CHANGE MANAGEMENT: HOW TO

ACHIEVE A CULTURE OF SAFETY

SUBSECTIONS
• Eight Steps of Change
• Organizational Change
• Team Member
Empowerment
• Creating a New Culture
• Planning for Change
• Teamwork Actions

MODULE TIME: 2 hours 15 minutes

 Change
OBJECTIVES Management

SAY:
Pursuit of the goal for the safest and highest quality health care
requires optimization of a complex and integrated delivery system
that includes people and processes. To achieve this goal, the
medical profession must evolve and adapt, using both new
approaches and tools. These will include such process
techniques as systems analysis, process analysis and Slide
reengineering, and individual skill training in improving
communications.
MODULE
The adaptation necessary to achieve this goal will therefore TIME:
require change, including recognizing the need for
change, developing a culture that will accept change, and 2 hours 15 minutes
fostering actual change in individuals’ approach to the health care
delivery process. Paramount in this effort is institutionalizing the
concept that health care is delivered not by a series of people but
by a coordinated health care team whose techniques and goals
must be understood and aligned within a system.
This module will help guide you through the phases and steps
necessary for your nursing home to successfully change its
culture.
In this module, we will:
• Identify and discuss the Eight Steps of Change
• Describe the actions required to set the stage for
organizational change
• Identify ways to empower team members to change
• Discuss what is involved in creating a new culture
• Begin planning for the change in the nursing home

TeamSTEPPS 06.1 | Change Management 2

 Change
Management EIGHT STEPS OF CHANGE

SAY:
Realizing that change is difficult, John Kotter has outlined an
eight-step model for successful change efforts. Steps 1–4 help
unfreeze the status quo, Steps 5–7 introduce new practices, and
Step 8 grounds the changes in a new culture to ensure
sustainability (Kotter, 1996). Because we know that implementing
Slide and sustaining change is difficult, it requires a comprehensive
strategy. Briefly, the steps are:
• Step 1: Create a Sense of Urgency. Help others see the need
for change and the importance of acting immediately.
• Step 2: Pull Together the Guiding Team. Pull together the
guiding team. Make sure there is a powerful group guiding the
change―one with leadership skills, credibility, communications
ability, authority, analytical skills, and a sense of urgency.
• Step 3: Develop the Change Vision and Strategy. Clarify
how the future will be different from the past, and how you can
make that future a reality.
• Step 4: Communicate for Understanding and Buy-in. Make
sure as many others as possible understand and accept the
vision and the strategy.
• Step 5: Empower Others to Act. Remove as many barriers as
possible so that those who want to make the vision a reality
can do so.
• Step 6: Produce Short-Term Wins. Create some visible,
unambiguous successes as soon as possible.
• Step 7: Don’t Let Up. Press harder and faster after the first
successes. Be relentless with instituting change after change
until the vision becomes a reality.
• Step 8: Create a New Culture. Hold onto the new ways of
behaving and make sure they succeed until they become a
part of the very culture of the group.
We’ll spend a little time talking about these steps and their
implications for the change efforts in the next few minutes.

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 SET THE STAGE AND CREATE A SENSE OF Change
URGENCY Management

SAY:
The first phase in implementing change is setting the stage. As
we noted previously, the first step is to create a sense of urgency.
Ensuring a sense of urgency among people is crucial to getting
cooperation for change. Unless individuals understand the
urgency of a situation, complacency sets in, and change
becomes very difficult, if not impossible. Think about the forces of Slide
complacency―what are some of them?
Begin thinking about who are the key stakeholders, groups, and
individuals in the nursing home who must feel the need for
change for team training to happen. Are they on board yet?
Talking about the need for change, the consequences of not
changing, and ways to solve the problems is essential to making
the case for change.

TeamSTEPPS 06.1 | Change Management 4

 Change
Management PULL TOGETHER THE GUIDING TEAM

SAY:
For the change effort to be successful, a powerful group must
lead the change; and members of that group must work together
as a team. Key characteristics that must be represented on the
team include power, leadership skills, credibility, communications
ability, expertise, authority, analytical skills, and a sense of
Slide urgency.
Remember that no one person can implement wide-scale change;
a coalition is essential. Most nursing homes have a guiding
coalition already in place. Think about our nursing home. Is there
a guiding coalition already established? Do they have the right
mix of skills, knowledge, and capabilities?

Recommendation:
• Consider existing committees within the nursing home and
designate the one most appropriate as a guiding coalition.
Especially in larger nursing homes, a change team should be
in place in each unit. These teams could all report updates to
the guiding coalition.

Instructor Note: (Optional) Include exercise on guiding

coalition/change team membership.

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 DEVELOP THE CHANGE VISION AND Change
STRATEGY Management

SAY:
An organization fosters a “culture of safety” with its practices,
processes, and procedures. Patterns of behavior determine the
commitment, style, and proficiency of an organization in relation
to safety. A positive culture of safety has:
• Foundation built on mutual trust Slide
• Shared perceptions on importance of safety
• Confidence in efficacy of preventive measures
The second phase in implementing change is deciding what to
do. Leaders must create a compelling vision―one that answers
the questions “What do we want to achieve?” and “Where do we
want to be in the future?” It’s important that the vision engage
both head and heart. Leadership must also develop the strategy
to make that vision a reality. It’s also important that the guiding
coalition be instrumental in the creation of the vision and strategy.
Michael Fullan writes, “The role of the leader is to help create a
process that helps people see new possibilities that engage their
emotions and thus change behaviors or reinforce changed
behavior” (Fullan, 2004).

ASK:
Do we have a vision and strategy in place?

TeamSTEPPS 06.1 | Change Management 6

 Change COMMUNICATE FOR UNDERSTANDING AND
Management BUY-IN

SAY:
The third phase in implementing change is making it happen.
When the vision and strategies have been determined, they must
be effectively communicated. Failure to implement change is
often the result of undercommunicating or communicating poorly.
In addition, people must both understand and accept the vision
Slide and strategy.
Creating a vision and implementing change are time consuming
and a great deal of hard work. It’s essential that trust be built in
the early stages within and among the guiding coalition/change
team, staff, and leadership. It’s also important that an
environment be established where concerns can be brought
forward and discussed without fear of retribution. Every
communication channel available should be used to put forth the
vision and the strategies in a planned way. It’s also essential that
the guiding coalition and change team model the expected
behavior of employees.
Accept and plan for resistance. Resisters help to clarify the
problem, and by addressing their concerns, you can actually
improve the change.
Use the following actions to overcome resistance to change: 
• Acknowledge change as a process
• Empower stakeholders
• Encourage all stakeholders
• Set concrete goals
• Show sensitivity
• Model process skills
• Develop strategies for dealing with emotions
• Manage conflict
• Communicate
• Monitor process dynamics

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 Change
EMPOWER OTHERS TO ACT Management

SAY:
Leaders must change the systems or structures that undermine
the change vision and also remove other obstacles to change.
They should also encourage risk taking and nontraditional ideas,
activities, and actions. It’s essential that leaders remove as many
barriers as possible so that those who want to make the vision a
reality can do so. Slide
• Give people freedom and direction
• Give people permission to find their own team-driven solutions
• Encourage people to speak up, even to differing views
• Encourage people to take risks
• Affirm and refine the vision—make room for others’ ideas
• Tell people as much as you know
• Encourage teamwork and collaboration
• Encourage personal reflection and learning
• Provide people with training and support
• Use existing quality improvement methods in your nursing
home to track activities on a daily basis
• Set short-term goals

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 Change
Management PRODUCE SHORT-TERM WINS

SAY:
Creating visible, unambiguous successes connected to the
change effort as early as possible demonstrates success of the
initiative. Plan and create the wins and be sure to visibly
recognize and reward people who made the wins possible.
Slide Some additional issues to think through:
• Think through the power of short-term wins in the first unit to be
trained or early adopters of the change.
• Think of the method you use to integrate lessons learned into
your own process modification. Will that method apply here?
• How do you plan to leverage lessons learned to drive change
in the second unit to be trained? To design and drive change
as you train up multiple departments across the nursing home?
• What measures provide evidence of success?
• It takes a lot of courage to openly communicate when resisters
are present (e.g., at a staff meeting). What method do you find
successful for communicating to staff where there are
numerous resisters present? How can you leverage your
change team to strategize, plan, and control the impact of
resistance?
• What means or methods tend to build momentum? Is our
facility a “storytelling” place? Are stories an effective manner to
help staff hear and internalize the short-term “win”?

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 Change
DON’T LET UP Management

SAY:
Press harder and faster after the first successes. Be relentless in
instituting all the necessary changes until the vision is a reality. To
realize the vision, you may have to change systems, structures,
and policies that don’t fit together and don’t fit the transformation
vision. You may need to reinvigorate the process with new
projects, themes, and change agents. Slide

Kotter recommends that to solidify the changes you should:

• Hire, promote, and develop people who can implement the
change vision
• Reinvigorate the process with new projects, themes, and
change agents

TeamSTEPPS 06.1 | Change Management 10

 Change
Management CREATE A NEW CULTURE

SAY:
The final phase in implementing change is making it stick. Hold
onto the new ways of behaving and make sure they succeed,
until they become a part of the very culture of the group. Also
develop a means to ensure leadership development and
succession. Remember that changing culture comes last, not first.
Slide It is only after people change their actions that there can be a
change in culture.

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 ERRORS COMMON TO ORGANIZATIONAL Change
CHANGE Management

SAY:
Training is not a stand-alone function. Pitfalls commonly arise and
derail organizations overly eager in their rush to change. Listed
on this slide are some things to avoid.
New approaches and methods become part of a culture when
they are effective. Dr. Kotter identifies ways to institutionalize Slide
change and counter these errors:
• Build new habits and skills
– Providing opportunities for discussions and tools to reinforce
skills (e.g., pocket guide) may assist staff in institutionalizing
processes
• Reward incremental change
• Make all staff accountable
• Assign responsibilities for change actions
• Encourage mutual leadership

TeamSTEPPS 06.1 | Change Management 12

 Change
Management SHIFT TOWARD A CULTURE OF SAFETY

SAY:
As we undertake this change initiative, it’s helpful to identify
where we are in the process. This model is one that
TeamSTEPPS recommends and we’ll go through this in more
detail during the Implementation module.

Slide
The process of change naturally lends itself to certain groupings:
Phase 1: Setting the stage and deciding what to do —
Assessment
Phase 2: Making it happen —Training and implementation
Phase 3: Making it stick—Monitoring, integrating, and providing
coaching for the initiatives to sustain over time
As you can see, each of these major action organizers correlates
with Kotter’s steps.

13 TeamSTEPPS 06.1 | Change Managem

 Change
CULTURE CHANGE COMES LAST, NOT FIRST Management

SAY:
According to Kotter, the process of anchoring change in the
culture has the following characteristics:
• It comes last, not first. Most alterations in norms and shared
values come at the end of the transformation process.
• It depends on results. New approaches usually sink into the Slide
culture only after it’s very clear that they work and are superior
to old methods.
• It requires a lot of talk. Without verbal instruction and support,
people are often reluctant to acknowledge the validity of new
practices.
• It may involve turnover. Sometimes the only way to change a
culture is to change the key people.

TeamSTEPPS 06.1 | Change Management 14

 Change
Management ROADMAP TO A CULTURE OF SAFETY

SAY:
These steps and activities form a high-level roadmap to create a
culture of safety. They provide an outline for a vision and strategy.
In the next activity, we’ll begin to think through these issues in our
nursing home. Once the vision and strategy are determined, you
must take these high-level ideas and develop a TeamSTEPPS
Slide Action Plan for your nursing home.

Instructor Note: You should update the group on where

your initiatives currently stand and the work that is left to
accomplish.

15 TeamSTEPPS 06.1 | Change Managem

 Change
EXERCISE: SIZING UP THE ICEBERG Management

Instructor Note: The prerequisite for the “Sizing Up the

Iceberg” activity is for participants to have read John Kotter’s Our
Iceberg Is Melting. If they have not, then you can either create
your own exercise or use the TeamSTEPPS exercise “Sizing Up
the Culture.” The purpose of this exercise is to have the group
begin discussing and addressing the change steps in their
nursing home. Slide
“Sizing Up the Culture” is provided in the train-the-trainer/coach
exercise sheets.
TIME:
60 minutes
DO:
• Have the participants break into groups of 3-4 that correspond
to their work units if possible. MATERIALS:
• Have the groups read through the questions and answer them. • Sizing up the
Depending on the amount of time, you may want to assign Iceberg Exercise
questions to different groups so that all the questions are Sheet
addressed.
• Circulate through the room and answer questions as needed.
• Bring the group together and review the questions in order. Ask
the groups to summarize their answers to the questions.
• Add other relevant information as needed.
• You may not get through all the questions, but inform the group
that they will be working through all these issues as the
teamwork initiatives are implemented in the nursing home.
Note where actions have already been implemented and
update people on the status as appropriate.

Continued…

TeamSTEPPS 06.1 | Change Management 16

 Change EXERCISE: SIZING UP THE ICEBERG
Management (continued)

DISCUSSION:
• Do you have a “Fred” in your nursing home? If so, how is this
person treated?
Step 1: A Sense of Urgency
• What information do you have that may indicate a need for
Slide change in your nursing home?
• Where else might you look for “hidden” information?
• In the story, Fred took Alice to see and experience the
potential dangers for herself. How would you do that in your
nursing home?
• Have you ever known a “Nono?” What impact has that person
had on change in your nursing home?
• How is the need for change communicated in your nursing
home? What do you think is the most appropriate way to
communicate the need for change?
• What can you do to create a sense of urgency for change in
the nursing home?
Step 2: The Guiding Team
• What characteristics would you look for in a team to guide
change in your nursing home?
• What do you think is the most crucial thing to enable this
guiding team to truly function as a team?
Step 3: A Change Vision and Strategy
• How might you best determine what your change strategy
needs to be?
Step 4: Understanding and Buy-In
• How could you best ensure understanding and buy-in of
needed changes in your nursing home?
• Identify ways to communicate and reinforce change that you
believe would be most effective in your nursing home.

Continued…

17 TeamSTEPPS 06.1 | Change Managem

 EXERCISE: SIZING UP THE ICEBERG Change
(continued) Management

DISCUSSION:
Step 5: Fewer Obstacles, More Empowerment
• Where might you anticipate and eliminate barriers to change
in the nursing home?
• What do you believe might be behind people’s resistance to
change? Slide
• What are the norms of your “colony” that may interfere with
change?
Step 6: Short-Term Wins
• Identify examples of successes relative to the changes
needed in your nursing home that you have already seen.
• What could you do to reinforce success? (Remember the
festival at the school?)
Step 7: Not Letting Up
• Describe what you think it will take to really keep change
going in your nursing home.
• What resources and/or support will people need to implement
the needed change?
Step 8: A New Culture
• Describe the new culture that you see for your nursing home.
What will the benefits of such a culture be?

Instructor Note: On John Kotter’s Web site

www.ouricebergismelting.com, you can purchase change step
cards that include questions to help your team get on the
same iceberg.

TeamSTEPPS 06.1 | Change Management 18

 Change
Management TEAMWORK ACTIONS

SAY:
Teamwork actions include:
• Relate the steps of change within your nursing home
• Within each change step, identify at least one key action to
affect your nursing home
Slide
“Create a new culture. Don’t let up – Be relentless. Empower.”
John Kotter

Instructor Note: You should revise and customize these as

appropriate.

ASK:
What teamwork actions will you begin to implement?

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 Change
REFERENCES Management

Kotter, J. Leading Change. Harvard Business School Press,

Boston, MA, 1996.
Kotter, J. and H. Rathgeber. Our Iceberg Is Melting: Changing
and Succeeding Under Adverse Conditions, 2005.
Fullan, M. and A. C. Ballew. Leading in a Culture of Change
Personal Action Guide and Workbook. Jossey-Bass, San Slide
Francisco, CA, 2004.
Russell, J. and L. Russell. Leading Change Training. ASTD
Press, Alexandria, VA, 2000.

TeamSTEPPS 06.1 | Change Management 20