As part of the ALiEM Faculty Incubator program, teams of 2-4 incubator participants authored a primer on a key education theory, linking the abstract to practical scenarios. For the third year, these posts are being serialized on our blog, as a joint collaboration with ALiEM. You can view the first e-book here – the second is nearing completion and will soon be released.  You can view all the blog posts from series 1 and 2 here.

The ALiEM team loves hearing your feedback prior to publication. No comment is too big or too small and they will be used to refine each primer prior to the eBook publication.  (note: the blog posts themselves will remain unchanged)

This is the eight post of Volume 3. You can find the previous posts here: Bolman and Deal’s Four-Frame Model; Validity; Mayer’s Cognitive Theory of Multimedia Learning; The Kirkpatrick Model: Four Levels of Learning Evaluation; Curriculum Development; Programmatic Assessment; and, Realist Evaluation.

Kotter’s Stages of Change

Authors:Dallas Holladay (@Dallas_Holladay); Melissa Parsons (@MEParsonsMD); Gannon Sungar (@GannonSungar)

Editor: Daniel Robinson

Main Authors or Originators: John Kotter
-Kotter JP. Leading Change: Why Transformation Efforts Fail. Harvard Business Review. 1995; (March-April): pp. 59–67.
-Kotter JP. Leading Change. Boston. Harvard Business School Press, 1996
Other important authors or works: N/A

Part 1: The Hook

Christy was ecstatic when the residency program director offered here the opportunity to overhaul the residency conference curriculum. As a junior faculty member with an interest in education and an alumnus of the residency program, she knew all too well about the shortcomings of the current curriculum and saw this as a great opportunity to have a positive impact on the residency. With the goal of eventually joining the residency leadership, Christy also saw this as a great professional opportunity for her to develop and demonstrate some success in an area about which she was passionate.

The residency conference curriculum had long been a source of struggle within the program. Faculty engagement and participation was low and the residents would often complain about the same boring lectures or the lack of relevant content. Residents attended conference only to satisfy requirements and were frequently caught sleeping or trying to complete their charts from their latest shift. Year after year, conference was battered on the yearly residency survey, and for good reason, it needed fixing.

Christy was confident that she had the necessary skills to create a more interesting and engaging curriculum and give both residents and faculty what they wanted. But she faced some challenges as well. This would mark the third significant curriculum overhaul in the past 6 years. Faculty were tired of efforts to reinvigorate the curriculum. Many felt that since the past efforts had failed, there was no sense in trying again.

And what if she failed? While this was a great opportunity to make a lasting mark on the residency program and to demonstrate her skills as an educator and leader, Christy needed to succeed. If things didn’t improve, it would reflect very poorly on her.

Questions for the reader:
· Why did past attempts to improve the curriculum fail?
· What can Christy do to ensure the successful implementation of the new curriculum?

Part 2: The Meat

Overview

John Kotter, a professor at Harvard Business School and world-renowned change expert, studied over 100 companies, in the US and globally, varying in size and industry type. His research of change implementation in these companies enabled him to describe why and how a majority of these change efforts failed. He developed an 8 step model to avoid major errors in the change process. There are two key lessons that Kotter suggests through his change model. First, that “the change process goes through a series of phases that, in total, usually require a considerable length of time,”¹ but “skipping steps creates only the illusion of speed and never produces a satisfying result.”¹ So to apply Kotter’s 8 step change model requires progressing in a sequential order and giving each step adequate time to be completed appropriately prior to progressing to the next step. The second lesson is that “critical mistakes in any of the phases can have a devastating impact, slowing momentum and negating hard-won gains.”¹ No step can be omitted or looked over in order to be successful in implementing change.

Background

Kotter initially described his 8 steps in terms of errors that the companies he observed made:¹

Error 1: Not establishing a great enough sense of urgency.
Error 2: Not creating a powerful enough guiding coalition.
Error 3: Lacking a vision.
Error 4: Under communicating the vision by a factor of ten.
Error 5: Not removing obstacles to the new vision.
Error 6: Not systematically planning for and creating short-term wins.
Error 7: Declaring victory too soon.
Error 8: Not anchoring changes into the corporation’s culture.

Instead of just describing the errors, Kotter’s eight-step model for transforming organizations has also been formulated into actions.

1. Establish a sense of urgency.
● The company or group of individuals involved need to develop a sense of urgency around the need for change. Approximately 75% of the company’s management needs to be convinced that change is required to achieve success.¹
● Consider performing a SWOT analysis in order to identify strengths, weaknesses, opportunities and potential threats. Examine the market and competitive realities.²

2. Form a powerful guiding coalition.
● To lead change, a coalition or team of influential people from a variety of sources need to come together to continue building urgency and momentum around the need for change. This team does not need to follow the traditional company hierarchy.1 It is ideal to have a good mix of people from different departments and different levels within the company, not just the top managers.
● To make this team a powerful coalition, consider team building events such as an off-site retreat or other team-building workshops.^1,3

3. Create a vision.
● A clear vision that can help employees understand why you’re asking them to do something, why you’re asking for change, is critical. According to Kotter, “a vision is something that clarifies the direction in which an organization needs to move.”¹ Develop a short summary of what you envision for the future of your organization and create a strategy of how to execute that vision. Make sure that this can be clearly communicated and quickly described. If the vision cannot be communicated in five minutes or less and received with a reaction that signifies both understanding and interest, then creating the vision is not completed.¹

4. Communicate the vision.
● Communicate your vision frequently and powerfully.¹ Embed it in everything you do. Keep it fresh on people’s minds so that they will remember it. Apply it to ALL aspects of operations – from training to performance reviews to regular meetings. Do not have one board meeting to discuss it or send out one email to publicize it. The change vision needs to be broadcast via all communication channels. Executives implementing the change need to “walk the talk” as well.¹

5. Empower others to act on the vision.
● Recognize and reward people that are making change happen, that are implementing the vision.3 Encourage risk taking in employees in order to act on the vision with new ideas and activities.²
● This step requires removing obstacles to the vision, or removing the people, processes and structures getting tin the way of the vision. Identify people that are resisting change and reach out to them to encourage change. Remove obstacles such as organizational structures, job descriptions or compensation systems that are not in line with the vision.^1,3

6. Plan for and create short-term wins.
● Success is motivating. Create quick wins to fuel continued change. Instead of just having one long-term goal, find short-term goals that are easily achievable.

7. Consolidate improvements to produce more change.
● Use prior successes as an opportunity for continued growth. Continue to analyze what is going right and what can use additional improvement. Continue to set future goals. A premature victory celebration can kill momentum according to Kotter.¹

8. Institutionalize new approaches
● For the change to endure, it has to become core of the organization, part of the culture, or “the way we do things around here.”¹ Include the change ideals and values in the hiring/training process. Recognize staff that have contributed to change and that continue to promote change. Highlight the progress that the team has made and connect those new approaches or behaviors involving change to the improved performance.

Modern takes or advances

In 2014, 18 years after the initial publication, Kotter’s 8 Steps of Change underwent some revisions. In the updated version, Kotter recommends that instead of performing the steps sequentially to achieve episodic change, the steps should be run continuously and concurrently. This more accurately represents the fast paced evolution of change in the modern, digital age and is more consistent with sustaining success. Improving on the original step 4, revised steps of change promotes the idea of “building an army of volunteers” to disseminate your message across the organization. This strengthens the communication and enhances the urgency created in step 1. Initially, Kotter discussed creating a traditional hierarchy, however, revisions recognized that change is best implemented when there is a flexible network as well as a hierarchy. This helps build volunteers of change horizontally and vertically across an organization. This is critical to previous steps of creating urgency and sustaining communication about the idea. Additional modifications include constantly seeking new opportunities and acting on those opportunities quickly. This allows for improved implementation of step 6 and generating short term wins.^3,4

Other examples of where this theory might apply in both the classroom & clinical setting

While Kotter’s 8 Stages of Change are typically discussed in the context of large, institutional change, the principles can be applied in micro situations as well. For example, if as an educator you have decided to implement a new education style such as bedside teaching, Kotter’s method can be useful. In this example, at the beginning of the shift the educator can create a sense of urgency by discussing the literature supporting improved learning and resident satisfaction with bedside teaching. Creating a guiding coalition can involve the educator, the learner and the patient. Involving each patient in the coalition can enrich the experience for the learner. Involve the learner by creating a clear vision of the goals for each bedside teaching encounter. During a short encounter, like a shift, frequent communication of the goals of bedside teaching is less important. This can be applied to debriefing to ensure the goals are being met. Remove obstacles by eliciting frequent feedback from the learner and incorporating any suggestions as necessary. Create short term wins by praising learners willingness to try different education models. Steps 7 and 8 are somewhat less applicable as they are geared toward larger institutional change, but they could apply loosely in this scenario by maintaining consistency using bedside teaching throughout the shift rather than switching between teaching methods.

Annotated Bibliography of Key Papers

Kotter JP. Leading Change: Why Transformation Efforts Fail. Harvard Business Review. 1995; (March-April): pp. 59–67.¹

This article is the initial article published by John Kotter elaborating his 8 Step pathway for leading change in companies successfully. This article was later expanded into a book called, Leading Change. In the original article, the steps to the pathway are defined in terms of the errors that Kotter saw companies make, instead of as a checklist or pathway of what to do. He does elaborate on these errors and how to avoid them in some detail, however this article is relatively short. His book would cover the steps in much more detail.

Applebaum SH, Habashy S, Malo JL, et al. Back to the Future: Revisiting Kotter’s 1996 Change Model. Journal of Management Development. 2012, 31(8):764-782.⁵

While widely accepted as the model for change management, Kotter’s eight steps were developed without any scientific evidence for their support. This article reviews the literature and provides the available evidence to support or refute each of Kotter’s eight steps. In addition, it mentions many of the major criticisms of Kotter’s original model.

Kotter JP. Accelerate! Harvard Business Review. 2012. 90(11):45-58.⁴

This 2012 article in the Harvard Business Review written by Kotter himself, provides an update on his original change model to address the increased pace of change challenging many contemporary organizations. While Kotter supports the initial model, he does offer some concessions in regard to the rigidity of the sequential approach and recommends a less hierarchical approach to that proposed in the original model. Additionally, Kotter argues that institutions should institute a dual operating system with a management hierarchy to conduct day-to-day operations and a dynamic strategy network to identify opportunities and implement change.

Limitations

While Kotter’s model of change management was an instant success when published in the late 1990s and is widely viewed as the definitive model for successfully implementing institutional change, it has been criticized on a number of fronts. From a methodologic standpoint, both the original article and the subsequent book were based on Kotter’s personal experience and did not reference any outside sources. In fact, neither the original article nor the book have footnotes, references or a bibliography.⁵  Since the original publication, much of the evidence to support Kotter’s model has been published by Kotter himself, raising concern in the validity of the model.⁵

In regards to the model itself, one common criticism is that it is too rigid.⁵ Change is a dynamic and complex process, and Kotter’s original model stresses the successful completion of each step before proceeding to the next with the assumption that change is a one-time event that ends in stability. While this approach looks good on paper, many have argued that, in reality, change is continuous. Steps likely occur in parallel, and often steps will need to be revisited during a single change process. Additionally, the original model argued for formation of the guiding coalition from high-level management, creating a top down process where employees can be seen as the object of change rather than participants.⁶ Both of these critiques were addressed by Kotter in follow-up publications in 20124 and 2014, in which he argues for more flexibility and agility within his own framework and for the formation of a “volunteer army” from all levels of the organization to replace the guiding coalition.

Part 3: The Denouement

Christy’s first task was to address the complacency, lack of interest, and engagement from both faculty and residents regarding the conference curriculum. She felt that her program was one of the top programs in the country; it was simply unacceptable that they had a conference curriculum that was so weak and uninspiring. Christy did a SWOT analysis to better understand the Strengths, Weaknesses, Opportunities and Threats within the current curriculum. She met with residents and faculty to create a sense of urgency, that improving the curriculum was a must.

Next, Christy created a committee including departmental leadership, residency program leadership, faculty and residents to create a vision for the what the new curriculum would entail. This group, covering all levels of the program, was relentless in communicating not only the need for change, but also their clear, concise vision for a more interactive, interesting, and high-yield curriculum. Christy met with residency leadership to see what structural changes could be made to how conference was organized, in order to make room for her innovative ideas. She empowered faculty and residents to brainstorm new and engaging ideas for the curriculum. After piloting a few of these ideas and seeing the excitement of both residents and faculty, Christy and her committee continued to refine the curriculum and made sure to communicate and celebrate their success to leadership, faculty and residents. As conference got more interesting and fun, faculty participation began to grow. Christy worked with departmental and residency leadership to solidify within the culture of the program the expectation of faculty participation.

Two years later, the conference curriculum was still running strong and continuing to innovate. Now residents, and faculty alike, are proud of the curriculum, boasting about it during recruitment season. The program has become much stronger due to the curricular changes, and Christy solidified herself as an educational leader and change agent within the department.

Don’t miss the 9th post in the series, coming out Tuesday, July 9, 2019!

PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW

References

1. Kotter JP. Leading change: Why transformation efforts fail. 1995;(March-April):59-67.

2. Mento A, Jones R, Dirndorfer W. A change management process: Grounded in both theory and practice. J Change Manag. 2002;3(1):45–59.

3. Kotter’s 8-Step Change Model – Change Management Tools from Mind Tools. https://www.mindtools.com/pages/article/newPPM_82.htm. Accessed July 9, 2018.

4. Kotter JP. Accelerate! Harv Bus Rev. 2012;(November 2012). https://hbr.org/2012/11/accelerate. Accessed July 9, 2018.

5. Appelbaum SH, Habashy S, Malo J-L, Shafiq H. Back to the future: revisiting Kotter’s 1996 change model. J Manag Dev. 2012;31(8):764–782.

6. O’Keefe K. Where Kotter’s 8 Steps Gets it Wrong. Corp Exec Board CEB. 2011. https://www.cebglobal.com/blogs/where-kotters-8-steps-gets-it-wrong/.