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    Initiating and Managing Organizational Change

    Sharon S. Lehman, MD
    Chief, Ophthalmology
    Nemours Children's Clinic-Wilmington/Alfred I. duPont Hospital for Children
    Robison D. Harley MD Endowed Chair of Pediatric Ophthalmology
    Clinical Professor of Ophthalmology and Pediatrics
    Assistant Dean of Faculty Affairs
    Sidney Kimmel Medical College at Thomas Jefferson University

    Bradley E. Barth, MD
    Associate Dean for Faculty Development
    Vice Chair for Leadership and Professional Development
    Associate Professor
    Department of Emergency Medicine
    University of Kansas Medical Center

    Change Is Inevitable in Academic Institutions

    Although academia is typically associated with stability and tradition, the reality in most academic medical centers is closer to continuous change with fits of rapid change. Often these changes are pressed onto groups or departments from external forces or outside initiatives. Another common occurrence in academic medicine is that a change — even when desired, anticipated, and appreciated — ends in failure after several weeks or months of furious activity, followed by the realization several months later that the change has failed and the old ways of doing things have returned. Why is it that change so rarely works and, more importantly, why is it so likely to fail?

    Business literature is replete with theories and research on organizational change. One of the best-known is based on the work of John P. Kotter.1,2 We will provide an overview of the eight steps of change management and common points of resistance. We will also review the four most common challenges and sticking points, based on our experience.

    The eight steps of change are: establish a sense of urgency, form a guiding coalition, develop a vision and strategy, communicate the change vision, remove obstacles, create short-term wins, consolidate gains and continue change, and anchor the change in the culture.

    1. Without a sense of urgency or clear case of why the change is necessary, it is difficult to overcome the inertia of the present situation. Change usually requires more energy than the status quo, so change leaders must build the case for expending extra energy.
    2. A guiding coalition needs to champion the change. The coalition needs to have either perceived or actual power. Coalition members must be committed to the change, but it also helps to incorporate people who may have been skeptical of the initiative.
    3. The vision for change needs to be communicated clearly and succinctly. The vision, mission, and strategy need to appeal to the hearts and minds of people in the organization.
    4. Communicating the vision needs to occur as often as possible and in as many modalities as possible. Change leaders needs to communicate the vision frequently and need to be seen living the vision and transparently making decisions based on the vision.
    5. Often obstacles arise as a result of not adequately completing the first four steps. When you identify an obstacle, immediately work to overcome it. Existing policies, skills, systems, rewards, or personnel are often obstacles to implementing the vision.
    6. Because change is hard, it is important to identify short-term wins that can demonstrate the benefits of the change to the organization. The guiding coalition should identify and plan for possible early wins at the beginning of the project.
    7. Beware of declaring victory too early. As gains accumulate, there is a tendency is to decrease the push for change. Consolidate recent changes as you continue to implement further change. Solidify and continue the change.
    8. Finally, ensure that systems, policies, rewards, and personnel reflect and support the new change. Communicate the wins, and promote the change as much as possible to ensure the new way of doing things sticks. Anchor the change in the culture.

    Next, we will discuss the four most common mistakes or challenges we have encountered in change management as leaders in faculty affairs: inadequate urgency, failing to plan for short-term wins, inadequate communication and funding, and failure to anchor the change.

    1. Do not understate the need for change. One of the most common errors in initiating change is to fail to communicate the breadth, depth, and risk that accompanies maintaining the status quo. It takes a leader and change agent to frankly discuss the unpleasant reasons change is necessary and why failure to change outweighs the fears of those who must live through the change. You must be careful not to paralyze constituents with fear every time change is needed but to communicate well enough to convince the majority there is no other option than to pursue change.
    2. All academics can detail change initiatives that did not stand the test of time. Meaningful change takes time. Initial supporters may turn into resistors of change if they do not see tangible evidence it is worth the sacrifice to change. To keep morale and commitment from wavering, leaders must plan for short-term wins along the way to re-energize the team. This should not be left to chance. Planning for these incremental wins can help provide a strategy for long-term transformation.
    3. Transformation is likely to fail if the change is not resourced properly. The most successful change strategies are the ones that become woven into the everyday life of the organization. Team members must know that leadership values the change. In effect, the changes have become shared values that allow members of an organization to have a common language and experience. This does not occur by chance. It is important that leaders communicate the connection between the change and the benefits to the performance of the organization and to the people of the organization. This must occur on an ongoing basis to ensure continued commitment. Providing adequate resources for change sends a message to the people of the organization that leadership values the change. 
    4. It is common for failure to arise from not anchoring change in the system (policies, procedures, etc.). Often, the first several steps in the change process succeed, but as time passes, the system returns to its previous level of performance. This is usually due to failing to create the policies, procedures, incentives, and training programs required to maintain the change. During this phase, go through policies and procedures meticulously to ensure there is no built-in encouragement or incentive to roll back the changes. For instance, if the change plan encourages more active participation in resident education, but the incentive plan doesn’t address participation (by either tracking and reporting participation or rewarding it), it is unlikely faculty participation in resident education will be sustained.

    Change in organizations often strikes fear into the hearts of both leaders and participants. By sharing best practices and pitfalls, we hope to alleviate that fear and provide a road map to successful change. 


    1. Kotter JP. Leading Change. Boston, MA: Harvard Business Review Press; 2012.
    2. Kotter JP, Kim WC, Mauborgne RA. HBR's 10 Must Reads on Change Management. Boston, MA: Harvard Business School Publishing; 2011.