8 Steps To Culture Change


Want a roadmap to create change in an organization?  Here’s Kotter’s classic roadmap on organizational change.

Once consensus has been established about the business situation (easier said than done sometimes), there are models and steps for how to go about change management.  One of the most well known is John Kotter’s 8 Steps to Culture Change.  John Kotter, previously a Harvard Business School Professor, developed these 8 steps in part to help articulate why change efforts fail and to better improve our numbers with respect to successful change efforts.


By way of review, let’s discuss them beneath:


Step 1 – Establishing a sense of urgency.


This is sometimes called ‘the burning platform’.  This can be a short timeline until a quality review or some event that is important to the organization.  Step 1 creates a timeline which justifies action etc.  Being sure that people around you understand the importance of the event and feel the urgency without being overly anxious is key.


Step 2 – Creating the guiding coalition.


The guiding coalition is a team with enough power to lead the change effort.  This team must be encouraged to work as a group.  This is also challenging especially in an organization where there may be no support.  If you find yourself where there are clear issues and yet you do not have administrative support (or are not able to enlist it) it is likely you have a nonstarter for change management.


Step 3 – Developing a change vision.


Creating a vision to help direct the change effort, and developing clear strategies for achieving that vision, are central to successful change.  This is key to give the team something to work towards and to give the team something to achieve.  Articulating this change as a vision is key and this must be represented by both how you act and what you say.


Step 4 – The vision must be communicated for buy in.


People have to understand and accept both the vision and the strategy.  Again, if there is no administrative support from you from your colleagues in administration, or if you don’t communicate the vision, then people are unlikely to understand and accept the roadmap for the future.


Step 5 – Empowering broad based action.


This means you are obligated to remove obstacles to change for those people who are working with you on the team and at different levels in the organization.  In short, this goes back to the classic idea that you must make it easier to act in the way that change effort requires people to act.  That is, you remove barriers to people acting in the way they need to act for the change to occur. Some leaders will add friction in the opposite direction.  That is, they erect barriers to acting in the current mode to create enough friction that people must favor the newer, easier pathway to which barriers have been removed.


Step 6 – Generating short term wins.


Achievements that can be made early on are key.  Sometimes this is just harvesting the low hanging fruit.  Whatever the short terms wins are, these must be visible and these must be followed through with people receiving recognition and reward in a way that gets noticed.


Step 7 – Never letting up.


This increased credibility must be utilized to change systems, structures, and policies that don’t fit the vision.  Your hiring, promotion, and development of employees must be such that those who can implement the vision are brought along.  This makes the change programmatic and lasting.


Step 8 – Incorporating the changes into the culture.


The connections between the new behaviors and organizational success must be articulated, and these changes must be institutionalized.  There must be a means to ensure succession in leadership roles so that these changes become commonplace and are reinforced.  It is useful at this point to demonstrate that the new way is superior to the old with data.


My personal recommendation is that data be made to underlie this entire process.  In fact, the lean six sigma statistical process control pathway satisfies each of these steps in a positive way that allows us to avoid taking issues with each other or personal attacks.  Incidentally, one of the things I have noticed in change efforts is that what are called ad hominem attacks may abound.  An ad hominem attack occurs when someone attacks the person / messenger involved rather than the argument or data.  Ad hominem attacks are difficult, insidious, and common in Medicine.  It can be a real challenge to let these pass.  It can be even harder when a change agent has clinical decision making, technical prowess, or other professional, patient care skills questioned as part of an ad hominem attack.  Stay calm, and think of how good it will look when the situation is successful, or, failing that, leave if the situation becomes threatening either personally or professionally.


In fact, one of the most challenging things I have found is to note ad hominem attacks and try to progress beyond them.  Fortunately I have not been in this situation often, but let me say this can be a real challenge especially in a failed change effort or in difficult organizations…and, of course, despite our best efforts most change efforts fail.  So we should always enter these situations with a “batting average” mentality:  I may only get a hit .333 of the time, but I take the at-bat because the hits are worth it.


I recommend a data-driven approach, in general, where people are educated in their data and the data are not personally assignable.  This prevents finger pointing and allows us to make data driven decisions which are reproducible, transparent, and may be followed over time to gauge improvement.  If you can get the culture to respond to data rather than personal attacks, the team can improve over time in a meaningful way.


This focus on data makes for a situation which is not often encountered in Medicine; yet, when we do attain it, it is truly magical.  Sometimes I see my colleagues in Medicine reinventing tools that have names and are well utilized in other fields.  Some of these are utilized in the lean six sigma toolset, which is mostly a pre-established pathway to use these advanced statistical process controls for quality improvement and culture change.


I really enjoy helping groups in healthcare see that not all changes or improvements need come by confrontation or finger pointing.  Often, in different service lines in Medicine, it is too often the case that staff attribute issues to personal defects rather than system defects.  Commonly, many of what are felt to be personal issues are in fact system issues.  This is supported by the quality control literature and I have often noticed that poor systems may set up physicians and healthcare providers for confrontation amongst themselves.


Functional systems based on data which run smoothly often alleviate the need for frustration, conflict, and other issues.  Such feelings may represent symptoms of opportunities for improvement.


Last, please remember:  even if you know the steps, practice them, and work to create positive business situations these change situations are challenging and high risk.  Our batting average may even be below .500 (after all .333 is a good average in the major leagues) yet we take the at-bats because we learn from them, they improve our skills, and the hits are worth it.


Comments, questions, or thoughts on change management in your healthcare organization?  Have you seen a failed change management situation? If you have, let us know in the comments section beneath.  We always enjoy hearing and learning about change management across different organizations.