Research Article: 2022 Vol: 28 Issue: 4
Anusi H.I, Durban University of Technology
Mutambara E., Durban University of Technology
Citation Information: Anusi, H.I., & Mutambara, E. (2022). A conceptual framework of organisational change process in hospitals. Academy of Entrepreneurship Journal, 28(S4), 1-11.
Change Management, Organisational Change, Theories of Change, Healthcare Organisations, Hospitals, Change Strategies and the Study Conclusion
Change management in health care organisations is a complex task considering the continuous change in global demography, technology, strategies, clinical communication, information transfer and changes in disease burden. Considering the current global pandemic, it becomes more expedient for health care organisation to continue to put in place measures that can adequately respond to the health challenges towards patients’ satisfaction. A theoretical analysis based on secondary information was adopted. This study provides an assessment of various change management theories through extensive literature review. Based on critical analysis of various theories, this study found that there exists a gap in literature as regard a change management framework that can respond to the continuous increase in demand for healthcare delivery particularly during these uncertain times. A conceptual framework of change management was proposed to assist health care organisations to respond to the increasing global health challenges. This study concludes by recommending the adoption of the proposed change management model for health care organisations particularly hospitals.
This study reports on the assessment of various theories of change towards the proposition of a conceptual framework for hospitals. Managing change in the health care context is always challenging, particularly when it involves changing deep-rooted habits grounded in expert expectations. Change management in health care organisations is a complex task considering the continuous change in global demography, technology, strategies, clinical communication, information transfer (McMurray, Chaboyer, Wallis & Fetherston, 2010) and changes in disease burden (Martin, Sutton, Willars & Dixon-Woods, 2013). Within this dynamic and changing environment, the ability to remain reactive to patient needs while managing these issues poses further challenges. For instance, with evidence of the current Covid-19 pandemic, many healthcare organisations are departing from traditional style to adopting more suitable model that can stimulate performance and patients’ satisfaction. To date, researchers have continued to address the development of a consistent and appropriate conceptual framework that can address organisational performance and patients’ satisfaction. The critical importance of a change model for hospitals cannot be overemphasised, particularly in this current global pandemic. This study critically examines various theories of change towards the proposition of a conceptual framework of change for hospitals.
The paper is structured as follows: need for change, conceptualisation of change management, theories of change, proposed conceptual framework for hospitals.
Need for Change
Change is construed as a phenomenon that occurs daily in every organisation. Armstrong (2009) defines change as any changes in structure, management, employee, and processes. For the past few decades change for organisations both large and small, private, public or voluntary sectors has been inevitable (Battilana, 2010). Such trends of organisational change are increasing in complexity and turbulence under current economic situation. The purpose of change management for different organisations are probably not the same. However, the ethos of change management is the same that is, ensuring that the organisations run effectively, efficiently, and are responsive to the turbulent environment changes. Today’s government strive for more efficient, effective and satisfactory health services for its citizenry. Delivery of quality health care is a constitutional responsibility of the government (Stuckler, Basu & Mckee 2011). In the developing world, change management has also been seen to emanate in all domains of the public sector. The government has therefore introduced health reform programmes to improve health care, efficiency, safety and quality of delivery and access for all users to ensure compliance in delivery of quality healthcare (Mogashoa & Pelser 2014). Despite these commendable initiatives in healthcare sector, National Department of Health (2012) revealed that the public health institutions were failing to meet basic standards of care and patient expectations. The failure of change programmes or reforms has been attributed to unsuccessful implementation of the change process (Mosadeghrad & Ansarian, 2014). Therefore, the management of a change process must identify key challenges peculiar to the organisation towards the development of a change model.
Conceptualisation of Change Management
Change management has been defined as the process of continually renewing an organisations direction and capabilities to serve the ever-changing needs of the internal and external environment (Moran & Brightman, 2001). Burnes (2017) posits that change management or organisational change is to change the activities of the organisation and this may include; organisational culture, technology, business process, job designs, human resources techniques and even the organisation’s brand image. Change management has been described as a continuous process that changes according to organisational demands and at the same time sustaining its overall vision (D’Ortenzio, 2012). Ikinchi (2014) state that change management is a structured approach to change in individuals or organisations and enables the transition from a current state to a desirable future state. Change management is also construed as creating, maintaining and systematic evaluation of changes in an organisation (Barcan, 2010). It involves changes of organisations’ mission, vision and/or processes, with influence at both individual and organisation level (Bejinariu, Jitarel, Sarca & Mocan, 2017).
Theories of Organisational Change
Several theories allow us to explain organizational change and development. In private or public sector, models to change is very crucial as it sets a guide for change interventions in the organisation. In literature for implementing change in an organisation, different models and theories exist. Different organisations may utilise different change model to remain competitive in the market. One widely used approach is the Lewin’s model of change process.
Kurt Lewin’s Model of Change
Most theories of organisational change originated from the landmark work Kurt Lewin. Lewin’s change management theory is based on a three-stage model of planned change - unfreezing, changing and refreezing which explained how to initiate, manage, and stabilise the change process. Many Organisation development (OD) practitioners widely consider this framework as the theoretical foundation of planned change. The assumptions underlying this model highlight that the change process involves learning something new, withdrawing from current attitudes, old behaviours or organisational practices. Lewin believes that change will not occur unless there is a motivation to change and also employees are the hub of every organisational change. Therefore, any change in forms of structure, group, process, rewards systems, or job design requires employees to change (Sarayeh, 2013) (Figure 1).
Step 1: unfreeze - Sarayeh (2013) depicts that for Lewin, human behaviour was based on a quasi-stationary equilibrium supported by a complex field of driving and restraining forces. For change to be implemented it must go through the unfreeze step. The focus of this stage is to create the motivation to change initiative. By doing so, employees are encouraged to replace old behaviours and attitudes with those desired by the management. Managers usually create motivation for change by presenting information on levels of effectiveness, efficiency, or customer satisfaction. This is because employees will naturally resist change. However, before old culture can be discarded and new culture successfully adopted, the equilibrium needs to be unfrozen. This can be characterised as the ability of individuals or groups to change as fast as their environment functions. Successful organisations often tend to ignore signs which might indicate the need for change (Burnes, 2017). Benchmarking is a great technique that can be used to help unfreeze an organisation. Because benchmarking describes the process by which an organisation can compare its performance to that of a high-performing organisation.
Step 2: Change– This can also be referred as to the changing, transitioning or moving step. Organisational change, whether large or small, is carried out to improve some process, procedure, product, and service. Lewin marked this as an implementation phase involving the current state of an organisation been transformed to the desired goal but this will not occur fairly quickly, hence a simultaneously transition (Hussain, 2016). In this step, change becomes very real. Consequently, employees begin to resist change as they struggle with the new reality on ground. During this transition, employees begin to learn new behaviours, processes and ways of thinking. Hence, it is very critical that employers should create a strong support and communication system throughout the process.
Step 3: Refreeze – This may be referred to as the final stage, symbolising the act of reinforcing, stabilising and solidifying the new status-quo. The changes made are accepted and refrozen as the new norm. Viljoen (2015) highlighted that Lewin saw successful change as a group activity, and thus for changes to individual behaviour be sustained, group norms and routines must be transformed. Hence from an organisational perspective, refreezing often requires changes to group norms, culture, polices and processes. This is an important step, because it ensures that employees don’t revert to their old behaviours prior to the implementation of change. Positive rewards and acknowledgment are usually adopted to reinforce the new state.
Lewin’s model has been criticised by some scholars who have raised concerns on some of the precepts of the model. For example, Palmer & Dunford, (1995) contend that the Lewin’s model produces the assumption that changes occur in sequence with progression and that managers are aware of organisation’s destination. The authors argue that such assumptions may contradict the context where changes occur. Kanter (1992) are of the opinion that organisations are never frozen, much less refrozen. These assertions may be related to the nature of health care organisations that are always going through continuous change process considering demographic and disease burdens. Change in health care organisations is continuous, because change is unceasing (Bartunek & Woodman, 2015).
John Kotter – 8 Step Model
Kotter (1996) has further developed Lewin’s theory in order to make it more practical in that it prescribes how managers should lead the change process. This model provides clear description to the entire change management process. Campbell (2008) believes that John Kotter’s eight stage process for transformational change is the only model that has been successfully used in the health care sector regardless of the other models. Pollack & Pollack (2014) argue that Kotter’s model recommends a people-driven approach that helps employees to see the reason for change in their organisations. The core issue is the behaviour of employees during the change process. The first four steps represent the Kurt Lewin “unfreezing” stage. Steps 5, 6, and 7 represent “changing” and step 8 corresponds to “refreezing”.
Step 1: Establish the urgency of change- this is a critical step and it involves helping employees see and understand why change needs to occur (Campbell, 2008). Urgency is needed in the change process, because without it, employees do not want to perform or become complacent. Establishing a sense of urgency helps managers of organisation to fight against complacency. Complacency is often seen in employees who are satisfied with the status quo and therefore resist change. When urgency is not established, it becomes very challenging to move to the next stage (creating a guiding coalition) because there is no employee commitment. Manager can take to create sense of urgency by establishing open communication amongst all stakeholders and employees about the current market and competitive realities, sharing relevant financial and customer data, and discussing opportunities and crises facing the organisation.
Step 2: Form a powerful coalition, leading change - in this stage the successful change agents build a guiding team with credibility, skills, and good reputations to provide change leadership. According to Kotter (1996), these team members guiding change must possess the knowledge, credibility, influence and skills required to mobilize change. The four characteristics for effective guiding coalition are Position Power, Expertise, Credibility and Leadership. Despite these characteristics the team must watch out for members who create mistrust to kill team work.
Step 3: Develop a new vision for change - a vision statement is a goal that is developed to reflect a sensible and an appealing future of an organization. The strategy for accomplishing vision is a plan that provides a clear roadmap and a set of guiding principles in achieving the desired goals. Goals gives direction and purpose to organisations. Brown (2011) posits that in the implementation of the organisational development programme, managers and employees develop ideas about what the organisation needs, they develop goals, which defines the series of steps that will move the organisation along to accomplish the goals. Organisations have different approaches to goal setting. Management by objectives (MBO) is a widely used method to improve total organisational effectiveness. MBO produces a system of mutual goal setting and performance review and enhances planning, communication, and motivation. Once a vision and strategy are defined, the management creates plans that have specific steps and time table to accomplish strategies and budgets (Ramasamy, 2017). The vision and strategy creation are responsibilities of top management for an organization
Step 4: Communicate the change vision - this step deals with how the organisation communicate the vision and strategies across the organisation by creating an awareness among the stakeholders involved in change implementation. The objective of this stage is to communicate to all stakeholders on the expectations to foster understanding and retention. According to Sanghi (2016), change vision needs to be communicated frequently and convincingly to all stakeholders to eradicate cynics that could lead to a failed change initiative. Vision is the very essence of leadership and it involves; sharing the vision, empowering the individual, acknowledging performance and rewarding the performance. Winning the support of organisation members for the vision nearly means putting “where we are going and why” in writing, distributing the written vision organisation-wide, and having executives personally explain the vision and its rationale to the employees (Kotter, 1996). An effectively communicated vision is a valuable management tool for enlisting the commitment of organisation employees to actions that get the organisation moving in the right direction (Hough, 2007).
Step 5: Empower others to act on the vision – the individual is one of the most critical elements in any large-scale organisational change. Central to empowerment is engaging all employees so that they develop a personal sense of pride, self-respect and responsibility and the promulgation of a shared vision of the future (Sutton, 2018). Employees who are empowered are more proactive and self-sufficient. The purpose is to have the individuals’ purpose and vision congruent with the organisations. In many organisations, employee empowerment has become a basic cornerstone of change and development programmes.
Step 6: Create a short-term win – this is very necessary in implementing changes because the use of short-term wins eliminates any organisational discouragement. Pollack and Pollack (2014) notes a win is any measurable visible, and unambiguous performance improvement related to change effort – this can include actions taken, new behaviours and improved processes. A short-term win should be every 6-18 months from the start of a change plan. Every individual wants to be a part of winning team. Hence, the fear on failure of implementing change and consequences leading to job lose makes employees resist change.
Step 7: Build on the change -this stage involves sustaining the implementation of change by ensuring that all stakeholders are working persistently towards achieving the change vision while measuring progress. It’s important not to declare wins prematurely. Ramasamy (2017) argues that many change initiatives fail because victory is declared prematurely. Declaring that the change has been successfully implemented may lead to stakeholders to losing all urgency and if the changes have not been firmly rooted into the culture, employees then to withdraw into their old routines.
Step 8: Anchoring new approaches in the corporate culture- at this stage, new learning and practices are inherited due to change implemented being standardized in to the culture. Changes identified and implemented should be focused on enriching customer experience with the organisation. A corporation’s culture is a major strength when it is consistent with its strategy. An effective corporate culture can result in superior-performance, but an organisation’s culture may also inhibit the organisation from meeting competitive threats or adapting to changing conditions (Mento, 2002). Cultural change can be difficult and time consuming; when the corporate culture is resistant to change, organisation development strategies can be used to move the culture in a more innovative direction.
The most sensitive element in all eight stages proposed by Kotter is changing people's behaviour, not strategy, systems, nor culture. Evidently all of these elements are extremely important, but the core issue is the behaviour - what people do, think and act (Alvesson & Sveningsson, 2017). On the contrary, Sarayeh, (2013) argue that Kotter’s model only reiterates the changing of employee’s behaviour, not culture, strategy nor process. According to Bejinariu, Jitarel, Sarca & Mocan, (2017), Kotter’s model does not emphasise the acceptance of change, but as an actual change of organisation members and readiness for change. The model depicts a sequential behavioural model, but also a disadvantage to a long-term sustenance of change (Bejinariu et al., 2017). Further, the model has been critisised as being a theoretical phenomenon that fails to provide explicit implementation of a change (Rajan & Ganesan, 2017). Another shortcoming of the model is the absence of a visual aid that represents “prior and after” implementation of a change to gain momentum for a sustainable practice beyond the organisation (Rajan & Ganesan, 2017).
McKinsey 7-S Model
Jharotia (2019) opines that this model offers a holistic approach to organization, a great tool for analysing organisation effectiveness, and also a collective agent of change. This model was developed in the early 1980’s by consultants Tom Peters and Robert Waterman, who worked for the consulting firm McKinsey and the company. One of the primary benefits of McKinsey’s 7-s model is that it offers an effective method to diagnose and understand an organisation even though the model is quite complex as compared to others (Demir & Kocaoglu, 2019). Some organisations that may have used this model experienced more cases of failure and this is because all parts are interrelated and interdependent on one another. McKinsey 7-S model reveals how effectiveness can be achieved in an organization through the interactions of seven key elements – Strategy, Structure, Systems, Shared Values, Style, Skills and Staff.
The first three elements; strategy, structure and systems are considered to be the hard ‘S’ because it places an emphasis on human resources and can be easily identified and influenced by the management as they contain organisation’s plan, organisational charts and work processes. Whilst conversely the other four soft “S” are influenced by the organisational culture (Ravanfar, 2015). The failure on one part means the failure to all. All the elements are interconnected, with shared values placed at the centre and thus reflecting the importance of “shared values” (Figure 2).
Strategy refers to the management’s action plan for running the business and conducting operations. Thus, an organisation’s strategy is all about the competitive moves and business approaches that managers are employing to grow the business, attract and please customers, compete successfully, conduct operations, and achieve the targeted levels of organizational performance (Hough, et al., 2007). Strategy is the main element to manage change in healthcare organisation, hence must clearly communicate the organisation’s objectives and goals;
Structure involves the way an organisation is structured and also organising value chain activities and business processes. The structure of healthcare organisation is made up of corporate hierarchy, chain of command and divisional makeup that outlines how their daily operations function;
Systems refers to a set of interrelated parts unified by design to achieve some goals. A system must be designed to accomplish an objective. Healthcare organisations should have proper systems in place to enhance business growth.
Shared values include the organisation’s beliefs, traits and behavioural norms that guide employees whilst pursuing its strategic vision and strategy. Shared values are the pinnacle of every organisation because they form the underpinning culture, strategy, effectiveness and performance and thus linking to every element in this framework (Salvarli & Dogu, 2018).
Style entails aligning managerial style to suit the organisations value system. The leadership approach of the management influences performance, productivity and corporate culture.
Staff -this refers to putting together a strong management team, recruiting and retaining employees with required experience, technical skills, and intellectual capacity.
Skills refers to individuals’ level of proficiency at performing particular tasks in achieving objectives in the organisation. Most times organisations assess its available skills in order to achieve the goals set forth in its change program.
McKinsey is known to be actively involved in project consultations for local hospitals in the UK (O’Mahoney & Sturdy, 2016). However, criticisms of the McKinsey 7S model is that it does not provide any direction on how to advance once one has established the areas of non- alignment. However, it is difficult to conceive of any management model that would not only diagnose but also treat the problems that are discovered (Grant, 2008). There is no domain for external impact. It is important to note that the choice of the letter ‘S’ itself limits the scope of the framework. When developing such a model, it leads to restrictions of ideas to start with a specific letter that accurately describes a concept (Grant, 2008). For instance, health care values such as caring, respect and collaboration are relevant concepts, but unfortunately do not begin with an “s”.
The ADKAR Model
According to Hiatt (2006), the Prosci ADKAR model was created by Prosci founder of Jeff Hiatt. ADKAR model name is an acronym and it is derived from five tangible elements that assists organisations achieve benefits from their change initiatives depicted in the figure below.
A = Awareness of the need for change
D = Desire (to participate and support change) K = Knowledge (of how to change)
A = Ability to implement skills and behaviour R = Reinforcement (to sustain change)
Gratiela (2014) cites the application of ADKAR model during change process can separate change out into the how things are done today (current state), how things will be done tomorrow (future state) and how to move the current state into the future state which is the transition state. The model is a diagnostic tool used to diagnose organisation as a system that is resistance to change, help managers and employees’ transition through the process of change, and create an action plan for development during change periods (Goyal & Patwardhan, 2018).
The remedial measures and growth of change resistance is the key characteristic of ADKAR model. Hiatt emphasizes it is impossible to achieve change in one area unless the previous act has been addressed (Figure 3).
This model is easy to understand and thus focuses on individual change which is also imperative in any organisational change. ADKAR model is very effective and it is used for creating an action plan for professional and individual development of employees while implementing change in the organisation (Bejinariu, et al., 2017). By focusing on employees, the ADKAR method limits resistance to change and thus speeding implementation. This model values employees input and support, thereby fostering the desire to participate in the change implementation. Notably, this framework is mostly suitable for small incremental changes, as daily routines are not significantly disrupted at once (Warrilow, 2019).
ADKAR model mainly focuses on individual change, which is the essence of any organisational changes. The disadvantage of this model is the process sequence underlying that, each stage is based on a previous action, which means that, if a step is not covered completely, it cannot move on to the next step, and success may not be achieved (Bejinariu, et al., 2017). Form the foregoing, it can be seen that similarities exist between ADKAR model and Kotter model regarding the gradual structure of the theories and their associated approaches.
It is instructive to note that all the above-mentioned models did little to incorporate the patient-centred factor during the process of change. Studies in healthcare literatures have shown that safety and patients’ satisfaction are at the epicentre of organisational change (Johnson, Nguyen, Groth, 2016; Wang et al., 2020). Stakeholders in healthcare industry who value safety and customer satisfaction mention that organisational culture is a major threat to organisational change (Carroll & Quijada, 2004). The challenge with organisational change within the health care industry is attributed to the complex nature of health management. More attention is being paid to the concept of patient-centeredness particularly in the era of Covid-19 pandemic. To this end, it becomes imperative to advance a model that guarantees a change towards the consciousness of patients’ safety and quality health delivery (Muls, Dougherty, Doyle, Shaw, Soanes & Stevens, 2015).
Proposed Conceptual Framework for Hospital
The aim of this paper is to assess various theories of change towards the proposition of a conceptual framework for hospitals. The figure 4 below is a proposed organisational change framework for healthcare organisations as derived from previous change management theories. It is instructive to note that both demographic and technological changes often influence the structure and operations in many organisations. In the view of this, some key elements from the reviewed theories were harness to provide a contemporary change management process for hospitals. The ideology of the proposed conceptual framework was derived from the various theories discussed in this paper.
Create a need for Change
This involves the sensitisation of all the employees towards having a change. There is need to create the awareness for employees to understand that there is a need for change to occur. This step will help create a sense of belonging and acknowledgement among the entire staff of the organisation and inform a participative process of change. This awareness must be geared towards patients’ satisfaction.
It involves the way an organisation is structured in terms of chain of activities and business processes. The structure of healthcare organisation is made up of corporate hierarchy, chain of command and divisional makeup that outlines how their daily operations function is organised. The idea of this structure is patients’ satisfaction inclusive.
Effective Communication of the Vision
This step deals with communication of the main aim of the change programme to all employees. Top management must continually communicate the vision and strategies by creating an awareness among the stakeholders involved in change implementation. The objective of this stage is to communicate to all stakeholders on the expectations to foster understanding and retention. Frequent communication of clear and honest change programme will help to empower employees and prevent resistant to change.
This includes the implementation approach by the management. The adopted strategy is initiated by the management as they contain organisation’s plan, organisational charts and work processes. A bottom-up approach has been identified as ideal implementation strategy particularly within health care organisations. The indicated strategy as shown in the framework above is linked towards patients’ centredness.
Refers to individuals’ level of proficiency at performing particular tasks in achieving objectives in the organisation. Most times organisations assess its available skills in order to achieve the goals set forth in its change program. The implementation of change within the healthcare industry requires competence and professional expertise.
Includes the organisation’s beliefs, values and behavioural norms that guide employees whilst pursuing its strategic vision and strategy. Shared values are the pinnacle of every organisation because they form the underpinning culture, strategy, effectiveness and performance that sustains the organisation. (Salvarli & Dogu, 2018). The share value of healthcare organisations should be such that is aimed towards patients’ centredness.
Refers to the concept of putting the patients at the heart of organisational goal. Putting patients first is a sustainable strategy for healthcare organisations, and thus linking to every element in this framework.
Evaluation of Change
This stage involves a re-examination of the entire process of change. Evaluation of the change process will enable the change agent to identify the areas of strength and weakness during and after the process. A feedback loop from the patients will also help to determine the periodical need of change project.
In this paper, the relevant literature has been reviewed and it was demonstrated that if this method is adopted, it also provides a means for addressing tough professional and organisational issues that are frequently unresolved in broader developments of organisational change. This paper is not offered as a remedy or the solution to all change projects, rather the argument here is that it is one means among many that can be used to bring about important changes in practice within healthcare domain.
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Received: 11-Mar-2022, Manuscript No. AEJ-21-10289; Editor assigned: 14-Mar-2022; PreQC No. AEJ-21-10289(PQ); Reviewed: 29-Mar-2022, QC No. AEJ-21-10289; Revised: 06-Apr-2022, Manuscript No. AEJ-21-10289(R); Published: 11-Apr-2022