Module 8

CHANGE MANAGEMENT: HOW TO
ACHIEVE A CULTURE OF SAFETY
(DRAFT)

SUBSECTIONS
•
•
•
•
•

Eight Steps of Change
Errors Common in
Organizational Change
Culture Change Comes
Last, Not First
Change Strategies
Roadmap to a Culture of
Safety
TIME: 60 minutes

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INSTRUCTOR OUTLINE: CHANGE
MANAGEMENT

Change
Management

Instructor Note: In this module, you will present information
about change management and how to achieve a culture of
safety. Cultivating a culture of safety requires an organizational
change strategy to be in place. This module will highlight Kotter’s
eight steps of change and introduce change management
strategies that can be adopted by any nursing home.
The Change Management module includes the content provided
in the outline below. There are two options for facilitating the
instruction of this module. One option is to facilitate the Change
Management Activity described on pages 6-7, which will highlight
the important aspects of culture change. Following this activity,
the information on pages 17-22 should be used to provide further
instruction. Alternatively, a lecture-based approach can be used to
review the 8 Steps of Change in detail (pages 9-16), followed by
the additional information included on pages 17-22.
In addition, more content is available than can be covered in the
time provided; therefore, optional content is noted. Instructors
should use the information below to plan how the module will be
taught within the time available.
Content

Page #
5

Slide
MODULE
TIME:
60 minutes

MATERIALS:
• Flipchart or
Whiteboard
(Optional)
• Markers
(Optional)
• On-Time Nutrition
Report Video
(On_Time_
Nutrition.wmv)

Approx. Time

1.

Introduction

2 mins

2.

Change Management Activity

6- 7

40 mins*

3.

Eight Steps of Change

8 - 16

40 mins
(Pages 9-16*)

4.

Errors Common to
Organizational Change

17

2 mins

5.

Culture Change Comes
Last, Not First

18

2 mins

6.

Change Strategies

19 - 20

8 mins

7.

On-Time Quality Improvement

21

15 mins**

8.

Roadmap to a Culture of Safety

22

2 mins

*In this module, there are two options for presenting information. Please
see the Instructor Note above for additional information.
**Although all instructional content and activities are recommended to
ensure that participants achieve the learning objectives, these activities may
be considered “optional” if time is constrained.
Continued…
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Change
Management
Slide

INSTRUCTOR OUTLINE: CHANGE
MANAGEMENT (Continued)
Additional Resources: Below are sources of additional
resources you may wish to use to customize this module or to
obtain additional information.
•

TeamSTEPPS for Long-Term Care DVD: The
TeamSTEPPS for Long-Term Care DVD includes two
additional exercises related to change management:
– Sizing Up the Iceberg Exercise
– Sizing Up the Culture Exercise

•

Kotter, J. (1996). Leading change. Boston, MA: Harvard Business
School Press.

•

Kotter, J. & Rathgeber, H. (2005). Our iceberg is melting:
Changing and succeeding under adverse conditions. New
York, NY: St. Martin’s Press.

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OBJECTIVES

Change
Management

SAY:
TeamSTEPPS provides a set of strategies and tools for improving
performance and resident safety. A key element in implementing
TeamSTEPPS is changing the nursing home’s culture. This
module will help guide you through the phases and steps
necessary to successfully change your nursing home’s culture.
Following this module, you will be able to:
•

List the Eight Steps of Change;

•

Identify errors common to organizational change;

•

Discuss what is involved in creating a new culture; and

•

Begin planning your nursing home’s change strategy.

Slide

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Change
Management
Slide
TIME:

(OPTIONAL) EXERCISE: CHANGE
MANAGEMENT ACTIVITY

• Flipchart or
Whiteboard

Instructor Note: Almost every participant in TeamSTEPPS
has been part of an organizational change initiative. Therefore, we
recommend you lead the participants through a discussion, rather
than lecturing on the topic of change management. The following
exercise will facilitate that discussion and ensure that all important
aspects of culture change are discussed. This exercise has been
used in numerous TeamSTEPPS Master Training courses. Below
are the steps.

• Markers

STEP 1. STORY TELLING (10 Minutes)

40 minutes
MATERIALS:

1. Instruct the participants to form groups of two or three.
2. Instruct the participants to individually “Think of a story (e.g., a
critical incident) that you experienced related to organizational
change. The story can be an example of either a successful or
unsuccessful change effort. It can be something that is work or
non-work related. Think about: How and why was the change
introduced and by whom? How was it received? Were there
any barriers? How were these barriers overcome? What
happened? Was it successful? Why?”
3. Instruct the participants to take turns sharing their stories with
their partners. While listening, they should take notes about
things that were critical to either the success or failure of the
change that is being described. Allow participants 5 minutes to
share their stories.
4. Ask three or more participants to share their stories with the
entire group. Be sure to allow participants to ask the person
sharing the story any questions. You should also ask
questions or highlight key points, if appropriate.
STEP 2. IDENTIFY BEST PRACTICES (10 Minutes)
1. Allow participants 2-3 minutes to reconvene into their groups
and identify best practices (i.e., do’s and don’ts) related to
implementing new programs in a nursing home.
2. Lead a facilitated discussion in which participants present their
best practices for organizational change. As the facilitator, you
should record these best practices on a whiteboard or flipchart.
(Note: It is possible to create a list of up to 50 best practices
from this activity!)

Continued…
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(OPTIONAL) EXERCISE: CHANGE
MANAGEMENT ACTIVITY (Continued)
STEP 3. PRIORITIZE BEST PRACTICES (10 Minutes)

Change
Management
Slide

1. Instruct participants to reconvene into their groups and identify
the one or two most important best practices (i.e., do’s and
don’ts) related to implementing new programs in a nursing
home. Participants should identify their one or two practices
from those listed in Step 2; however, participants may add new
practices if they choose to do so.
2. Ask each group to report which best practices they identified
as most important. Record the responses by placing check
marks next to the best practices you listed on the whiteboard
or flipchart. Be sure that all groups are given an opportunity to
share their responses.
3. Ask the participants to review the final list of “important” best
practices. Do they agree with the final list? Would they
recommend any changes?
STEP 4. REVIEW KOTTER’S EIGHTS STEPS OF CHANGE (5
Minutes)
1. Present the slide listing Kotter’s eight steps of change (refer to
the next page) and review the steps with the participants.
2. Compare Kotter’s eight steps to the list the participants
identified.
3. Ask the class to discuss any similarities and differences.
STEP 5. COMMON ERRORS TO CHANGE (5 Minutes)
1. Ask participants what some of the common errors are when
trying to make an organizational change.
2. Compare the errors to those found presented on the slide that
accompanies page 17.

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Change
Management

EIGHT STEPS OF CHANGE
SAY:

Slide

Harvard Business School Professor Dr. 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. Because we know that implementing 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. 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.

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(OPTIONAL) SET THE STAGE AND CREATE A
SENSE OF URGENCY

Change
Management

Instructor Note. Pages 9-16 (Slides 4-14) are optional
content. They review each step in the Kotter Model in more detail.
If you choose to conduct the Change Management Activity
described on pages 6-7, you will cover the key aspects of change
management. If you choose to skip the slides that review each
step in the Kotter Model, you may proceed to page 17.
SAY:

Slide

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
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.

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Change
Management

(OPTIONAL) PULL TOGETHER THE GUIDING
TEAM
SAY:

Slide

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 leadership, credibility, communication, expertise, authority,
and a sense of urgency.
Remember that no one person can implement wide-scale change;
a coalition is essential. Most organizations have a guiding
coalition, or team of individuals who lead the change efforts,
already in place. Think about your nursing home. Is there a guiding
coalition already established? Do they have the right mix of skills,
knowledge, and capabilities?
One recommendation is to consider existing committees within the
nursing home and designate the one most appropriate as the
Guiding Coalition. Especially in larger nursing homes, a Change
Team should be in place in each unit, department, or work area.
These teams could all report updates to the Guiding Coalition.

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(OPTIONAL) DEVELOP THE CHANGE VISION
AND STRATEGY

Change
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 the importance of safety; and
• Confidence in the 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 is important that the vision engage
both head and heart. Leadership must also develop the strategy to
make that vision a reality. It is also important that the Guiding
Coalition be instrumental in the creation of the vision and strategy.
ASK:
• Does your nursing home have a vision and strategy in place?

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Change
Management

(OPTIONAL) COMMUNICATE FOR
UNDERSTANDING AND BUY-IN
SAY:

Slide

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, everyone involved must both understand and accept the
vision 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 staff.
Accept and plan for resistance. Resisters help to clarify the
problem. 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; and

•

Monitor process dynamics.

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(OPTIONAL) EMPOWER OTHERS TO ACT

Change
Management

SAY:
Leaders must change the systems or structures that undermine
the change vision and remove other obstacles to change. They
should also encourage risk taking and nontraditional ideas,
activities, and actions. It is essential that leaders remove as many
barriers as possible so that those who want to make the vision a
reality can do so.

Slide

Empowering others to act involves:
• Giving people freedom and direction;
• Giving people permission to find their own team-driven
solutions;
• Encouraging people to speak up, even to differing views;
• Encouraging people to take risks;
• Affirming and refining the vision—make room for others’ ideas;
• Telling people as much as you know;
• Encouraging teamwork and collaboration;
• Encouraging personal reflection and learning;
• Providing people with training and support;
• Using existing quality improvement methods in your
nursing home to track activities on a daily basis;
and
• Setting short-term goals.

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Change
Management

(OPTIONAL) 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,
department, or work area 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, department, or work area 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 when
numerous resisters are 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 your
nursing home a “story-telling” place? Are stories an effective
manner to help staff hear and internalize the short-term
“win”?

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(OPTIONAL) DON’T LET UP

Change
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; and

•

Reinvigorate the process with new projects, themes, and
change agents.

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Change
Management

(OPTIONAL) CREATE A NEW CULTURE
SAY:

Slide

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 culture of the group. Also develop a
means to ensure leadership development and succession.
Remember that changing culture comes last, not first. 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 standalone function. Pitfalls commonly arise and
derail organizations that are 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. Kotter identifies ways to institutionalize change
and counter these errors. These include:
•

Slide

Build new habits and skills.
– Providing opportunities for discussions and tools to reinforce
skill, such as the TeamSTEPPS Pocket Guide, may assist
staff in institutionalizing processes.

•

Reward incremental change.

•

Make all staff accountable.

•

Assign responsibilities for change actions.

•

Encourage mutual leadership.

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Change
Management

CULTURE CHANGE COMES LAST, NOT
FIRST
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
culture only after it’s very clear that they work and are
superior to old methods.

•

It requires a lot of talk. W ithout 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.

Slide

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TEAMSTEPPS CHANGE MODEL

Change
Management

SAY:
While TeamSTEPPS teaches teamwork skills and strategies and
tools to enhance teamwork, TeamSTEPPS is at its roots an
organizational change initiative. This slide depicts the
TeamSTEPPS Model of Change, which can be organized into
three phases:

Slide

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. W e will apply the TeamSTEPPS Change Model
during the Implementation Planning module.

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Change
Management

CHANGE MANAGEMENT MODELS
SAY:
The TeamSTEPPS Change Model is one of a number of change
management strategies. These include PDSA, Six Sigma –
DMAIC, IHI’s Model for Improvement, and CUSP. Each strategy
includes similar components.

Slide

Your nursing home may already use or be familiar with one of
these approaches. If so, TeamSTEPPS recommends that you
use the approach your nursing home already knows instead of the
TeamSTEPPS Change Model. As shown in the slide, the
implementation of TeamSTEPPS tools and strategies fits within
the components of other models for change. As such,
TeamSTEPPS can complement and be coordinated with your
existing change strategy.

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(OPTIONAL) ON-TIME QUALITY
IMPROVEMENT

Change
Management

SAY:
One example of integrating TeamSTEPPS into existing nursing
home efforts is the On-Time Quality Improvement Program.
Developed with funding and support from the Agency for
Healthcare Research and Quality (AHRQ), On-Time uses
electronic reports to provide timely information to frontline (or
direct care) staff about residents who might be at risk for a bad
outcome, such as pressure ulcers or falls. Specialized reports
indicate which residents are at increased risk based on various
factors, such as a new red area, decreased meal intake, or
new incontinence. Subtle changes are noted early and the
resident’s care plan is updated to include interventions to
address and minimize the risk. The On-Time program helps
staff integrate the use of these reports into their daily work
routines.
Let’s watch a video that illustrates the use of one type of OnTime report. Look for the TeamSTEPPS skills in use.
DO:

Play the video by clicking the director icon on the slide.

Slide

VIDEO TIME:
8:10 seconds

MATERIALS:
• On-Time
Nutrition Video
(On_Time_
Nutrition.wmv)

DISCUSSION:

•

Which TeamSTEPPS skills did you see the team
members using in the Nutrition Report Video?
– Huddle: Lucy (Nursing Assistant) and Rose (Dietitian) meet
briefly to discuss Mrs. Jones’ progress with eating
breakfast foods.
– Debrief: Gayle (Nurse Manager) facilitates a discussion by
asking questions related to team performance.
– Feedback: Rose (Dietitian) provides positive feedback to
Lucy the nursing assistant about providing promised and
specific information about Mrs. Jones. Gayle (Nurse
Manager) provides feedback about the process as well.

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Change
Management

ROADMAP TO A CULTURE OF SAFETY
SAY:

Slide

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 your nursing home. Once the vision and strategy are
determined, you must take these high-level ideas and develop a
TeamSTEPPS 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.

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