Hard and Soft Aspects of Change Management
Approaches: Multiple-Case Analysis in a Healthcare
Organization
By
BEAU EGGENS
University of Groningen Faculty of Economics and Business
MSc Business Administration - Change Management
June, 2018
Student number: 2716070
Supervisor: Dr. C. Reezigt
Co-assessor: Drs. H.P. van Peet
ABSTRACT
The healthcare sector is continuously pressured to change, which is necessary to improve. Simultaneously, however, change initiatives in healthcare organizations often fail. Previous research argues that change agents in healthcare organizations primarily focus on hard aspects of change and tend to ignore soft aspects. Particularly, the present research aims to uncover how soft and hard aspects can be brought together in change approaches. This is important because soft aspects contribute to the successful implementation of change initiatives in healthcare practices. To this end, this study relied on a multiple-case analysis in a Dutch hospital. The findings of this study demonstrated the different combinations of hard and soft aspects in change approaches. Hard aspects are often used by change agents to set a clear framework for change, while there is an emphasis on soft aspects in the guidance of the change process. Furthermore, this study identified contingency factors, such as content and scope of the change, availability of resources and knowledge and team maturity, which influence the choice for either hard or soft aspects or a combination of both in change approaches. The most important implication of this research for managers is that indeed both hard and soft aspects should be incorporated in change approaches for change to be successful in healthcare organizations.
INTRODUCTION
The healthcare sector has to deal with the continuous pressure to change and improve (Van Rossum, Aij, Simons, Van Der Eng & Ten Have, 2016). On the one hand, healthcare service providers are struggling to reduce costs and on the other hand to improve the quality of care (Drupsteen, Van Der Vaart & Van Donk, 2013). In healthcare, front-line and middle managers are often responsible for organizational change and deal with the consequences of change processes (Kelliher & Parry, 2015). While change is necessary for healthcare organizations to improve patient care, implementation of these change projects are often challenging and fail (Lavoie-Tremblay et al., 2012). A reason for unsuccessful change implementations is that change agents often do not pay attention to soft criteria (Crawford & Pollack, 2004).
Redfern and Christian (2003) list factors that contribute to successful change implementation in healthcare practices. These factors can be categorised as ‘soft aspects’ and are ‘organizational commitment’; ‘active support from key stakeholders’; ‘recognition of the importance of change’; ‘a credible change agent’; ‘face-to-face contact with practitioners to promote enthusiasm’; and ‘ensuring targeted staff have ownership of the innovation and are empowered to change’ (Redfern & Christian, 2003). Moreover, Crawford, Costello, Pollack and Bentley (2003) found that a successful implementation of a project requires a flexible process based on shared professional experience. This flexible process is part of soft project management (Crawford et al., 2003). In other words, soft aspects are important for the success of change projects. However, soft aspects require a different management approach and different skills than hard aspects (Crawford & Pollack, 2004).
While literature does suggest that soft and hard aspects require two distinct ways of managing change projects (Crawford & Pollack, 2004; Gustavsson & Hallin, 2014), often little is said about how soft and hard aspects both can be incorporated in a change approach. This is especially important because, hard aspects are more often used in change projects in healthcare settings than soft aspects. For example, costs or financial performance (De Koning, Does & De Mast, 2005; Hyer, Wemmerlöv & Morris, 2009; Litvak & Long, 2000), quality (De Koning et al., 2005; Litvak & Long, 2000), and service and waiting times (Drupsteen, Van Der Vaart & Van Donk, 2016) are measures that are often used in studies to measure the success of healthcare change projects. Similarly, Sanchez, Terlizzi and De Moraes (2017) state that project management success is commonly measured based on budget, time and scope/quality, what they call the “iron triangle”.
they deal with the lives and deaths of patients (Lee, Ridzi, Lo & Coskun, 2011). The complexity of healthcare organizations arises from the number of elements involved inside and outside of the healthcare organization; the continuous discovery of new diseases, which require the continuous development and improvement of (new) treatments; and the uniqueness of each patient’s case and special needs (Lee et al., 2011). For these reasons, the healthcare sector is in particular an interesting setting to study how both hard and soft aspects can be incorporated in change approaches.
Based on this, the following research question will be answered: How are hard and soft aspects of change management incorporated in change approaches in healthcare organizations? Moreover, this research aims to identify which contingency factors influence the choice for either hard or soft aspects in change approaches of change agent.
LITERATURE REVIEW
The framework of Crawford and Pollack (2004) will be used as starting framework for this study. This framework shows the interaction of seven hard and soft aspects of project management and their origins in the literature on hard and soft project management. Furthermore, this paper will use literature on healthcare management.
Hard aspects of change management. Traditionally, hard approaches of change management are so-called ‘stage-gate models’, which emphasize structure and control (Gustavsson & Hallin, 2014). According to Crawford and Pollack (2004, p. 650) hard projects are characterized by “a clear definition of tangible goals, quantitative measures, not subject to external influences, single solution option, an expert practitioner, no stakeholder participation, management by monitoring and control and technological performance”. The measurements of hard projects consist of quality, cost and time (Crawford & Pollack, 2004). Therefore, it could be argued that the success of hard projects is less complex to measure compared to soft projects (Crawford & Pollack, 2004). This could be the reason why usually hard measures are used to measure project success or performance.
Sirkin, Keenan and Jackson (2005) state that hard aspects are essential in change management. Hard aspects can be measured in indirect or direct ways and their importance can be easily communicated in organizations and outside of them (Sirkin et al., 2005). Moreover, organizations are capable of influencing hard aspects quickly when necessary (Sirkin et al., 2005).
Gustavsson and Hallin (2014) argue that the term ‘hard’ is used to indicate a systems’ approach where the project is divided into smaller parts or stages which will be analyzed and handled in a systematic and rational way. Sometimes, the goal setting for change projects is set at the top of the organization and goals are handed down to managers without discussion about how these goals should be implemented. In these situations, hard project management is most suitable, because in this way managers can focus on the optimisation of the planned solution (Crawford & Pollack, 2004).
Since there are high failure rates of change projects in healthcare, it is important that change initiatives will be cost effective, efficient and safe (Lavoie-Tremblay et al., 2012). Hard aspects of change management are useful to most efficiently achieve the defined objectives (Crawford & Pollack, 2004) and thus hard project management can be an effective method for change implementations in healthcare.
Soft aspects of change management. Soft approaches of change management are more involved with the human-side of project management (Gustavsson & Hallin, 2014). Following the framework of Crawford and Pollack (2004, p. 650), the soft dimension of project management is characterized by: “highly ambiguous definition of goals; abstract concept; qualitative measures; subject to external influences; multiple alternative solutions; facilitative practitioner; high stakeholder involvement; importance of relationships, culture and meaning; and management by negotiation and discussion”. As mentioned above, measurements of soft projects involve qualitative data. Qualitative data give rich, in-depth understanding of a situation and significant factors will arise from the data through analysis (Crawford & Pollack, 2004). Soft aspects in change management refer to “an holistic approach” and complexity cannot be reduced by dividing the project into smaller parts, as with hard project management (Gustavsson & Hallin, 2014, p. 570).
In literature, soft aspects of project management are often linked to measures of some sort of uncertainty (Gustavsson & Hallin, 2014). Neal (1995) argues that a soft systems approach is especially appropriate in a changing environment where project objectives may change during the implementation. Healthcare organizations are under constant pressure to change and therefore, external influences may affect the change implementation (Crawford & Pollack, 2004). Furthermore, Winter (2006) argues that a soft systems methodology is appropriate to use when project managers have to deal with messy and complex problems and project situations rather than well-defined problems and different perspectives.
Previous studies provided examples of theories and approaches that are affiliated with soft change approaches. Recent literature gave examples as Theory O (Steinke, Dastmalchian, Blyton & Hasselback, 2013) and Agile methods (Gustavsson & Hallin, 2014). Theory O is a change approach that focuses on the internal dynamics and capabilities of organizations and its process is emergent (Steinke et al., 2013). Furthermore, the focus is on the organizational culture and a large commitment of employees is required (Steinke et al., 2013). This emergent and high involvement character of soft approaches is also emphasized in the framework of Crawford and Pollack (2004).
According to Gustavsson & Hallin (2014) Agile methods focus on collaboration, interaction and situational action. Agile methods respond to changes instead of following predetermined plans (Gustavsson & Hallin, 2014). However, Gustavsson and Hallin (2014) also mention that the line between “hard” stage-gate-models and “soft” Agile methods is not that clear in practice. Therefore, this paper will investigate what the complementarities are of soft and hard aspects of change management and how they both can be incorporated for successful change implementations in healthcare settings.
undertake in organizations and systems, however, it is even more challenging in healthcare organizations and systems (Chreim, Williams & Coller, 2012). This is because healthcare organizations have to pursue divergent objectives with multiple actors connected through fluid power arrangements (Chreim et al., 2012).
Change initiatives in healthcare may also be more complex compared to other industries, because healthcare systems significantly differ from other industries. Healthcare organizations should always be able to deliver care, in other words, to meet demand. When healthcare organizations deny demand, patients will face negative consequences, such as patient death (Jack & Powers, 2004). Jack and Powers (2004) argue that in other industries, limited ability to meet demand can even have positive consequences, because high demand of customers and low supply of organisations will increase service or product prices. When healthcare organizations have too much capacity for meeting demand, the healthcare costs will significantly increase. Healthcare organizations are thus challenged to meet “a highly variable rate of demand with a constant rate of high quality service where the consequences of poor service can result in patient death” (Jack & Powers, 2004: p. 231).
VanDeusen Lukas et al. (2007) found five critical drivers for change in healthcare systems, which were the motivation to transform, improvement initiatives that actively engage staff in meaningful problem solving, leadership commitment to quality, alignment to achieve consistency of organization-wide goals with resource allocation and actions at all levels of the organization, and integration to bridge traditional intra-organizational boundaries between individual components. In their framework, VanDeusen Lukas et al. (2007) incorporate soft aspects (e.g., leadership and motivation to transform) and they emphasize that alignment between improvement initiatives and the organization’s strategic direction is key to build momentum for further change.
The conceptual model shows that hard and soft aspects both lead to different change approaches. This paper aims to explore how both hard and soft aspects can be incorporated in a change approach and which combinations between hard and soft aspects arise. This is represented by the dotted line in figure 1. Moreover, this paper aims to explore which factors influence the choice for either hard or soft aspects and what influence these factors have on the combination of hard and soft aspects in change approaches.
METHODOLOGY Research approach
Change in healthcare is an organic process that develops over time with different unstructured and unexpected situations (Lee et al., 2011). The use of qualitative methods, such as case studies, is the best method to explore novel or unusual phenomena (Strauss & Corbin, 1990). Qualitative research is a multimethod research that uses a naturalistic, interpretive approach to what is being studied (Gephart, 2004). This paper aimed to explore “why” and “how” both hard and soft approaches of change management are incorporated by change agents in healthcare organizations, because a deeper understanding of how both approaches are and can be used is needed to guide change agents or managers of healthcare organizations in future change projects. Eisenhardt (1989) states that qualitative data will provide a more detailed understanding of the underlying dynamics of a relationship. Hence, a case study design was suitable for this research, because case studies focus on the understanding of dynamics present in single or multiple settings (Eisenhardt, 1989). The selected case site is a healthcare organization (e.g., hospital, mental healthcare organizations or a medical diagnostics provider) where multiple change projects run, most preferably three to four projects in different departments. Change agents or project coordinators were most suitable for analysis, because they guide change projects and thus, are the ones that develop the change approaches and give substance to set objectives.
Data collection
who were willing to be interviewed, two of the ten interviews have been conducted in collaboration with a fellow student.
During the data collection, the researcher should be aware to avoid multiple biases. First, the researcher should be aware that the research instrument measures what is intended to measure (i.e., construct validity) (Van Aken, Berends & Van Der Bij, 2012). To guarantee construct validity use of multiple sources of evidence, establishing a chain of evidence or having key informants review draft of the case study report can be applied (Miles & Huberman, 1994). In this study, construct validity is guaranteed by establishing a chain of evidence by providing a codebook with the deductive and inductive codes and corresponding quotes of the interview transcripts (Appendix C). Moreover, the interview guideline is provided in Appendix B. Second, internal validity should be controlled in the data analysis process by pattern matching and explanation building (Yin, 2003). According to Miles and Huberman (1994), there are several tactics to guarantee the internal validity of a study. They suggest to engage in pattern matching, explanation building, addressing rival explanations and use of logic models. Therefore, the collected data was coded and within-case and cross-case analyses were executed to find patterns. During the data analysis process conceptual and causal patterns were identified. Third, external validity (i.e., generalizability of results) can be controlled by multi-case studies (Yin, 2003). Therefore, three change projects were being studied. However, generalization is limited in qualitative studies. Finally, the study should be reliable (i.e., the possibility to repeat the study with the same results). Use of a case study protocol or development of a case study database are methods to secure reliability (Miles & Huberman, 1994). Therefore, the case study protocol can be found in Appendix D.
Overview of selected cases
This research is based on three cases in a hospital in the province of Groningen in the Netherlands. This hospital was selected because this organisation engages in multiple change projects to improve the quality of care. The first case contains interviews with a project leader and three change agents who implement the change initiative in their departments. Similarly, the second case contains interviews with a project leader and three change agents who implement the change in their departments. The third case contains interviews with a project leader and a change agent who was at the same time a change recipient. In total, ten semi-structured interviews with change agents were conducted.
Case 1
of the hospital for either centralization or decentralization of planning, the project leader decided that the departments who plan themselves, in the future will plan in the same planning tool using the same planning process, to have consistency between all departments.
Case 2
The second case concerns a change project that is initiated by a change in legislation. This change in legislation concerns a function differentiation between two different educational levels of nurses. Currently, there is no difference in job description and job tasks between nurses with different educational levels. However, the government decided to make a differentiation in job description and tasks between nurses with different levels of educational background to improve the quality of care. Nurses will thus have different functions and tasks when this change is implemented. Moreover, nurses need training and education to be able to work in the new function. Additionally, a management layer will be removed and decision-making authority will be given to the higher educated nurses.
Case 3
The third case which was selected concerns a Lean Six Sigma project. The initiative of this change project was from the project leader who successfully obtained its certificates for Lean Management. The hospital recognized the value of Lean Management for the hospital. Currently, Lean Management is implemented in various departments of the hospital. Two interviews have been conducted within this project. One of these two interviews was with the project leader and the other interview was conducted with a care coordinator of a nursing ward where Lean was implemented.
Data analysis
RESULTS
In this section, each case is first discussed separately, using a case analysis. The within-case analysis is followed by a cross-within-case analysis where the three within-cases are compared and contrasted. From the coding process two interesting topics were identified in the within-case analysis. First, the combinations of hard and soft aspects are identified in the change approaches of the change agents. Second, the contingency factors that influence the choice for either hard or soft aspects are identified.
Within-case analysis
Combinations of hard and soft aspects in change approaches.
Case 1. In the first case, change agents aimed to set concrete and tangible goals to create an action plan for the change initiative. However, these goals were not clearly described in terms of costs or efficiency measures, but they did indicate time targets. One of the change agents mentioned the following about goal clarity and goal tangibility (1.1):
“
The overarching goal of this project is to plan integrally. (…) And what you really want to achieve is concrete gains in costs, capacity, rest and less rectifying. We did not do that, but that would be nice.”Another change agent indicated that a concrete action plan is necessary to evaluate later in the change process whether goals are achieved or not (1.2): “I made an action plan, that consists of one
page of the concrete plan, to make it easier to check during the change process. (…) Clear goals are set in advance, within the planning of hospital admission with the departmental planners. That is our “coat rack” of the project. We have clear guidelines when things should be done.”
Finally, one of the change agents chose a more soft approach concerning goal clarity and tangibility, since there have been no concrete or tangible goals set for this project (1.4): “I never set
clear objectives. If something is going on, then we will discuss this. Why do we need to do it differently and what do we want to achieve? We first try it and then we will decide what to do.”
All four change agents were emphasizing the importance of involvement and participation of the employees to make the change initiative successful: “Involving the doctors and secretaries is
necessary if you want the change to succeed.” (1.2) The goal behind involving employees in the
change process is to create support for the change initiative. Here, change agents tend to focus more on the soft aspects of change management. “Allowing employees to participate in the change process
is one of the most important interventions, I believe.” (1.2)
everyone has ideas about how we can improve certain aspects. Due to years of experience or because you worked in another hospital or you do not have any experience at all and are a trainee and think: why are you doing it the way you do it? So it doesn’t matter from which layer in the organization you are, express yourself! Surprising solutions and ideas arise from these sessions.” (1.3)
Moreover, involvement of employees was used to avoid resistance to the change initiative. By creating ownership for the change project the change agent tried to make employees more motivated for the change initiative. “Another way is to position employees and to appeal to someone, like this is
why I need you. Do you want to help or do you want to think along with me? Thus putting people in their strength. And from there, I try to make employees co-owners of the change project.” (1.1)
Finally, one of the change agents involved employees and let them decide which direction to go with the change process. The reason behind this is that the change agent believes that these employees have the expertise to decide which change solution is best for executing their work. “I
engage the two secretaries in the change process and they have to figure out which way to go. (…) I leave the solution to them. I think they have the authority to decide on which solution is best. I am not the one who is going to decide what’s best. I do come up with some solutions, because I am a very solution-oriented person. Eventually, they will have the final say.” (1.4)
Thus, in the preparation phase, the framework for the change initiative and the way change agents plan the change process tends to be more focused on hard aspects (i.e., clear and tangible goal setting), while when the change process is evolving and change agents try to create support, change agents tend to focus more on the soft side of change management (i.e., involvement and participation of employees).
Case 2. The second change initiative has its origins outside of the hospital, due to a change in legislation concerning function differentiation of nurses. Therefore, the change initiative was not only imposed on the change agents, but even on the hospital itself. Despite this top-down character of the change initiative, the change agents were generally supporting this initiative, because this project will eventually improve the quality of care: “At first, there was no differentiation. The level of the nurse
was levelled out, so intermediate vocational educated (MBO) nurses worked in the same way as the higher professional educated (HBO) nurses and vice versa. Now that care is changing, they want to differentiate between them. Scientific research has also shown that if there are highly educated nurses, the mortality rate will also decrease. So that really is the basis for this change initiative.” (2.6) Thus,
the need for change was clear for the change agents and the project leader established support of the change agents for the change initiative. The project leader described her change approach as follows:
This preparation phase is more focused on the hard aspects of change management. The project leader also emphasizes the importance of the combination of hard and soft aspects in her change approach and how both hard and soft aspects are combined. The basic framework of the change initiative contains hard aspects (i.e., preparation phase), while the guidance of the change process is focused on soft aspects, such as involvement of employees. “The basic structure of my
change approach consists of hard aspects, such as planning, budget and quality. We discuss these hard factors within the program team. In the guidance of the change process we tend to focus more on the soft factors. What does a team need to change? As project leaders, we try to connect the hard and soft aspects at both the operational level (i.e., the nursing wards) and tactical level (i.e., program team). Without soft factors it is difficult to achieve the hard objectives of a project and the other way around.” (2.5)
Since this change project will be implemented throughout the whole hospital, the scope of the change project is significant. Therefore, the project leader decided to run two pilots at two different departments. One of the pilots was very successful while the other was not. According to the unit head of the successful pilot this has to do with the management skills and competences of the change agent. Next to a nursing background, this change agent studied ‘Management in Healthcare’, in which he completed various change management modules. Knowledge about change management is required for change agents to be successful, according to respondent 2.6: “I completed various change
management modules during my study. In this way I am able to connect theory with practice, and therefore I can manage change initiatives more easily.”
Moreover, early involvement of employees in the change process is important to make employees ready for the change initiative and to eventually create support for the change. Timely announcement of the change initiative ensures that employees are slowly getting used to the idea of the project and employees will therefore be less surprised or overwhelmed when the project will start.
“Employees are involved in the whole change process. People will now what is coming and what to expect. This will create a sense of security, but also the feeling that employees can think along and participate in the whole process and that the change is not being imposed on them.” (2.7)
Furthermore, coping with emerging resistance is essential for the success of the project. Often, change agents believe openness to employees is important and they use involvement and participation strategies to avoid or reduce resistance during the process: “I think that openness and involvement are
important and that is also my vision. Constantly including employees in certain processes. That already makes them a step further than when you suddenly start saying ‘we're going to do something new. This and this is what we need to develop. How are we going to do that?’ Then all kinds of resistance arise of course. By taking them with you in what is to come, but not yet knowing when, they will be prepared for it. Think about it in advance. Then you can take that step easier in the end.” (2.7)
the set goals. Involvement and participation can thus be seen as strategies to create support for the change initiative: “When tasks and responsibilities are appointed to employees, I hope that the change
process will run more smoothly. Then, people will take initiative to take action.” (2.8)
Finally, change agents emphasize the importance of combining soft and hard aspects in their change approaches. “I think you need both hard and soft aspects in change management. The hard
side to set a clear framework of what is possible during the change process. And the soft side… Yes, you really need both of them.” (2.8) Again, in the preparation phase, the basic framework of the
change initiative contains hard aspects, while soft aspects are important for the human-side of the change initiative.
Case 3. The third case concerns the implementation of Lean Six Sigma across the whole hospital. The goal behind the project is to remove waste, specifically waste in searching time of nurses. In the current situation, each department is arranged differently and nurses spend a lot of time searching for the resources they need for the delivery of care. Furthermore, the hospital hires many temporary nurses to fill the scheduling gaps due to high turnover. For this group of nurses, it would be convenient to find resources on the same location in each department of the hospital. Also, the corridors are filled with equipment and devices, such as wheelchairs or computers on wheels. Lean management is therefore selected as the solution to these problems. The project leader summarized the contributions of the implementation of Lean management as follows: “Lean contributes to a safer
working environment, a more standardized way of working, a greater exchange of personnel, because all departments are set up in the same way. It increases the job satisfaction of employees, because they spend less time searching. So, yes, it does have a lot of influence.” (3.9)
The idea for the implementation of Lean in the hospital originated from the project leader and he gained formal approval of the board of the hospital to start the project. This could be seen as a bottom-up initiative to change, however, the implementation of Lean by the project leader can be seen as top-down. This is because the departments did not have an influence on the implementation of Lean and just had to accept its implementation. The project leader described his approach as follows:
“First, I want to make clear: what do I want? What does the organization want? And how can I contribute to that? Then I will make a plan. So talking to a lot of people and then, in the end, put that plan down on paper and get started with it.” (3.9)
As project leader, his role is to set frameworks for the project, managing the project, time management, ensuring that people deliver things, and trying to motivate employees during the project.
To be able to do this, he aims to set concrete goals. These activities tend to lie more towards the hard end on the continuum of hard and soft. However, with this Lean project, setting concrete goals is difficult, because the outcome of the project is not clear in advance. When problems in processes arise, these problems will be identified and the problem will be solved with the employees who are involved in this process: “In generic projects I always aim to set concrete goals. This is
because then the result is known and you have to work towards it. With Lean Six Sigma projects the results are not known. Is there only a problem in a process, then you are going to solve this problem with the people who are part of the process. There you can only determine the amount of meetings. That is the first definition phase, what is the problem? Then you are going to do a measuring phase, so I make sure that there are measuring forms. These measurement methods are being developed. Then you are going to analyse, you have all kinds of tools to do so. So in that sense, the Lean Six Sigma part is more the tooling you use than having all the results.” (3.9) Therefore, the change process in Lean
management will be divided in different phases (i.e., DMAIC cycle): Define, Measure, Analyse, Improve and Control phases.
The aim of the Lean project is to improve quality, however, the hospital is usually more interested in efficiency and cost-effectiveness. For this specific project, it is hard to quantify the outcomes in cost reductions. A clear outcome of the project is that nurses spend less time searching for new supplies or other resources; however, the hospital is not able to fire nurses due to this reduction in wasted time. This sometimes causes tensions between the project team and the hospital’s board. “The
complicated thing about this project is that the philosophy of this project is to improve quality of care. Some positions in the hospital want to see these outcomes quantifiable in cost. We notice tensions due to this perspective of the hospital.” (3.9)
Thus, the outcome of the Lean project is not quantifiable in quantitative data such as cost, which belongs more to the hard side of change management. The benefits of Lean are more evident in qualitative data, thus when the nurses explain that Lean made the execution of their work easier. Therefore, the outcomes of the Lean project tend to be more soft on the continuum of hard and soft aspects of change management.
In the first phase of the project, improvement teams were formed at the departments and one wall on each department was transformed into an improvement board to identify waste. In the composition of the improvement teams, not only employees who support the change initiative were selected, but also employees who have reservations about the project. During the start of the project, the project leader worked two days together with the improvement teams of the departments to identify waste in the current process. Employees became very enthusiastic and motivated, because their input was asked and they were working together with the project leaders. By distributing post-its to nurses and by asking them to write down all the waste in their process, the project leader created involvement: “What we have done is to attend to a team meeting or theme discussion of all the teams
how is it translated to this project. After that, we created the waste walls at the departments. (…) We gave everyone post-its and said to those people: ‘here, you have the post-its. Write on every post-it where you see waste in your department.’ Well, in no time the wall was full with examples of waste. (…) When you talk to employees during the presentation, they do not have a real picture of it yet. But when they start working with it, all of a sudden it becomes clear. And then suddenly they realize that we actually do have a lot of waste at the department. And then people become enthusiastic.”
Despite the initial enthusiasm of employees, the change momentum did not last. One of the members of the improvement team stated the following: “The enthusiasm of the project leaders made
us enthusiastic as well. However, this initial enthusiasm did not last. Because the project leaders are physically there, that also makes you enthusiastic. As soon as they were gone, we have to do it ourselves. However, this did not happen.” (3.10).
While enthusiasm and motivation to continue the project disappeared, the project leader did not feel responsible for this. The departments themselves should see the benefits of continuing the project and take ownership to continue with it: “The project stops because a project has a starting
point and an ending point. We have a project plan with which we are going to deliver a number of things. Once we have done that, we will give it back to the organization, so to the unit heads and to the head of the clinic: this is what we have delivered and now it is up to you to continuously improve. (…) I cannot be responsible for everything. I have already done 100 projects, so if I still have to be responsible for every project... At some point you have to finish it. (…) It is an enrichment for people and teams and if they do not see this at the moment, so be it.” (3.9)
Lean management can be seen as a cultural change, since employees have to take ownership to continue to improve processes, the continuous improvement value should eventually be embedded in the organizational culture. However, the project leader deliberately chose not to call the Lean project a cultural change. The project leader tried to improve the quality of care, the safety of care and the efficiency of care by using Lean tools, such as the waste wall and the improvement board. In turn, these tools should cause a cultural change within the hospital. “I am convinced that cultural change
cannot be designed behind a drawing board.” (3.9)
According to the project leader, the power of Lean management as change approach is that even though the project is imposed on employees, employees feel that they have influence in the change process. “An intrinsic motivation has to be opened up and that is the only way that people will
Concerning the Lean project, the project leader aims to incorporate both hard and soft aspects of change management. Problems are identified with the employees and the goals are therefore tangible for employees. This demonstrates more the hard side of change management. While there are reductions of costs and efficiency involved in the change process, quality improvement is seen as a soft benefit according to the project leader. The use of interviews and conversations with employees to involve employees in the change process demonstrates the soft side of the change approach: “The soft
side of my approach is fulfilled by for example conducting interviews or having conversations.” (3.9)
According to the project leader, if you set a clear framework, it is easier to delegate tasks to employees, because it is clear what they have to do: “If you set up a good framework, then it is also
much easier to delegate it to people, because it is clear what they have to do.” (3.9) Thus, a hard
framework enables the project leader to focus as well on the soft side of change management.
To summarize, this first part of the within-case analysis identified the different combinations of hard and soft aspects in change approaches of change agents of each of the three cases. In case 1, change agents focus more on the hard aspects to set the framework for change, while they focus more on the soft aspects to create support for the change initiative. In case 2, change agents also emphasize the combination of hard and soft aspects in their change approaches. The basic framework of the change initaitive contains of hard aspects, while the guidance of the change process is focused on soft aspects. Finally, in case 3, the project leader chose for Lean Six Sigma as change approach. Lean management provides various tools to plan and guide the change process where both hard and soft aspects of change management are incorporated.
Contingency factors and their influence on the combination of hard and soft aspects
The previous section demonstrated the different change approaches of the change agents of all three cases. In this section, the contingency factors that influence the combination of hard and soft aspects will be identified.
Case 1. In this case, it became clear that change agents focused on the hard aspects to set a clear framework and they focused on soft aspects when the change process is evolving. The choice for hard or soft aspects or a combination of both is influenced by the content of the change initiative, the availability of resources and the hierarchical power to implement change.
Content of change initiative. Change agents make choices concerning their change approaches
based on the content of the change initiative: “The change itself is a change of the first order. That
departments schedule their patients. To establish unity in the way departments in the hospital plan, the decision is made to plan in the same planning system (HIX), using the same, standardized process. Therefore, tasks and procedures of employees will be changed. Generally, changing protocols can be relatively rapidly dealt with compared to cultural change:“Does it have to do with culture, then of
course it takes much more time than, for example, just changing a protocol.” (1.2) The way in which
doctors, surgeons and secretaries work, is anchored in their culture, because this way of working has been done for years: “Actually, as long as XXX surgery is present in the hospital, the planning process
has not been changed. It is something that has always been stubbornly detained, and it must remain the way it is because we have been doing it for years. So the culture is quite deep.” (1.2) This change
agent (1.2) also emphasizes that changing protocols requires less change management activities compared to changes with a cultural component, such as this change initiative: “For example, if you
modify a protocol, then you need less change management activities than this change.”
This cultural component of the change initiative causes that change agents make the choice to involve their employees in the change process. This involvement is necessary for creating support, because when employees do not support the change in the planning procedures, they will not use these new procedures to plan appointments for patients and the change project will be unsuccessful:
“Involving the doctors and secretaries is necessary if you want it to succeed.” (1.2).
In this case, we see that the content of change (i.e., the cultural component of the change project) ensures that change agents engage more in the soft side of change management (e.g., learning): “I experience the urgency, but I do have the freedom to change it because it does have to do
with culture, behaviour and employees. It is a process that evolves step by step. And we are also part of a professional improvement culture in this hospital, which allows you to learn, make mistakes and innovate.” (1.2)
Availability of resources and knowledge. Change agents argue that the necessary resources
and knowledge should be present at the departments to implement the change. The project leader recognizes that certain knowledge and competencies are not present to pursue the set goals, but he also mentions other factors that can cause stagnation in the change process: “It may have to do with setting
priorities, but it can also be a lack in knowledge or skills, and maybe even insufficient courage to actually take certain steps. Or insufficient urgency or interest. That may also be resistance of employees. It is not very explicit, but not doing it is also resistance.” (1.1)
Change agents therefore exchange experiences in order to learn from each other. The hospital also provides tools and resources to support change agents in the process. “If it turns out that
compentencies are lacking to implement the change, it is possible to discuss with HR that training is required. I keep track of this myself.” (1.2) Thus, change agents tend to assess whether resources and
Hierarchical power to implement change. Partnerships of doctors are a characteristic of the
organizational structure of Dutch hospitals. This means that doctors and surgeons have significant power in the decision-making process of the hospital and therefore also in change projects. Change agents should thus deal with the power of the doctors when they start a project. Especially in this change initiative, surgeons have a significant influence in how the department arrange the scheduling of their patients. One of the change agents acknowledged this issue: “Actually, as long as XXX
surgery is present in the hospital, the planning process has not been changed. It is something that has always been stubbornly detained, and it must remain the way it is because we have been doing it for years. So the culture is quite deep. So first, I have to establish safety and trust. As a manager I need to work with the surgeons to establish support for the change process and to get a voice in the hierarchy.” (1.2)
Thus, change agents must engage in coalition building and the need for change should be clear for the employees. This emphasis on underlying social processes to build a coalition tends to be more soft on the continuum of hard and soft aspects of change management. To support the need for change, clear and good argumentation is necessary to convince employees about the change. For example, at one of the departments the change solution originated from the secretaries but the doctors should still be convinced. The change agent have to ask doctors what they think about it, but good argumentation is generally enough to convince these doctors: “And when it comes from the secretaries, it is always
the case that I first have to ask the doctors what they think of it. Anyway, if they come up with very good arguments, then it is not a problem at all. Substantiate what you want and why you want it. And then we just discuss it with each other.” (1.4)
Case 2. In this case, it became clear that the basic framework of the change initiative contains hard aspects, while soft aspects are important for the human-side of the change initiative. The choice for hard or soft aspects or a combination of both is influenced by the content and scope of change, emergence of resistance, and coaching of change agents.
Content and scope of change. This change project is characterized as a cultural change,
according to change agent 2.6: “It is just a cultural change.” Another change agent (2.8) also acknowledges that next to changes in responsibilities and tasks, such as extra coordination and coaching tasks of the HBO nurses, the function differentiation contains a cultural component: “This
means that not much has changed in terms of the content of care. The patient care that the hbo'er and the mbo'er deliver will remain the same. Only the HBO nurses will execute the superseding, the coordination and the coaching. So that's the biggest difference. This has an impact on the department in the sense that you suddenly have two groups of nurses. So there's a cultural component in this. There's an "I-am-still-equal-to-you" thing in it.” Thus, underlying values, such as equality between the
One of the change agents argues that cultural change needs a different approach compared to more structural changes because it is more time consuming to implement: “Cultural change usually
takes five years until the new culture is completely integrated. Therefore, it needs time.” (2.6)
In cultural changes, goals cannot be as clearly and concrete described according to the change agents. They argue that in other types of change initiatives, such as the Lean project, change agents can easier set goals that are concrete, measurable and tangible due to the scope of the project: “We are
also involved in the Lean project. In this project, we relocated resources on the department with a “lean” perspective. This is a small change. We just make arrangements for deadlines when parts of the project should be completed and then we are going to work according to the new changes. (…) I am able to make more concrete agreements for this change initiative. (…) Setting more concrete goals in smaller change initiatives is thus easier.” (2.6)
Another change agent (2.8) also compared this change initiative to other projects of the department and states that the difference between these projects and the function differentiation project is that the other projects concern small adaptations in the process that eventually will transform the whole process. Thus, each adaptation is a small step to change the whole process and can therefore be more easily managed. The function differentiation project is a transformational change that impacts the whole process at once and its impact for employees is significant. “Changes happen every day.
(...) But these are all such little things in the process. (...) These changes are part of a greater whole. This is a large whole which affects the smaller things. That is perhaps the best way to describe it. This has a real impact on the entire, total work process. And those other things are part of the work process and you can steer them a little to the left or to the right and therefore it runs better or flows better. But this does have a real impact on everyone.” (2.8) Therefore, the focus of change agents is
more on the soft side of change management, like participation and involvement of employees and coping with resistance.
The content and scope of change thus determine the choice for a certain approach during change initiatives. In cultural change or larger change initiatives, change agents tend to focus more on the soft aspects of change management. Goals are less clearly defined and change agents are less focused on hard aspects such as costs and time. More attention is paid to the human side of the change.
According to change agent 2.6, involvement of employees to think along during the change process, creation of space and time for the change process, coaching employees and continuously evaluating the progress of the change are critical success factors in a change project: “The way I
Additionally, change agents acknowledge the importance of collaborating with the employees during the change process instead of imposing the change upon them. “Just that people are involved
in the whole process. And people know what's coming. Yes, that just gives a feeling of security but also the feeling that they can think along in the whole and not that something is being imposed on you and you should do in this way. Just feeling involved, being reliable. That's the hospital's vision too.” (2.7)
Thus, according to this change agent, involving employees helps to avoid uncertainty, because they know what is coming. Moreover, another change agent’s reason to involve employees is because the change will fail when people are not involved: “If you don't involve people in a change initiative and
just say that's how we're going to do it, then it's usually doomed to fail.” (2.8)
Emergence of resistance. This large change initiative caused for some resistance among the
nurses, who felt suppressed by the decision of job differentiation. One reason for resistance is that nurses who used to work on the so-called HBO level for years, are now not allowed anymore to execute these kind of tasks: “The mbo nurses felt very disadvantaged, because they said: ‘I have also
worked as a HBO nurse for years. Where is my appreciation for this?’ So I have paid a lot of attention to this, and involvement. Also, I just asked what do you need? That is a question I have continuously asked.” (2.6) Another change agent (2.8) also acknowledges these feeling of some of the nurses: “It is unavoidable that there really are people who are disappointed or feel disadvantaged. Especially the in-service educated nurses, for who it was for a long time unclear whether they will be regarded as MBO or HBO educated, feel sometimes put aside, or not heard or seen. And it is not so much that that is the case, but these feelings exist.” Therefore, more attention to address to these feelings of some
nurses was necessary in the change approaches of the change agents.
Thus, the emergence of resistance or negative feelings regarding the change initiative can be seen as a contingency factor for the choice for a certain change approach, because support for the change initiative is important for the project to succeed: “I really want this change to succeed. I think
that is very important. But not only succeeding because we have to implement it, but also because we are up for it! And because everyone is motivated and because you can really improve care in this way. I believe in that. And yes, of course there are changes that have to be done, and this is one of them. But you actually want the change to be supported.” (2.8) Therefore, engaging in the soft aspects of
change management is more appropriate when resistance emerges.
According to the change agents, it is important to emphasize that the change will happen, because it is coerced by new legislation, but that employees do have an influence in how the change process will be executed: “My message to the team is that the function differentiation is a fact, we
Coaching of change agents. This change initiative required extra training from the nurses to
successfully implement the new function of the higher educated nurses. In the beginning, these nurses also need guidance and coaching of the change agent to develop in their new role: “In particular, I
think that the coaching at the departments is very good. At least that's what I really like. And besides that, you need time. Time to see what is actually happening to a team? And time to allow people to develop themselves and to allow people to step into their new role.” (2.8) Thus, it is important to have
time and space available to do this and change agents should be able to coach employees during this process. Therefore, a coach from the hospital is appointed to the change agents to guide and coach them in this process. In turn, the change agents should coach the nurses in their new role.
The coaches of the hospital have thus also an influence in the change approaches of change agents. The coaching of the change agents is particularly focused on how to cope with their own pitfalls as change agent. For example, one of the change agents indicated that she struggles to reduce control over employees: “It is hard for me to let go of things. That is what I am being coached for.
Can I do it differently? Or, what is your perspective on this situation? Why is it hard for you to reduce control? (…) It is also a learning process for me.” (2.8)
This emphasis on learning and development of all employees, including the change agents, can be regarded as the soft side of change management (e.g., coaching by and of the change agents).
Turnover, absenteeism and work pressure. Currently, there is a large demand for skilled
nurses in hospitals while there is a small availability of skilled nurses. Moreover, many nurses were temporarily absent due to an influenza epidemic and this had significant effect on the work pressure of nurses, while the work pressure is already significant for nurses. “Between December and March,
there has been an influenze epidemic. It is then difficult to really engage in the change project.” (2.6)
Change projects are therefore often not the priority of nurses, since all time is spent on the delivery of care for patients. Thus, change agents need to be aware of these external factors when they want to implement change initiatives.
The implementation of the function differentiation is therefore multiple times postponed, since there was no time available for the change process. “It is difficult to implement the change now,
because I have to deal with the high turnover within the team. Time is granted to us, but it is all a bit too much right now.” (2.8) In these situations, the change agent makes a consideration between time,
costs and the delivery of care: “I can hire extra nurses, however, these temporary employees are often
not available either. So the priority is always the patient! When the delivery of care is in place, we can start learning. (…) I do not worry about costs, since I can always justify why I exceeded the budget. (…) So these are the hard aspects. The soft aspects are more what do people think about this? So be in conversation with the nurses and ask what they need.” (2.7)
you have a lot of absenteeism due to illness, and you should actually put a HBO nurse in the role.. Yes, in the meantime the work process continues at the department so it is possible that you will have to put the nurse back on the work floor.” (2.7) The project is thus subject to external influences (i.e.,
project permeability) and this tends to be more on the soft side of the continuum of hard and soft aspects in change management.
Case 3. In this case, it became clear that the project leader chose for Lean Six Sigma as change approach in which both hard and soft aspects of change management are incorporated. The choice for hard or soft aspects or a combination of both is influenced by team maturity and stakeholder involvement.
Team maturity. Whether teams are implementing Lean by themselves or not is dependent on
the degree to which a team is mature in executing their tasks: “It depends on the team, the
improvement team. And also the team of the department and also in which phase the team of the department is. There are teams in the clinic that are very mature in their tasks and there are teams that are very young. And you often see in the teams that are a bit more mature and that pick it up a bit easier and they start working with it. And the teams that are very young, or that have all kinds of other projects running, you can see that you have to pull and push a bit more as project leader. That you need to facilitate a little more and ask them: what have you done now? Where are you now? What are you going to deliver in the coming period?” (3.9)
Thus, more guidance and facilitation of the project leader is required when teams are less mature in terms of task responsibility and project management. The project leader referred to a growth model used in the hospital to identify where the team is located in terms of maturity. When a team is identified as immature, a generic approach is not suitable for them: “Before we start, we will
determine where the team is located in the growth model. When teams are in the first part, they barely even know what a process is. When people do not even know what a process is, they are not able to change it. A generic approach to change management is therefore not suitable.” (3.9) A more specific
approach is more appropriate in these situations according to the project leader (3.9): “Of course you
can make gains on a number of things and you can obtain support, but then you have to make a specific approach.” Thus, the hard paradigm of change management is more appropriate in situations
where more guidance and facilitation of the project leader is required and when initiative of employees to implement the change is low due to team immaturity.
Stakeholder involvement. Moreover, stakeholders are also important for the success of Lean
implementation. For example, when departments were redesigned according to Lean principles, Technical Service was needed for this part of the process. Therefore, good communication and concrete action points are necessary: “I should have handled the involvement of the Technical Service
Technical Service was not what we expected. They were too busy to execute it and they had to plan this, since there was no time available at the moment. Hence, we did not involve them enough and I will do it differently the next time.” (3.9) Here, a combination of soft and hard aspects is necessary to
maintain a good relationship with important stakeholders. Again, hard aspects are required to provide a clear action list, while soft aspects are required to manage the relationship with stakeholders.
To summarize, this second part of the within-case analysis identified the various contingency factors that influence the choice for either hard or soft aspects in change approaches of change agents. In case 1, the content of the change initiative, the availability of resources and knowledge and the hierachical power to implement the change are the contingency factors that influence the choice of hard or soft approaches. In case 2, the content and scope of the change, the emergence of resistance, coaching of change agents, and turnover, absenteeism and work pressure were identified as contingency factors. Finally, in case 3, team maturity and stakeholder involvement were identified as contingency factors that influence the choice for either hard or soft aspects in the change approaches of change agents.
Cross-case analysis
In this section, the findings of the within-case analyses will be analyzed in a cross-case analysis. Similarities and differences between the three cases will be discussed.
Top-down initiative, bottom-up implementation. Two change projects were initiated top-down
by the hospital. In case 1, the hospital’s mission to more efficiently use scarce resources of the hospital was the reason to start the change initiative. In case 2, the government made a change in legislation and this was the reason that the hospital started with the change project of function differentiation between nurses. However, in case 3, one of the project leaders gained formal approval to implement Lean in the hospital. This can be seen as a bottom-up initiative of the project leader, however, the change initiative can be seen as top-down for the change agents (e.g., unit heads and care coordinators), because they have to implement Lean, which was not their initiative.
Despite of this top-down character of change projects in the hospital, change agents often try to involve employees in the change process. They focus on their own influence as department by discussing how the change will be implemented. Therefore, change agents want to create ownership for the implementation among the employees. The change agents are convinced that this is the only way to make the implementation of the change project successful. One of the change agents expresses this process (2.8): “The initiative is top-down and I have to execute this. But how we are going to do it
The reason for this is that if employees feel that they do not have an influence in how the change process evolves, they feel powerless and ignored. When people feel powerless, implicit resistance may arise, because employees will not proactively engage in the change process: “They
already made the plan, so why should I still put energy into it? While I think it's about my department. As with other departments, we need to involve the nursing staff at an earlier stage. Because they have to work with it and they have to act upon it.” (3.10) To overcome these issues, it is therefore
important that change agents have attention for the feelings of employees and listen to them: “I think
that just being heard would already help in terms of motivation and involvement, because then employees also get the feeling that they have a say and that they participate.” (3.10)
In case 1 and 2, the influence of employees on how the change will be implemented has resulted in general acceptance of the change initiatives and a low level of resistance. In case 1, only one doctor was resistant regarding the change, but the change agent states that this doctor is resistant against change in general: “One doctor is resistant, just generally against changes. Just changing is
resistance, so it is important to get him on board.” (1.2) Also in case 2, there was a low level of
resistance: “There is some resistance every now and then. But that's also allowed.” (2.8)
In case 3, however, a high level of involvement was present during the change process, but here employees were not satisfied with the degree of involvement in the early stage of the project: “I
was reserved concerning the change initiative. There they are again with something new.... Just as if they have nothing else to do, it suddenly comes out of nowhere. I don't have the feeling that our own staff thinks along, people from the work floor. How do we do that and how do we tackle it? No, they are just people from outside the department who, in our view, have nothing to do with the department. Who don't know what is going on at a department. How people work and what does someone need? What does someone need immediately, what kind of spaces do people need? Things like that.” (3.10)
The input of employees was asked to remove waste in the process and the employees were responsible for the waste walls that were created: “The influence of project members is significant,
because they are responsible for the waste walls. So everyone on the team has influence.” (3.9) While
Lean management is a change approach that thrives on involvement of employees, a change recipient indicated that this involvement should have been earlier in the process: “I would discuss the idea first.
The idea behind it. This is the line of thought and we could set it up together. How would we like that to do it and does it make sense at all? First of all, brainstorm about this. (...) That is what it is all about. You get a very strong feeling that this step is being skipped. No, these are the people behind the desk who come up with it. Or we need to have some sort of research agency for it. (...) That's our feeling though.” (3.10)
initiative and to some extent resistance still arises (Case 3). In other words, it seems that incorporating soft aspects leads to successful implementation when (1) these soft aspects are introduced early in the change process and when (2) change agents keep focusing on these soft aspects during the entire change process.
Success measures. All change projects are at least to some extent concerned with changing the
behaviors of employees. The change agents aimed to set clear goals, however, most of them were struggling to make these goals measurable or to measure the outcome of the change project. Besides the impact of the change initiatives on the behaviors of employees, multiple other factors influence the delivery of care and therefore it is hard to measure the effect of the specific project. In case 1, the goal of integral planning is more efficient use of the shared and scarce resources of the hospital (e.g., operating theatres and radiology department). Measuring the outcome of this project is complex, according to the project leader (1.1): “In science, you can execute an experiment in which you change
one variable to see what the causal effect is on another variable. In our situation, we change the way we plan, but simultaneously other factors change as well and you cannot isolate this effect from other influencing factors. Moreover, time passes as well. But it would be nice if we could measure the effect!”
In case 2, there were similar reactions to the success measures of the project. First, change agents do not want to emphasize the quality improvement due to function differentiation. The reason behind this is that they do not want to offend the lower educated nurses by saying that the delivered care improved because their role in the delivery of care has changed: “I do not think that we should
want to measure that, because then you'll put the mbo nurses down. If you show it was like that, and now the hbo nurses are doing it, look, now we're doing it well! I do not know whether you should want to express that in this way.” (2.7) Second, since the delivery of care is influenced by many factors and
other projects that are executed in the hospital, it is hard to measure the individual effect of the function differentiation: “I think the success of the project will be measured. But you have to take into
account various perspectives. For example, does the patient experience better quality of care? So many factors influence the delivery of care, so it is hard to measure it. Care changes each day, so we learn everyday. I do think that there is added value to the implementation of function differentiation, however, I don’t know how to measure it. I think this would be a perfect question for a research institute.” (2.6).
In case 3, the outcome of Lean management is hard to quantify in direct cost savings: “With a
project like Lean, you do not want to talk about money, because you are talking about people’s work.”
(3.9) However, the visible outcome is that nurses experience the benefits of Lean management in their daily work practices.
