A model of cascading change: Successful change and improved relational coordination

Understanding how and why changes succeeds is paramount as most organizational changes fail or do not deliver the expected results (Hughes, 2011). Achieving change is particularly challenging in Professional service firms (PSF)—spanning industries such as universities, accounting, law, advertising, banking, IT, consulting, and hospitals—as this type of firm primarily depend on complex technical expertise and the knowledge of their workforce to transform inputs into outputs (Von Nordenflycht, 2010).

The PSF known to exhibit particular challenging change processes are hospitals (Heldal, 2015; Ramanujam & Rousseau, 2006) because strong professional identities and autonomy clash with managerial logics of change and efficiency (Garman, Leach, & Spector, 2006; Mintzberg, 1989; Pool, 1982; Powell & Davies, 2012; Strauss, Fagerhaugh, Suczek, & Wiener, 1997).

Another reason behind change skepticism within hospitals is that changes often produce more problems than they solve (Ackroyd, Kirkpatrick, & Walker, 2007). Thus, finding ways to manage hospital change successfully is paramount because the need to change is a basic condition to meet patient and public demands for cost efficient, safe and high quality care (Institute of Medicine, 2013).

Using a case study approach, we examine a change process in a within a large world-leading cardiology department in Denmark. The case is intriguing because post-project evaluation showed that 27 of 28 proposed improvements were completed successfully. Even more interesting is it that the project resulted in a large and significant increase in relational coordination (cf.

Gittell, 2002). Methodologically the study was based in organisational development tradition of action research (e.g. Coghlan, 2011). The first author served as consultant researcher and part of the steering group in the project and was allowed to document the project. This dual role provides a deeper understand (Eady, Drew and Smith, 2015) of the change process.

Workshops, meetings and internal document such a meeting minutes and project plans were collected. Relational coordination was measured before and after implementation using Gittell’s (2002) 7 item instrument. We argue that the successful implementation as well as improved well-being at work (relational coordination) was a direct consequence of the change process.

We have named this a ‘cascading model of change’. This a hybrid change model that incorporates elements of the top-down planned formal and the bottom-up emergent approach to change. The cascading model refer to the finding that each involved group (team leaders, surgical teams and employees in general) goes through the same Lewinian process of unfreeze, refreeze.

The cascades of change refer to the finding that the process of identifying problems, developing solutions and deciding happened through a sequence of steps. The result of one step was documented and distributed to all employees. The next group would then use the results in their work creating a chain.

This created a transparent process where employees had access to data, analysis and result. The initial process of defining the scope of the project was done by the top management team (TMT). The TMT believed productivity was not sufficient and a recent survey had shown that well-being at work was low.

However, as the top management team was uncertain of the nature of the problems and underlying causes the project started by collecting data. Surgery was observed and work diaries were distributed to collect employees’ descriptions of problems at work. 402 notes were collected from the work diaries, sorted in themes and transcribed.

The transcriptions were email to all staff to ensure transparency. Problems were identified and solutions were developed at three workshops each with a full surgical team and each lasting two days. The workshops produced 28 suggestions for change, which were distributed to all staff to ensure transparency.

All staff the participated in a deliberation process where the 28 suggestions for change were discussed and commented on. It was the decided that all 28 suggestions some related to layout, some to relations and the tone among staff and yet others related to equipment and surgical processes. The deliberation concluded that all 28 suggestions were relevant, and it was agreed by the TMT that they should be implemented.

Implementation was uneventful at the 28 suggestions was implemented over 1.5 years. We argue that the improved relational coordination was a consequence of the employee driven cascading change model. Several change proposals directly influenced working practice and the tone i.e. how staff addressed each other and for instance a change proposal directly specified that outbursts were only permitted when there was a real medical emergency.