The purpose of this article is to examine how organizational culture influences the likelihood of success for change strategies, and to provide tools for the reader to apply within his or her organization. Evidence suggests that organization members are more inclined to embrace change when the organization’s culture is aligned with the mission and goals of the company. Although senior management may espouse a set of values that they assume defines the organizational culture, the reality is that the way members perceive what is rewardedand what they believe to be the underlying messagewill constitute the “real,” in-use culture of how things are accomplished. Therefore, we suggest that a cultural analysis be undertaken to facilitate the planning and implementation of organizational change.
Understanding culture can be useful in two ways. First, cultural insight provides awareness of the extent to which organization members are willing to accept change; and second, a cultural assessment is likely to determine the root cause of the problems that impede stronger performance.
Measurement of Organizational Culture
By investigating two disparate organizationsa family-owned business and a global manufacturing companythis article describes ways that management can utilize cultural assessments to increase the likelihood of success in managing change. The Goodwin Company, an organization specializing in contract packaging of household and automotive cleaning products, and Patagonia, a global brand supplying high-quality outdoor clothing and equipment, provide examples of this phenomenon. In both cases, the instrument used to assess culture was the Integrated Cultural Framework (ICF), which was adapted by the authors from the work of Hofstede and Kluckhohn and Strodtbeck. The ICF has been used to analyze culture across a number of companies and industries and stands up to reliability and validity testing. The dimensions of measurement include:
- Ability to Influence: The extent to which organization members have an opportunity to influence decision making.
- Comfort with Ambiguity: The extent to which members are comfortable with uncertainty and risk taking.
- Achievement Orientation: The extent to which members are assertive, goal-directed, and achievement-oriented.
- Individualism versus Collectivism: The extent to which individual versus group loyalty exists.
- Egalitarianism: The extent to which equal opportunity exists for advancement.
- Time Orientation: The extent to which the organizational goal/mission is focused on values from the past, present, or future.
- Space Orientation: The extent to which the physical layout of the organization is public, private, or a mix of both.
The 35-item ICF survey was initially used to collect responses from organization members. Following the collection of survey data, an extensive number of interviews were carried out to provide more substantive information concerning organizational culture.
For several years, Goodwin Company, founded in 1922 by Thomas A. Goodwin, manufactured and sold its own line of household cleaning products. However, due to the competitiveness of the retail market, its focus shifted to contract packaging and distribution in the household, industrial, and automotive cleaning markets. Only the original product, Goodwin’s Ammonia, maintains the Goodwin label. Still a family enterprise, Goodwin Company currently has approximately 300 employees and manufacturing and distribution facilities in Los Angeles, California, and Atlanta, Georgia.
In response to concerns about increased labor costs and stagnant revenues, an organizational culture study was launched to determine the appropriate change strategy. Forty-three members of the organization, including managerial and clerical staff, completed the ICF survey and 13 one-on-one interviews were conducted.
The results revealed the following key findings:
- Ability to Influence: The data indicated that the ability of employees to propose and implement change in the company was low. The interviews suggested that marginal regard for input had caused the staff to become discouraged and had reduced motivation for process improvements.
- Individualism/Collectivism: Although Goodwin Company espoused teamwork as a core value, feedback from the management teams in California and Georgia indicated a low level of trust among management, which resulted in a lack of collaboration among the managers.
- Time Orientation: The data showed that employees viewed the company as focused on the past and present while lacking a strategic plan for the future.
Proposed Structural Changes
Given the results of the study, three recommendations were presented to the management team:
- Establish a strategic management group that meets weekly to address business challenges, coordinate travel between facilities, and find common ground to build trust.
- Give employees, customers, and suppliers a voice and increase their ability to influence policy and procedures. Initiate an electronic comment box for employees, and implement surveys on customer service and supplier satisfaction.
- Establish a company vision and mission statement to encourage a sense of ownership, and incorporate management teams from Atlanta and Los Angeles to spearhead this effort. Relocate artifacts, such as company photos from the early years and bottles from the product lines of the 1930s and 1940s, to both facilities in order to acknowledge the company’s history and longevity and encourage teamwork between members of the two offices.
The establishment of the strategic management team proved to be very beneficial. By having the management team travel between facilities, the group developed a better understanding of the challenges at both locations, and they began to build a baseline of trust. The resulting collaborative effort of the team yielded two new contracts. In addition, Goodwin Company was certified by a major chemical manufacturer as a top facility in the nation, which resulted in requests for manufacturing proposals that would not have been possible without improvements in cooperation among regional managers.
Goodwin Company was able to correlate changes that emerged in response to the organizational culture study; however, not all of the recommendations produced the desired results. For example, the customer service surveys did not yield the expected outcomes due to a lack of customer response. Additional customer contact will likely be necessary for future surveys to be effective. And although the recommendation to create a vision, mission, and values statement was originally well received, the management team eventually backed off the project, deciding that the company vision should come from its CEO.
Patagonia’s corporate headquarters are located in southern California and the company has overseas offices in Japan and France. Revenues in 2007 totaled $275 million and the firm currently has 1,300 employees worldwide, with 382 located in the corporate office. In 1966, founder Yvon Chouinard was dissatisfied with the conventional equipment used in adventure climbing and so he redesigned and manufactured almost every climbing tool to make each stronger, simpler, more functional, and environmentally friendly. From that operational base, Chouinard Equipment, which later became Patagonia, expanded to include outdoor and casual clothing and a line of underwear. The unique mission and focus of the organization was to make the best products, cause no unnecessary harm, and rely on the business model to inspire and implement solutions to the environmental crisis. Chouinard’s management principles were captured in a self-published book, Let My People Go Surfing: The Education of a Reluctant Businessman.
Although the essence of Patagonia’s initial philosophy has survived, increased growth and operational complexity have created challenges for the organization in its quest to remain committed to the mission. To better understand the underlying issues and develop a strategic direction, an organizational culture study was initiated. Using the ICF, 27 surveys were completed at the corporate office along with 15 one-on-one interviews with 4 senior managers and 11 mid-level managers from 8 departments.
- Ability to influence: The data showed that organization members felt they had a moderately high degree of opportunity to influence, but the inclusion of their input also led to a prolonged decision-making process.
- Comfort with ambiguity: Although the climate seemed to foster innovation and encourage risk taking, the lack of a systematic feedback process minimized the flow of ideas. In addition, the dilemma of attending to what appear to be dichotomous goalsattaining a profitable return while maintaining a commitment to environmentally safe productscreated a challenge.
- Individualism/Collectivism: Patagonia attempted to build community by establishing an on-site childcare center, comprehensive health insurance, and a family setting. However, the company employs a large number of unique and creative independent-minded people, and in supporting innovation, it created a sense of individualism, as well as a limited incentive for teamwork.
Although Patagonia has been successful, the study indicated that to remain competitive, the organization needed to address the duality of encouraging individual creativity and promoting a collaborative work environment, particularly as this duality related to the corporate mission. In addition, it appeared that information flow and decision-making efficiency needed to be addressed.
The organizational culture study was presented to the Board of Directors, who recognized the need to enhance productivity by reinforcing the organization’s mission and emphasizing the importance of a collaborative environment. The following structural changes emerged:
- The human resources director was appointed to the senior management steering team to assist in the development of a strategic training initiative. Training courses were developed to provide skills directed toward facilitating performance management feedback, improving communication skills, and enhancing negotiation capability in dealing with suppliers.
- A new employee training manual was created to better educate new hires regarding the organizational structure and the flow of product lines from development to sales. The purpose was to build teamwork and collaboration and to emphasize the company’s core values related to quality, integrity, environmentalism, and the desire to not be bound by convention. In addition, Yvon Chouinard’s book was presented to each hire with the hope of inculcating new members to the principles associated with the organization’s mission.
- All employees are now encouraged to participate in the Patagonia National Park protection program in Chile and Argentina to reinforce the importance of the mission statement and its meaning in their work. Employees receive a salary and all related expenses are paid by the organization during the three-week program.
- The selection process for hiring new members was reviewed with a focus on measuring candidates’ knowledge and skills, particularly their ability to work in a team.
Shifting a culture that has to some extent moved away from the values established by its founder is always a challenge. A number of Patagonia’s high performers have been successful because of their innovative talents. However, unless these individuals are also able to recognize the importance of collaboration, in the long term, the organization may not be able to respond in a timely manner to competitive pressure.
The article examined two distinct organizations, a family-owned operation and a global manufacturer, which utilized a cultural framework to determine underlying organizational issues. In both cases, the plans of action were system-wide and strategic. Although each company experienced favorable outcomes, considerable follow-up strategies must still be implemented before significant change is realized.
Cameron and Quinn claim that organizational improvements are unlikely without culture change as an initial step in the process. But culture change is illusive, requires lengthy interventions, and, for many organizations, is either too costly or too time-consuming, making successful transformation problematic. This study offers another perspective. Although culture change is necessary in creating and reinforcing organizational transformation, our position is that making necessary structural changes may serve as the initial intervention for shifting culture. At Patagonia, changes in how new members are socialized may bring about a commitment to organizational values and encourage a team-oriented mindset. The impact of these initiatives is likely to result in norms that reflect organizational objectives. Goodwin Company’s focus on enhancing collaboration, particularly among the management team, may result in continued dialogue between members, which will hopefully become embedded in their working relationships. In conclusion, the creation of structural initiatives that incentivize the desired ways of accomplishing goals may be more effective in responding to inefficiencies than a commitment to changing culture, which, over time, may naturally occur as shifts in behavior emerge.
 John Kotter, The Heart of Change: Real Life Stories of How People Change Their Organizations, (Harvard Business School Press, 2002).
 Janet Parish, Susan Cadwallader, and Paul Busch, “Want to, Need to, Ought to: Employee Commitment to Organizational Change,” Journal of Organizational Change Management, 21, no. 1 (2008).
 Edgar Schein, The Corporate Culture Survival Guide, (California: Jossey-Bass, 1999); Sally Riad, “Of Mergers and Cultures: What Happened to Shared Values and Joint Assumptions,” Journal of Organizational Change Management, 20, no. 1 (2007).
 Chris Argyris, “Teaching Smart People How to Learn,” Harvard Business Review, 14 (1991).
 Celeste Wilderom, Ursula Glunk, and Ralf Maslowski, “Organizational Culture as a Predictor of Organizational Performance,” in the Handbook of Organizational Culture and Climate, Eds. Neal Ashkanasy, Celeste Wilderom, and Mark Peterson, (California: Sage Publications, 2000).
 Geret Hofstede, Culture’s Consequences: International Differences in Work-Related Values, (London: Sage Publications, 2001).
 F. Kluchhohn and F.Strodtbeck, Variations in Value Orientation, (Illinois: Row, Peterson, 1961).
 Mark Mallinger and Gerard Rossy, “Film as a Lens for Studying Culture and its Implications for Management,” lecture, presented at the Western Academy of Management, (Redondo Beach, CA: 1999); Mark Mallinger and Gerard Rossy, “The Trader Joe’s Experience: The Impact of Corporate Culture on Business Strategy,” Graziadio Business Report, 10, no. 2 (2007); Mark Mallinger and Lindsley Boiney, “An Interdisciplinary Approach to Teaching Organizational Culture,” presented at the Western Academy of Management, (2002).
 Yvon Chouinard, Let My People Go Surfing: The Education of a Reluctant Businessman, (Penguin Press HC, 2005).
 Kim Cameron and Robert Quinn, Diagnosing and Changing Organizational Culture: Based on the Competing Values Framework, (California: Jossey-Bass, 2006).
Authors of the article
Mark Mallinger, PhD, is a professor of applied behavioral science at the Graziadio School of Business and Management’s at Pepperdine University. He teaches in the full-time, fully-employed, and executive programs. Dr. Mallinger is a management development consultant and has published works in a number of academic and practitioner journals.
Don Goodwin, MBA, obtained his BS in Business Administration from Pepperdine University’s Seaver College and his MBA from Pepperdine’s Graziadio School of Business and Management. Don is a fifth-generation family member in the Goodwin Company, his family’s contract packaging and distribution company, which began operating in 1922. Hired originally as the Director of Purchasing, his focus has changed to encompass overall responsibility for the operations of the company, specifically software integration and modernization. He is currently focused on the day-to-day operations of all departments and on helping to develop the strategic direction for the company’s future.
Tetsuya O’Hara, MBA, attended Doshisha University in Kyoto, Japan, where he received a bachelor’s degree in economics in 1985. He was then employed at Teijin Limited, a multinational chemical company in Osaka, Japan, where he was in charge of sailcloth from 1985 until 1995, and contributed to America’s Cup as an official sailcloth supplier. In 1992, he won the Most Valuable Employee Award at Teijin. In 1996, he moved his family to Connecticut to work for Dimension Polyant Sailcloth, Inc. As Executive Manager, he developed new materials, including polyester-laminated fabric for NASA’s environmental research balloon. In 2003, he moved his family to California to join Patagonia, Inc., as Director of Material Development and Advanced Concepts. There he manages the raw material sourcing, development, new business concepts, and new technologies for the product lines, along with finding materials that are the most environmentally friendly. He received his MBA from Pepperdine’s Graziadio School of Business and Management in 2008. The United States Patent Office approved his scientific inventions and granted him patents in January 2000 and July 2008.
Nancy M. Lorenzi, PhD and Robert T. Riley, PhD
Affiliations of the authors: University of Cincinnati, Cincinnati, Ohio (NML); Riley Associates, Cincinnati (RTR).
Nancy M. Lorenzi, PhD, University of Cincinnati Medical Center, P.O. Box 0663, 250 Health Professions Building, Cincinnati, OH 45267-0663. e-mail <ude.cu@iznerol>.
Author information ►Article notes ►Copyright and License information ►
Received 1999 Nov 1; Accepted 1999 Nov 18.
Copyright © 2000, American Medical Informatics Association
J Am Med Inform Assoc. 2000 Mar-Apr; 7(2): 116–124.
This article has been cited by other articles in PMC.
As increasingly powerful informatics systems are designed, developed, and implemented, they inevitably affect larger, more heterogeneous groups of people and more organizational areas. In turn, the major challenges to system success are often more behavioral than technical. Successfully introducing such systems into complex health care organizations requires an effective blend of good technical and good organizational skills. People who have low psychological ownership in a system and who vigorously resist its implementation can bring a “technically best” system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change—including to new technologies—to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.
It's not the progress I mind, it's the change I don't like. —Mark Twain
Along with the inevitable failures, medical informatics has had many successes—probably more than should have been expected, given the challenges of the hardware, software, and infrastructure that faced us in the past. However, many of the successful systems were implemented as stand-alone systems that involved a modest number of people. Furthermore, the systems were often implemented in specific, limited areas that could see potential direct benefits from the systems. Typically, there were local champions, who made major and personal commitments to the success of the systems, and the enthusiasm of these champions was readily transmitted to the people with whom they worked directly. In turn, most of the people working on these systems felt like pioneers, and the literature of medical informatics is filled with their accomplishments.
When we embark today on designing, developing, and implementing more complex systems that have wider impact, a new set of challenges looms even larger. Certainly, technical challenges still exist; they always will. However, as our new systems affect larger, more heterogeneous groups of people and more organizational areas, the major challenges to systems success often become more behavioral than technical.
It has become apparent in recent years that successfully introducing major information systems into complex health care organizations requires an effective blend of good technical and good organizational skills. A “technically best” system can be brought to its knees by people who have low psychological ownership in the system and who vigorously resist its implementation. The leader who knows how to manage the organizational impact of information systems can sharply reduce the behavioral resistance to change, including to new technology, to achieve a more rapid and productive introduction of information technology.
Knowledge of the significance of people and organizational issues is not new. One of our informatics pioneers, Octo Barnett, identified political and organizational factors as being important 30 years ago.1 However, given the realities of that era, they were “well down the list.” By 1998, Reed Gardner, another definite pioneer, stated in his Davies Lecture2:
In my opinion, the success of a project is perhaps 80 percent dependent on the development of the social and political interaction skills of the developer and 20 percent or less on the implementation of the hardware and software technology!
We are seeing a shift in the balance of the people and organizational issues as opposed to the technical issues. An effective medical informatics change strategy can help convert what health care organizations are experiencing today—technology-centered tension—into welcomed opportunities that will lead to improvement in all phases of the health care process.
The content that supports both the intellectual content and strategy for this cornerstone comes from multiple disciplines, e.g. psychology, sociology, management, and anthropology. This paper discusses four major topics—why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.
Why Do Information System Failures Occur?
If only it weren't for the people, those awful people, always getting tangled up with the systems. If it weren't for them, the health care area would be an informatician's paradise.*
Complex problems rarely have simple solutions. During the many stages of the solution process, there are numerous opportunities to go wrong, whether the solution tends to be a technical one or not. As we delve into increasingly complex medical informatics problems, we will increasingly face this challenge. In reviewing information system failures cited in the literature as well as drawing on our personal observations and experiences, we have seen the rising importance of the human issues that are often referred to as people and organizational issues.
▶ presents a categorized overview of the reasons for contemporary failures in implementing major information systems. There is typically no one single cause in a given case. In fact, a snowball effect is often seen, with a shortcoming in one area leading to subsequent shortcomings in other areas. No precise statistics exist for the relative importance of the causes; however, personal observation tells us that the two most important are communications deficiencies and the failure to develop user ownership.
Reasons for Contemporary System Failures
Change and Change Management
Technology has indeed taken a place next to war, death, divorce, and taxes as a prime cause of bone-shuddering anxiety.—John Seymour
Change is a constant in both our professional and our private lives. Our children grow up taking for granted such things as powerful personal computers that we could not envision at their ages. The idea that human beings naturally resist change is deeply embedded in our thinking about change. Our language (e.g., “resistance to change”), our assumptions, and our mental models about change all seem to imply that something in our natures leads us to resist change. However, it is easy to find examples of human beings, from childhood on through old age, actively seeking out change of all sorts. Human beings do not necessarily resist change automatically; however, many people do resist being changed, i.e., having changes imposed on them.
Organizational change normally involves some threat, real or perceived, of personal loss for those involved. This threat may vary from job security to simply the disruption of an established routine. Furthermore, there may be tradeoffs between the long and short run. As an individual, I may clearly perceive that a particular proposed change is, in the long run, in my own best interests, and I may be very interested in seeing it happen, yet I may have short-run concerns that lead me to oppose particular aspects of the change or even the entire change project.
The rate of change is escalating in virtually all organizations. The pressure is intense on anybody connected with the health-related world to focus time and attention on understanding the forces driving the changing environment and develop or implement the information systems needed to support the altered environment.
The phrase change management is very common in management articles as well as newspapers.4,5 Moreover, managerial interest in the topic has been stimulated by the comments of Peter Drucker6 as to whether one can manage change at all or merely lead or facilitate its occurrence within an organization. Nevertheless, using the traditional terminology, what is meant by change management, how did it evolve, and why has this concept become so important?
Change management is the process by which an organization gets to its future state, its vision. While traditional planning processes delineate the steps on the journey, change management attempts to facilitate that journey. Therefore, creating change starts with creating a vision for change and then empowering individuals to act as change agents to attain that vision. The empowered change management agents need plans that provide a total systems approach, are realistic, and are future oriented. Change management encompasses the effective strategies and programs to enable those change agents to achieve the new vision.
Today's change management strategies and techniques derive from the theoretic work of a number of early researchers.
Examples of Core Theories from Other Disciplines
In 1974, Watzlawick, Weakland, and Fisch published their now classic book, Change: Principles of Problem Formation and Problem Resolution.7 Theories about change had long existed. However, Watzlawick et al. found that most of the theories of change were philosophical and had been derived from mathematics and physics. Watzlawick et al. selected two theories from the field of mathematical logic on which to base their beliefs about change. They selected the theory of groups and the theory of logical types. Their goal of reviewing the theories of change was to explain the accelerated phenomenon of change that they were witnessing.
Watzlawick et al. concluded that the earlier theories explained first-order and second-order changes:
First-order change is a variation in the way processes and procedures have been done in a given system, leaving the system itself relatively unchanged. Some examples are creating new reports, creating new ways to collect the same data, and refining existing processes and procedures.
Second-order change occurs when the system itself is changed. This type of change usually occurs as the result of a strategic change or a major crisis such as a threat against system survival. Second-order change involves a redefinition or reconceptualization of the business of the organization and the way it is to be conducted. In the medical area, changing from a paper medical record to an electronic medical record represents a second-order change, just as automated teller machines redefined the way that many banking functions are conducted worldwide.
These two orders of change represent extremes. First-order change involves doing better what we already do, while second-order change alters the core ways we conduct business or even the basic business itself.
Golembiewski, Billingsley, and Yeager8 subsequently added another level of change, defining middle-order change as lying somewhere between the extremes of first- and second-order change. Middle-order change “represents a compromise; the magnitude of change is greater than first-order change, yet it neither affects the critical success factors nor is strategic in nature.”
Kurt Lewin is credited with combining theories from psychology and sociology into the field theory in social psychology.9 Lewin focused on motivation and the motivational concepts that underlie an individual's behavior. Lewin believed that there is tension in a person whenever a psychological need or an intention exists, and the tension is released only when the need or intention is fulfilled. The tension may be positive or negative. These positive and negative tension concepts were translated into a more refined understanding of conflict situations and, in turn, what Lewin called “force fields.”
Lewin indicated that there are three fundamental types of conflict:
Individuals stand midway between two positive goals of approximately equal strength. A classic metaphor is the donkey starving between two stacks of hay because of the inability to choose. In information technology, if there are two “good” systems to purchase or options to pursue, then we must be willing to choose.
Individuals find themselves between two approximately equal negative goals. This certainly has been a conflict in many organizations that wish to purchase or build a health informatics system. A combination of the economics, the available technologies, the organizational issues, among other factors, may well mean that the organization's informatics needs cannot be satisfied with any available products, whether purchased or developed in-house. Thus, the decision makers must make a choice of an information system that they know will not completely meet their needs. Their choice will probably be the lesser of two evils.
Individuals are exposed to opposing positive and negative forces. This conflict is very common in health care organizations today, especially regarding health informatics. This conflict usually occurs between the system users and the information technology or financial people.
Kurt Lewin's field theory allows the types of conflict situations commonly found in health care to be diagrammed and analyzed.
Small-group theory is another tool that is highly applicable to health informatics because of the way that health care environments and activities are organized. Caring for patients and educating students typically involves many small groups of people. Small-group theory can help us understand why there are such wide ranges of effectiveness among these groups.
These are just a few examples of the social science theories that can help the change management leader understand some of the underlying behavioral issues that need to be faced as health informatics technology is brought into today's complex health systems.
Practical Applications of Change Management
There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.—Niccolo Machiavelli
One of the most difficult problems organizations face is dealing with change. In today's rapidly changing, highly competitive environment, the ability to change rapidly, efficiently, and almost continually will distinguish the winners from the losers. Many health-related organizations will disappear because they find themselves unable to adapt. Furthermore, many of the pressures for change in health care organizations are independent of technologic change. This means that informaticians working for change are doing so in organizations that are already highly stressed by other pressures.
Major organizational changes typically involve many different types and levels of personal loss for the people in the organization. For example, change always requires the effort to learn the new, which is a loss in terms of time and energy that could have been used elsewhere. Although some may welcome the learning opportunity, many of us don't want to invest that time and energy unless we are dissatisfied with the current arrangements or see powerful advantages to the proposed change. Upgrading to new software is a common example, in which the future benefits may not be seen as sufficient to outweigh the short-term investment required to learn the new programs.
Second, people want to feel good about themselves. Ideally, people are able to take pride in their work, feel responsible for a job well done, feel they are part of a high-quality enterprise, and feel that their time has some significance. In many work situations, the work itself and the organizational culture make it difficult for people to feel good about themselves. In these poorer situations, people usually invent strategies to help them feel better about themselves, and these strategies involve getting some sense of control, belongingness, and significance out of their work. Sometimes this involves opposition to management, on the assumption that management is always up to no good. More commonly, the worker-management relationships are not completely alienated. Still, the workers' strategies for achieving “good” feelings are unknown to or quite misunderstood by management. Therefore, change initiatives, unknowingly and unintentionally, threaten to cause the workers serious personal loss. Not surprisingly, the workers resist and do all they can to sabotage such change initiatives.
Third, change initiatives often require large losses for middle managers. Generally, people perceive that information systems increase the ability of top executives to know more about what is going on and to exert more direct control. This means a serious loss of personal and organizational significance for the middle manager. Sometimes middle managers fight this loss. Any significant organizational change involves changing habits, that is, changing the way we actually do our work. This usually involves changes in the way we interact, both with people and our tools. New systems require us to learn a new set of behaviors.
Types of Change
Changes in an organization can often be identified as one of four types, with the definite possibility of overlap among them:
Operational changes affect the way the ongoing operations of the business are conducted, such as the automation of a particular area.
Strategic changes occur in the strategic business direction, e.g., moving from an inpatient to an outpatient focus.
Cultural changes affect the basic organizational philosophies by which the business is conducted, e.g., implementing a continuous quality improvement (CQI) system.
Political changes in staffing occur primarily for political reasons of various types, such as those that occur at top patronage job levels in government agencies.
These four different types of change typically have their greatest impacts at different levels of the organization. For example, operational changes tend to have their greatest impacts at the lower levels of the organization, right on the firing line. People working at the upper levels may never notice changes that cause significant stress and turmoil to those attempting to implement the changes. On the other hand, the impact of political changes is typically felt most at the higher organizational levels. As the name implies, these changes are typically made not for results-oriented reasons but for reasons such as partisan politics or internal power struggles. When these changes occur in a relatively bureaucratic organization, as they often do, those working at the bottom often hardly notice the changes at the top. Patients are seen and the floors are cleaned exactly as they were before. The key point is that performance was not the basis of the change; therefore, the performers are not much affected.
Microchanges and Megachanges
When communicating about change, the models of Watzlawick and Golembiewski tend to be too abstract or difficult to explain. A more practical model that we frequently use divides changes into microchanges and megachanges, with no great attempt at elaborate definitions. As a first approximation, the following scheme can be used to differentiate between the two:
Microchanges—differences in degree
Megachanges—differences in kind
Using an information system as an example, modifications, enhancements, improvements, and upgrades would typically be microchanges, while a new system or a very major revision of an existing one would be a megachange. This scheme works surprisingly well for communication within organizations as long as we remember that one person's microchange is often another person's megachange. So while the system designers think they are making a minor change to enhance the total system, an individual end user may see the change as a megachange and resist it vehemently. When designing the total “people” strategy for any system, it is important to involve a variety of people from the very beginning, to clearly understand how groups function in the organization and how the work is really done.
The Cast of Characters
For any given change, people can occupy a wide range of roles that will strongly influence their perceptions of the change and their reactions to it. These are roles such as champion, end user, developer/builder, watchful observer, obstructionist, and such. As on the stage, some people may occasionally play more than one role. In other cases, the roles are unique. Unless we clearly identify both the players and their roles in any change situation, we risk making decisions and taking action based on generalizations that are not true for some of the key players.
An overview term often applied to the various roles is stakeholders. The stakeholders have some interest or stake in the quality of both the change and the change implementation process. The role of the stakeholders are subject to change, especially during a change process that extends over some time.
For those implementing change, the following steps are critical:
To identify what roles they themselves are occupying in the process
To identify what roles the others involved in the process are playing, being careful to recognize multiple roles
To identify carefully which role is speaking when one is communicating with those playing multiple roles
To monitor throughout the process whether any roles are changing
Resistance to Change
It is easy to change the things that nobody cares about. It becomes difficult when you start to change the things that people do care about—or when they start to care about the things that you are changing.—Lorenzi and Riley
Resistance to change is an ongoing problem. At both the individual and the organizational levels, resistance to change impairs concerted efforts to improve performance. Many corporate change efforts have been initiated at tremendous cost only to be halted by resistance among the organization's employees. Organizations as a whole also manifest behavior similar to that of individuals when faced with the need to change.
The relationship between individual and organizational resistance to change is important. An organization is a complex system of relationships between people, leaders, technologies, and work processes. From this interaction emerges organizational behavior, culture, and performance.
These emergent properties and behaviors are tightly linked in two directions to the lower-level interactions. Organizational resistance to change is an emergent property, and individual resistance to change can give rise to organizational resistance. A self-reinforcing loop of increasing resistance can develop as individuals create a environment in which resistance to change is the norm. That environment in turn encourages increased resistance to change among individual employees. The self-reinforcing nature of this loop can be tremendously powerful, defeating repeated attempts to break out of it.
Studies of system dynamics frequently reveal that major problems that everyone thought were external are actually the unintended consequences of internal policies. The basic dynamic behind this phenomenon is that the organization is made up of a network of circular causal processes: A influences B, which then influences C, which in turn influences A, i.e., the snake bites its own tail. Understanding these internal organizational dynamics is a prerequisite for leading effective change processes.
Rituals of Transition
All change involves loss. In many cases, change requires at the minimum that individuals give up familiar routines. In some cases, the loss is substantial, affecting position, power, networks of friends and colleagues, and such. In all these situations, rituals of transition can be crucial in assisting people to grieve and let go of the old and move on to the new.
The strategies for overcoming the barriers to change are quite diverse and touch on every aspect of the organization. No organization can begin using all the strategies at the same time or even in a short period of time. A better approach is to focus on one or two until they become part of the normal way of operating, i.e., until they become engrained in people's habits. Only then is it time to introduce another strategy. In this way, over time, the organization gradually improves its abilities to learn rapidly, to adapt to new conditions, and to embrace change.
Change Management Efforts in Medical Informatics
If you design something that works with an already existing model and doesn't require people to change their religion, the idea has a better chance of working.—Ted Selker, IBM
The current formal focus on change management in the medical informatics area is relatively new. Two early pioneers in analyzing the impact of information systems were Diana Forsythe and Henry Lundsgaarde. Diana Forsythe worked at the boundaries of cultural anthropology, medicine, and computer science. She was among the first anthropologists or sociologists to collaborate with computer scientists to study the work practices of computing. Her ethnographic work on software development in medical informatics revealed that cultural and disciplinary assumptions are routinely (but often unintentionally) designed into such software, potentially reducing the system's benefits to clinicians or patients. Her field research in various medical disciplines suggested ways in which software and other technology might better meet those needs.11,12,13 Henry Lundsgaarde14,15 evaluated the PROMIS system. This study produced insights into people and organizational issues and is an excellent example of how to combine qualitative and ethnographic methods with quantitative ones.
A concerted effort to introduce the people and organizational aspects more formally and broadly into medical informatics began in 1993 with a working conference in Cincinnati, Ohio, held under the auspices of the International Medical Informatics Association (IMIA). The years since have shown that this working conference was a seminal event, in that it brought together for the first time isolated individuals interested in the topical area. A number of today's leaders in the area were present at that conference, representing different academic backgrounds, different types of organizations, and different countries.
Following that working conference, IMIA approved a working group to study further the organizational impact of computers in medicine. Other related working groups were approved by AMIA, the European Federation for Medical Informatics, and the Health Informatics Society of Australia. These working groups accepted as their charge some variation of the following theme—applying knowledge of human behaviors to the implementation of informatics in a health care environment.
The IMIA and AMIA working groups, under the initial leadership of Nancy Lorenzi, accepted a fourphase driving-wedge diffusion strategy to spread their messages across the profession. The first phase of this strategy was designed to build awareness of the importance of the topic of people and organizational issues in the area of health informatics. One diffusion product was the book Organizational Aspects of Health Informatics: Managing Technological Change, published in 1994.10 This was followed by a case studies book, Transforming Health Care through Information: Case Studies, published in 1995.16
The second phase of the diffusion process was designed to educate people about the research from other disciplines, e.g. psychology, sociology, anthropology, and cognitive sciences, that is directly relevant to medical informatics. Products that support this diffusion strategy include the working group newsletter, Organized Aspects of Medical Informatics, edited by Bonnie Kaplan, PhD, and co-edited by Marilynne Herbert, PhD. Presentations at national and multinational conferences and publications in recognized informatics journals are other examples of this phase of the diffusion strategy.17,18,19,20
The third phase of the diffusion process is to apply established methods and models from other disciplines (e.g., psychology and sociology) to the medical informatics area. The working groups actively encourage current practitioners and students to model their medical informatics research efforts using documented and accepted concepts from other disciplines.
The fourth phase assumes that our ongoing research will reveal the need for some concepts and methods that are unique to medical informatics. This phase is designed to develop new, discipline-specific research methods and models. The working group encourages students in master's and doctoral programs as well as active researchers to consider innovative research designed specifically for the area of medical informatics.
The Road Ahead
I'm very interested in the future because I plan to spend the rest of my life there.—Robert Wood Johnson
As medical informatics becomes involved in ever larger and more complex systems, both the overall organizational leaders and the informatics leaders must adapt to the following realities.
When the impact of technologic change is being managed, people's needs come first: Without people, we don't have an organization. We must implement the new technologies to do what they do best—structured, repetitive work—and let the people do what they do best—think, be creative, and solve problems. People are far better at reviewing boring work than doing it. It is because of these concepts that workflow technology is rapidly changing the role of today's information worker from an information transcriber and mover to a true knowledge worker—an information user.
The knowledge workers are the foundation. According to Peter Drucker in “The New Society of Organizations,”21 the world economy is in the midst of transformation to the “knowledge society.” Increasingly, knowledge is not just one resource among many; it is “the primary resource for individuals and for the economy overall.” The essential purpose of management in the knowledge society is to encourage systematic organizational innovation. Drucker makes the important point that in a knowledge economy, the true source of competitive advantage is not so much technology, research and development, or even knowledge itself. It is the people, the knowledge workers whose skills and expertise are the foundation for all innovation.
We need to develop a new way of looking at how we currently function in our organizations. Management and workers will have to come together to build better, more productive work environments by understanding the long-term issues affecting their future and by creating a new way of thinking about how these current enabling technologies can best be used.
Technology Is Not Enough
Because technology investments are largely made up of things (i.e., hardware and software), it is easy to make the mistake of believing that a technology is implemented once it has been bought and installed. In fact, nothing works without people. These human issues become magnified in the process of redesigning work processes. Many work-process redesign projects focus exclusively on technology and fail to address the human and organizational aspects of work. In these instances, organizations fail to explore nontechnical solutions to improving organization processes, such as training or changes in structures, procedures, and management practices. Most often, technology strategy drives organizational change. While the business strategy may be clear, it is often not reflected in a defined organizational change strategy.
Too many technically good applications have failed because of sabotage by users who like the old ways in which things were done. Managing the natural resistance to change and helping convert that resistance into commitment and enthusiasm must be a planned process. New systems should enhance the quality of work life and increase responsibility, empowerment, and motivation.
The Role of Customers
We must rethink our customers' needs, using the concept of customer in the broad sense in the complex health care world. Any time our customers see us doing something better, we win. The message is that we need to identify correctly those parts of our processes that are visible to our customers and consider reengineering them first. The real key is to ensure that we are getting the right process right. For example, Mutual Benefit in the United States transformed their insurance policy issuing and payment process. They were ecstatic with the results of redesigning what had previously been a 24-day process of paying insurance claims, after the redesign payments could be made, in less than a day, generally within three hours. Within 90 days after implementing the new processes, they filed for protection from their creditors. Why? They did not pay equal attention to re-engineering the processes that brought in the money.
However, the concept of customer needs is also important in the internal sense. In these times of increasing change, it will be even more critical that our people do not perceive that changes are being made just for the sake of change. When the culture is focused on constantly improving the meeting of customer needs, the rationale for rapid and frequent changes becomes much clearer to those in the organization. This point is constantly stressed by Oren Harari in his books22 and monthly columns in Management Review.
The Road to Success
Common wisdom suggests that technology drives change in the organizational environment, but common wisdom is wrong. Instead, information technology is a powerful enabling force that creates new options and opportunities in the environment for what organizations produce—whether goods or services—and how they produce it. The early response by innovative players drives change. Each of the enabling technologies has the potential to transform one or more dimensions of the workplace. Taken together they act as a powerful set of technologies that organizations will have to harness to be successful in the 21st century. There are no quick fixes. Solving these problems requires a response targeted to the needs of our organization, but we need to know how our organization's strategy will play out in the environment as a whole.
The road ahead will not be an easy one. However, the medical informatics area is poised to create outcomes that many of us could only dream of a few years ago. Our challenge will be to implement our concepts and systems as smoothly as possible, not wasting our precious opportunities and resources because we ignored the pitfalls of managing change.
This paper was the basis of a presentation by Dr. Lorenzi that was part of the Cornerstone on Managing Change, one of four Cornerstone sessions included in the program of the AMIA Annual Fall Symposium, Washington, DC, November 6-10, 1999.
*Paraphrased from Kurt Vonnegut, Jr., in Slaughterhouse-five: “ `If only it weren't for the people, the goddamned people,' said Finnerty, `always getting tangled up with the machinery. If it weren't for them, earth would be an engineer's paradise.' ”3
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Articles from Journal of the American Medical Informatics Association : JAMIA are provided here courtesy of American Medical Informatics Association