Change Management: A Survey of Literature in View of Analysing the Advantages of ADKAR Model

Introduction

The domineering trend in business to move towards digital platforms which can provide delighting experience to the customers is now being widely accepted in healthcare as it did in other realms of business and life. National Digital Health Mission of India mandates all hospitals to go digital and subsequently share all the patient data on national portal in view of assuring healthcare to all citizens of the country irrespective of their location when in need of healthcare.¹ The political will of the government to bring forward such an initiative is a major reason why the Indian hospitals are making a quick move to digital systems. Nonetheless, one has to be mindful of the fact that the world is going digital in all sorts of business, compelling the organizations to change or perish.

It is difficult to draw individuals together in a collective effort to strive toward change; in many circumstances people reject change. Change management is a constant process of renewing an organization's direction, structure, and capabilities in order to meet the everchanging needs of internal and external consumers. Despite significant education and training in change management for healthcare leadership and management, attempts to change frequently fail, change fatigue is common, and a lack of adequate change management is identified as a major cause of failed initiatives.

Many organizations rely on a variety of change management strategies to get through the change phase and make the best use of their resources. In practice, the most often used change management models are Prosci's ADKAR model, Kotter's 8 step change model, Mckinsey 7S model, and Kurt Lewin’s change management model. A quick survey of the literature showed that ADKAR is a model widely applauded as a best suited model for change management. This study is an attempt to further explore the literature in line with this observation and to check for the contrary.

The change management model is applied at societal, organizational and individual levels. The most often used change management models are Prosci's ADKAR model, Kotter's 8 step change model, Mckinsey 7S model, and Kurt Lewin’s model.

Kurt Lewin's change management model seems to have some flaws. It is unsure about changing employee behaviour during the organizational change process. In addition, change is resisted. This resistance to change, however, can be overcome with proper planning, management, and leadership. This model does not specify how change is effected or how each stage is completed. Change is also assumed to be linear in his model; but in reality it is wavy. This model also assumed that the future state is preferable to the current one. Because the future cannot be predicted, this model is criticised for assuming it. Furthermore, it is based on a cause and effect relationship and ignores unforeseen events.²

Kotter's 8-step change model is essentially a top-down model. It is ineffective in situations where people expect a more participatory or bottom-up approach to deal with change. It is also a little mechanical. Organizations are more than just machines; they are communities of people. Even though Kotter's model is dynamic when it comes to initiating change, it appears to be frail when it comes to managing change. Its steps specifically do not provide additional details for maintaining the change.²

The McKinsey 7S model refers to the sevenkey interconnected or integrated elements of an organization, which are further subdivided into hard and soft elements. This model ignores the importance of the external environment and depicts only the most important elements in this model for explaining the interdependence of the key processes and factors within the organization. The model does not explicitly explain the concept of organizational effectiveness or performance. The model has been chastised for not providing enough empirical evidence to back up their explanation. The model is thought to be more of a static type of model.²

This study, in the light of the above mentioned reasons, is more inclined towards ADKAR model, but not a blind acceptance of the same. It is rather a critical review of literature to ascertain the primacy of the ADKAR model among the different change management models and to highlight with the support of the scholarly studies the reasons to consider other models as weaker ones.

Materials and Methods

We undertook a critical review of the available literature with the objectives: (a) to identify the application of change management model in studies from healthcare context (b) to critically analyse the success of ADKAR model for change management in healthcare settings, and (c) to analyse the various aspects in which ADKAR as a model is used for change management in hospitals.

Search Strategy

A survey was done among the most popular databases, the PubMed and Google Scholar for published materials in this line. “Change management”, “Healthcare”, “Digitalization”, “ADKAR model”, and “ADKAR model in healthcare” were used as the keywords. The search terms (Table 1) were kept as broad as possible in order to cover all possible studies. Potentially relevant studies with the aforementioned titles were chosen, and their contents were retrieved. A preliminary screening was performed based on the titles of the articles that were retrieved.

Study inclusion and exclusion criteria

Studies were searched by date of publication from 2015 to 2021. The language of articles published was filtered to English only. These full texts were then examined to determine their compliance with the following eligibility criteria: Papers published from 2015 to 2021 that reported ADKAR change management in healthcare digitalization and published in English language. Thereafter, eligible articles were selected for final analysis. The exclusion criteria included, papers published before 2015 and after 2021, published in language other than English, papers reporting change management models other than ADKAR, absence or unclear reporting change management, isolated reports and commentaries.

Results

The change management model is applied at societal, organizational and individual levels. These models provide a scientific basis for change planning, monitoring of change and assuring the desired results through effective management of the whole episode of change. They would save organizations from potential dangers of unplanned change and mitigate the risks of change. The most widely used change management models are Prosci's ADKAR model, Kotter's 8 step change model, Mckinsey 7S model, and Kurt Lewin’s model.

ADKAR Change Management Model History

The Prosci ADKAR model is one of the two foundational models of the Prosci methodology, in addition to the Prosci change Triangle (PCT) model. The word “ADKAR” is an acronym for five stages of change: Awareness, Desire, Knowledge, Ability and Resistance. The ADKAR change management model is one of the effective successful model used in many organizations and healthcare centers. This model is developed from a study of 900 organizations across 59 countries over a 14-year period, carried out by the American research organization, Prosci.³

This model, developed by Jeff Hiatt, and first published in 2003, focuses on participatory approach of dealing with change. The model is simple to learn, makes sense, and focuses on the actions and outcomes required for change.⁴

Five building blocks of ADKAR model

1. Awareness: It is the first building block of ADKAR model. The principle is to make every employee understand the need for change. The questions, Why, What, and When - regarding the process of change will be answered by this factor. Communication plays a key role in creating effective awareness.

2. Desire: This is the second building block. Cultivation of desire among the employees to take part in the change and implement change in their regular work is a vital part of change management. Organizing communication and enhancing feedback system will motivate the stakeholders to accept the change.

3. Knowledge: One of the most essential element that represents how to implement change is knowledge. This step focuses on providing knowledge on how to achieve change. Assessment of gap between current knowledge and required knowledge to implement change will help in deciding the depth and extend of training and coaching required.

4. Ability: The fourth building block in this model is Ability. It is the potential to learn new skills in order to implement change and achieve desired outcome. Focusing on the above factors can eventually enhance the intellectual capability of employees. Providing with sufficient resources and time plays a vital role in enhancing the ability to successfully implement change.

5. Reinforcement: It is the last step in this change model. It emphasizes on sustaining the implemented change. Celebrating milestones, recognition, rewards, positive feedbacks and sharing the success stories are important approaches in reinforcement of change. This will form a strong base for the future changes in an organization.

Kotter’s 8 Step Change Model

John Kotter introduced the 8 step model of change. The process of change is divided into 8 steps, such as, (A) Creating an urgency for change (B) Forming powerful guiding coalition (C) Developing a vision and strategy (D) Communicating the vision (E) Removing the obstacle (F) Creating short term wins (G) Consolidating gains (H) Anchoring change in corporate culture.⁵

McKinsey 7S Change Management Model

McKinsey framework was developed by McKinsey Consultants in the 1980s. The McKinsey 7S Model recommends seven changes for effective management which are as follows- (A) Strategy: Organizational strategy provides a solid foundation for change management plan. (B) Structure: Structure is important because it helps to define the roles which employees play within an organization such as their level of authority and what they are responsible for. (C) Systems: Organization system is about getting the job done on daily basis and also the specific procedures and protocols that has be followed for completing their tasks. (D) Style: Represents the style of leadership and decision making that is currently in place within the organization. (E) Staff: The staff involved or their capabilities. (F) Skills: Assessing the employees’ competencies and understanding their current knowledge and skills. (G) Shared values: Shared values of employees should reflect vision and mission of the organization.⁴

Lewin’s Change Management Model

Lewin’s model was named after Kurt Lewin who developed it in the 1950s. The change process is divided into three stages: (A) Unfreeze: This is Preparation stage, where the organization is prepared to accept the change. This part of the change process is the most difficult and stressful stage where a message has to be developed to show why the existing way of doing things cannot continue. In this stage, employees are not committed or certain towards the change; so it is called Unfreeze. (B) Change: This is the implementation phase, where the change is put into practice. Time and communication are the two keys to the changes occurring successfully. People need time to understand the changes, and they also need to feel highly connected to the organization throughout the transition period. (C) Refreeze: When the changes are taking shape and people have embraced the new ways of working, the organization is ready to refreeze.^5,6

Discussion

Application of ADKAR for change management in organizations is varied. We limit by referring to an exemplary report, to be brief. The difference in gender and its impact on perception towards organizational change was studied in the context of a leading banking organization in India. The authors concluded that there is no difference in the perception of male and female employee in organizational change, the results would help the firms to understand the fact that gender has no significant role in forming perceptions towards change management and accordingly formulate their future strategies.⁷

ADKAR – the best fir for healthcare

ADKAR model has proved to be very effective in healthcare where participatory approach of dealing with change is imperative, such as involving healthcare stakeholders like Doctors, Nurses and Administrative staff, in the process of organizational change to provide safe and quality health service to the patients. The main reason for selecting this model by healthcare organizations is that it reinforces the change and it is sustainability oriented.

In healthcare sector and hospitals, ADKAR model proved to be successful in implementing change management in various areas such as the readiness of nurses in using nursing Kardex in hospitals. It was investigated and was found that more than half of the nurses had readiness for using nursing Kardex in Iran.⁸

Healthcare Laboratories in Australia were undergoing a change in screening Pap tests, which will no longer be required as the test changes from being microscopically viewed to an automated test processed on an analyzer. This change required the re-evaluation of staffing and workflow, and an attempt was made to identify management initiatives and strategies that might assist staff and management with the transition whilst maintaining staff engagement and high quality standards. ADKAR model played a great role in achieving a reduction in redundancy and redeployment, benefitting all staff members, those remaining and those leaving, while providing financial benefit for the organization.⁹

Academic medical center in New York, faced a task of transitioning over a thousand clinicians into a new facility with a change in care delivery model adopting Acuity Adaptable Care in adults in-patient units. Quyen Wong described how transformational leadership and an evidence-based change management model was used to guide staff through the complexity of this transition. Change was facilitated by involving steering committee development, Town hall series, workflow focus groups, training curriculum development, and unit based team cohesion sessions. Change efforts began two years before the transition into a new building with a new care delivery model. As a result, Preliminary Hospital Consumer Assessment of Healthcare Providers and Systems survey scores for the new facility showed an overall rise in rating by 26.8% in the initial month after the move.¹⁰

Preparedness of selected healthcare professional education institutions in sub-Saharan Africa for remote teaching and learning during the COVID-19 pandemic was assessed and findings were provided to Health Education Institutions regarding the preparedness for remote teaching and learning to influence efforts related to web-based teaching and learning, which is envisaged to become the new normal in the future.¹¹ How Tlokweng land board (TLB) implemented its electronic records management program using Kotter’s model and ADKAR model was assessed, and the findings of the study revealed that communication was used as the most effective tool for managing change at TLB.¹² ADKAR and CLARC change models were utilized to guide a transition from primary to team nursing to face unprecedented patient volumes resulting from the COVID-19 outbreak.¹³

Experts are of the view that ADKAR can be a model best for digital transformation. Employees' resistance, perceptions and attitudes to change in hospital information system were examined through a change management approach and the level of usage of the change management tools and change management phases in a university hospital were examined. It was found that most resistant groups were doctors and nurses and the least resistant employees were administrative staff.¹⁴

Hospital Information System was implemented in 24 Ministry of Health (MOH) hospitals in three different regions of Saudi Arabia. Change management was conducted in three phases such as, pre-implementation, implementation, post go-live phase using hybrid change management approach combining the best models, namely ADAKR model, NHS change model and Health system approach to change. Converting the senior physicians to adapt to the new HIS was the major challenge that was successfully resolved.¹⁵ A change management prevention model was developed to address the failure of information systems project implementation in Malaysian government hospitals. This model combines elements of Lewin's model, Kotter's model, and Prosci's ADKAR model and was created to map the human and support issues of the implementation project. Authors suggested that proposed model can be used in other government hospitals of Malaysia for the implementation of other information systems.¹⁶

The children’s hospital in Europe adopted Prosci’s ADKAR change model’s bottom up approach in the journey to attain American Nursing Credentialing Centre (ANCC). This was the first hospital in Europe to achieve international accreditation by involving the nursing staff in creating a culture of excellence. The author concluded that ADKAR principles played a key role in facilitating and guiding staff engagement processes.¹⁷ A gap analysis of education and competencies of healthcare assistants in an acute surgical unit was performed by the process of audit. ADKAR change management tool was adopted in the process of two days of training, in which positive feedback was obtained from the attendees.¹⁸

From the above said, it can be derived that ADKAR is a model framework which is suitable for organizational studies in healthcare, be it for digitalization, operational issues, service delivery and even pedagogy management. The application of the said model is found in Europe, America, Australia, Africa, Middle East Asia and India. Its global acceptance is vivified in the studies considered which gives the scholastic community an open invitation to adopt this model for research and change management.

Conclusion

The change management models widely applied in organizations and healthcare industry are ADKAR model, Kotter’s model and Lewin’s model. Kurt Lewin’s model is unsure about changing employee behaviour in the process of change which is accompanied by resistance. This model lacks the tracking of the stages of change and assumes it to be linear. Kotter’s model is essentially known as top-down model, which becomes inefficient in participatory approach making the process of change mechanical. ADKAR model has been identified as the best model in comparison with other models. This model is based on the understanding that organizational change occurs when the individual attempts to change, hence ensures about changing employees’ behavior in the process of organizational change. Change is always accompanied by resistance, which is dealt by measuring the progression of change at individual level and the rate of progression. This model specifies how change is effected or how each stage is implemented by providing checklist of things that need to be done in order to manage the change. Unlike Kotter’s eight-step model, this model is non-mechanical and recognizes that it is ultimately people that facilitate change and not simply processes.

The ADKAR model has been widely used in the healthcare sector and hospitals, and it has been proven to be a successful model in the implementation of change management in several areas identifying gaps to rectify. Hence this model is best for healthcare organization where goal of change has to be identified in a participative way and all categories of employees need to be on board with change.

Conflict of Interest

Nil

Acknowledgement

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