Change Management in Health Care: Robert James Campbell, Edd

The Health Care Manager
Volume 27, Number 1, pp. 23–39

Copyright # 2008 Wolters Kluwer Health |
Lippincott Williams & Wilkins
Change Management
in Health Care
Robert James Campbell, EdD
This article introduces health care managers to the theories and philosophies of John Kotter and
William Bridges, 2 leaders in the evolving field of change management. For Kotter, change has
both an emotional and situational component, and methods for managing each are expressed in
his 8-step model (developing urgency, building a guiding team, creating a vision, communicating
for buy-in, enabling action, creating short-term wins, don’t let up, and making it stick). Bridges
deals with change at a more granular, individual level, suggesting that change within a health care
organization means that individuals must transition from one identity to a new identity when they
are involved in a process of change. According to Bridges, transitions occur in 3 steps: endings,
the neutral zone, and beginnings. The major steps and important concepts within the models of
each are addressed, and examples are provided to demonstrate how health care managers can
actualize the models within their health care organizations. Key words: change management,
information technology, transitions
If your time to you most widely regarded thinkers in change man-

Is worth savin’ agement. The following discussion focuses
Then you better start swimmin’ on how the ideas of these 2 experts can be
Or you’ll sink like a stone
For the times they are a-changin’ used to successfully implement a change man-
(Bob Dylan) agement project.
ODAY’S HEALTH CARE manager occu-

T pies an extremely challenging position:
how to maintain a competitive edge in the
KOTTER’S CHANGE
MANAGEMENT MODEL
health care market while leading an organiza-
tion through constant change. Rapid change is Kotter believes that organizational change
occurring as health care organizations (HCOs) can be managed using a dynamic, nonlinear
strive to adopt new technology such as the 8-step approach. The steps in his model
electronic health record (EHR), implement include the following:
quality improvement initiatives, and institute Increase urgency
pay-for-performance plans. To deal with this Build guiding teams
change and help employees transition to new Get the vision right
ways of doing things, managers need an edge. Communicate for buy-in
Providing this edge are the philosophies of Enable action
John Kotter and William Bridges, two of the Create short-term wins
Don’t let up
Make it stick
Kotter organizes each of these steps into 3
distinct phases. The first phase is called
Author Affiliations: Department of Health Services ‘‘creating a climate for change’’ and includes
and Information Technology, East Carolina
University, Greenville, North Carolina. steps 1, 2, and 3. The second phase, ‘‘engag-
ing and enabling the whole organization,’’
Corresponding author: Robert James Campbell, EdD, consists of steps 4, 5, and 6. The final phase,
Department of Health Services and Information
Technology, East Carolina University, Greenville, ‘‘implementing and sustaining the change,’’
NC 27834 ([email protected]). encompasses steps 7 and 8.
23
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
24 THE HEALTH CARE MANAGER/JANUARY–MARCH 2008
SEE ME, FEEL ME, TOUCH ME adopt a ‘‘see-feel-change’’ approach. Using

this approach at each stage in the model, the
To fully appreciate Kotter’s work, the health care manager must create a ‘‘compel-
manager must understand 2 prominent ideas ling, eye-catching, dramatic situation,’’1(p11)
about the suppression and engenderment of geared to helping an employee envision a
employee emotions. During any period of problem and to identifying a solution to a
change, a manager must deal with feelings problem. This creates feelings within em-
of complacency, anger, false pride, pessimism, ployees that help them overcome negative
arrogance, cynicism, panic, exhaustion, in- feelings toward change and adopt feelings
security, complacency, and anxiety among that promote change. This engenders what
employees.1(p180) These are all emotions that Kotter describes as ‘‘emotionally charged
can undermine attempts at promoting change. change behavior or reinforced changed
As will be discussed below, Kotter’s model behavior.’’1(p11) When behavior is fueled by
provides tools for turning these negative emotion, it is more likely to last longer than
feelings into positive proactive feelings such when fueled by analysis because it will be
as faith, trust, optimism, urgency, reality- resistant to negative emotions such as cyni-
based pride, passion, excitement, hope, and cism and rumination, which are driven by
enthusiasm,1(p180) emotions that promote analysis and a skewed interpretation of the
change. A second major idea centers on the facts. One caveat is that during the see-feel-
mindset that a health care manager must change process, analysis and facts will be
adopt before setting out on a change ini- needed to bolster a dramatic presentation.
tiative. Kotter identifies the ‘‘analysis-think- However, analysis alone will not guarantee
change’’ mindset as the traditional method the success of a change management project.
used by managers to initiate change. At To further flesh out how the see-feel-change
this level, the focus is on cognition and mindset is actualized, each step in Kotter’s
rational thought, by presenting individuals Change Model will be introduced and
with information in the form of reports, discussed from the perspective of a health
PowerPoint presentations, and Excel spread- care manager.
sheets, which form the basis of analysis.
This leads individuals to change their think-
ing and, ultimately, their behavior. For CREATING A CLIMATE FOR CHANGE
Kotter, this mindset rarely uncovers the ‘‘big
Urgency—let’s do it!
truths’’1(p12) about why change is necessary.
Employees do not need 200-page reports to At the end of the movie Animal House (1978),
show them why paper patient documenta- John Belushi’s character, Bluto Blutarsky, pro-
tion hinders physician decision making and vides a perfect example of how to develop a
generates increased risk of medical errors. sense of urgency in a group of complacent,
Moreover, ‘‘analytical tools work best when anxious, dispirited individuals. Rather than
parameters are known, assumptions are mini- overwhelming his peers with information—
mal, and the future is not as fuzzy.’’1(p12) in fact, the little information he does divulge
Finally, according to Kotter, analysis rarely is wrong—as he wants us to believe that the
changes how people think, and it does not Germans bombed Pearl Harbor, Blutarsky im-
‘‘send people running out the door to act in plores his fraternity brothers to believe that
significantly new ways?’’1(p13) To drive home the war between the fraternity and the ad-
this point home, when employees are moti- ministration is not over until they say it is
vated, it is something that they feel in their over. In the end, everyone rushes out of the
hearts and not in their heads that impel room and into action to the cry of Blutarsky’s
them into action. ‘‘let’s do it!’’
To instill a feeling of action in employees’ This is the kind of urgency that Kotter calls
hearts, Kotter recommends that a manager for managers to instill in their employees,
Change Management in Health Care 25
‘‘making sure that sufficient people act with group, administrators sent a letter about
sufficient urgency—with on your toes be- the need for more cost-effective prescribing
havior that looks for opportunities and along with a photocopy of the $400,000
problems, that energizes colleagues, that check that the group had to pay to the health
beams a sense of let’s go.’’1(p17) plan to cover losses. This immediately grabbed
To develop a sense of urgency in an orga- the physicians’ attention and changed the way
nization preparing to implement an EHR, a they prescribed medications.3 To reiterate, the
health care manager has several options. One key to developing urgency among employees
powerful option is to create a video presen- is to help them see firsthand what or why a
tation showing an angry parent whose change needs to occur.
daughter has died in the hospital because
of a medical error that could have been
Building a guiding team
prevented if the patient’s information was
stored electronically rather than on paper.2 As a sense of urgency grows among em-
Using another video-based scenario, a pre- ployees, managers must turn their attention
sentation that provides examples of treating to the development of a guiding team. Select-
a patient with multiple health problems ing the right members for a team is im-
using a paper record and the electronic perative because these individuals will guide
record could be developed. Using the paper the change management project throughout
record, the attending physician, along with the remaining steps. Kotter believes that
other health care professionals, will have to candidates for the guiding team must possess
sift through many paper documents to find a well-defined skill set. First off, a candidate
the needed information. On the other hand, must have relevant knowledge about the
the electronic record allows the physician to changes that occur in the health care
locate information rapidly and even create industry. This includes familiarity with the
trend data on the fly. This can reduce the benefits of EHR implementation, various
cognitive load placed on the physician and quality initiatives, the reduction in medical
speed up the decision-making process. errors, and measures for reducing the esca-
A more interactive example would be to lating cost of health care. This knowledge
find a similar facility that has successfully will help team members develop the overall
implemented an EHR product. The manager vision for the change management project.
could then schedule times when staff mem- A second skill is the ability to establish
bers (nurses, physicians, residents, and ad- credibility with peers. Guiding team mem-
ministrators) could visit the facility, with staff bers who are perceived as credible will bring
members engaging their counterparts. They a sense of trust to the team, and with trust
could ask questions and share stories with comes believability. When employees trust
each other. In this manner, employees would individuals in a leadership role, they are
get a chance to see the product in action, more likely to believe what is being commu-
gain firsthand knowledge of how the elec- nicated and are more likely to be motivated
tronic record could benefit their own facili- to take action.
ties, and interact with colleagues who are A third skill, development of relevant
using the technology on a daily basis. This knowledge, focuses on the expertise that
will heighten a sense of urgency while driv- an individual has regarding the inner work-
ing down feelings that prevent change from ings of the department, division, or group.
taking place. This will help remove barriers that hinder
A final example comes from a multispe- people from enacting change within specific
cialty group that found itself in the red areas of the organization. A fourth skill,
because of its prescribing practices under a formal authority, recognizes that the individ-
full-risk capitation contract. To develop a ual has the ‘‘managerial skills associated with
sense of urgency among the physicians in the planning, organizing, and control’’1(p46) to
identify tasks and procedures that will help a diverse, multitalented group of individuals
the change management project achieve a to form sets of teams to guide a change man-
series of short-term wins. agement project.
The final skill, leadership, guarantees that
the individual has the ability to develop and
Get the vision right!
communicate a vision and motivate individ-
uals to achieve the vision. Along with these Daily, health care managers are inundated
skills, a manager should identify candidates with information found in trade and research
for the guiding team that provide ‘‘different journals, newspapers, conference proceed-
perspectives and backgrounds’’1(p45) from ings, and Internet Web sites calling for their
throughout the organization. To achieve this HCO to implement information technology
goal, candidates should be selected from to improve patient safety, reduce medical
horizontal and vertical positions on the errors, institute quality control initiatives,
organizational chart. increase physician order writing, provide
A good example of how a guiding team better decision support, reduce transcription
was developed to facilitate the implementa- errors, and redesign hospital workflow. To
tion of a computerized physician order entry produce this type of change, the health care
system (CPOE) comes from the Ohio State manager, along with the guiding team, must
University Health System (OSUHS). This sys- develop a vision expressed in a clear, concise
tem includes a university hospital, a tertiary statement about the direction in which their
medical-surgical care facility, a comprehen- organization is headed. A good vision state-
sive cancer center, a neuropsychiatric hos- ment will consider the options that are
pital, and numerous clinics and physician available when answering questions such as
offices. The OSUHS guiding team included 2 the following:
components, a design team and a physician What does it mean to be a completely
consultant team. The design team included a wireless health care facility?
laboratory technician, a pharmacist, a radiol- What does it mean to completely rede-
ogy technician, information systems person- sign physician workflow to incorporate
nel, nurses, and clinical staff. electronic documentation?
Because physicians were to be the primary What does it mean to create a quality-
users of the CPOE system, OSUHS manage- sensitive culture within a health care
ment created a separate physician consultant facility?
team, charged with ‘‘approving system de- What does it mean to be a paperless
sign and operational policy’’4 that directly HCO?
affected the CPOE implementation. The con- If a manager and guiding team do not
sultant team was made up of experts from understand the answers to these questions,
emergency medicine, oncology, gynecol- they will never be able to develop an
ogy, pulmonary, cardiology, surgical oncol- adequate vision for their organization and
ogy, surgical transplant, pathology, radiology, successful change will be impossible.
and general medicine. Members of this team To develop a vision statement, Kotter rec-
included both ‘‘junior and senior attending ommends that the guiding team identify ‘‘six
staff and fellows.’’4 To ensure project suc- or seven broad visions of the future.’’1(p64)
cess, OSUHS managers paid for release time For each vision, identify key dimensions that
to departments who would be losing physi- would help describe the options available for
cians to the consultant team. Both the design each vision. In health care, sample dimen-
and consultant teams played key roles in sions include the following:
validating design elements, policies, imple- Support staff: What support staff would
mentation plans, and training methodologies be needed to sustain this vision?
for the CPOE project. This example shows Health care professionals: How would
how management was able to bring together this vision affect the medical staff?
Patients: How would this vision affect adopted, the design team can debate the
our patients? following kinds of questions:
Care: Under this vision, what kind of 1. What would our organization look like
care could we provide our patients? under this picture?
What other forms of medicine could be 2. What technology would we need?
practiced? Could we, for example, de- 3. Would this affect the care we give our
velop a telemedicine department? Could patients?
we perform more outpatient care? 4. Would this change the demands our
Competitors: What are our major com- patients make on the medical staff?
petitors doing in this area? Are we 5. What would our support staff look like?
keeping pace or falling behind? 6. Would our patient mix change?
Revenues: How much revenue would be 7. How would present workflow change?
produced if we implemented this vision? 8. How would this affect our medical staff ?
Would revenue increase or decrease? Discussions centering on each picture can
Would we experience cost savings in be an iterative process, and when a specific
other areas, such as transcription? picture becomes clearer, there will be a
Action steps: What steps must be taken natural tendency for the discussion to
to make this option attainable? gravitate toward that picture. When this
As the guiding team comes together to happens, more options will be uncovered
discuss their vision of the organization, an while others will be dismissed until a single
attempt should be made to ‘‘paint pic- picture begins to emerge. Guiding team
tures of the future.’’1(p65) In a situation members will know that they have a com-
where a guiding team is thinking about pelling picture if it appeals to the heart and
how the organization can adopt the use of motivates members of the guiding team.
the electronic record, several pictures may One warning that Kotter delivers that can
develop, examples of which can be found be applied to health care is that many
in Table 1. pictures and subsequent vision statements
For each resulting picture, a brief summary are tied directly to cost containment, greater
is created and distributed to members of the efficiency, and savings, and these kinds of
team. At team meetings, each picture is visions may be a turnoff to many health
discussed. To focus discussion and deter- professionals because they consider their
mine the ‘‘magnitude of change’’1(p65) that primary reason for being in their specific
would take place if a specific picture were fields is to be of service. A guiding team,
Table 1. Future pictures of the organization
Picture Scenario
Picture 1: Integrate a hybrid medical record into Dictation, laboratory, and x-rays might be available
the facility. electronically, whereas progress notes, ancillary care,
provider information, trend data, and orders remain
on paper.
Picture 2: Implement EHR in physician offices.
Picture 3: Implement EHR as part of an effort to Install EHR in physician offices and the pharmacy.
reduce prescription order errors.
Picture 4: Implement EHR to improve physician Install EHR in physician offices, radiology, laboratory,
order entry. and pharmacy.
Picture 5: Implement EHR to reduce medication Install EHR in physician offices, pharmacy, nursing
errors. stations, and bedside.
Picture 6: Fully implement the EHR within all the
departments of the health care organization.
faced with implementing an electronic re- when all the information he needs can be
cord, will focus on how this type of change found on a computer. Cogley replies that if
can improve the service that the organization you want to understand the law, the true
provides to the patients and families who intent of the law, you must understand and
come to them for care. Adoption of a service- comprehend the original sources of the law
oriented vision statement will raise urgency itself, which can be found only in books, not
among staff and motivate them to work as in the synthesized and homogenized legal
hard as they can to make the proposed decisions and precedents found on the com-
changes a reality. The following is an ex- puter. This scene highlights the current
ample of a service-related vision statement: existential debate taking place between
physicians and proponents of EHR systems.
To serve patients through the implemen-
tation of a comprehensive, technologically Many physicians fear that the EHR, with its
evolving electronic medical record that will practice guidelines and orders sets, will make
provide reliable, efficient, and affordable them obsolete and usurp their power to
health care services by enthusiastic, helpful, make case-by-case decisions. This example
and qualified personnel who will strive for also highlights the fact that whenever a guid-
better disease management to improve pa-
tient outcomes. ing team announces an impending change,
anxiety, anger, fear, and panic among staff
From this example, we see that a guiding and health care professionals will rise. Kotter
team will first develop a set of pictures de- points out that whenever a change is about
scribing possible scenarios for planning for to take place, people begin to wonder: ‘‘Will
the adoption of an electronic record. Once a this hurt me?’’1(p84) To quell these negative
picture is selected, the team will develop a feelings, the guiding team must develop
vision statement that can be used to describe methods of communication that address
the picture to the organization’s constituency. these feelings and help employees to ‘‘think
For Kotter, a successful vision statement and act in accordance with the new direc-
explains the employee behaviors needed, as tion’’5(p91) that the organization is headed.
well as those that should be eliminated. The To strategically plan for buy-in, a guiding
vision statement must call on people’s team can adopt a layered approach (Figure 1).
emotions and motivate them to take action. The communication buy-in layered approach
A good vision statement can be explained in model is based on the guidelines set forth by
a ‘‘sixty second elevator ride.’’5(p77) Kotter. At the center of the model is the vi-
Once the vision statement has been created, sion for the new HCO. Each successive layer
the guiding team can begin to flesh out the represents a set of strategies to promote the
strategy that will be used to achieve the vision, vision statement, detect and overcome resis-
develop plans to implement the strategy, and tance, and build commitment toward the
fund the budget to pay for the plans. proposed changes.
To effectively use the model, a guiding
ENGAGING AND ENABLING THE team must identify the individuals or groups,
WHOLE ORGANIZATION internal and external to the HCO, who will
be affected by the change. Examples include
Communicate buy-in
physicians, nurses, radiologists, pharmacists,
The original Star Trek series included an administrators, patients, and third-party pay-
episode titled ‘‘Court Martial.’’ In this epi- ers. For each individual or group, the guiding
sode, Kirk is accused by the ship’s computer team needs to create a set of projections that
of inadvertently killing one of the members forecast how proposed changes will influ-
of his crew and must stand trial. In a ence the information needs, concerns, roles,
poignant scene, Kirk confronts his lawyer, levels of effort, and degrees of commitment
Samuel T. Cogley. Kirk wants to know why of each group. These projections will be use-
Cogley has turned his quarters into a library, ful for developing and selecting appropriate
Figure 1. Communicate for buy-in layered model.
messages and channels of communication at at the first layer of the communication for buy-
each layer of the model. in model: communicating the vision.
Feeling the heat
Communicating the vision
A guiding team must take the same ap-
An effective way to communicate the vi-
proach to monitoring change as a thermostat
sion is to develop an engaging story that
monitors the temperature in a room. Over
catches the attention of the change initiates.
the course of a change project, different in-
This step works to maintain the sense of
dividuals and groups will have a different
urgency developed earlier in the first step
temperature, represented by their feelings
of the change model and to display how
toward the changes taking place at a specific
achievement of the vision will lead to the
point in time. These feelings, according to continued growth and development of the
Kotter, can be mapped out along a con-
HCO. A short, inexpensive video presenta-
tinuum ranging from awareness, understand-
tion showing an interview done with a
ing, collaboration, commitment, and advocacy.
patient injured by a medical error would
Awareness is achieved when an individual or
provide a concrete example of how the im-
group is cognizant and familiar with the
plementation of an electronic medical record
change project. They display understanding
can be used to reduce medical and transcrip-
when they realize the assets, rewards, and
tion errors and improve patient documenta-
perquisites that will be gained once the tion and treatment.
change project has been completed. Collabo-
ration occurs when the individual is willing
Engaging in a continuous dialogue
to endorse or stand behind the change, and
with stakeholders
they will display commitment when they are
willing to engage in activities supporting the The goal at this layer is to monitor how
change. Finally, individuals display advocacy change initiates feel about the vision and the
when they maintain attitudes and behaviors change project at specific points in time. Is
that support the change process. By adopt- resistance building up in certain groups? Do
ing the metaphor of a thermostat, the guiding certain individuals feel left out of the
team can use generated projections to tailor process? Where pockets of resistance exist,
specific messages to specific individuals and the guiding team can use this information to
groups to help move them along the different communicate why the change is necessary
points in the continuum. This process begins and to build commitment and trust among
those groups and individuals resistant to display messages that employees will see on
change. a daily basis.
One powerful method described by Kotter Returning to the OSUHS CPOE implemen-
for creating a dialogue between the guiding tation, we find an effective example of how
team and change initiates is the question-and- one HCO communicated for buy-in across all
answer (Q&A) session.1(p84) Using this tech- 3 layers of the model. As discussed above,
nique, a guiding team prepares a set of OSUHS developed a physician consultant
questions they feel that employees within team charged with designing every order
the organization would ask regarding a pathway from basic consult to laboratories
proposed change project. For each question, for their CPOE system. The group would
the guiding team develops a short, clearly meet daily at 7 o’clock in the morning for 2
defined answer. To enact the Q&A session, hours to discuss prototypes of order path-
the guiding team uses role play, with the ways. After each meeting, physicians would
guiding team taking the role of management return to their departments and ask their
and the management taking on the role of colleagues to comment on the prototypes.
the employees asking the questions. Employ- The next morning, they would share those
ees play the role of observers. A variation of observations with the consultant team and
this practice could have the guiding team system programmers. This rapid develop-
develop a set of questions they feel that spe- ment cycle would continue until the selected
cific groups, such as radiologists, pharma- pathway was completed. In a conversation
cists, and nurses, might have regarding with Phyllis Teater, director of Information
proposed changes. For each question, the Systems Applications at Ohio State University
guiding team could develop an answer, re- Hospital Systems:
hearse their roles, and then meet with each
. . .the frequency and intensity of the meetings
group to discuss their concerns. made participants zealots. They would take
Enrolling the organization in the explanations and discussions back to their
departments. They became fantastic change
change effort management champions. They developed
At this layer, the guiding team needs to urgency and knowledge about why we were
doing something, and they gave clear and
increase the commitment that individuals concise explanations to the people in their
and groups have toward the change project. departments why something was done.
This means getting change initiates to take
action and participate in the change project. From this example, it can be seen how
New technologies can be a wonderful tool each layer of the communication buy-in
to help get people to take action. For exam- model can be actualized within an HCO
ple, Kotter explains how a portal can be managing change. To communicate the
designed to provide employees with infor- vision, members of the physician consultant
mation they need to do their jobs and to team meet with each other and with
learn why the proposed change is important members of their department to discuss the
to the organization. At another level, Web importance of clinical pathways. A dialogue
casts can be used to exchange important ensues with both groups sharing their feel-
messages between management and employ- ings regarding the prototypes. Because they
ees describing how the proposed change were involved in the design of the pathways,
project will enhance the HCO. Web casts can members of each department enrolled in the
be used to provide demonstrations of how change process by using the CPOE system
the adoption of new technologies, such as and the pathways contained within.
the EHR, can improve patient care and
Empowering action
enhance physician-patient communication.
Finally, as Kotter points out, screen savers As more and more people in the HCO
and desktop wallpaper images can be used to become involved in a change management
project, there will be times when they en- In terms of system roadblocks, an HCO can
counter obstacles preventing them from provide incentives, in the form of bonuses,
completing required tasks. These barriers raises, and promotions, to those individuals
can take shape in various forms and include who embrace the change effort. This practice
the supervisor, the system, mental barriers, will send a strong message to others within
and lack of information. Because of fear, the organization that those who embrace
arrogance, and stubbornness, supervisors are change will be rewarded, whereas those who
notorious for blocking changes within an resist will ‘‘sink like a stone.’’
organization. The system itself can block When the roadblock to change is more
change efforts by failing to reward and pro- mental than organizational, the guiding team
mote individuals who enthusiastically adopt can rely on the experiences of other
proposed changes. Individuals, whether they individuals, such as colleagues at other HCOs
are physicians, nurses, or radiologists, can who have gone through a similar change—
become roadblocks to change by adopting and survived. These individuals can be
the attitude that a specific change cannot take brought on as consultants who can reassure
place or by wholeheartedly believing that and present information that sends the
they will never survive the proposed changes. message ‘‘I survived this type of change,
In essence, the barriers exist in their minds you can too.’’1(p113)
and not within the organization. The final For the final roadblock, information, one of
barrier, information, comes in 2 forms, knowl- the most vital pieces of knowledge you can
edge needed to make decisions and feedback provide someone is feedback on how he or
on actions taken. When either 1 of these 2 she is performing. All too often, in many
sources of information is missing, individuals organizations, individuals feel that they are
and groups will be disempowered from already performing their jobs at a high level.
moving forward with proposed changes. Giving them accurate, timely feedback can
To overcome these barriers, several possi- show individuals how they can improve or
bilities exist. For a physician or department use a proposed change to their benefit.
head who is an obstacle to an EHR imple- Returning to the EHR example, suppose a
mentation, the design team can present the physician does not want to adopt an elec-
individual with a diabetic patient’s paper tronic medical record because in doing so, he
chart and the same chart in electronic form. or she will have to abandon the practice of
Team members can, after some training, ask dictation. One possibility to overcoming this
the physician to perform several tasks using barrier is to create an inexpensive video that
both forms of documentation. Those tasks documents all the steps involved in using a
include the following: paper record to document a patient encoun-
1. Charting how the patient’s weight has ter. This will allow physicians to see how
fluctuated over a 6-month time span much of their time is spent documenting
2. Charting how the patient’s hemoglobin patient care as opposed to providing patient
A1c levels have varied based on the care. To provide even more detail and expe-
current treatment regimen riential knowledge, physicians can be video-
3. Developing a list of all the medications taped using an EHR system, which will allow
that the patient has taken over the them to see that much of their documenta-
course of the year tion can be completed at the point of care,
As in other examples, this approach is based rather than at home, when they could be
on Kotter’s see-feel-change method to altering spending time with their family.
organizational behavior. Instead of inundating
Short-term wins
recalcitrant physicians with numbers and
facts, this instance provides them with first- As the pathways to change are cleared,
hand experience of how the EHR can improve empowered individuals and groups must be
their own and other physician’s workflow. careful to choose and complete tasks that
clearly show that the change management certainty. This kind of thinking, ‘‘we have
project is succeeding. Completed tasks won,’’ can be very detrimental to any type of
provide examples of short-term wins that change project. As short-term wins begin to
help to further build urgency and momen- pile up, people may start to believe that the
tum within the HCO and to lessen the impact change project is going to be a success and
that negative comments made by critics have they start to lose their sense of urgency. To
on the project. To succeed at this step, prevent this from occurring, the guiding
Kotter advises that guiding teams ‘‘achieve team can look for external factors that force
visible, meaningful, and unambiguous prog- an HCO to look at its current position in
ress quickly.’’1(p134) comparison to their competition. For exam-
The OSUHS CPOE installation provides a ple, an HCO may arrive at the point where it
further example of how short-term wins can has successfully implemented an EHR. While
be used to drive a change management everyone is standing around, congratulating
project. Recall the use of the physician themselves, the guiding team can remind
consultation team to create order pathways employees that a competing HCO has not
for the CPOE system. With each completed only installed an EHR but is also providing
pathway, the consultation team created a its patients with the ability to create a per-
short-term win that signaled to the rest of the sonal health record, make appointments,
organization that the CPOE change project view laboratory results, and pay bills via the
was successfully moving forward. Another Internet. This knowledge can help reener-
related short-term win was a process change gize the group and drive up their sense of
made before the implementation of the sys- urgency. In other instances, the guiding team
tem. When ordering tests, frequency is an can look for examples within the HCO that
important issue to consider; however, in the display to employees that the change process
current paper ordering system at OSUHS, is working but is not fully complete.
there was no standard for documenting order Once the OSUHS went live with their
frequency. Before moving to the online sys- CPOE system, they developed a special team
tem, the design team undertook a manual called the red coats. The red coats were a
effort to make people write orders with stan- group of physicians who received extensive
dard frequencies.4 This change in process training on the CPOE system and in conflict
provided a short-term win signaling that when resolution. Whenever physicians or other
people work together, change is possible. staff members had a problem using the
system, they would call the help desk and a
red coat was immediately dispatched to solve
IMPLEMENTING AND SUSTAINING the problem. The red coats were also helpful
THE CHANGE in resolving problems that arose where a
belligerent physician claimed that the system
Don’t let up
was too difficult to use or that the system had
In mid-August of 1969, the Chicago Cubs caused them to lose all their data or was
had what was thought to be an insurmount- malfunctioning, again. The red coats would
able 9 1/2–game lead over the New York Mets investigate what happened and make a
for the National League’s Eastern Division determination as to whether the problem
title. Over the course of the next month and was system or user related.4
a half, in what has been described by many as This highlights the fact that even though
one of the greatest collapses in major league the CPOE system was successfully installed,
history, the Cubs ended the season 9 games the OSUHS guiding team realized that they
behind the Mets and out of the playoffs. To would have to deal with problematic end
many baseball observers, the Cubs thought users and unforeseen system problems. By
they had the pennant wrapped up, a playoff creating a team of physicians dedicated to
berth was not just a possibility, it was a solving these issues face-to-face, in a personal,
nonconfrontational manner, the OSUHS this conversation, 1 key point needs to be

guiding team created a means for maintain- reinforced. Kotter’s model is not a step-by-
ing the momentum of change throughout the step approach to managing change. It is an
HCO. They did not let up! iterative model, and its use will rely on the
skills and knowledge of the health care
manager charged with bringing about
Make change stick
change within his or her HCO. The model
In many competitive environments, from is iterative in that one step can be used to
sports to business, a belief exists that to get accomplish another step. For example, to
people to change their behavior, you must create urgency, a health care manager may
first change the culture. However, according need to create a series of short-term wins to
to Kotter, ‘‘culture change comes last, not help employees see that change is possible.
first. . .. Culture changes when a new way of These short-term wins generate a sense of
operating has been shown to succeed over urgency among employees and help them to
some minimum period of time.’’1(p176) This become aware of the need for change. As
means that to get an HCO to adopt new with most management practices, a carefully
technology, such as the EHR or biometric thought out plan of action must be devel-
identification systems, you must prove to oped before any action is taken.
employees that the technology actually works
and reward those individuals who enthusias- ADDRESSING TRANSITIONS
tically embrace changes made within the
organization. You guarantee that employees According to William Bridges,6 it is the not
will continue to use these systems when ‘‘a the changes that determine the success or
new, supportive and sufficiently strong or- failure of a project, it is the transitions. For
ganizational culture’’1(p161) is in place that Bridges, changes are situational, whereas
continually reminds individuals and groups transitions are more psychological. To illu-
that this is the way we do things around minate this point, consider the example
here. This is the right way to do something, of a professional making the move from
and this in the wrong way. Pittsburgh, Pennsylvania, to Greenville, North
To make change stick, the OSUHS devel- Carolina. The change itself is easy to manage.
oped a practice called ‘‘Post Live,’’ or what Sell the home, find a new place to live, hire a
they called ‘‘Focused Rounds.’’ In Post Live, moving company, locate a new physician,
an expert was sent on rounds with a find a bank and a school for the kids. With
physician to help physicians make more proper planning, this change can be man-
efficient use of the system. In some instan- aged in a relatively straightforward manner.
ces, the experts helped develop order sets However, the transition involved is much
for physicians when needed or worked to more difficult because it demands that the
help physicians continually improve how individual go through a series of internal
they used the system. This action prevented ‘‘repatternings’’6(p5) that require him or her
physicians from becoming immune to per- to drop an old identity and adopt a totally
ceived flaws and to prevent physicians from new one. Anyone who has lived most of his
saying: ‘‘Oh, that is part of the system, it or her life in one city and then suddenly de-
cannot be fixed.’’4 In this example, the cides to move to a totally new city will know
OSUHS guiding team created a method that that this is not an easy thing to do because, in
supported the continued use of the CPOE most cases, people’s identities and way of life
system within the HCO and further en- are tied directly to where they live and the
hanced the new culture that developed jobs they perform. With that move, the old
around the use of the new system. identity must be left behind, and to be
This concludes the discussion of Kotter’s successful, a new identity must be adopted
change management model. Before leaving along with a new way of doing things.
Letting go of the old identity is not easy for eventually develops into a butterfly. They
an individual because it means letting go of must shed old patterns of operating in their
the world as he or she knows it and the world and adopt new patterns. To make a
security, self-identity, and self-efficacy that successful change, an individual enters the
come with it. The same processes apply neutral zone in one form, only to exit
when a change is made within an HCO. Old transformed into a new being.
technology can be replaced with new tech- The last step, beginnings, is where the
nology, but the change in technology will individual breaks through the chrysalis, em-
bring new transitions for the employees braces his or her new identity with zeal and
of the HCO. If a health care manager does with a new sense of purpose, and works hard
not manage these transitions properly, the to make the proposed changes a reality
change management project, according to within the HCO.6(pp4,5) In what follows, the
Bridges, will fail. It is important to note that primary focus will be on the techniques that
Kotter is concerned primarily with situa- health care managers can use to help their
tional change. Although his model contains employees navigate through each stage of
elements for handling the psychological the transition process.
effects created by change, it is not solely de-
voted to managing the transitions that occur
Dealing with endings
during a change management project. This
task falls to Bridges and his theory of tran- Recall the discussion centering on the Star
sitional management. Trek episode ‘‘Court Martial,’’ in which Kirk
confronts a lawyer strongly opposed to the
use of a computer to practice law. This same
MANAGING DURING TRANSITION diffidence can be found among physicians
faced with the prospect of using an EHR to
During a period of transition, Bridges feels document patient encounters. In handling
that individuals within an organization must these physicians, Kotter would propose that
proceed through 3 distinct stages if success- the guiding team communicate how the EHR
ful change is to occur. These stages include will help them perform their job more
endings, the neutral zone, and beginnings. efficiently. Bridges, on the other hand, asks
Recall that for Bridges, changes focus on the health care manager and the guiding
an outcome: a move to a new city, the im- team to consider what it is that the physician
plementation of an EHR system, or the de- is losing by adopting the EHR. Bridges6(p24)
velopment of a quality control program. explains: ‘‘It isn’t the changes themselves
Transitions differ in the sense that the initial that the people in these cases resist. It’s the
focus is on an ending rather than an out- losses and endings that they will experience
come. When change occurs, individuals must and the transitions that they are resisting.’’
let go of the world as they know it and pre- For the physicians, they might feel that they
pare to assume a new identity and the tasks are losing the way that they treat patients.
associated with it. Some of them might voice the concern:
The neutral zone is the unfamiliar space ‘‘Now, the computer will tell me how to
that exists as individuals progress from let- practice medicine!’’ Others may feel that
ting go of an old reality to learning how to use of the EHR will disrupt the relation-
navigate in the new reality. It is the space ships they have with their patients. The key
that individuals must live in as they transition is to document what people feel they are
from being single to being married, from losing with the proposed change. Bridges,
being employed at one institution to another, however, warns that what people feel they
or graduating from high school and going off are losing cannot always be measured in
to college. As individuals move through the concrete terms. This ‘‘includes an indi-
neutral zone, they are akin to a larva that vidual’s sense of competence, chances for
promotions, and strategies that fit their Sending a signal

values.’’6(p25) People go through life with a
To lure a merchant ship into a compro-
specific set of beliefs, self-assurance, and
mising position, a pirate ship would display
anticipation that if their world continues on
the flag of a friendly nation, but once the
its present course, certain events will occur.
ship was within close proximity pirates
Changes disrupt these beliefs and turn an
would raise the Joliet Rouge, which signaled
individual’s world upside down. That is why
‘‘surrender or die.’’7 Although the endings
it is so important for the health care manager
being discussed are not as life threatening, at
and the guiding team to document these
times, individuals need a clear sign that an
beliefs, acknowledge their importance, and
ending has occurred. This can be accom-
make decisions sensitive to those beliefs.
plished in the following manner. The guiding
This will help move individuals along the
team can put into words what is going to
path toward committing to the proposed
change and then make that change occur.
changes.
During the CPOE implementation at OSUHS,
Another technique that helps move indi-
rather than doing a pilot test at 1 site, the
viduals along the path toward commitment is
guiding team made the decision to end the
the open acknowledgment of loss and a
use of paper order entry at all hospitals
tolerance for overreaction. As individuals
within the system before switching over to
begin to realize that something is going to
the CPOE system for all electronic ordering.
end in their life, they will go through a
This sent a clear message to all participants
natural progression of anger, bargaining,
that an ending had occurred.4
anxiety, sadness, disorientation, and depres-
sion. The key is to be sympathetic to these The ending as a continual life process
feelings, be willing to discuss to them,
provide information to dispel fear of the The final step in dealing with endings is
unknown, and help people understand that if to remind individuals that endings are one of
they are willing to deal with the current state the only constants we have in life. Nothing is
of affairs and work through their feelings, permanent; everything, according to Buddha,
they will survive the proposed changes. is transient. When we reach the age of 5
years, we go to kindergarten, only to graduate
to the first grade. This leads to a progression
Compensating for loss of graduations, which eventually lead to the
Because endings inevitably entail loss, attainment of undergraduate and graduate
Bridges suggests finding ways to compensate degrees. With degrees in hand, an individual
individuals for those things that they feel joins the workforce, which leads to a job and
have been lost. Whether those items are a set of responsibilities. Over the years, jobs
tangible (eg, team membership, monetary change, and so do the responsibilities. It is
rewards) or intangible (eg, status, perceived important to note that without change, and
competence), individuals must be given the eventual endings, no growth will occur, and
feeling or sense that they have some control both the organization and the individual will
over the proposed changes. Recall the become stagnant, decay, and then eventually
example of the OSUHS CPOE installation cease to exist in a productive fashion. Endings
and the use of the physician consultation are an important part of life. Once an ending
team. The physicians chosen to be consul- has occurred, an individual will move into
tants gained status through their participa- what Bridges calls the neutral zone.
tion on the team. Furthermore, physicians
The neutral zone
from each department gained a sense of
control over proposed changes through their Professional and personal lives can be
participation in the development and ap- marked with both endings and beginnings,
proval of order pathway prototypes. which are not always well defined. A space
exists between these 2 points, a space that Identification of a metaphor is similar to the
Bridges calls the neutral zone. In the neutral step in Kotter’s model called ‘‘Vision.’’ For
zone, individuals will vacillate between their example, if professionals are making the
longings for the way things used to be and move because of a layoff or job termination,
the anticipation and excitement that come they might adopt either the metaphor of
with a new beginning. Within the workplace, ‘‘Loss’’ or ‘‘Life’s a Journey’’ to describe their
this vacillation will polarize groups and will neutral zone experiences. Each metaphor
manifest the following symptoms: anxiety, colors individuals’ perception of the neutral
lack of motivation, absenteeism, susceptibil- zone and influences the types of experiences
ity to illness, overload, confusion, and failure that they are willing to engage in. For
to communicate. These feelings will have a example, adoption of the ‘‘Loss’’ metaphor
major impact on both teamwork and loyalty could engender resentment, anger, and fear,
and, if not properly managed, doom an HCO causing individuals to question why they
to perpetual internment in the neutral zone. must make the move in the first place. They
Bridges provides several recommendations may even say to themselves over and over
for helping navigate the neutral zone, which again: ‘‘Why do I have to make this move?
will be highlighted below. It’s not fair!’’ This attitude will cause
individuals to resist change and to be less
The journey of a thousand miles begins than proactive when engaging in activities
with the first step that help them navigate the treacherous
currents of the neutral zone. However, when
The key to making it through the neutral
individuals view the changes as part of
zone is to realize that it is a journey, not a
‘‘Life’s Journey,’’ they may see themselves
single step. When spring training ends and
as an explorer setting out to discover a new
the regular baseball season begins, a team is
world that provides them with a set of
not automatically a winning ball club. It takes
experiences that they would never have
the crucible of a 162-game season to help
encountered if the change had not occurred.
reorient and redefine a group of individuals
In the role of the explorer, individuals will be
into a playoff contender. The same holds true
willing to engage in training programs, work
for the example of the professional making
with new individuals, and take on new roles
the move to Greenville. There is more to the
that dramatically reshape who they are.
transition than simply moving from Pitts-
For the health care manager, the lesson is
burgh to Greenville. Individuals must begin
to provide employees with a positive meta-
to let go of their ‘‘outlook, attitudes, values,
phor that they can use to navigate the un-
and self images’’6(p43) that defined them as a
certainty and ambiguity found in the neutral
person living and working in Pittsburgh and
zone. Some examples relevant to the adop-
begin the process of developing these same
tion of the EHR include ‘‘Charting a New
qualities as someone working in Greenville.
Course in Health Care’’ or ‘‘Taking Patient
This process is called normalization of the
Care to New Heights.’’ These metaphors are
neutral zone, and it begins when individuals
not only positive, they also provide employ-
and groups realize that the transition from an
ees with an impetus to engage in behaviors
ending to a new beginning will take time;
that make the metaphors come to life.
that feelings of fear, confusion, and ambigu-
ity are natural; and that they must be willing
to accept them and work with them 7 Points on a compass
throughout their time in the neutral zone.
Being in the neutral zone can be like a
being ship out at sea without a compass. To
Metaphorically speaking
provide individuals with direction and to
Another important factor to consider is the help them get their bearings, Bridges of-
metaphor used to describe the neutral zone. fers the following 7 guidelines. First, try to
protect people from being overwhelmed No one receives or should receive special
with change. If changes can be managed in treatment.
blocks, or what Bridges calls clusters, indi- The seventh and final suggestion involves
viduals will not be so overwrought with feel- the creation of a transition monitoring team.
ings of ‘‘loss and confusion.’’6(p45) Second, This team should be a composite of the
consider the fact that when policies, proce- organization that meets on a biweekly basis
dures, and organizational charts were created, to discuss how well the transition process
the organization was relatively stable. Now is proceeding. The group should have no
that a period of transition is underway, decision-making authority and will exist for
think of how they may be updated to help the sole purpose of showing employees
people move through the neutral zone. For within the HCO that the administration is
example, during the CPOE implementation interested in gathering feedback and pro-
project at OSUHS, departments with physi- viding an accurate channel for disseminating
cians serving on the physician consultant information.
team were compensated for their absence. One final caveat that Bridges offers in-
Furthermore, nurses, information technology volves creativity. Because the neutral zone
staff members, and clinicians were placed can place everyone in an HCO in a state of
on the guiding team on a full-time basis, al- uncertainty, this is a great opportunity to
lowing them to fully concentrate on the take stock in how things are done. One po-
transitions, without being distracted by their tent example, especially as it relates to the
normal daily routines. Small procedural implementation of the EHR, is to examine
changes, such as these, can help minimize current workflow processes and determine
the impact that the neutral zone has on the how they can be reengineered to work more
organization during periods of transition. efficiently on a new electronic system. Far
Third, much like Kotter’s step ‘‘Create too many times, HCOs will simply remap an
Short-Term Wins,’’ help individuals and old process onto to a new technology im-
groups set short-range goals that lead to the plementation, which means that the same
achievement of projected results. Fourth, do old inefficiencies will exist. During this pe-
not bite off more than you can chew. riod in the neutral zone, health care man-
Remember, the neutral zone is like being in agers should allow individuals to use trial and
the fun house at an amusement park, where error and experimentation to find new and
the floors shake, the walls spin, and images exciting ways to perform their jobs. Be
in the mirror do not always reflect a true creative! If individuals feel that they will be
image. In this state, people will not produce punished if they do something new and
at a high level, so be careful of committing different and it fails, they will not take the
them to tasks they will never complete. Fifth, chance, and the HCO will remain stagnate.
consider what kind of special training super- As individuals reach the end of the neutral
visors and managers will need to navigate the zone, they are ready for the final stage in the
neutral zone. Examples include instruction in transition process: a new beginning.
problem solving, team building, and transi-
tional management.6(p45) Sixth, similar to
Beginnings
Kotter’s ‘‘Communication for Buy-in,’’ develop
a ‘‘sense of connectedness’’6(p47) among groups When dealing with beginnings, health care
and individuals within the HCO. This can managers must be careful that they do not
be accomplished through weekly meetings, become like the kid and the chrysalis, won-
Q&A sessions, family picnics or special dering when the butterfly is going to emerge.
events held at an amusement park, a news- No matter how long you watch, poke, and
letter or Web site devoted to the transition, prod, the butterfly will emerge in its own
and maintenance of the belief that every- time. Much like the butterfly, individuals will
one must go through this transition together. emerge in a new beginning when their heart
and mind6(p57) tell them that it is time and picture of what life is going to be like in the
when they are ready to assume their new coming months. He tells them that from now
identity. Therefore, it is important for the on, their goal is to find the lost 13th colony:
health care manager to know where every- Earth. Even more stirring is the biblical
one is in the transition process and make sure nature that this picture takes when you
that the ending and neutral zone phases have remove the letter a from the end of Adama’s
been properly planned, or the new begin- name. With this example, a set of individuals
nings will never occur. In essence, a new are given a concrete picture of what the
beginning cannot be ‘‘forced,’’6(p60) only outcome of their new beginning is going to
encouraged. To provide encouragement, the look like. Better yet, it provides them with an
health care manager must provide a purpose, impetus for reaching that goal: a place to
a plan, a picture, and a part for the individual live. This is the power that a well-chosen
to follow to engender a new beginning. picture can have on individuals as they enter
a new beginning. In a health care setting,
Purpose pictures can be as simple as a doctor sitting
with a laptop showing a patient how his or
The key at this point is to explain the
her blood glucose levels have fluctuated over
problems that the HCO faces and then
the past 6 months.
explain the solution to those problems.
Individuals need to understand the who, Plan
what, where, and why behind the problem
and the solution and the evidence that states An effective plan shows an individual or
that this is the best solution to the problem. group of individuals how their lives are going
to change: when they will receive training,
Picture when they will receive the information they
need to do their jobs, and the scaffolding
One of the unique characteristics of hu- they will need to make the transitions to
man beings is how a good deal of their moti- their new identities and new way of doing
vation comes from the pictures they carry in things. The key here is that the plan is more
their minds. For example, one of the most oriented toward the process that individuals
troubling aspects of an ending is that the will have to go through to make the tran-
pictures we have regarding our old identities sition, not the final outcome.
will cease to exist, and as we move into the
neutral zone and a new beginning, we have Part to play
no pictures of what life will be like in those
People need to know what role they are
phases. This can be the cause of a great deal
going to play in the transition process. If you
of anxiety. Therefore, it is important for an
do not provide them with this information,
HCO to provide pictures of what life will be
their imaginations will run wild. Examples of
like in the new beginning. To highlight this
how people can become involved include
notion, the science fiction drama BattleStar
guiding teams, planning task forces, survey
Galatica provides an illuminating example.
groups, quality circles, and transition moni-
In the pilot to the series, we find the human
toring team. The goal is to get everyone
race inhabiting 12 colonies. In a surprise
involved in the process so they feel part of
attack, the 12 colonies are destroyed and the
the team and the transition.
human race is reduced to 50,000 survivors.
In a final scene, after the colonists have
escaped their attackers, barely alive, wander- CONCLUSION
ing through space, wondering whether it
was not better to be killed than to have In comparing the theories of Kotter and
survived, Commander Adama (Edward James Bridges, it is essential to remain aware that
Olmos) provides the survivors with a brilliant change is both situational and psychological,
and thus, any organizational change is going ical aspects of change will doom any health
to impact the identities of the individuals care manager to being caught in a constant
involved in the change process. Ignoring spin cycle of always trying to implement
either or both the situational and psycholog- change, without realization of any results.
REFERENCES
1. Kotter J, Cohen D. The Heart of Change: Real Life mentation in a multi-hospital environment. J Am
Stories of How People Change Their Organization. Med Inform Assoc. 2002;9:16-24.
Boston, MA: Harvard Business School Press; 2002. 5. Cohen D. The Heart of Change Field Guide: Tools
2. Landro L. Patients, families take up the cause of hos- and Tactics for Leading Change in Your Organi-
pital safety. Wall Street Journal. May 30, 2007: D1. zation. Boston, MA: Harvard Business School Press;
3. Silversin J, Kornacki M. Implementing change: from 2005.
ideas to reality. Fam Pract Manag. 2003;10(1): 6. Bridges W. Managing Transitions: Making the Most
57-62. of Change. 2nd ed. Cambridge, MA: Perseus Publish-
4. Ahmad A, Teater P, Bentley TD, Kuehn L, Kumer RB, ing; 2003.
Thomas A, Mekhjian HS. Key attributes of a 7. Zacks R. The Pirate Hunter: The True Story of
successful physician order entry system imple- Captain Kidd. New York, NY: Hyperion; 2002.

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Change Management in Health Care: Robert James Campbell, Edd

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The Health Care Manager

Volume 27, Number 1, pp. 23–39

If your time to you most widely regarded thinkers in change man-

ODAY’S HEALTH CARE manager occu-

pay-for-performance plans. To deal with this Build guiding teams

ways of doing things, managers need an edge. Communicate for buy-in

Providing this edge are the philosophies of Enable action

SEE ME, FEEL ME, TOUCH ME adopt a ‘‘see-feel-change’’ approach. Using

Table 1. Future pictures of the organization

Figure 1. Communicate for buy-in layered model.

nonconfrontational manner, the OSUHS this conversation, 1 key point needs to be

promotions, and strategies that fit their Sending a signal

You might also like

Change Management in Health Care: Robert James Campbell, Edd

Uploaded by

Copyright:

Available Formats

Change Management in Health Care: Robert James Campbell, Edd

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

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Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Change Management in Health Care: Robert James Campbell, Edd

Uploaded by

Copyright:

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The Health Care Manager

Volume 27, Number 1, pp. 23–39

If your time to you most widely regarded thinkers in change man-

ODAY’S HEALTH CARE manager occu-

pay-for-performance plans. To deal with this  Build guiding teams

ways of doing things, managers need an edge.  Communicate for buy-in

Providing this edge are the philosophies of  Enable action

SEE ME, FEEL ME, TOUCH ME adopt a ‘‘see-feel-change’’ approach. Using

Table 1. Future pictures of the organization

Figure 1. Communicate for buy-in layered model.

nonconfrontational manner, the OSUHS this conversation, 1 key point needs to be

promotions, and strategies that fit their Sending a signal

You might also like

pay-for-performance plans. To deal with this Build guiding teams

ways of doing things, managers need an edge. Communicate for buy-in

Providing this edge are the philosophies of Enable action