MANAGEMENT DECISION AND RESEARCH CENTER

H E A LTH SERVICES RESEARCH AND 

DEVELOPMENT SERVICE

OFFICE OF RESEARCH AND DEVELOPMENT

D E PARTMENT OF VETERANS AFFA I R S

P r i m e r

Organizational Change

Organizational Change

MANAGEMENT DECISION AND RESEARCH CENTER

H E A LTH SERVICES RESEARCH AND 

DEVELOPMENT SERVICE

OFFICE OF RESEARCH AND DEVELOPMENT

D E PARTMENT OF VETERANS AFFA I R S

P r i m e r
Organizational Change.

Boston, MA: Management Decision and

Research Center; Washington, DC: VA

Health Services Research and Development

Service, Office of Research and

Development, Dept. of Veterans Affairs

[2000].

p. cm.

Includes bibliographical references. Primer.

DNLM: 1. Hospitals, Veterans –organization and administration. 2. Organizational

Innovation. 3. United States, Department

of Veterans Affairs, Management Decision

and Research Center.

UH 463.068 2000

The Health Services Research and Development

Service (HSR&D) is a program within the

Veterans Health Administration’s Office of

Research and Development. HSR&D provides

expertise in health services research, a field that

examines the effects of organization, financing

and management on a wide range of problems 

in health care delivery—quality of care, access,

cost and patient outcomes. Its programs span

the continuum of health care research and delivery, from basic research to the dissemination 

of research results, and ultimately to the application of these findings to clinical, managerial 

and policy decisions.
Organizational Change

Purpose of primer series: to help bridge the 

gap between re s e a rchers, policy makers, managers

and clinicians in an effort to improve the quality

and cost effectiveness of health care for veterans.

The primer series is part of a larger set of dissemination initiatives developed by VHA’s Office 

of Research and Development through the

Management Decision and Research Center, 

a program within the Health Services Research

and Development Service.

Purpose of the Organizational Change Primer:

to provide an introduction or to expand u n d e rstanding, information, and knowledge about the

concepts and application of organizational change

processes in general and, specifically, within 

VA. The primer provides a basic framework for

understanding organizational change and how 

it applies to VHA, a large health care system

undergoing change. More in depth readings and

other resources are listed in the appendices.

Suggested audience: VA professionals, clini c i a n s ,

managers, front line supervisors, re s e a rc h e r s and

staff involved in health care delivery in all parts of

the Veterans Health Administration.

Suggested uses: individual study, orientation 

for professional staff and health care providers,

management training programs in Veterans

Integrated Service Networks and within VA facilities, and continuing medical education courses

and other medical and health professional 

training programs.

May 2000

i

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

What is Organizational Change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Why is it important to actively manage the change process? . . . . . . . . . . . . . . .2

What is the human side of change and why is it important? . . . . . . . . . . . . . . .2

What are some critical activities for managing change? . . . . . . . . . . . . . . . . . .3

Change Snapshots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

What are some pitfalls in implementing change? . . . . . . . . . . . . . . . . . . . . . .5

What lessons has VA learned to date from its experiences 

in managing organizational change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

What research has VA done on organizational change? . . . . . . . . . . . . . . . . . .7

Is there a relationship between performance improvement

and change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

What resources and references are available to VA managers? . . . . . . . . . . . . .9

Concluding remarks & References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Appendices: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

Appendix A: What VA and non-VA resources are available 

to managers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Appendix B: What reading materials are available to 

provide more in-depth information on change, the change 

process, and the impact of change on staff and managers? . . . . . . . . . . . .21

Appendix C: A glossary of organizational change terms . . . . . . . . . . . . . .29

Fax us your comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Table of Contents
i i
i i i

Contributors

Contributors:

The MDRC staff thanks the many managers and

researchers who participated in the development

of this primer. Mary Darby, editorial consultant,

wrote the primer with Gerry McGlynn and 

with input from a number of researchers and 

others with expertise in organizational change.

Special thanks go to the following individuals 

for their assistance: Robert A. Petzel, MD,

Director, VISN 13, Minneapolis, MN; Fred

Malphurs, Director, VISN 2, Albany, NY; Sheila

Gelman, MD, Chief Medical Officer, VISN 10,

Cincinnati, OH; Brian Mittman, PhD, HSR&D

Center of Excellence, Sepulveda, CA; Linda

Watson, RN, MSN, Director, Central Alabama

Health Care System, Montgomery, AL;

Paul Rosenfeld, MD, Chief of Staff, VAMC New

Orleans, LA; Laura Miller, Director, VISN 10,

Cincinnati, OH; William Weeks, MD, MBA,

Director, Patient Safety Center, White River

Junction, VT; Stanlie Daniels, RN, Director,

Performance Measurement Program, Office of

Quality and Performance VAHQ.

Acknowledgements:

We also extend our appreciation to colleagues

throughout VA for their thoughtful comments in

reviewing an earlier draft of this primer: Martin

P. Charns, DBA, VA HSR&D MDRC, Boston;

Jeannette Chirico-Post, MD, Director, VISN 1,

Bedford, MA; Carol Ann Bedford, MD, Quality

Management Officer, VISN 2, Albany, NY;

Richard McCormick, PhD, Service Line Manager,

Psychiatry, Louis Stokes VAMC, Cleveland, OH;

Elwood Headley, MD, System Director, VA North

Florida/Southern Georgia Health Care System,

Gainsville, FL; Stephen Ezeji-Okoye, MD,

Primary Care Service Line Manager, VAMC Palo

Alto, CA; Bill Feeley, LICSW, Medical Center

Director, VAMC Buffalo, NY; Al Perry, FACHE,

Director, VA Central California Health Care

System, Fresno, CA.

Primer development and editing:

Geraldine McGlynn, MEd, Elaine Alligood, MLS,

Laurel Long, MS, Diane Hanks, MA, and Scott

Brigante, all of VA HSR&D Management Decision

& Research Center, Boston, MA.
i v
v

Preface

The VA health care system is a system in flux –

changing its focus, expanding its activities, and

restructuring its services. With the reorganization

of VA into networks and the change in focus from

specialty-based hospital services to outpatientbased primary care, today’s VA looks nothing like

yesterday’s.

And the fact is that tomorrow’s VA likely will not

be the same either.

Change is a fact of life in today’s health care

environment. The spread of managed care,

demands for increased accountability, concerns

about patient safety, and heightened emphasis 

on cost-effectiveness and quality improvement

contribute to a dynamic that requires all health

care providers to be on the alert, flexible, and

ready to respond to change.

That’s as true for the VA health care system as it 

is for any other system. The same forces that have

rocked the rest of the industry during the past 

few years have also forced VA to re-examine all

facets of its operations to determine how well it is

serving America’s veterans and how it might better

accomplish that mission. 

Change can be frightening. And, I’ll be the first

to admit, it is extremely difficult. But we can’t

afford not to change. In fact, for VA, change is

now a continuous process – a means for identifying

new and better ways of doing things and, ultimately, for improving the quality and efficiency 

of veterans’ services. 

This primer is designed to help VA managers 

and staff understand, accept, and implement

change. Think of it as a survival guide. We believe

that by helping managers and staff cope with and

survive change, we are assuring VA’s long-term

survival and growth as an organization driven by

new knowledge and learning.

As Benjamin Franklin observed, "When you’re

finished changing, you’re finished.” VA’s work is

not finished. Our mission is a dynamic one. 

Our patients’ needs will continue to change, new

medical treatments and technologies will continue

to emerge, and demands for services will evolve

accordingly. 

Commitment to quality means commitment to

change. VA remains firmly committed to providing the best possible care for America’s veterans –

not just today or tomorrow, but for many decades

to come.

John G. Demakis, M.D.

Director, 

Health Services Research and Development

Service
v i
v i i

Introduction

Every organization must change – not only to 

survive, but also to retain its relevance in a world

of intense competition, constant scientific

progress, and rapid communication. But in order

for change to bring a benefit and advance an

organization to a higher level of service and operation, that change must be driven by knowledge.

At VA, this is where the Health Services Research

and Development Service (HSR&D) comes into

play. All change efforts are fraught with questions:

How do we know when change is needed? How

do we know what kind of change is needed? How

can we effectively manage change? How do we

know that our efforts are producing the desired

effects and that the changes we are bringing about

are actually desirable? HSR&D is working to supply answers to these and other important questions, as VA continues its journey of improvement

through learning and change.

In this Primer, we share some of the important

lessons we’ve learned to date about organizational

change – why it’s important, what we can do to

manage it, and some pitfalls to avoid. Our intent

is to help managers respond effectively to the great

opportunities before us by answering some basic

questions about organizational change. A question-and-answer format is used for easier reading

and accessibility. Appendices provide VA managers and others involved in implementing change

with resources for additional information and

references for more in-depth reading.

We recognize that implementing change is one 

of the most challenging and critical responsibilities any manager can face. We also recognize that

organizational change can be challenging for all

those asked to participate in the change process.

We hope that this primer will help make the 

job a little easier. VA is committed to supporting 

its managers and staff throughout this continuous

process, and to developing new tools and

resources for facilitating change that will benefit

all veterans.

Martin P. Charns, DBA

Director, 

Management Decision and Research Center
v i i i
1

W H AT IS ORGANIZATIONAL 

C H A N G E ?

Organizational change is any action or set of

actions resulting in a shift in direction or process

that affects the way an organization works. Change

can be deliberate and planned by leaders within

the organization (i.e., shift from inpatient hospital focus to outpatient primary care model), or

change can originate outside the organization

(i.e., budget cut by Congress) and be beyond its

control.

Change may affect the strategies an organization

uses to carry out its mission, the processes for

implementing those strategies, the tasks and functions performed by the people in the organization, and the relationships between those people.

Naturally, some changes are relatively small, while

others are sweeping in scope, amounting to an

organizational transformation. 

Change is a fact of organizational life, just as 

it is in human life. An organization that does not

change cannot survive long – much less thrive – 

in an unpredictable world. Several factors may

make organizational change necessary, including

new competition in the marketplace or new

demands by customers. These types of external

forces may create expectations of improved efficiency, better service, or innovative products. 

When organizational change is well planned and

implemented, it helps assure the organization’s 

continued survival. It can produce many tangible

benefits, including improved competitiveness, 

better financial performance, and higher levels of

customer and employee satisfaction. These benefits may take some time to achieve, however, and

the transition period that accompanies major

organizational change usually is a time of upheaval

and uncertainty. Not every individual in the 

organization will benefit personally from change;

some will be casualties of change, especially if jobs

are cut or realigned. But change should make

the organization as a whole stronger and better

equipped for the future.
WHY IS IT IMPORTANT TO ACTIVELY 

MANAGE THE CHANGE PROCESS?

The change process must be managed in order 

to keep the organization moving toward its new

vision and its stated objectives. We’ve all heard

examples, in health care and elsewhere, of organizations that launched ambitious change initiatives

founded on excellent ideas that were never 

fully implemented because they weren’t appropriately managed. At best, an unmanaged change

process accomplishes nothing, and the work that

went into planning the change is wasted effort.

But at worst, an unmanaged change initiative 

can produce unintended, detrimental effects1

such as poor morale, loss of trust in management,

workplace jealousy, and lower productivity. 

Thus, orchestrating the process of change is as

important as selecting the content of change.

V

"Change isn’t always positive; but it can be handled 

in ways that strengthen rather than diminish 

the commitment people have to an organization." 

WILLIAM A. PA S M O R E

C R E ATING STRATEGIC CHANGE

W H AT IS THE HUMAN SIDE OF CHANGE 

AND WHY IS IT IMPORTA N T ?

Organizational change is about people changing.

Organizational change, then, is a highly complex

process that must take into account how people

respond psychologically when asked to make major

changes at work. Their reactions inevitably vary.

While some people embrace change, others will

resist it – sometimes passively, giving the impression that they support it. A small number of 

people are energized by change, but many others

feel threatened and anxious. This is particularly

true if, under the change initiative, people 

may be transferred to new positions or work sites

or even lose their jobs.

The human side of change is frequently ignored

or handled inadequately despite managers’ best

intentions or their intellectual understanding of

how difficult change is. Recognizing the pain and

insecurity that change can cause in the workplace

is not enough; managers must devise ways for

responding effectively to these feelings. This may

involve engaging employees more actively in

change efforts, communicating with them more

frequently and comprehensively about new developments, creating a forum for them to vent their

frustrations and fears, or simply maintaining an

"open door" environment, where employees can

approach their managers individually to discuss

concerns. For more information see Backer, 1997

and Flarey, 1998 in Appendix B.

V

"The first rule of change, therefore, is to begin any

process of change with concern for its impact on 

people. The second rule is to prepare people for the

change by educating them in what they need to know

in order for the change to be successful; the third, 

to involve them in the change as much as possible; 

and the fourth, with their involvement, to change

what really needs to be changed about the entire 

system in order for the effort to produce real results." 

WILLIAM A. PA S M O R E

C R E ATING STRATEGIC CHANGE

2
W H A 3

T ARE SOME CRITICAL ACTIVITIES 

FOR MANAGING CHANGE?

There is no one-size-fits-all formula for 

managing change. Managers may approach change

in a number of ways, depending on the organization’s culture, history, and the nature of the

change being implemented. At the most basic

level, however, managers should try to build flexibility into the organization (into its people, 

technology, systems and thinking) to create a work

environment that is open to change and able to

accept it.2Following are some key points that can

help managers achieve this goal. 

Determine the context for change. This is a

period of information gathering and analysis.

Some questions for managers include: What is the

imperative for change? Who are all the groups

that need to be involved in the proposed change –

both within and outside the organization? How

are they likely to be affected by the change? What

support will be needed from them during the

change process, and how prepared are they to give

it? What are the potential impediments – both

internal and external – to change? What resources

and system supports does the organization have

available to implement the proposed change?

What others are needed?3

Build support for change. Commitment to

change usually begins with a small group of "core

believers" or champions of the change initiative,

who share a common new vision for the organization and are willing to do what it takes to make it 

a reality. The core believer group is usually comprised of high level, influential managers and staff

who bring credibility and personal influence to

the change initiative. Their involvement may also

be viewed as a demonstration of the organization’s

commitment to change. In addition, these leaders

frequently control resources and rewards within

the organization. Early in the change process,

these core believers need to involve a larger group

of "initial participators" who don’t necessarily

have the same level of commitment to change as

do the core believers, but they participate in the

initiative out of loyalty to the organization. As 

the change process takes hold and its successes are

publicized, support will spread to others who 

typically "wait and see" whether they should 

commit to the initiative. Last to commit to the

effort are the "hard-core resisters," some of whom

will never support the change process.

4

Develop a motivating vision. A clear and concise

motivating vision is needed to "inspire" a large

number of employees to change. People need to

know why change is desirable, why they should

make the effort to support it, and what it will

achieve. The change can be very painful to some

employees whose jobs may require new skills,

transfers or even elimination. The motivating

vision should be sufficiently concrete so that 

people can understand what it means and why the

change is necessary, but not so rigid that it has 

no room to evolve. A motivating vision is one that

enables people to imagine new possibilities for the

organization as a whole and for themselves as

members of the organization. 

Articulate clear, specific and realistic goals and

strategies. A vision helps motivate people, but

specific goals and strategies are needed to guide

them as they undertake the steps necessary to make

the vision a reality. In addition, having clear goals

helps the organization assess its progress during

the change process. One general strategy is to 

look for natural opportunities to effect change. 

In other words, search for natural connections

among existing programs, events, communication

channels, activities and the change program. 

If natural connections emerge, utilize them 

to enhance change efforts. For example, development of teams or introduction of case management could be linked with programs to improve

quality of care. Such connections may also open

up opportunities for creative collaborations and

partnerships that might otherwise be overlooked.

The key here is to leverage what is already going

on and to complement new initiatives being

launched.
4 Change Snapshots

Example 1: 

A chief of medicine at a large teaching hospital was

ambivalent about the hospital’s change program 

for implementing patient-centered care. Although

he could articulate numerous problems regarding

delivery of care at the hospital, he did not yet 

see how the change program could solve these problems. Change leaders at the hospital used several

methods to communicate the program’s goals

throughout the hospital, but the chief and many

others viewed this information as meaningless 

jargon. With many academic and patient care

responsibilities, the chief did not make the time 

to focus on the change program.

This situation changed when the hospital chief executive and the vice president for medical affairs each

met with the chief and discussed how the program

was designed to improve patient care. They listened

to the chief’s problems and asked him to help the

change program work to address them. They also

made commitments to address problems with hospital systems that were important to the chief. In

doing so, they noted that these fixes were part of the

change program. Over time, as he saw that the

change program was addressing issues of importance

to him, the chief became a supporter of change. 

From this experience, change leaders at the hospital

also learned that their communication efforts with

staff were ineffective. As a result, they began to use

focus groups of staff to critique hospital employee

newsletter articles and videotapes about the change

program. They found that what seemed perfectly

clear to change leaders was not meaningful to many

others in the hospital. Accordingly, they set out to

develop more effective communication vehicles.

Example 2: 

A hospital chief executive did not realize how much

his own communications (or perceived lack of 

communication) signaled a lack of commitment

throughout the organization to a multi-milliondollar, multi-year change initiative. In fact, the

executive was very committed to this program. 

He thought that his few communications through 

formal channels about the change program conveyed to others his support for it and interest in its

success. When the change project manager and 

consultant realized that staff did not view the chief

executive as committed to the change, they took

immediate action. They worked with him to develop

a set of presentations, both formal and informal,

about the change process and his vision for it. 

They even arranged for him to be featured on a

local talk radio show. Surprisingly, after the radio

show some staff commented that this was the first

that they had heard of the change initiative. 

Example 3: 

This story illustrates what can happen when top

leadership is not on board with a change initiative.

At one hospital, a vice president who expressed 

support for a change program during senior management meetings behaved differently during his

own staff meetings and in fact did little or nothing

to promote the change process. Without a clear 

signal that their VP supported change and their

efforts to implement it, staff in that department did

not work to implement new methods or systems

needed under the change program. Ultimately, the

change program failed.
W H A 5

T ARE SOME PITFALLS IN 

IMPLEMENTING CHANGE?

Every change process has its setbacks and complications. Throughout the change initiative, 

managers should keep in mind that these setbacks

frequently have a positive aspect because they 

offer opportunities to reassess and improve 

the implementation process. Mid-course corrections are to be expected—if things are going too

smoothly, managers might want to take a closer

look and make sure that they are not missing

something.

Following are some mistakes that managers 

commonly make when implementing a major

change initiative.

The manager tries to bring everybody on board.

Not everyone in the organization will support 

the change immediately. Managers should focus

their efforts on their core supporters and on

swaying the undecideds. In this way, they can

achieve a critical mass to move the process 

forward. Investing too much effort to win over 

hard-core resisters will merely drain energy and

resources needed for other parts of the change

process. 

The manager leaves it to others higher up in the

organization to explain "the big picture."

Communication is a crucial activity in all change

initiatives. The needs of staff for information 

at every step of the way cannot be underestimated.

Managers cannot expect to simply deliver a 

message once and assume that it has been understood and accepted by everyone in the organization. In addition, they will need to use a variety 

of media – including staff meetings, newsletters,

posters, suggestion boxes, email, and Internet 

and Intranet sites – because different communication methods are more effective with different

people. Finally, managers should keep in mind

that communication is an excellent opportunity

for them to build trust and credibility with 

their staff.

The manager has to make everyone part of 

the team. Managers need to accept that a small

percentage of hard-core resisters simply will not

adapt. These people may drag others down. If 

this happens, the manager should talk privately

with the person, acknowledge his objections,

explain why his support is needed, and invite his

participation in solving problems. If the person

still doesn’t accept the change, he may have to

Communicate. Clear concise communications

about the need for change, the vision, and the

change process pave the way for understanding

and acceptance. The rule of thumb is to use all

available methods of communication to stakeholders and staff including: meetings or retreats, 

e-mail, department newsletters, bulletins, posters,

and, in some instances, one-on-one meetings

with staff members, particularly those who are

having difficulty accepting the change. Managers

need to be aware that communication is a continuous process and that messages related to the

change effort require constant reinforcement.

The change process should be a regular item on

meeting agendas, successes should be publicized,

and participants commended for their efforts.

Identify barriers to change and develop strategies for overcoming them. There are many types

of barriers – internal, external, psychological,

cultural, systemic, and logistical – that can block

or subvert the change process. Engaging staff

and/or stakeholders in structured creative dialogue can identify these. Once identified, address

barriers and concerns promptly. Problems that

are ignored and allowed to fester, breed resentment, distrust, and uncertainty. Managers who

take charge of a problem and try to solve it before

it gets out of hand, demonstrate their leadership,

honesty, and concern for staff.

Look for the early win. By making the most out

of small, early successes, managers can establish

the credibility of the change initiative, provide a

boost for initial participators, and demonstrate 

to the "wait and see" group that the proposed

change can work and is worth their involvement.

Recognize participants for their efforts. Change

is hard work. Managers can reward participants

productively involved in the change process by

giving them promotions, bonuses, awards, desirable assignments, praise, attention, and notes of

appreciation. They can also use the opportunity to

further train/develop participants and encourage

them to continue or even increase their efforts in

supporting the change process.

V

“There is nothing permanent except change.”

H E R A C L I T U S
leave the organization – both for his own good

and for the good of the group.

5 This is a difficult

situation for managers to deal with especially 

in a federal personnel system. If, in the end, the

manager decides the employee will not fit into the

new team and the employee does not leave the

organization, the manager may need to work on

finding another placement for the employee.

The manager confuses stakeholder consultation

with change management. Although stakeholder

consultation and participation in the change initiative are important, managers should be careful

not to allow stakeholders to take over the process.

Stakeholders should be viewed as expert resources

like any other. Managers need to be aware that

stakeholder interaction is essentially a dialogue

with individuals who have similar interests 

but who may or may not share the organization’s 

perspective. This interaction must be managed

effectively, especially with regard to stakeholders’

expectations of how their input from consultations will be used.6

V

A useful rule of thumb about vision: 

“Whenever you cannot describe the vision driving 

a change initiative in five minutes or less 

and get a reaction that signifies both understanding

and interest, you are in for trouble."

JOHN KOT T E R

LEADING CHANGE

W H AT LESSONS HAS VA LEARNED TO

D ATE FROM ITS EXPERIENCES IN 

MANAGING ORGANIZATIONAL CHANGE?

At VA, as in other organizations, each change

implementation is unique. Thus, different 

managers glean different lessons from their experiences with managing change processes.

Following are some examples of lessons learned.

Different management strategies inevitably

entail different tradeoffs. For example, a long

roll-out period may allow managers to develop

more detailed and precise implementation plans,

deploy their financial and human resources 

more efficiently, and engage stakeholders more

effectively. But a prolonged roll-out can also

exacerbate staff uncertainty about the future,

heighten anxiety, and lower morale.

Adapted from: Galpin, T.J. The Human Side of Change; Jossey-Bass; 1995.

The human element of managing change 

cannot be overemphasized. For most people,

organizational change creates major anxieties –

about job security, whether and how their jobs 

will change, who their supervisors will be, and

whether they’ll have to move to another work site.

Staff may become distrustful of the organization’s

leaders and change managers. The rumor mill

kicks into overdrive. Staff turnover increases.

Managers need to try to anticipate staff members’

fears, answer their questions as quickly and 

completely as possible, dispel false information,

and develop a number of communication strategies for keeping people informed of the change

process.

6
7

Set specific goals and objectives before involving

staff in strategy development for change implementation. This is particularly important when

convening change teams. Left to their own

devices, these groups usually have little incentive

to initiate major changes. Instead, they are more

likely to try to solve problems by "tinkering

around the edges." By giving change teams clearly

defined expectations regarding quality, cost, 

and performance, and then allowing them to 

help develop strategies for meeting those goals, 

managers are more likely to elicit innovative and

effective plans.

Communication is critical to the success of any

change effort, but it is extremely difficult.

As mentioned, organizational change creates a

great deal of uncertainty and anxiety for staff. 

The initial reaction of many people is to deny that

the change will actually take place, or that it 

is permanent and not simply a "passing phase."

Managers need to develop solid communication

plans that are embedded in the change process

and that use a variety of media to reach different

audiences with different communication needs

and preferences. Some managers find that staff

react positively to more interactive approaches,

such as town meetings, small focus groups, or

one-on-one meetings with supervisors. Managers

should also keep in mind that messages about

change need to be repeated – sometimes 

frequently – because they seldom sink in with

everyone the first time.

Experience with changing organization systems

at the facility level is helpful. Much of the

groundwork for implementing change involves

setting up standard procedures and structures for

accounting, information management, workload

reporting, and other functions. If facility 

managers can put these processes and structures

into place early, the rest of the change implementation will proceed more smoothly.

Change implementation requires persistence.

Change rarely works out exactly as planned.

Managers may feel overwhelmed at times by their

responsibilities and by the stress of change. They

may need to ask the organization’s leaders for

additional support or training to deal more

effectively with certain issues. They may also need

to experiment and learn a few lessons the hard

way before hitting on the combination of strategies and approaches that will work best for them. 

W H AT RESEARCH HAS VA DONE ON

O R G A N I Z ATIONAL CHANGE?

HSR&D, through its Centers of Excellence and 

the Management Decision and Research Center

(MDRC), is examining many of the organizational

changes taking place within VA. (See Appendix A

for Center descriptions and contact information).

For example, the MDRC is working on three

major research projects, the Service Line

Implementation Study, the Facility Integration

Study, and the National VA Quality Improvement

Study, which explore the development and 

implementation of innovations in care delivery

and organizational design. 

Updates on the progress of these three studies 

are reported quarterly in the MDRC Newsletter,

Transition Watch, which is available on the web.

( h t t p : / / w w w . v a . g o v / re s d e v / p r t / c a t e g o r y . h t m # n e w s ) .

Service Line Implementation Study. VA is working to improve health care delivery to veterans 

by restructuring organization and management

practices to increase efficiencies and responsiveness. Service Lines are one aspect of this restructuring. Service Lines are a comprehensive set 

of services designed to meet the needs of a specific

veteran patient group, such as women or elderly

veterans. Service Lines are also characterized 

as an integrated set of services – such as primary

care, mental health, geriatrics and extended care –

that are distinguished from other services by the

technology or specialty employed. 

In collaboration with the HSR&D Houston Center

for Quality of Care and Utilization Studies, the

MDRC is conducting a study of service line management implementation among the VA networks,

investigating the process of change and the effectiveness of service lines. The study will qualitatively and quantitatively evaluate the various forms of

service line management in VA.

Facility Integration Study: Hospital or facility

integrations are highly complex endeavors, and

analyzing the processes and progress of integration can provide unique and valuable information

for other systems striving to integrate independent facilities. The MDRC, initially in collaboration with the HSR&D Center for the Study of

Healthcare Provider Behavior in Sepulveda, is

studying facility integration in VA. The first 

component of the study looked at the process of

integration, including the factors that facilitated

or hindered the process, and the structure of 
the resulting integrated systems in fourteen 

VA systems. The second component of the study

monitored the structures and assessed the effects

of integration on patient satisfaction, cost, access,

and quality enhancement in all VA systems integrated since January 1995. Effects were measured

over multiple years so that system changes had

time to achieve stability. Among the key findings

of the study:

• Clear direction from leadership about new structure and guidelines for planning, as well as early

involvement of staff and middle management in the

planning process, produced higher staff morale and

satisfaction. 

• Systems with a central headquarters – where the top

leadership and all or most service chiefs are physically based at one campus – tend to integrate more

quickly and extensively than other systems. 

• While integrated systems significantly improved

staffing efficiency after integration, there were only

modest effects on other measures of efficiency and

performance.

The MDRC will continue to track the nature

and extent of systems integration in VA and will

disseminate results. 

National VA Quality Improvement Study.

This study is a three-year project examining and

supporting VA’s transformation through a range

of data collection strategies, including employee

surveys, interviews with Headquarters staff and

network directors, plus site visits to facilities.

Surveys obtained information on a variety of indicators related to quality improvement, customer

service orientation, and organizational culture.

Survey results have been disseminated to provide

managers with timely information. By repeating

the survey three times, study investigators can

assess VA’s progress over time on specific survey

indicators. 

Monitoring these large-scale change efforts will

help inform the planning and implementation 

of future change efforts required by VA’s commitment to continuous learning and improvement.

By continuously assessing and disseminating

lessons learned, as well as problems encountered

and solved, VA advances health care delivery 

and management.

IS THERE A RELATIONSHIP BETWEEN 

PERFORMANCE IMPROVEMENT AND

C H A N G E ?

As noted quality expert Donald Berwick observes,

"Not all change is improvement but all improvement is change."7 Real improvement, he believes,

comes from changing systems – not from changes

within systems. Thus, improvement requires a

model for systemic change.

In VA’s Prescription for Change, clinical quality is

described as being "critically dependent on 

organizational systems and structures that minimize the chances for mistakes to occur, improve

efficiency, promote accountability, and encourage

continuous improvement." VA is committed 

to measuring, reporting, and comparing performance for multiple patient outcomes at the

national, network and facility levels. The idea is

that these activities will result in changes that

improve the quality and the efficiency of health

care services provided by VA.

8
W H A

9

T RESOURCES AND REFERENCES 

ARE AVAILABLE TO VA MANAGERS?

A wide array of resources and references are

available to assist VA managers with organizational

change. Resources range from local and national

groups with expertise in organizational change, 

to education and training programs, change and

improvement consultants, as well as additional

web site resources. Appendix A provides an annotated listing of some of these resources both within

and outside VA. Appendix B provides an annotated

listing of change process books and articles for

further reading on the topic. Appendix C provides 

a glossary of terms used in this Primer and in the

change management literature in general. We

hope that you will find these useful.
1 0
Concluding Remarks & References

At VA, change has been rapid and sweeping, as 

VA transforms itself into an organization of 

continuous learning and innovation. While many

changes have already been implemented, others

are still in the works. The reality is that VA is 

re-examining each of its processes and practices 

to determine whether they meet the demands for

quality, effectiveness, and efficiency in today’s

constantly changing environment – and whether

they will continue to meet new demands in

tomorrow’s world. Thus, change will be a continuous enterprise at VA, a process of continually

learning and seeking ways to do things better. 

In an ever-changing world with constantly emerging challenges, VA cannot afford to merely move

from one rigid state to another – albeit better –

rigid state. VA is also aware that many others 

outside VA – including members of Congress 

and private-sector providers – are watching to see 

how VA implements its performance improvement and benchmarking activities, and what it

achieves from these efforts. Thus, VA can provide

leadership for the rest of the health care community in planning, implementing and learning

from change. 

VA might do well to borrow a phrase from noted

change author James Lundy as its motto for

change: "Lead, follow, or get out of the way!" 

VA managers are invited to embrace change, 

learn how they can advance it, and ask for training

or other types of support when they need it.

1 1

1 Charns MP. Implementing organizational change.

FO RU M [HSR&D Newsletter] 1994; (December):2-3.

2 Pasmore WA. Creating strategic change: designing the flexible,

high-performing organization. New York: John Wiley &

Sons; 1994.

3 Wilson P, Sowden A, Watt I. On the evidence.

Managing change. Health Services Journal 1999;

109(5643):34-35. 

4 Charns, op. cit.

5 Anonymous. Change: overturning myths and blocks.

OR Manager 1998; 14(5):31-32. 

6 Axler H, Donner GJ, Underwood E, Van de Bogart

L. Planning for complex change: insights from 

the Metro Toronto District Health Council hospital

restructuring project. Healthcare Management Forum

1997; 10(2):33-34.

7 Berwick DM. A primer on leading the improvement

of systems. British Medical Journal 1996;

312(7031):619-622.
1 2
These appendices are provided to support change

efforts across the VHA organization. As of 

publication, Spring 2000, the lists are up-to-date

and complete. If you have updates or additional

resources to add, please contact this office with

the specific information. New resources will be

added to the electronic Web version of the Pr i m e r .

Geraldine McGlynn, MEd

Manager, Information Dissemination Program

Management Decision & Research Center 152-M

VA Boston Healthcare System

150 So. Huntington Avenue

Boston, MA 02130

Telephone: (617) 278-4433 

Fax: (617) 278-4438

geraldine.mcglynn@med.va.gov

Appendices:

1 3

Organizational Change,

Resources, Books, Articles, 

and Definitions
1 4
Appendix A: 

1 5

What VA & non-VA resources

are available to Managers?

There are several different types of resources, 

references and tools for managers to use in their

change planning, implementation or evaluation.

First, many people have planned and experienced

change within VA. We have asked several of 

these VA Change Agents if they would be willing 

and able to share their experiences or serve 

as resources to other VA managers. A list of their

names and contact information follows. Next,

there are lists of important VA offices and 

contacts that can provide information or guidance

on change efforts, as well as some non-VA

contacts and websites of interest.

Resource List of Experienced VA Change Agents

The following VA individuals have experienced large-scale change efforts and are willing to share their experiences.

N A M E T I T L E / L O C AT I O N TYPE OF CHANGE C O N TACT INFO

Scott Sherman, MD PACE Development of FIRM System (818) 891-7711 Ext. 9909

Sepulveda, CA ssherman@ucla.edu

Terry Washam Chief, Mental Health Development of Service Lines (440) 526-3030 Ext. 7949

Services, Cleveland, OH terry.washam@med.va.gov

Mark Peddle Clinical Program Supervisor, Implementation of Service Lines (440) 526-3030 Ext. 7977

Cleveland, OH mark.peddle@med.va.gov

John H. Edwards, MD Staff Psychiatrist, Restructuring traditional services (509) 328-4521

Spokane, WA to multi-disciplinary teams john.edwards@med.va.gov

Robert Perreault VAMC Director, Implementation of Service Lines (404) 728-7601

Atlanta, GA robert.perreault@med.va.gov

David Cornwall AA/Director, Facility integration (203) 932-5711 Ext. 4734

West Haven, CT david.cornwall@med.va.gov 

Nicheole Amundsen Director, Primary Care, Implementation of "managed care (202) 273-8558

VAHQ models" for ambulatory care and nicheole.amundsen@hq.med.va.gov

primary care

Scott Murray Network Care Line Director, Implementation of Service Lines (518) 462-3311 Ext. 3482

Behavioral Health, Albany, NY scott.murray@med.va.gov

Timothy R. Smith, PhD Program Leader, Behavioral Implementation of Service Lines (814) 860-2061

Health, Erie, PA timothy.smith@med.va.gov

Pamela Chester, RN, MSM Practice Manager, Medical VA Implementation of Service Lines (716) 393-7133

Care Line, Canandaigua, NY pamela.chester@med.va.gov
Within VA

Contact information listed below is current as of 

April, 2000

Health Services Research and 

Development Service

Within the Office of Research and Development, 

the Health Services Research and Development Service

provides expertise in health services research, a field 

that examines the effects of health care organization,

financing and management on a wide range of delivery

issues including quality of care, access, cost and patient

outcomes. The following list provides contact information for some of the HSR&D centers and programs 

related to organizational change.

Management Decision and Research Center

Martin P. Charns, DBA, Director

Boston, MA

Telephone: (617) 278-4433

Fax: (617) 278-4438

Email: martin.charns@med.va.gov

The Management Decision and Research Center

(MDRC) conducts, coordinates and disseminates

research to inform policymakers and managers

about organizational and managerial practices

affecting the quality, cost and accessibility 

of patient care. MDRC staff have expertise in 

such areas as organizational development, 

program evaluation, policy analysis, strategic

planning, and information dissemination. 

MDRC researchers are currently engaged in three

major studies of organizational change and 

innovation discussed elsewhere in this document:

the Service Line Implementation Project, the

National Quality Improvement Study, and the

Facility Integration Study.

1 6 Center for the Study of Healthcare Provider Behavior

Lisa V. Rubenstein, MD, MSPH, Director

Sepulveda, CA

Telephone: (818) 895-9449

Fax: (818) 895-5838

Email: lisar@rand.org

Researchers specifically focus on provider behavior and practice patterns, health care quality 

and outcomes, quality improvement, clinical

practice guideline implementation, and primary

care/managed care evaluation. Providing technical

assistance and education opportunities are

also high priorities. Researchers at the Sepulveda

Center are collaborating with researchers at the

MDRC on the Facility Integration Study mentioned earlier.

Center for Health Care Quality of Care 

and Utilization Studies 

Carol Ashton, MD, MPH, Director

Houston, TX

Telephone: (713) 794-7615

Fax: (713) 794-7103

Email: cashton@bmc.tmc.edu

Much of the work at the Houston Center focuses

on quality of care assessments and on the study 

of the levels and determinants of veterans’ utilization of health services. A distinctive feature of 

the Houston Center is its expertise in using large

health care database analysis both within and 

outside the Department of Veterans Affairs.

Researchers at the Houston Center are collaborating with MDRC researchers on the Service Line

Implementation Study discussed in the text.

Veterans Evidence-Based Research, Dissemination 

and Implementation Center (VERDICT)

Jacqueline Pugh, MD, Director

San Antonio, TX

Telephone: (210) 617-5314

Fax: (210) 567-4423

Email: j p u g h@ v e rd i c t . u t h s c s a . e d u

Research efforts at this Center aim to link

research evidence with clinical practice by summarizing and translating the evidence into useful

documents for various consumers, such as

providers, patients, managers and policymakers.
Employee Education System 1 7

The Employee Education System (EES) is committed 

to providing for the learning needs of VA employees. 

EES provides a wide array of training, education, 

and other resources to support the development of VA

employees. Many EES programs are designed to support

organizational change efforts.

Two examples of EES activities that support organizational

change are listed below:

Creating the Future Primer:

This online primer is an outcome of the work

done by the Primary Managed Care Task Force of

the Employee Education System (EES), charged

with examining the future of primary care within

VHA. The online primer is available on the VHA

intranet at http://vaww.sites.lrn.va.gov/futures

High Performance Development Model

The High Performance Development Model 

is the Department of Veterans Affairs model 

for leadership during change. The HPDM helps 

focus VHA efforts to develop a highly skilled 

workforce for the 21st century, and to develop 

a continuous supply of skilled leaders committed

to VA’s mission. Additional information is 

available on the VHA intranet at:

http://vaww.va.gov/hpdm 

or by contacting: 

Kathryn Young - youngkat@lrn.va.gov

Bunny Huller - hullermar@lrn.va.gov 

EES Cleveland Center, Brecksville OH 

Telephone: (440) 526-3030 Ext. 6630 

Fax: (440) 838-6034

Many of the resources available through EES are listed on

the EES intranet web page at http://vaww.ees.lrn.va.gov/.

For more information on learning activities, products

and services available to VA employees through the

Employee Education System contact the Education Service

Representative (ESR) assigned to your VISN. A list of

ESRs with contact information is provided on the 

EES web page at http://vaww.ees.lrn.va.gov/Resources/

VALU_STAFF/ESRLIST.vep

VHA/Institute for Healthcare Improvement

Collaboration

Through the Chief Network Director’s Office, 

V H A is working with the Institute for Health Care

Improvement (IHI) on quality improvement and

change initiatives. IHI is an independent, nonprofit organization working to accelerate health

care improvement in the United States, Canada

and Europe. IHI works with health care organizations to develop and implement programs to 

promote better clinical outcomes, reduced costs

that do not compromise quality, an easier-to-use

health care system, and improved satisfaction 

for patients and communities. 

V H A is working with IHI utilizing their

B re a k t h r o u g h Series methodology of trial and

learning to address a number of areas including

reducing VA delays and waiting times and reducing adverse drug events. The collaborative is based

on the premise that small tests of change in local

settings are most effective at promoting internal

innovation. If these tests are successful, the results

can be used to spread change and improvement 

to other sites. This approach helps to minimize 

fear of failure by allowing people to experiment

on small-scale projects initially. In addition, 

it encourages participants to learn from their

mistakes as well as from their successes.

For more information about IHI, see their web

site: http://www.ihi.org
Office of Quality and Performance

The Office of Quality and Performance (OQP)

provides staff support and liaison to the Offices 

of the Under Secretary for Health and Network

Directors on matters involving performance and

organizational improvement. OQP has several 

initiatives that support the VHA’s commitment to

continuous quality improvement and drive for

organizational change including: 1) a Pe r f o r m a n c e

Measurement Program that is based on comparing

performance in five domains of value -- quality 

of care, functionality, access to care, satisfaction

of care delivery, and cost of care; 2) development

and administration of Patient Satisfaction Surveys

for different patient populations such as inpatients, outpatients, spinal cord injury patients,

and prosthetic and sensory aids recipients; 

3) a functional survey that measures quality of life

over time; 4) development of data collection 

and reporting methodologies; and 5) coordination of accreditation from external agencies. 

OQP ensures the delivery of health care value as

defined by price/cost, quality, access, functional

status, and customer satisfaction. Contacts in 

this office include:

Jonathan Perlin, MD, PhD, MSHA

Chief, Office of Quality and Performance 

Telephone: (202) 273-8936

Fax: (202) 273-9030

Scott Beck, ME 

Executive Assistant

Telephone: (202) 273-8327

Fax: (202) 273-9030 

Stanlie Daniels, RN 

Director, Performance Measurement Program

Telephone: (202) 273-8316

Fax: (202) 263-9030

Debby Walder, RN 

CPG and EPRP Manager

Telephone: (202) 273-8336

Fax: (202) 273-9030 

Eileen Ciesco 

Director, National Customer Feedback Center

Telephone: (919) 993-3035

Fax: (919) 993-3053

Patricia O’Bryant 

Accreditation Manager

Telephone: (202) 273-8334

Fax: (202) 273-9030

Other Government Resources

A variety of other government agencies provide information or services to support organizational change efforts.

The following list provides a starting point for obtaining

information about available programs and resources 

in several federal agencies.

NASA Headquarters Library

• Organizational Change Resource List

h t t p : / / w w w . h q . n a s a . g o v / o f f i c e / h q l i b ra r y / p p m /

p p m 1 1 . h t m

• Index to Program/Project Management Resources

h t t p : / / w w w . h q . n a s a . g o v / o f f i c e / h q l i b ra r y / p p m /

p p m b i b . h t m

U.S. Army Total Army Quality Program

• Leading Change: Links to other information

resources

h t t p : / / w w w . h q d a . a r m y . m i l / l e a d i n g c h a n g e /

U.S. Office of Personnel Management

• Organizational Change and Performance

Improvement Services

h t t p : / / w w w . o p m . g o v / e m p l o y / h t m l / o r g _ c h a n . h t m

1 8
Non-government Resources

American Productivity and Quality Center

• Organizational Change: 

Managing the Human Side of Change

h t t p : / / w w w . a p q c . o r g / f re e

Picker Institute

The Picker Institute is a non-profit institution

working to improve the quality of health care

"through the patient’s eyes." The Picker Institute

offers a variety of products and services for health

care providers and organizations looking to develop

practical approaches to improving health care

through the eyes of the patient.

h t t p : / / w w w . p i c ke r . o r g

Online Change-related 

Reference Resources

Web Sites

Change Management Resource Library

h t t p : / /ww w . c h a n g e - m a n a g e m e n t . o r g /

Managing Change in Organizations

h t t p : / / w w w . m a p n p . o r g / l i b ra r y / o r g _ c h n g / c h n g _ m n g /

c h n g _ m n g . h t m

1 9
2 0
Appendix B: 

What reading materials are

available to provide more 

in-depth information on

change, the change process,

and the impact of change on

staff and managers?

Much is published on all aspects of change for 

all staff levels. The list below is comprehensive but 

by no means complete. These books and articles

are categorized for easily finding resources for

staff and managers. The books below are generally

available from http://www.Amazon.com or Barnes

& Noble, http://www.bn.com. Many of the listed

books as well as the journal articles are also available from the VA Library Service or Learning

Resources Service in your VISN. 

VA Publications Relevant to the 

Change Process:

Transition Watch 

A quarterly newsletter monitoring three VHA

change research projects: facility integrations,

quality improvement, and service lines implementation. Volumes 1, 2, 3, 1997 to the present 

are available in print and online:

http://www.va.gov/resdev/prt/category.htm#news

A Guidebook for VHA Medical Facility Integration

Published in April 1998, this guide was sent to 

all networks. It contains an overview of the five

phases of facility integration with appendices 

of useful integration documents. Available from

the VA Employee Education Service in St. Louis,

(314) 894-5742.

VHA's Strategic Planning Documents

http://vaww.va.gov/vhareorg/ This VA Intranet 

web-based resource pulls together key VHA

change documents and publications: VHA 

Re-engineering: selected results in brief; Journey

of change II, July 1998; VISN strategic submissions 1999-2003; Summary of network strategic

planning information 1999-2003; Network

strategic plan summary 1998-2002; Journey of

change I, April 1997; Maintaining capacity to

provide for the specialized treatment & rehabilitative needs of disabled veterans, June 1999; 

2 1
A guide book for VHA medical facility integration, April 1998; Health care, not hospitals:

transforming the Veterans Health Administration

– Dr. Kenneth Kizer, former Under Secretary for

Health; VHA’s prescription for change & appendices; Vision for change – reorganization plan.

Looking Ahead: Creating the Future. 

An introduction to the development of scenarios

for use in organizational planning. This online

primer grew out of work done by the Primary

Managed Care Task Force of the Employee

Education System (EES) charged with examining

the future of primary care within VHA. The task

force learned the importance of scenario building

in articulating an organizational vision and strategic planning. This methodology offers a means 

to identify and refine issues and tre n d s i m p o r t a n t

to health care. http://vaww.sites.lrn.va.gov/futures/

default.asp

Books for Everyone Involved in the 

Change Process:

Campbell SM. From chaos to confidence: survival strategies

for the new workplace. Phoenix: Fireside; 1996. A

practical guide to thriving in the changing workplace of the nineties offers six core "meta-skills"

and emphasizes the importance of participating in

the change process instead of trying to control it.

Fisher R, Sharp A, Richardson J. Getting it done:

how to lead when you're not in charge. New York: Harper

Business; 1998. Does it seem that good ideas go

unnoticed? That meetings are a waste of time?

Roger Fisher, author of Getting to yes, and Alan

Sharp tackle the inertia that afflicts many groups.

The authors describe the idea of lateral leadership

as a means of breaking apart the logjams that

inhibit effective collaboration in organizations.

This is a practical guide to solving common workplace woes, relieving the frustrations many of us

experience everyday and at the same time helping

us to stand out as leaders.

Galpin TJ. The human side of change: a practical guide 

to organization redesign. Jossey-Bass Business &

Management Series. San Francisco: Jossey-Bass

Publishers; 1996. Over 1800 books a year are

published with the word change in the title.

Galpin concentrates on the soft side–the human

element. What are the ways to get management to

buy into the process? How about the grass roots–

frontline employees and their supervisors? 

How best to act like a coach? What are the parameters for effective goal setting? These questions

and others are answered in a series of chapters

designed not to focus on the nine-stage change

process but on the behaviors needed to effect

those changes: forming teams, developing leadership, measuring performance, providing feedback, and so on. Each in turn zeroes in on different guidelines; coaches, for instance, need to

adopt a non-critical, positive, and empathic

approach.

Giovagnoli M. Angels in the workplace: stories and inspirations for creating a new world of work. San Francisco:

Jossey-Bass Publishers; 1998. Giovagnoli shows

readers that there are practical, powerful things 

we can all do daily to make a difference in our

changing workplaces. A moving book that

describes heroes and their stories providing tips

for changing work environments by changing 

attitudes and behaviors in simple ways.

Gladwell M. The tipping point: how little things can make 

a big difference. New York: Little Brown & Company;

2000. This book is about change--about how 

the smallest things can induce very big changes.

"The best way to understand the dramatic 

of unknown books into bestsellers, or the rise 

of teenage smoking, or the phenomena of word

of mouth or any number of the other mysterious

changes that mark everyday life," writes Malcolm

Gladwell, "is to think of them as epidemics. 

Ideas and products and messages and behaviors

spread just like viruses do." Although anyone

familiar with the theory of memetics will recognize

this concept, Gladwell's The tipping point has quite 

a few interesting twists on the subject.

Hall DT. The career is dead - long live the career: 

a relational approach to careers. Jossey-Bass Business &

Management Series. San Francisco: Jossey-Bass

Publishers; 1996. The career is dead redefines

"career" as a series of lifelong work experiences

and personal learnings, making career security 

the responsibility of the individual. Fourteen

essays present views on new organizational forms,

career development, secure base relationships 

at work, growth-enhancing relationships outside

work, career issues for single adults without 

children, the value of diversity, and career development for older workers.

Heyman R. Why didn't you say that in the first place? 

How to be understood at work. San Francisco: Jossey-Bass;

1994. Misunderstanding at work seems to be 

business as usual, yet nothing is more unproductive, costly, or frustrating. It frays tempers, 

2 2
saps energy, and causes errors, delays, and even

lawsuits. Heyman offers a path to clear communication by demonstrating how we can always reach

full mutual understanding with others by using

the power of plain talk in a systematic way. In this

down-to-earth book, he explains why creating

understanding is such a challenge: we can only

understand each other by interpreting what we

hear or read and no two people interpret the same

words in exactly the same way. The success or 

failure of our communication depends largely on

us, and Heyman shows how we can all make a 

difference. Heyman offers step-by-step methods

for using strategic talk to create shared contexts

for understanding and clear communication.

Sample conversations, stories, examples, and

checklists show how misunderstanding can be prevented when we understand the ambiguities of

language. Forget about stereotypes and use strategic talk to communicate. Learn to systematically

use questions, examples, and paraphrasing in our

everyday talk; and build a culture that encourages

people to say, without fear, "I don't understand."

Why didn't you say that in the first place? provides a practical guide for speaking and writing to be understood--the first time!

Johnson S. Who moved my cheese? An amazing way to 

deal with change in your work and in your life. New York:

Putnam Publishing Group; 1998. Change can 

be a blessing or a curse, depending on your 

perspective. The message of Who Moved My Cheese?

is that all can come to see it as a blessing if they

understand the nature of cheese and the role 

it plays in their lives. Who Moved My Cheese? is a

parable that takes place in a maze. Four beings 

live in that maze: Sniff and Scurry are mice –

non-analytical and non-judgmental, they just

want cheese and are willing to do whatever it takes

to get it. Hem and Haw are "little people,"

mouse-size humans who have an entirely different

relationship with cheese. It's not just sustenance

to them; it's their self-image. Their lives and

belief systems are built around the cheese they've

found. Most of us reading the story will see the

cheese as something related to our livelihoods –

our jobs, our career paths, the industries we work

in--although it can stand for anything, from

health to relationships. The point of the story is

that we have to be alert to changes in the cheese,

and be prepared to go running off in search 

of new sources of cheese when the cheese we have

runs out.

Kotter JP. Leading change. Cambridge: Harvard

Business School Press; 1996: 187 Pages. Harvard

Business School professor Kotter (A Force for

Change) breaks from the mold of M.B.A. jargonfilled texts to produce a truly accessible, clear and

visionary guide to the business world's buzzword

for the late '90s--change. In this manual, Kotter

emphasizes a comprehensive eight-step framework

that can be followed by executives at all levels.

Kotter advises those who would implement change

to foster a sense of urgency within the organization. "A higher rate of urgency does not imply

ever-present panic, anxiety, or fear. It means 

a state in which complacency is virtually absent."

Twenty-first century business change must 

overcome overmanaged and underled cultures.

"Because management deals mostly with the status

quo and leadership deals mostly with change, 

in the next century we are going to have to try to

become much more skilled at creating leaders."

Kotter also identifies pitfalls to be avoided, like

"big egos and snakes" or personalities that can

undermine a successful change effort. Kotter

convincingly argues for the promotion and recognition of teams rather than individuals. He aptly

concludes with an emphasis on lifelong learning.

"In an ever changing world, you never learn 

it all, even if you keep growing into your '90s."

Larkin S, Larkin TJ. Communicating change: how to

win employee support for new business directions. New York:

McGraw-Hill; 1994. When a company decides 

to make a major organizational change–whether 

it's a new emphasis on customer service, quality 

management, restructuring or downsizing–

managers must get the message through to frontline employees, and enlist their support, orthe

changes will create more turmoil than progress.

Written for busy managers at all levels, this book

offers specific prescriptions for effecting successful change centered around three guiding principles: conveying the message through supervisors,

communicating face-to-face, and making the

changes relevant to each work area. In addition, 

a variety of helpful forms, checklists, sample 

communications, and surveys help managers to

quickly put the principles into action.

Noer DM. Healing the wounds: overcoming the trauma of

layoffs and revitalizing downsized organizations. Jossey-Bass

Management Series. San Francisco: Jossey-Bass

Publishers; 1995. Healing the wounds provides 

an antidote to the wide-spread malaise on the

American business scene left in the wake of 

massive layoffs. David Noer provides executives,

human resource professionals, managers, and

2 3
consultants with an original model and clear

guidelines for revitalizing downsized organizations. Noer examines the effects of layoffs on 

survivors and their organizations, offering strategies to relieve the paralysis of layoff survivor 

sickness and foster personal and organizational

growth. He provides practical guidelines for 

revitalizing a downsized organization and gives

layoff survivors specific coping mechanisms to

help understand, survive, and transcend the toxic

effects of the experience.

Noer DM. Breaking free: a prescription for personal and

organizational change. Jossey-Bass Business &

Management Series. San Francisco: Jossey-Bass

Publishers; 1996. David Noer's methods for tre a t i n g

"survivor sickness syndrome" have made him the

expert on the psychological effects of downsizing. As

major organizations continue the trend of massive

layoffs, Noer focuses on the employees struggling

with the new rules of today's workplace. Bre a k i n g

f ree encourages all of us to let go of the past and

look to our self-directed future with excitement.

Stone D, Patton B, Heen S. Difficult conversations:

how to discuss what matters most. New York: Viking

Press; 1999. This latest how-to from the Harvard

Negotiation Project will appeal to readers who've

endured hostile, annoying, and utterly unproductive talks with family members, bosses, coworkers,

neighbors and acquaintances. The authors' 

central insight is that tough conversations are

difficult because they blend three layers: each

party's version of "what happened"; each party's

feelings; and the identity issues the subject raises

for each party. By sorting out these three layers

and adopting a curious, "learning" approach, 

one can take on sensitive subjects while strengthening rather than threatening long-term relationships. The authors draw on their background 

in negotiation, mediation and law, and also on

"organizational behavior; cognitive, clientcentered, and family therapies; social psychology;

communication theory; and the growing body 

of work around the idea of ‘dialogue.’" These 

talented communicators blend a daunting array 

of disciplines into highly readable and practical

advice–advice selected by both The Literary Guild

and the Doubleday Book Club for their readers.

What is a difficult conversation? Asking for a

raise. Ending a relationship. Saying "no" to your

boss or spouse. Confronting disrespectful behavior. Apologizing. Conversations we dread, and

often handle clumsily as a result, are part of all

our lives: in boardrooms and family rooms, across

the negotiation table and the dinner table. 

Now, Difficult conversations teaches us how to handle

these dialogues with more success and less anxiety.

Articles on Change for Supervisors and Staff:

Abernathy DJ. A conversation with Rosabeth

Moss Kanter about leaders. Training & Development

1998; 52(7):44-46.

Aiken LH, Sochalski J, Lake ET. Studying outcomes of organizational change in health services.

Medical Care 1997; 35(11 Suppl):NS6-18.

Anonymous. Change: overturning myths and

blocks. OR Manager 1998; 14(5):31-32.

Anonymous. Clerical, clinical changes increase

nursing efficiency. Patient-Focused Care and Satisfaction

1998; 6(2):19-21.

Anonymous. On leading change: a conversation

with John P. Kotter. Strategy & Leadership 1997;

25(1):18-23.

Anonymous. Staff narratives perpetuate patientfocused values in face of rapid change. PatientFocused Care and Satisfaction 1998; 6(8):89-93.

Backer TE. Managing the human side of change

in VA's transformation. Hospital & Health Services

Administration 1997; 42(3):433-459.

Baker R. Avedis Donabedian: an interview. 

Quality in Health Care 1993; 240-46.

Berwick D. Spreading innovation. Quality

Connection 1997; 6(1):1-3.

Boever S. Helping your staff become more receptive to change. Balance 1999; 3(3):10-12.

Bonalumi N, Fisher K. Health care change:

challenge for nurse administrators. Nursing

Administration Quarterly 1999; 23(2):69-73.

Brown G. Interview with Avedis Donabedian,

M.D. American Journal of Medical Quality 1996;

11(4):167-172.

Cameron G. Transformational leadership : 

a strategy for organizational change. Journal of

Nursing Administration 1998; 28(10):3.

Ciarcia PM. Nurses' reactions to change. Nursing

Management 1998; 29(6):48p-48r.

Darby M. Driving fear out of the workplace. The

Quality Letter for Healthcare Leaders 1997; 9(2):13-16.

2 4
Deems RS. Change: a new look at worn-out paradigms. Human Resources Professional 1998; 11(4):6-9.

Dowd SB, Shearer R, Davidhizar R. Helping

staff cope with change. Hospital Materiel Management

Quarterly 1998; 20(1):23-28.

Drucker PF. Managing oneself. Harvard Business

Review 1999; 77(2):65-74.

Eliopoulos C. Teaching the snail to fly: affecting

change in long-term care. Director 1997; 5(4):

141-142, 145-147.

Flarey DL. Management restructuring and care

delivery redesign: dealing effectively with fear.

Seminars for Nurse Managers 1998; 6(2):56-58.

Freer J, Jackson S. Using the business excellence

model to effectively manage change within clinical

support services. Health Manpower Management 1998;

24(2-3):76-81.

Gardner JR. The evolution of change: from

nurse auditor to clinical reimbursement specialist.

Best Practices and Benchmarking in Healthcare 1996;

1(2):101-106.

Giunipero LC. Organizational change and survival skills for materiel managers. Hospital Materiel

Management Quarterly 1997; 18(3):36-44.

Greene J. How does your CEO spell "relief"?

Leadership survey shows how execs are dealing

with change. Trustee 1997; 50(8):8-14.

Grindel CG, Bayley E, Kingston MB, Tuck

MB, Wood L, Bryan Y. Nurses preparing for

change: their needs and concerns. Medsurg Nursing

1997; 6(5):278-283, 286-277.

Harari O. Leading change from the middle.

Management Review 1999; 88(2):29-32.

Hardison CD. Readiness, action, and resolve for

change: do health care leaders have what it takes?

Quality Management in Health Care 1998; 6(2):44-51.

Kanter RM. (1999). The enduring skills of change leaders.

[Web Site]. Available: http://www.pfdf.org/

leaderbooks/L2L/summer99/kanter.html,

[January 15, 2000].

Kelly DL. Reframing beliefs about work and

change processes in redesigning laboratory 

services. Joint Commission Journal on Quality Improvement

1998; 24(3):154-167.

Kerfoot K. The change leader. AANA Journal 1996;

64(6):590-592.

Knox S, Irving JA. Nurse manager perceptions 

of healthcare executive behaviors during organizational change. Journal of Nursing Administration 1997;

27(11): 33-39.

Lesic SA. Using instrumental leadership to 

manage change. Radiology Management 1999; 21(3):

44-52; quiz 53-46.

Morrison L. Explosive change -and opportunityin the VA system. Journal of the American Geriatrics

Society 1997; 45(3):367-368.

O'Connell C. A culture of change or a change of

culture? Nursing Administration Quarterly 1999;

23(2):65-68.

O'Neil E. When a leader is confronted with

change. Hospital Practice (Office Edition) 1998;

33(12):95-96.

Porter-O'Grady T. Technology demands quickchange nursing roles. Nursing Management 1999;

30(5):7.

Redmond G, Riggleman J, Sorrell JM, Zerull

L. Creative winds of change: nurses collaborating

for quality outcomes. Nursing Administration Quarterly

1999; 23(2):55-64.

Schonberger RJ. Customer-focused service 

management: driving change up the hierarchy and

outward. Hospital Materiel Management Quarterly 1998;

19(3):35-41.

Scott FF, Levitsky ME. Meeting the needs of

patients and staff in an era of change. Caring 1997;

16(10):66-68, 70.

Sheaffer CM, Phillips CY, Donlevy JA,

Pietruch BL. Continuing education as a facilitator of change: implementing a new nursing delivery model. Journal of Continuing Education in Nursing

1998; 29(1):35-39.

Umiker W. How to prevent and cope with resistance to change. Health Care Supervisor 1997;

15(4):35-41.

Valentine NM. Quality measures essential to the

transformation of the Veterans Health Administration: implications for nurses as co-creators 

of change. Nursing Administration Quarterly 1998;

22(4):76-87.

Vander Wilt B, Overbeck B, Fox R. Helping staff

cope with change. Quality Letter for Healthcare Leaders

1998; 10(4):13-17.

Wilson P, et al. On the evidence. Managing

change. Health Service Journal 1999; 109(5643):34-35.

2 5
Books on Change, Leadership, 

and Organizational Communication:

Barbour GL. Redefining a Public Health System: How the

Veterans Health Administration Improved Quality Measurement

San Francisco: Jossey-Bass; 1996: 196 Pages.

Barbour GL, Lussier RR, Thomale J, R. W.,

Lerner JA. Quality in the Veterans Health Administration:

Lessons from the People Who Changed the System.

San Franscisco: Jossey-Bass; 1996: 301 Pages.

Barger NJ, Kirby LK. The Challenge of Change in

Organizations: Helping Employees Thrive in the New Frontier.

Palo Alto: Davies-Black Publishing; 1995: 

283 Pages.

Beckhard R, Harris RT. Organizational Transitions:

Managing Complex Change. Addison-Wesley Series 

on Organization Development. Reading:

Addison-Wesley Publishers; 1987: 117 Pages.

Berger LA, Sikora MJ. The Change Management

Handbook: a Road Map to Corporate Transformation.

Toronto: Irwin Professional Publishers; 1993:

489 Pages.

Bridges W. Managing Transitions, Making the Most of

Change. Reading, MA: Perseus; 1991: 130 Pages.

Caplan G, Teese M. Survivors: How to Keep Your Best

People on Board after Downsizing. Palo Alto: Consulting

Psychologists Press; 1997: 288 Pages.

D'Aprix R. Communicating for Change. The Jossey-Bas

Management Series. San Francisco: Jossey-Bass;

1996: 158 Pages.

Ingraham P. Transforming Governments: Lessons from 

the Reinvention Laboratories. Jossey-Bass Nonprofit 

& Public Management Series. San Francisco:

Jossey-Bass, Inc; 1997: 256 Pages.

Kohles MK, Baker WGJ, Donaho BA.

Transformational Leadership: Renewing Fundamental Values 

and Achieving New Relationships in Health Care. Chicago:

American Hospital Publishing, Inc; 1995: 275

Pages.

Kouzes JM, Posner BZ. Encouraging the Heart: a

Leader's Guide to Rewarding and Recognizing Others. 

Jossey-Bass Business & Management Series. 

San Francisco: Jossey-Bass Publishers; 1999: 

201 Pages.

Kouzes JM, Posner BZ, Peters T. The Leadership

Challenge: How to Keep Getting Extraordinary Things Done in

Organizations. Jossey-Bass Management Series. 

San Francisco: Jossey-Bass Publishers; 1996: 

405 Pages.

Kouzes JM, Posner BZ. Credibility: How Leaders Gain

and Lose It, Why People Demand It. Jossey-Bass

Management Series. San Francisco: Jossey-Bass

Publishers; 1995: 334 Pages.

Levesque P, Marshall DR. Breakaway Planning: 

8 Big Questions to Guide Organizational Change. New York:

AMACOM; 1998: 272 Pages.

Maira A. The Accelerating Organization: Embracing the

Human Face of Change. New York: McGraw-Hill; 1996.

Maurer R. Beyond the Wall of Resistance: Unconventional

Strategies that Build Support for Change. Austin: Bard

Press; 1996: 208 Pages.

Nevis EC, Lancourt J, Vassallo HC. Intentional

Revolutions: a Seven Point Strategy for Transforming

Organizations. Jossey-Bass Business and Management

Series. San Francisco: Jossey-Bass Publishers;

1996:.

Oakley E, Krug D. Enlightened Leadership. Getting to the

Heart of Change. New York: Fi reside; 1991: 265 Pa g e s .

O'Toole J. Leading Change: the Argument for Values-Based

Leadership. New York: Ballantine; 1996: 282 Pages.

Pasmore WA. Creating Strategic Change: Designing 

the Flexible, High-performing Organization. New York: 

John Wiley & Sons; 1994: 284 Pages.

Peters T. Thriving on Chaos: Handbook for a Management

Revolution. New York: Knopf; 1987: 561 Pages.

Phillips JJ, Holton EF. In Action: Leading Organizational

C h a n g e . Alexandria, VA: American Society for

Training and Development; 1997: 260 Pa g e s .

Robinson JC. The Corporate Practice of Medicine:

Competition and Innovation in Health Care.

California/Milbank Series on Health & the

Public. Los Angeles: University of California

Press; 1999: 306 Pages.

Schneider B, Bowen DE. Winning the Service Game.

Boston: Harvard Business School Press; 1995:

295 Pages.

Senge PM. The Fifth Discipline: the Art and Practice of the

Learning Organization. New York: Doubleday; 1990:

424 Pages.

Tushman ML, O'Reilly CA. Winning through

Innovation: a Practical Guide to Leading Organizational Change

and Renewal. Cambridge: Harvard Business School

Press; 1997: 304 Pages.

Woodward H, Buchholz S, Hess K. Aftershock:

Helping People through Corporate Change. New York: John

Wiley & Sons; 1987: 256 Pages.

.

s

2 6
Articles on Change Leadership, 

Change Research and Evaluation: 

Ackoff RL. Transformational leadership. 

Strategy & Leadership 1999; 27(1):20-26. 

Aiken LH, Sochalski J, Lake ET. Studying outcomes of organizational change in health services.

Medical Care 1997; 35(11 Suppl):NS6-18. 

Anderson S, et al. Managing organizational 

challenge and change: closing an inpatient unit.

Nursing Administration Quarterly 1998; 23(1):15-23. 

Appelbaum SH, St-Pierre N, Glavas W. S t ra t e g i c

organizational change: the role of leadership.

Management Decision 1998; 36(5-6):289-292. 

Axler H, Donner GJ, Underwood E, Van de

Bogart L. Planning for complex change: insights

from the Metro Toronto District Health Council

hospital restructuring project. Healthcare Management

Forum 1997; 10(2):33-34. 

Barth TJ, Bartenstein J. Fostering a learning,

innovative government: the role of academicpractitioner collaboration. Public Manager 1998;

27(1):21-26. 

Berwick DM. A primer on leading the improvement of systems. British Medical Journal 1996;

312(7031):619-622. 

Berwick DM. Crossing the boundary: changing

mental models in the service of improvement.

International Journal for Quality in Health Care 1998;

10(5):435-444. 

Berwick DM. Developing and testing changes in

delivery of care. Annals of Internal Medicine 1998;

128(8):651-656. 

Boland P. The role of reengineering in health

c a re delivery. Managed Care Quarterly 1996; 4(4):1-11.

Bolman LG, Deal TE. Four steps to keeping

change efforts heading in the right direction.

Journal for Quality & Participation 1999; 22(3):6-11. 

Charns MP. Organization and design of integrated delivery systems. Hospital & Health Services

Administration 1997; 42(3):411-432. 

Cleverley WO. The health care industry: in 

evolution or revolution? Journal of Health Care Finance

1999; 25(4):2-14. 

Coyle-Shapiro JAM. Employee participation 

and assessment of an organizational change. Journal

of Applied Behavioral Science 1999; 35(4):439-456. 

Dent EB, Goldberg SG. Challenging "resistance

to change." Journal of Applied Behavioral Science 1999;

35(1):25-41. 

Donabedian A. Continuity and change in the

quest for quality. Clinical Performance and Quality Health

Care 1993; 1(1):9-16. 

Donabedian A. The effectiveness of quality assurance. International Journal for Quality in Health Care 1996;

8(4):401-407. 

Donlon JP, Alberthal L, Disney A, Donald J,

Adams W, Ruettgers M, et al. In search of the

new change leader. Chief Executive (US)

1997;(129):64-74. 

Finnie B, Norris M. On leading change:

a conversation with John P. Kotter. Strategy &

Leadership 1997; 25(1):18-24. 

Gilles RR, Shortell SM, Young GJ. Best 

practices in managing organized delivery systems.

Hospital & Health Services Administration 1997;

42(3):299-321. 

Gilman SC, Lammers JC. Tool use and team

success in continuous quality improvement: 

are all tools created equal? Quality Management in

Health Care 1995; 4(1):56-61. 

Goldsmith JC. Reconsidering integration 

strategies: an interview with Jeff C. Goldsmith.

Healthcare Financial Management 1998; 52(4):32-34, 36.

Halverson PK, et al. Strategic alliances in

healthcare: opportunities for the Veterans Affairs

healthcare system. Hospital & Health Services

Administration 1997; 42(3):383-410. 

Harari O. The spirit of leadership. Management

Review 1999; 88(4):33-36. 

Harari O. Why do leaders avoid change?

Management Review 1999; 88(3):35-38. 

Harris M. A breakthrough series update: closing 

the gap between what we know and what we do. 

The Quality Letter for Healthcare Leaders 1997; 9(2):2-12. 

Kane DA. Innovation and customer focus drive 

successful ambulatory care programs. Journal 

of Ambulatory Care Management 1999; 22(1):50-57. 

Kezsbom DS. On becoming a "change master":

change management for creating innovative, 

competitive environments. Transactions of AACE

International 1997;161-163. 

2 7
Tushman ML. Winning through innovation.

Strategy & Leadership 1997; 25(4):14-19. 

Vestal KW, et al. Organizational culture: 

the critical link between strategy and results.

Hospital & Health Services Administration 1997;

42(3):339-365. 

West TD. Comparing change readiness, quality

improvement, and cost management. Journal of

Health Care Finance 1998; 25(1):46-58. 

Wilson P, Sowden A, Watt I. On the evidence.

Managing change. Health Services Journal 1999;

109(5643):34-35. 

Youngblood MD. Leadership at the edge 

of chaos: from control to creativity. Strategy &

Leadership 1997; 25(5):8-15. 

2 8 Kotnour T, Barton S, Jennings J, Bridges RD,

Jr. Understanding and leading large-scale change

at the Kennedy Space Center. Engineering Management

Journal: EMJ 1998; 10(2):17-21. 

Kotter JP. Leading by vision and strategy. Executive

Excellence 1997; 14(10):15-16. 

Lammers JC, Cretin S, Gilman S, Calingo E.

Total quality management in hospitals: the 

contributions of commitment, quality councils,

teams, budgets, and training to perceived

improvement at Veterans Health Administration

Hospitals. Medical Care 1996; 34(5):463-478. 

Lee S-YD, Alexander JA. Managing hospitals in

turbulent times: do organizational changes

improve hospital survival? Health Services Research

1999; 34(4):923-946. 

Markides C. Strategic innovation in established

companies. Sloan Management Review 1998; 39(3):

31-43. 

Maurer R. From resistance to support. Executive

Excellence 1998; 15(8):16. 

Maurer R. Is it resistance, or isn't it? Manage

1998; 50(1):28-29. 

Mitchell PH, Shortell SM. Adverse outcomes

and variations in organization of care delivery.

Medical Care 1997; 35(11 Suppl):NS19-32. 

Nolan TW, Berwick DM. Integration from the

viewpoint of improvement. Health System Leader

1995; 2(1):14-19. 

Provost LP, Langley GJ. The importance of 

concepts in creativity and improvement. Quality

Progress 1998; 31(3):31-38. 

Russo EM. Change leadership. Executive Excellence

1997; 14(10):12. 

Sanchez R, Heene A. Managing for an uncertain

future: a systems view of strategic organizational

change. International Studies of Management & Organization

1997; 27(2):21-42. 

Schneider DM, Goldwasser C. Be a model leader

of change. Management Review 1998; 87(3):41-45. 

Senge P. Learning leaders. Executive Excellence 1999;

16(11):12-13. 

Sung T. Quality and the 21st Century leader.

Public Manager 1997; 26(2):35-39. 

Tetenbaum TJ. Shifting paradigms: from Newton 

to chaos. Organizational Dynamics 1998; 26(4):21-33. 
Appendix C: 

A glossary of 

organizational change 

terms

2 9

Benchmarking: A process that quantitatively

assesses an organization's performance thereby

establishing a reference point by which to 

compare operations or procedures within the

same organization, with competitors, or with other

organizations that can be measured or rated in 

the same way. 

Best Practices: The most productive or advanta-

geous methods for accomplishing a task(s), usually

determined by benchmarking.

Champion: A recognized leader who motivates

and encourages by setting an example others may

follow, and by actively promoting the group's

goals within the organization.

Change Agent: An individual who can successfully

begin and maintain the change process through

his/her ability to initiate the new direction 

or goal. Change Agents respond to and dissipate

adverse reactions as well as keep a positive attitude

about the benefits and necessity of the change.

Change Management: A consistent set of 

techniques or strategies aiding and/or directing

the progress, evolution, or policy of the design

and implementation of the change process within

an organization.

Communication Strategy: A skillfully planned

system of giving or exchanging information about

the change in accessible formats and at regular

intervals.

Communication Vehicles: The methods by which

information or data can be exchanged such as audio,

video, written memos or electronic mail, etc.

Continuous Improvement: Using evaluations

and feedback to regularly monitor and/or reassess

and adjust a process or operation to increase its

value to an organization.

Discontinuous Change: A sudden, drastic

process of development. Growth is toward a more

desirable or more profitable end by an extreme redesign of the system or its processes.
Dissemination: Goes beyond communicating to

actively dispersing information to targeted groups

with the goal of information utilization. 

Driving Forces: Any cause or agent (economic,

technological, social, etc.) that dominates 

conditions leading to change and that cannot be

redirected.

Evolutionary Change: A gradual, progressive

process of change. Growth is toward a more

desirable or more profitable end by continuous

improvement.

Facilitation: The act of making a process or 

discussion easier through directed communication

and/or information exchange in directed discussions. Usually a facilitator leads these discussions. 

Re-Engineering: The radical redesign of 

business processes to achieve major gains in cost,

service or time. Re-engineering answers the 

question: if we could start from scratch, how

would we do this? 

Reorganization: Examining and altering an 

organization to reconstitute it in a new form.

Resister: A person or group of people who either

actively or passively oppose the change.

Restraining Forces: Any cause or agent 

(economic, environmental, political, etc.) that

represses conditions leading to impending 

change and may reshape the direction of change.

Stakeholders: Any persons or groups affected 

by an organization’s actions. For example,

patients, employees, managers, suppliers, outside

contacts, community groups, customers, etc. 

Unfreezing the System: Acknowledging the 

need to alter an established order to allow change

to progress smoothly. 

3 0
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Organizational Change is available in electronic 

and printed formats. Additional copies may be

obtained from the sources listed below.

Electronic copies (PDF format) can be 

downloaded from the VA R&D home page on 

the world wide web. Point your browser to

http://www.va.gov/resdev/prt Faxed copies: Call (617) 278-4492. Follow the

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primer. Requesters are advised that fax transmis-

sion can take up to 30 minutes. Printed copies: Contact 

Special Projects Office (152), VA Maryland Health Care System, 

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Building 82, Room 232, Perry Point, MD 21902 Telephone: (410) 642-1092

fax: (410) 642-1095

Email: rainelle.holcomb@med.va.gov

Other primers in the series include: Primary Care in VA

Health Technology Assessment in VA

Using Outcomes to Improve Healthcare Decision Making Program Evaluation for Managers

Risk Adjustment: A Tool for Leveling the Playing Field

Clinical Practice Guidelines
Management Decision and Research Center

(152-M)

Boston VA Health Care System

150 South Huntington Avenue, Bldg 4

Boston, MA 02130-4893

Tel: (617) 278-4433 / Fax: (617) 278-4438