Blog Posts


Implementing Lean: Change Management Theories to Consider

Posted on Wed, Dec 21, 2016
Implementing Lean: Change Management Theories to Consider

By John Bitting, RN, BSN, MA

The healthcare industry is continually changing, and as leaders, we help staff as they struggle through change management challenges every day.

Evidence-based practice is the cornerstone of today’s medicine, and new research seems to happen at phenomenal rates. Intellectually we understand the need to change in order to improve and that “change is good.” However, the human part of us that prefers to be comfortable approaches change kicking and screaming. The adoption of the electronic health record is a good example. Good healthcare leaders and lean proponents love the data that can be revealed with a good reporting system in an electronic health record. Younger, tech-savvy, practitioners are even more comfortable in using the electronic devices and interfaces. But, in every electronic chart conversion, it is all too common for providers, nurses and allied health professionals to fight the inevitable. Some are even left by the wayside due to an inability to make the change.

Change is the foundation of lean. Through a lean event, we are going to change processes and even our environment. So, when implementing lean, we must be prepared to encounter and neutralize resistance, confusion and habits. You want to have a clear vision of the future state as well as the path to get there. You also want to have several arrows in your quiver for managing change.

Force Field Analysis

One model of change is Force Field Analysis (FFA) developed by Kurt Lewin (1951). It represents the concept of opposing forces in change. Change is viewed as a process of modifying two types of forces in a system; one which tends to maintain the status quo and the other which pushes for change. For change to occur, the balance of driving forces needs to overcome the restraining forces. Strengthening driving forces may include building win-win solutions. In developing a plan of action, Lewin recognized that actions to remove or reduce restraining forces were more effective than actions to increase driving forces, which would serve to increase tension in the system.

To change behavior, Lewin gave us his three step process:

  • Unfreeze
  • Movement
  • Refreezing

The first step in Lewin’s process is breaking the existing situation or status quo. Driving forces must move the situation into an uncomfortable place. Comfort is a powerful motivator, in both positive and negative ways. Discomfort can set the stage for “movement” to a new level of equilibrium. This is done by getting the followers to agree that the status quo is undesirable or not beneficial and encouraging them to look at things differently. The final phase is refreezing, or making the new situation the new status quo. The phase of refreezing is the sustainment of the change. The challenge of staying lean largely depends on how well you refreeze the new expectations.

The Seven Phases of Change

Gordon Lippitt expanded on Lewin’s theories and added seven phases. The seven phases of change model is not rigid or necessarily sequential, but instead flows between the different stages. It focuses on the change agent and how to use the phases to help guide the change.

The phases are:
  1. Identification and diagnosis of the problem
  2. Assessment of the motivation and capacity to change
  3. Assessment of the change agent’s ability to lead this change along with motivation factors that may influence them
  4. Change agent assumes the appropriate role
  5. Level of involvement of the change agent is determined
  6. Maintaining the change
  7. Stopping the helping relationship

Only when the team has confidently worked through each phase reaching acceptance of change has change occurred.

Advanced Change Theory

Another model for dealing with organizational change is the 13-part Advanced Change Theory (ACT). This model requires a lot of practice. It is called “Advanced” for a reason. It is a complex model for dealing with change. The concept seems fairly simple; it is the alignment of the change agent, the change target and the current reality. Getting those things aligned is the difficult part.

The complexity of the assumptions makes it a cumbersome model for a leader to use to enact change. However, some of the concepts within the model can help the leader as a change agent. Each leader will likely find assumptions they feel comfortable using.

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

Advanced Change Theory is one of many subjects included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about implementing lean at your facility and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

How leaders support, propagate and promote the change process will determine the success of the endeavor. The different theories are just that, theories. Some work very well. Others are hard to put into practice. Your personal level of comfort directly affects your ability to operationalize these concepts. New leaders must actively think about how to use these concepts with the lean team and other change processes. Seasoned leaders end up doing it as second nature. It is also easier when the leader believes in the change. It needs to be personal.

John Bitting, RN

John Bitting, RN, is a Divisional Director of Client Services for EmCare.



Posted on Thu, Jan 08, 2015

Since 2010, EmCare has maintained a strong partnership with Studer Group to improve clinical and operational results for our client hospitals. As a result of this partnership, Studer Group has provided access to exclusive content only available on Each month, one of Studer Group's insightful articles will be made available to blog readers. For more information about EmCare's partnership with Studer Group, click here. For more exclusive content, including webinars, learning labs, networking opportunities and more, visit 

by Quint Studer

Copyright 2014 by Studer Group, reprinted with permission.

"People wish to be settled; but only as far as they are unsettled, is there any hope for them." - Ralph Waldo Emerson

Being a leader in healthcare is tough. In fact, when you do it right, it feels kind of like you're climbing up a downward moving escalator. (I've actually tried this and it's not easy!)

Yes, we live and work in an ever-changing, fast-paced environment – both externally and internally. In order to make and sustain the improvements necessary to provide the best possible patient care, we often need to adopt new technologies, tools and processes that require us, and our staff, to change the way we do things.

You've probably noticed that people don't always welcome change with open arms. In fact, they resist it. This is natural. However, as leaders we can help people become more comfortable with that “unsettled” feeling.

The first step is to understand the phases of competency and change. At Studer Group, we often use the following model to illustrate the various stages that individuals will find themselves in at some point in their lives and careers.

Phase one: Unconsciously unskilled (incompetent) – During this phase, we are new to a role, process or skill. We don't know what we don't know because it is still too new.

Phase two: Consciously unskilled (incompetent) – In this phase, we consciously know what we don't know. We've identified a gap between our current skill set and where we need to be to become successful.

Phase three: Consciously skilled (competent) – Here we have the skill set, but we still need reminders or checklists to fully execute. We are likely still unsettled, but we understand the need for change and have embraced it.

Phase four: Unconsciously skilled (competent) – It's in this phase that we can complete tasks without reminders. They have become second nature and we can't imagine doing it any other way.

Anytime change is involved, there will be a level of adjustment for both staff and leaders. Part of our job as a leader is to unsettle people. We like to feel successful in our role, but in order to improve we need to be unsettled from time to time.

Realize that discomfort will be associated with change and that's okay. For example, when you ask a high-performing physician to implement a new process, such as electronic medical records, you will likely receive pushback. It's not because they are trying to be difficult, or even because they don't see the benefit. It's because you are asking them to change when they already feel successful.

When you think about this in terms of the four phases of change, you will see that you are actually requiring that physician to move from being consciously skilled back to being unconsciously unskilled.

You can ease anxiety by explaining how this change will make a difference (and for the better!). Describe what the outcome will be after the change is made. This is the why that makes people willing to be unsettled for a while.

Remember, it takes a lot of frequency to become effective and efficient. The phases of competency and change can be a lengthy process. The first six months are by far the hardest and when resistance is at its highest. The next six months are better but some uncertainty may still be present. But by year two, it no longer feels like we've changed; it's simply the way we do things.

Ultimately, change is necessary to standardize leadership, create consistency, and keep ahead of that downward moving escalator. In turn, we produce better outcomes for our employees and our patients.

Watch accompanying video here.