility and flexibility to overcome.

3. Implement the Changes

After the plan has been created, all that remains is to follow the steps outlined within it to implement the required change. Whether that involves changes to the company’s structure, strategy, systems, processes, employee behaviors, or other aspects will depend on the specifics of the initiative.

During the implementation process, change managers must be focused on empowering their employees to take the necessary steps to achieve the goals of the initiative and celebrate any short-term wins. They should also do their best to anticipate roadblocks and prevent, remove, or mitigate them once identified. Repeated communication of the organization’s vision is critical throughout the implementation process to remind team members why change is being pursued.

4. Embed Changes Within Company Culture and Practices

Once the change initiative has been completed, change managers must prevent a reversion to the prior state or status quo. This is particularly important for organizational change related to business processes such as workflows, culture, and strategy formulation. Without an adequate plan, employees may backslide into the “old way” of doing things, particularly during the transitory period.

By embedding changes within the company’s culture and practices, it becomes more difficult for backsliding to occur. New organizational structures, controls, and reward systems should all be considered as tools to help change stick.

5. Review Progress and Analyze Results

Just because a change initiative is complete doesn’t mean it was successful. Conducting analysis and review, or a “project post mortem,” can help business leaders understand whether a change initiative was a success, failure, or mixed result. It can also offer valuable insights and lessons that can be leveraged in future change efforts.

Ask yourself questions like: Were project goals met? If yes, can this success be replicated elsewhere? If not, what went wrong?

The Key to Successful Change for Managers

While no two change initiatives are the same, they typically follow a similar process. To effectively manage change, managers and business leaders must thoroughly understand the steps involved.

Some other tips for managing organizational change include asking yourself questions like:

• Do you understand the forces making change necessary? Without this understanding, it can be difficult to effectively address the underlying causes that have necessitated change, hampering your ability to succeed.
• Do you have a plan? Without a detailed plan and defined strategy, it can be difficult to usher a change initiative through to completion.
• How will you communicate? Successful change management requires effective communication with both your team members and key stakeholders. Designing a communication strategy that acknowledges this reality is critical.
• Have you identified potential roadblocks? While it’s impossible to predict everything that might potentially go wrong with a project, taking the time to anticipate potential barriers and devise mitigation strategies before you get started is generally a good idea.

How to Lead Change Management Successfully

If you’ve been asked to lead a change initiative within your organization, or you’d like to position yourself to oversee such projects in the future, it’s critical to begin laying the groundwork for success by developing the skills that can equip you to do the job.

Completing an online management course can be an effective way of developing those skills and lead to several other benefits . When evaluating your options for training, seek a program that aligns with your personal and professional goals; for example, one that emphasizes organizational change.

Do you want to become a more effective leader and manager? Explore Leadership Principles , Management Essentials , and Organizational Leadership —three of our online leadership and management courses —to learn how you can take charge of your professional development and accelerate your career. Not sure which course is the right fit? Download our free flowchart .

This post was updated on August 8, 2023. It was originally published on March 19, 2020.

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A Change Management Case Study for Safe Opioid Prescribing and Opioid Use Disorder Treatment

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Background: Given that prescribing practices have contributed to the current opioid epidemic and that primary care clinicians are the largest prescribers of opioids, family physicians must consider the twin goals of safely prescribing opioids for patients with chronic pain while effectively identifying and treating those who have developed opioid use disorder (OUD). However, family physicians may feel constrained by a culture and systems in their offices that do not support achieving these twin goals.

Methods: In a family medicine clinic within a larger academic institution that cares for an underserved, multicultural patient population in the greater Boston area, we provide a case study that illustrates the twin goals of safe opioid prescribing and treating OUD. We used 2 models of change management—Lewin's Three-Step Change Theory and the McKinsey 7S Model of Change—as a framework to describe our 5-year process of using cultural and structural elements to support these efforts.

Results: Deliberate use of change management theory to support both safe opioid prescribing and treating patients with OUD over the past 5 years resulted in changes to the practices, people, skills, and infrastructure within our clinic. These changes have demonstrated a sense of stability and sustainability and hence now represent our clinic's current culture.

Conclusion: The Lewin and 7S models of change can be helpful guides to creating and maintaining a foundation of office-wide culture and structural support to meet the twin goals of safe opioid prescribing and treating patients with OUD.

• Addictive Behavior
• Chronic Pain
• Family Physicians
• Opioid-Related Disorders
• Pain Management
• Patient-Centered Care
• Primary Health Care
• Quality Improvement

The opioid epidemic has become a palpable reality across the country. Every day in the United States, more than 40 people die from an overdose involving prescription opioids; since 1999, there have been more than 165,000 deaths from overdoses related to prescription opioids, and overdose deaths related to prescription opioids has now passed deaths from illicit opioids. 1 , 2 At the same time, there has been a dramatic increase in prescribing opioids for patients with chronic pain. In 2013, 249 million opioid prescriptions were written by physicians, and primary care clinicians were the largest prescribers. 1 , 2 Although prescription opioids may provide some analgesic benefit to patients struggling with chronic pain, 21% to 29% of patients receiving chronic opioid treatment will misuse their medications and 8% to 12% will eventually develop an opioid use disorder (OUD). 3

The rampant prescribing of opioids may have resulted from an outdated understanding of pain relief and addiction. It was only recently that clinicians have started to move away from thinking of pain as the “fifth vital sign” that should be assessed and treated at every visit 4 and from thinking that those treated for chronic pain with opioids could not become addicted. 5 In addition, only recently has society started to shift from viewing illicit drug use as a criminal activity warranting arrest and incarceration to a neurobiological disease warranting a chronic disease management approach 6 , 7 and that such an approach is well-suited in a primary care setting rather than siloed in addiction treatment programs. 8

As family physicians embrace these new paradigms, it will be important to consider, in concert, the twin goals of safely prescribing opioids for patients with chronic pain while effectively identifying and treating those who have developed OUD. However, family physicians may feel constrained in their offices by cultures and systems that do not support the achievement of these twin goals.

For example, physicians attempting to decrease opioid dosing in patients with chronic pain may find it difficult to make this change if treatment approaches and practices are not agreed on and coordinated among prescribers. 9 Routine monitoring of patients, such as checking urine toxicology tests, 9 setting up controlled substance agreements, and using the state's prescription drug monitoring program (PDMP) 10 may also be difficult without adequate support systems in place. 11

Similarly, physicians attempting to treat patients with OUD may face cultural and system-level barriers that prevent treatment from becoming mainstream. Although more family physicians are receiving waivers to provide medication for OUD (MOUD) in the form of buprenorphine-naloxone (B/N), one-third never go on to prescribe it, largely due to concerns about having appropriate office, nursing, and administrative support; lacking access to mental health clinicians and addiction specialists; and concerns about being the lone B/N provider. 11 ⇓ – 13

Thus, treating patients with chronic pain and patients with OUD requires not only individual physician efforts but also a foundation of office-wide cultural and structural support. About 5 years ago our office faced similar barriers. This article describes a case study of our clinic's deliberate approach using change management theory to support individual clinician efforts in meeting these twin goals. 14

Our institution is an academic health care center that serves as a safety net system for a large urban population across the greater Boston area. As part of its vision and mission statement to care for our patients, our institute has declared treating patients with substance use disorders and mental health comorbidities a high priority. Our family medicine clinic is 1 of its 13 primary care sites. We are located in a medium-sized, multicultural city approximately 8 miles north of Boston, Massachusetts. The clinic serves approximately 23,000 empaneled patients with 17 faculty physicians, 24 residents, 6 physician assistants, and 9 behavioral care clinicians, including 3 primary care-based integrated psychologists. Of all the 13 primary care sites in our organization, our site has the largest number of patients with OUD.

Approximately 5 years ago, we became sensitized to the high use of opioids in our community and the rapidly escalating death rate due to opioid overdose. Although our institution recognized the need to focus on treating patients with addiction and made it a core part of its mission statement, prescribing within our clinic varied widely among physicians; our policies on opioid prescribing and monitoring were not well known or followed; and the state-based PDMP 10 was not routinely reviewed before prescribing. We had a minimal curriculum to train residents in pain management or OUD treatment; only 1 core faculty member had been trained to provide B/N for patients with OUD, and only 5 patients were receiving treatment.

Recognizing the impact of opioid prescribing in our community, we realized we needed to develop a more intentional approach to safely treat patients prescribed opioid analgesics for chronic pain while also treating patients with OUD. We began our approach to process improvement change using the tenets of Lewin's Three-Step Change Theory 15 to provide the overall approach. Briefly, this theory suggests that practices within an organization are inherently stable and resistant to change. As a result, change only occurs by (1) “unfreezing,” in which clinicians are made aware of the need for change; (2) “changing,” in which new systems and expectations for behavior are implemented; and 3) “refreezing,” in which the new ways of thinking and doing are institutionalized and, therefore, solidified into new practices.

To begin the unfreezing, a resident led a grand rounds presentation to our entire clinic that served as a call-to-action, informing participants about the current opioid epidemic affecting our community, the efficacy of treating OUD with medication, and explaining why this effort should be incorporated into our clinic. At the same time, a relatively new faculty member kept the conversation alive by displaying a poster on her office door highlighting the local drug overdose rates ( Figure 1 ), attracting passersby to pause and consider the issue. Situated within a larger system that had stated its intentions to prioritize addressing addiction and safe opioid prescribing, these efforts launched further clinical and residency attention to formally and systemically examine and identify the gap between current and desired performance.

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Poster highlighting drug-related deaths in our practice catchment area.

To guide specific aspects of our change process, we used the principles of the McKinsey 7S model of change 16 management. Briefly, this model identifies 6 barriers that need to be addressed to support the adoption and maintenance of new practices. The model considers 3 “hard” elements that can be readily seen, including strategy, systems, and structure. It also recognizes 3 “soft” elements that are more intangible, including the types of people, the skills of the people, and the overarching leadership style within the organization. Managing change by addressing all these barriers leads to the 7 th “S,” creation of shared values underpinning the culture of the group. We used this structure to meet our twin goals of enhancing the care of patients with chronic pain and treating patients with OUD (see Table 1 ).

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Description of the Change Elements Addressed using the 7S Model

Hard Elements

Strategy: the plan of action to be used.

To promote the safe and appropriate use of opioids, our strategy began by developing shared general principles for safe opioid prescribing and then supporting them through education and health informatics systems. These principles fit into system-wide strategies to address OUD and chronic pain management, although the process began locally and not because of an institutional directive.

To care for patients with OUD, we instituted processes that created a safe and welcoming environment that destigmatized opioid use, greatly expanded use of MOUD primarily through shared medical appointments, 17 and emphasized a team-based approach to care.

Both strategies were supported by a chronic pain and OUD curriculum for our residents and faculty and training for all members of the patient care team.

Systems: Daily Activities and Procedures Implemented to Get the Job Done

To improve the management of chronic pain, our clinic created a workgroup comprising faculty and residents to develop guidelines for prescribing opioids based on institution-level approaches and policies around safe opioid prescribing that represented evidence-based and best-practice recommendations. These guidelines were implemented through the use of electronic health record smart-phrases, note templates, and clinical workflows to ensure consistency in application and to foster collaborative care around safe prescribing, monitoring, and response to aberrant patient behavior. These efforts were augmented by the introduction of in-office mental health clinicians and by a consultation service for complex cases.

OUD care within our clinic is supported by institution-wide substance use disorder-related efforts, including at-large addiction nurses who provide central triaging, first-point contact, and ongoing support to patients with OUD. In addition, institution-wide list-serves serve as forums to pose questions and get support from providers across the institution with various experiences in addiction medicine.

Structure: How Our System Is Organized/Who Reports to Who

To change our structure of managing patients with chronic pain, we added a quality improvement process that was part of a larger, institution-wide project. We developed a registry of all patients on chronic opioids and a dashboard with clearly defined quality metrics. The clinic director used this registry to review these metrics at regular staff meetings.

We also created a structure to improve the management of patients with OUD by creating an interdisciplinary team comprising a physician, physician assistant, nurse, an appointment scheduler, medical assistant, and psychotherapist to provide group-based opioid treatment (GBOT) as the primary treatment approach to OUD 17 ⇓ – 19 and to provide oversight and support to all providers. All patients diagnosed with OUD were referred to this GBOT team for initial treatment. The team had designated time for weekly meetings to discuss patient care, and a full-time addiction nurse served as the hub of the team, always available to patients and clinicians.

Soft Elements

Staff: the people and their special capabilities.

For chronic pain management, we use a team-based, patient-centered medical home approach to clinical care, in which each member of the clinical team was taught to manage specific responsibilities when patients are seen for chronic pain visits. 20 ⇓ ⇓ – 23 This approach also includes utilization of primary care-based, on-site mental health staff who provide individual and group-based treatment for patients with chronic pain. As our institute evolved to dedicate more time and resources to managing chronic pain, our mental health staff (psychologists and care partners) at all 13 primary care sites were trained to offer evidence-based chronic pain treatment modalities.

For management of patients with OUD, we identified a core group of clinical and administrative staff members who expressed an interest and passion to work collaboratively helping patients with OUD. They were given designated time for training and mentorship to build their competencies over time. Both the lead physician and nurse have since acquired specialized addiction training and made addiction care a majority part of their practice. At the larger, system-wide level, our institution hired additional nurse case managers, who had specialized training in addiction to support the integrated health system efforts to provide OUD treatment across all primary care sites, hospitals, and our outpatient addiction services site.

In addition, we created a team comprising a psychologist, psychiatrist, pharmacist, addiction experts, palliative care, and primary care physician to provide consultation services for chronic pain and addiction management.

Skills: Skills and Competencies Needed to Get the Job Done

In caring for patients with chronic pain, medical assistants were trained to complete the prework of the visit, such as collecting urine samples for toxicology testing, checking the PDMP, and administering questionnaires. Care partners learned how to teach patients about nonpharmacologic approaches to pain management, such as relaxation and stress management techniques, cognitive restructuring, and pacing strategies. Psychologists used specific psychotherapeutic modalities for pain management, including Acceptance Commitment Therapy, Cognitive Behavioral Therapy, and Mindfulness.

In addition to training and certification of all physicians to provide MOUD, all nurses, staff members, and clinicians received training in emergency opioid overdose reversal via naloxone administration. We used regular meetings with all clinical and administrative staff to share personal stories of opioid addiction and overdose as well as patient success stories to create a culture that destigmatizes patients with OUD and promotes a medical treatment model.

Leadership Style

In managing patients with chronic pain, we used a participative leadership model, 24 which encourages the participation of all members of the practice with the final decision made by those in official leadership positions. Our clinic director shared institution-based and site-specific recommendations at clinic-wide meetings. She invited discussion and solicited feedback from providers to promote buy-in and create a shared approach to managing patients with chronic pain. Emerging change leaders 25 bore more responsibility, such as ongoing revision of clinic policy and oversight of provider education.

In managing patients with OUD, we used a centralized leadership approach in which a physician and full-time addiction nurse assumed clinic-wide oversight and were further supported by an interdisciplinary care team, a system-wide consultation service, and a shared provider list-serve.

As a result of these changes implemented over the past 5 years, we were able to unfreeze the existing culture and have since refrozen this culture, with its associated strategy, systems, structure, staff, skills, and leadership style, to care for patients with chronic pain and patients with OUD.

For patients with chronic pain, our efforts resulted in the creation of standardized rules (see Appendix). Our institution developed quality metrics around patients with chronic pain on chronic opioids and electronic health record tracking methods. Among our patients with chronic pain on chronic opioids (1% of our empaneled patients), 73% have signed a controlled substance use agreement, 60% have had adequate urine monitoring over the past year, and only 35 patients receive high doses (more than 100 morphine milligram-equivalents per day). Our goal is to continue to improve these measures.

For patients with OUD, our efforts have resulted in policies that require all physicians and residents to receive B/N training and waiver. Clinic-wide meetings have resulted in all staff members being trained on responding to an opioid overdose using naloxone. Our group-based approach to treating OUD has become embedded into our clinical practice, with clearly defined roles and responsibilities for all team members (including designation of a full-time addictions nurse). We provide multiple weekly group visit medical appointments on a rolling basis so that patients have received continuous access to care since its inception, and we are able to care for approximately 125 patients at any given point in time. Similar to efforts around chronic pain management, our institution has set OUD metrics and now tracks them via our electronic health record. Thirty percent of patients with a diagnosis of OUD are receiving MOUD, with a goal of 34%.

We provide ongoing, regularly scheduled training and support to providers via monthly practice inquiry meetings 26 and biweekly interdisciplinary consultation service meetings that support primary care clinicians in managing difficult pain and addiction cases. We have developed and implemented a chronic pain and addiction curriculum for our residents that builds in experiential and didactic learning throughout all 3 years of their training.

Limitations

The goal of this project was to describe our process for implementing change in an organization, rather than showing its effect. We believe that using the Lewin and McKinsey 7S models to guide change can be helpful for practices wishing to address the twin goals of better management of patients with chronic pain with opioid analgesics and the treatment of patients with OUD. There are other models of change management that may also be helpful to provide guidance. 27 ⇓ – 29

Although we feel the culture has changed within our clinic, there are likely pockets within our organization in which the old attitudes remain. Our 5-year time frame to measure culture change induction and sustainability is relatively arbitrary, although it fits into standard estimates of culture change. 30 Rather, the nature of the cycle of a change project is inherently iterative and requires constant reinforcement. Our results attempt to highlight the practices, people, skills, and infrastructure that have been built into our system, have demonstrated a sense of stability and sustainability, and now represent our clinic's current culture.

We recognize that, within this overall framework, the change components we chose are unique to our environment; other organizations should choose components that are best suited to their local setting and context. Our environment was likely bolstered by a clinical and educational milieu that supports ongoing change improvement efforts. At the system-wide level, our institute supported change efforts around managing chronic pain and addiction, making it a priority in its vision and mission, providing time and resources to support institution-wide chronic pain and OUD treatment. At the clinic-wide level, we were fortunate enough to have agreement about the need for change from both clinical and residency leadership, an enthusiastic leader who overcame the inertia common in many organizations 31 to start the change process, and many key leaders and office staff who had received extensive training in organizational change management and process improvement methodology. As a result, continuous quality improvement was an everyday aspect of our practice and change fatigue 32 was not a barrier.

This article describes a case study of an approach to addressing the twin goals of improving opioid prescribing for pain management and treating patients with OUD through a collaborative, interdisciplinary, team-based, evidence-based, and patient-centered culture with associated structural supports. The Lewin and 7S models of change can be helpful approaches to practice transformation because they acknowledge the system, culture, and individuals in an organization that have to be addressed to initiate change and make it stable and sustainable. Other practices interested in such transformation can consider these models as guides.

Chronic Pain: “The Rules”

New patients on opioids from an outside clinic should not be continued since the clinician needs time to review previous records, check MassPAT, and determine if opioids are appropriate

Generally, patients on chronic opioids managed by the team should see their primary care clinician a minimum of every third visit

Visits should be every 3 months for most patients (they might need to be seen more frequently if actively adjusting meds/higher risk; or space out if low risk)

If starting on opioids: use the Opioid Risk Tool to assess risk 1

All patients must have controlled substance agreement; this should be renewed annually

Check PDMP for EVERY opioid prescription (document with “.opiateprescriptionadult”)

Order urine drug screen twice annually for low risk, more frequently for higher risk 2

Order in Epic: “Addiction” Maintenance/ Pain Management (makes sure that fentanyl, methadone, and buprenorphine are included)

Add Chronic Pain Plan in the problem list (“.painplan”)-this should be a shared document that is continually updated for care coordination/management between multiple clinicians and inbox coverage

Use templated notes: Chronic pain note (“.chronicpaininitial” or “.chronicpainfollowup”)

PEG 3 score at every visit (Embedded in note and can use “.painpeg” as a way to monitor pain and quality of life)

Goal is to keep daily morphine-equivalents to <100 mg/day 4

Avoid concurrent central nervous system depressants, especially benzodiazepines

Focus on function/quality of life/safety

Naloxone prescription; Naloxone instructions in AVS (“naloxone”)

Refer complex cases to PASS (Pain and Addiction Support Services) Team

This article was externally peer reviewed.

Funding: none.

Conflict of interest: none declared.

To see this article online, please go to: http://jabfm.org/content/33/1/129.full .

↵ 1 There are numerous screening tools to assess risk for starting chronic opioids for pain management, including the Opioid Risk Tool (ORT), Diagnosis, Intractability, Risk, Efficacy (DIRE), Screener and Opioid Assessment for Patients with Pain (SOAPP), and Screening Tool for Addiction Risk (START). None of these has been proven superior to the others. (Moore TM, Jones T, Browder JH, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med 2009;10(8):1426–33. doi: 10.1111/j.1526–4637.2009.00743.x [published Online First: 2009/12/22]) We chose ORT for its simplicity.

↵ 2 Urine drug screen (UDS) frequency should be governed by physician-based judgment and concern for misuse of medications. There is not one established way to risk assess ongoing opioid use but rather numerous ways by using a benefit versus risk framework. Benefit can be assessed using functional scores such as the PEG functional questionnaire that we use and achievement of goals set by the patient and provider. Risk/harm of the opioid medication can be assessed using monitoring in the form of UDS (scheduled or random), pill counts, (scheduled or random), PDMP, reported history, and the Current Opioid Misuse Measure (COMM-9) tool. (McCaffrey SA, Black RA, Villapiano AJ, et al. Development of a Brief Version of the Current Opioid Misuse Measure (COMM): The COMM-9. Pain Med 2019;20(1):113–18. doi: 10.1093/pm/pnx311 [published Online First: 2017/12/14]) Providers are encouraged to use multiple approaches to make an overall benefit versus harm assessment. The Centers for Disease Control and Prevention recommends performing UDS annually (2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report.: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services; 2018 [Available from: https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf accessed June 10, 2019 2019.), and our institute recommends at least every 6 months. For patients at higher risk, based on other benefit versus harm assessments, the physician may decide to do more frequent monitoring; our clinic-working group suggested every 1–3 months for high-risk patients.

↵ 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686775/ .

↵ 4 The Centers for Disease Control and Prevention now suggests less than 90 morphine equivalents/day.

• Received for publication June 25, 2019.
• Revision received September 23, 2019.
• Accepted for publication September 25, 2019.
• 1. ↵ 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Surveillance Special Report . Washington, DC : Centers for Disease Control and Prevention, U.S. Department of Health and Human Services ; 2018 . ( Accessed June 10, 2019 , at https://www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf ).
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Walmart Change Management Case Study

Change management is an essential aspect of any business that seeks to remain competitive in a dynamic market environment.

Walmart, one of the world’s largest retail giants, has had to navigate through significant changes in the retail industry, including the growth of e-commerce and shifting consumer behaviors. 

To maintain its position as a leader in the retail industry, Walmart has had to employ effective change management strategies to adapt to these changes successfully. 

This blog post presents a case study of Walmart’s change management efforts, exploring the strategies employed, the results achieved, and the lessons learned. 

By understanding Walmart’s approach to change management, businesses can learn valuable lessons and insights to help them navigate through their own organizational changes successfully.

Introduction to Walmart and its significance in the retail industry

Walmart is a multinational retail corporation that operates a chain of discount department stores, grocery stores, and hypermarkets. 

Founded in 1962 by Sam Walton, Walmart has grown to become one of the world’s largest retail companies, with over 10,000 stores in 27 countries and employing over two million people globally. 

Walmart’s success can be attributed to its focus on providing low-cost products, a wide range of merchandise, and a convenient shopping experience to its customers. 

Walmart’s innovative business strategies, such as its use of technology and supply chain management, have significantly impacted the retail industry, driving competitors to adopt similar approaches to remain competitive. 

Walmart’s success has made it a significant player in the retail industry, with its strategies being studied and emulated by businesses around the world

History of Walmart’s growth and success

Walmart’s growth and success can be traced back to its founder, Sam Walton, who had a vision of creating a retail store that offered low prices to customers. 

Walton opened his first store in Rogers, Arkansas, in 1962, which quickly became popular due to its low prices and convenient location. 

In the following years, Walmart expanded rapidly, opening more stores across the United States and becoming a publicly traded company in 1972.

Throughout the 1980s and 1990s, Walmart continued to grow, opening new stores and expanding into new markets. 

Walmart’s success was due, in part, to its innovative business strategies, such as its use of technology to manage inventory and supply chain operations, as well as its focus on providing low-cost products to customers. 

Walmart’s efficient operations and ability to negotiate lower prices with suppliers allowed the company to offer products at a lower cost than its competitors.

By the 2000s, Walmart had become a global retail giant, with stores in multiple countries and a significant impact on the retail industry. 

Despite facing criticism over its labor practices and impact on small businesses, Walmart’s focus on low prices and convenience to customers continued to make it a popular choice for shoppers. 

Today, Walmart remains one of the largest and most successful retailers in the world, with a significant presence in the retail industry.

Overview of Walmart’s organizational structure and culture

Walmart has a hierarchical organizational structure, with a clear chain of command and multiple levels of management. 

At the top of the hierarchy is the CEO, followed by executive vice presidents, senior vice presidents, and vice presidents. 

Each level of management is responsible for overseeing specific areas of the company’s operations, with clear lines of authority and responsibility.

Walmart’s culture is focused on providing low-cost products to customers and delivering a convenient shopping experience.

The company values efficiency, innovation, and collaboration, and encourages employees to take ownership of their work and contribute to the company’s success. 

Walmart’s culture is also characterized by its emphasis on customer service, with employees trained to prioritize the needs of customers and ensure they have a positive shopping experience.

Walmart’s culture has been shaped by its founder, Sam Walton, who believed in empowering employees and giving them the resources they needed to succeed. 

This approach has been reflected in the company’s employee policies, such as its emphasis on training and development programs, as well as its commitment to offering competitive wages and benefits to its workers. 

Need for Change Management at Walmart 

The retail industry has undergone significant changes in recent years, with the growth of e-commerce, shifting consumer behaviors, and increased competition. 

To remain competitive in this dynamic environment, businesses need to be agile and adaptable, constantly evolving their strategies to meet changing customer needs and market conditions. 

For Walmart, this has meant the need for effective change management strategies to remain competitive.

One of the main challenges facing Walmart has been the growth of e-commerce, with online retailers such as Amazon disrupting the traditional brick-and-mortar retail model. 

To compete in this new environment, Walmart has had to invest heavily in its e-commerce capabilities, including expanding its online product offerings and improving its supply chain operations. 

Walmart’s change management strategies have included acquiring online retailers, such as Jet.com and Bonobos, and investing in its own e-commerce platform to better compete with Amazon and other online retailers.

Another challenge facing Walmart has been shifting consumer behaviors, with customers demanding more convenience and personalized experiences. 

Walmart has responded by investing in its mobile app, offering online grocery pickup and delivery services, and improving its in-store experience through the use of technology such as self-checkout machines and interactive displays. 

These changes have required effective change management strategies, including employee training programs and leadership support, to ensure successful implementation and adoption.

How did Walmart manage changes?

Walmart’s response to the need for change has been largely successful, with the company implementing a range of strategies to remain competitive in a rapidly changing retail environment. 

Here are three examples of Walmart’s successful responses to the need for change:

1. Expansion of E-commerce capabilities

Walmart recognized the need to improve its online presence to compete with e-commerce giants like Amazon. To achieve this, Walmart acquired online retailer Jet.com and other e-commerce companies, and invested in its own online platform. These moves have helped Walmart significantly improve its online offerings, including its product selection and delivery options.

Walmart has leveraged its physical stores to offer convenient options like online grocery pickup and delivery, which has helped attract customers looking for a blend of online and offline shopping experiences.

Walmart’s investments in e-commerce have paid off, with its online sales increasing by 79% in Q2 2020, driven in part by the COVID-19 pandemic and increased demand for online shopping.

2. Focus on Sustainability

Walmart has recognized the importance of sustainability and environmental responsibility in its operations. The company has implemented a range of initiatives to reduce waste, lower carbon emissions, and promote sustainable practices across its operations. These initiatives include reducing plastic waste, investing in renewable energy, and sourcing more sustainable products.

Walmart’s sustainability efforts have not only helped the environment but have also resonated with customers who are increasingly conscious of the impact of their purchases. Walmart’s focus on sustainability has also helped the company reduce costs and improve efficiency, which has contributed to its bottom line.

3. Embracing Digital Transformation

Walmart has been at the forefront of using technology to improve its operations and customer experience. The company has invested in technologies such as robotics, artificial intelligence, and data analytics to improve its supply chain operations and enhance its in-store experience.

For example, Walmart has implemented autonomous robots in its stores to help with tasks like restocking shelves and cleaning floors, which has helped free up employees to focus on customer service. Additionally, Walmart has leveraged data analytics to better understand customer behavior and personalize its offerings, such as offering tailored product recommendations to shoppers.

Two Factors that explained the successful implementation of Walmart change management 

Walmart’s successful implementation of changes has been driven by a combination of strong leadership, employee engagement, and embracing new technology. 

By leveraging these factors, Walmart has been able to adapt to changing market conditions and remain competitive in a rapidly evolving retail industry. 

But the two most crucial factors behind the successful change management at Walmart are as follows:

Data-Driven Decision Making

Walmart has leveraged data analytics to make more informed and strategic decisions. By collecting and analyzing data on customer behavior, supply chain operations, and other key metrics, Walmart has been able to identify areas for improvement and make data-driven decisions about where to invest resources. This has helped Walmart prioritize its efforts and ensure that it is focusing on the initiatives that will have the greatest impact on its business

Focus on Customer Experience

Walmart has made a concerted effort to prioritize the customer experience in its change management efforts. For example, the company has invested in technologies like data analytics and artificial intelligence to better understand customer behavior and preferences, and has used this information to tailor its offerings to individual customers.

05 Lessons Learned from Walmart successful implementation of change management 

Here are five lessons that can be learned from Walmart’s successful change management efforts

• Emphasize strong leadership: Strong leadership is critical to the success of any change management effort. Walmart’s leadership was instrumental in driving the company’s change management efforts and ensuring that everyone was aligned with the company’s strategic goals.
• Engage employees: Engaging employees in the change management process is essential to building a resilient and adaptable workforce. Walmart invested heavily in employee training and encouraged workers to take ownership of their work, which helped foster a culture of innovation and adaptability.
• Leverage data analytics: Data analytics can provide valuable insights into customer behavior and other key metrics, which can help identify areas for improvement and guide strategic decision-making.
• Be flexible and agile: Flexibility and agility are critical to adapting to changing market conditions. Walmart was able to stay ahead of the curve by quickly adapting its operations to meet changing customer needs and preferences.
• Prioritize the customer experience: Prioritizing the customer experience is essential to building loyalty and driving sales. Walmart made a concerted effort to tailor its offerings to individual customers and invested in initiatives like online grocery pickup and delivery to make shopping more convenient and efficient

Final Words 

Walmart’s successful change management efforts provide valuable insights into how organizations can adapt to changing market conditions and remain competitive. By prioritizing strong leadership, employee engagement, data analytics, flexibility and agility, and the customer experience, Walmart was able to successfully implement changes that helped the company stay ahead of the curve.

As the retail industry continues to evolve, Walmart’s example serves as a reminder of the importance of remaining adaptable and open to change. By embracing new technologies, investing in employee training, and prioritizing the customer experience, organizations can position themselves for success in an ever-changing marketplace.

About The Author

Tahir Abbas

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An Agile Approach to Change Management

• Sarah Jensen Clayton

Six lessons on moving quickly under pressure.

In the wake of Covid-19, organizations are fundamentally rethinking their product and service portfolios, reinventing their supply chains, pursuing large-scale organizational restructuring and digital transformation, and rebuilding to correct systemic racism from the ground up. Traditional change management process won’t cut it. The author borrows from agile software development processes to reinvent the change management playbook.

The business world has arguably seen more disruption in the last nine months than in the last nine years, bringing new and urgent demand for change. Initiatives are being launched by the dozen, adoption can’t happen fast enough, and the stakes are higher than ever. In the midst of a Covid-induced recession, and with some industries on the brink of extinction, change isn’t about fine-tuning — it’s existential.

• Sarah Jensen Clayton is a senior partner with Korn Ferry. She works with leadership teams to define, align around, and activate enterprise and ecosystem change.

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