What are the two most common reasons that healthcare improvement initiatives fail? According to IHI, QI initiatives fail to address the “who” and the “why.” So, why do the people who are directly or indirectly affected by an improvement take a back seat to the focus on the “what” and “how”? How can this change?

While healthcare improvement focuses deeply on the “what” and “how” of an initiative, it would benefit us to gain better insight into the people affected and their motivations to advance improvement in a more sustainable way. One way to do this is through a better understanding of the Psychology of Change.

What is the Psychology of Change and how can it positively impact quality improvement efforts?

The Psychology of Change and Forming Effective Improvement Teams

The Psychology of Change shifts focus toward the human side of change. Without taking this into account the improvement project is likely to fail or not be sustainable.

What are the team dynamics for an effective improvement team?

An effective improvement team requires three areas of focus:  

  1. System leadership. This person understands the effects that the change has on the system.
  2. Technical/subject-matter expertise. This person understands the process of care as well as possesses deep knowledge about the subject.
  3. Day-to-day leadership. This person understands the details of the system and works well with physicians.

The improvement team also needs the following members:

  1. Executive sponsor. This person is a project reviewer, has executive authority, and aligns improvement efforts to strategic aims and priorities. They liaison with different areas of the organization and provide accountability and resources to the team. 
  2. QI team coordinator. This person attends all learning sessions, collects and reports data, sets agendas and meetings, and ensures task completion. 
  3. QI team member. This person collects and reports data, attends some learning sessions, tests new ideas, and spreads change in the organization. 

Four Stages of Team Development

When a new team comes together, you can’t expect immediate synergy. As new team members begin to grow toward achieving a result, a sequence of stages tends to play out. These stages of team development were named in 1965 by Bruce Tuckman, called “forming, norming, storming, and performing.”

figure illustrating the four stages of team development
Source: Davies, S. (2017). The Psychology of Change [PowerPoint slide]. 

Here are the four phases of team development and leadership strategies for each.

  1. Forming. The leader plays a dominant role in a new team. At the forming stage, the leader directs the team to identify common goals, determines roles and responsibilities, and models the standards for behavior.
  2. Storming. Clarify roles and strategies to achieve shared goals, and resolve conflicts.  
  3. Norming. The leader begins to shift responsibility to the team, asks for solutions before offering their own, begins delegating smaller tasks, and encourages social activity.
  4. Performing. Leaders delegate and influence, begin to step away from the team, develop the team interpersonally, give credit where it’s due.

A team will go through two additional stages at the end of a project: adjourning, when the team has (ideally) accomplished their aim, and re-forming, when the team returns to the norming stage and integrates new team members to its culture and vision.


Leading Change in an Organization

Now that the team is formed, it must plan its processes for leading change as well as meeting resistance to that change within the organization.

Let’s explore Kotter’s 8-step process for leading change, as well as Rogers’ framework for addressing resistance. 

Dr. John P. Kotter studied countless leaders and organizations over the course of 40 years and published his original 8-step process for leading change in his book Leading Change. Kotter describes leadership as establishing direction, aligning people, and motivating and inspiring them. 

Kotter’s 8-step process for leading change can be summarized as:

  1. Increase urgency. 
  2. Build the right team who has enough influence to guide change.
  3. Get the vision and strategies right to guide action.
  4. Communicate for understanding and buy-in.
  5. Empower action and deal with obstacles.
  6. Create short-term wins to build momentum.
  7. Don’t let up until vision is reality.
  8. Make change stick by embedding in culture.

Overcoming Resistance to Change within an Organization

The evolution of innovation is fundamental to the concept of improvement because adopting and accepting change is the root of improvement in action. E.M. Rogers developed the Diffusion of Innovation (DOI) Theory in 1962 to explain how to plan to overcome resistance to change in an organization.

According to Rogers, the evolution of innovation can be explained in 5 steps:

figure illustrating Rogers' evolution of innovation steps
Sources: Rogers E. Diffusion of Innovations, 4th ed. New York; Wittkugel, E. (2019). Leading Change in Quality Improvement [PowerPoint slide]
  1. The process starts with the innovators, who create new ideas.
  2. The early adopters make it happen and demonstrate viability.
  3. The early majority adopts the change.
  4. The late majority accepts the change after seeing proof that the change offers a better way.
  5. The laggards are the traditionalists who are most resistant and last to adopt innovation.

Through the Psychology of Change, the Leading Change framework, and Evolution of Innovation process, quality improvement leaders can work to create effective teams, lead change, and effectively manage resistance to change within their organizations.