Change Management in Healthcare

Editor's note: This text-based course is a transcript of the webinar, Change Management In Healthcare, presented by Robin Arthur, PsyD.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

After the course, participants will be able to: 

• List 3 key change management models and frameworks, distinguishing between individual, organizational, and system-level approaches in healthcare.
• Describe how to apply relevant change models to specific healthcare challenges.

• Explain the importance of psychological safety in sustaining change and the emerging role of artificial intelligence in change management in healthcare.

Introduction

I approach this work from the perspective of a psychologist who understands that our brains naturally crave comfort, and change represents the direct opposite of that safety. We currently navigate a workplace, a world, and a moment in history where change is not just a constant factor but one that is accelerating. My goal today is not to convince you to like change, as that feels unrealistic given the circumstances, but rather to help you understand the mechanics of change so you can implement it within your organization to ensure it remains a thriving entity.

Before I dive into specific models and strategies, I want to address something deeply human about this process. When any new change comes our way, whether it involves a new workflow, a new leader, a new technology, or even a new flavor of chaos, our brains do not immediately jump to the conclusion that we should optimize it. It would be wonderful if we functioned that way, but we simply do not. We react emotionally first because our nervous system responds before our logic has a chance to catch up. I see this often in my clinical practice, where even when a change is objectively positive, it can feel complicated and overwhelming for the individual. However, when change is necessary, we have to find ways to adapt. In today’s world, particularly in the healthcare sector, change occurs constantly, which is why formal change management is so vital to our collective success and well-being.

Why Change Management Matters

I view the high failure rate of change initiatives through the lens of human performance and adaptation, noting that statistics suggest about 70 percent of these projects fail not due to poor ideas, but because the human side of change was not fully addressed. In healthcare specifically, we see the same barriers repeat themselves. Many of you working in healthcare organizations will likely recognize these patterns. For example, we often operate within a hierarchical culture where decisions are made at the top and handed down with little room for dialogue. This approach immediately elevates our physiological threat response and decreases our personal buy-in. Furthermore, we frequently face staff shortages, leaving teams already stretched thin. In that environment, any new initiative feels like just one more thing to manage, even if it is ultimately designed to help us.

Poor communication is another significant barrier, characterized by unclear or inconsistent messaging that fails to address staff's genuine concerns. Finally, there is the issue of lack of sustainment. We often push hard for a few weeks or months when launching something new, only to see everyone revert to old habits once the initial pressure fades. Having worked in many healthcare organizations, I have seen the frustration this causes, leading to a mindset of here we go again. This happens when staff feel that another consultant has arrived to change something that will not stick. We are going to work today to figure out how to prevent that cycle in our own organizations. These challenges are not signs of failure; rather, they are signs that the human brain and the workplace environment were not aligned. Effective change management serves to close the gap between a great idea and successful execution, which is why choosing the right framework is so crucial.

Models

I want to take a look at some of the models now, going back to 1947, when change management first began.

Lewin’s 3-Step Model

Lewin proposed that change unfolds in three distinct stages. We begin by unfreezing, which involves preparing the system for the upcoming change. Next, we move into the implementation phase to introduce a new process or behavior. Finally, we reach the refreeze stage to stabilize the progress we have made.

While this model was foundational for change management work, I find it is often too simplistic to be fully effective in the complex and fast-paced nature of today's healthcare settings.

Stages of Change: Transtheoretical Model

I often draw on the work of Prochaska and DiClemente when navigating organizational shifts. Many of you who work in healthcare might recognize this model because we use it frequently, especially in the addiction areas. When we talk about organizational change, it is important to remember that employees are not just resistant or supportive of change. They are moving through predictable psychological stages.

We start in precontemplation, which is the stage where an individual might feel they do not see a problem. I have heard employees say they do not know why we have to do this because they do not believe change is necessary or relevant to them. Then, they move into the contemplation stage. Here, they are aware that something needs to shift, but they have not committed yet. This is where ambivalence lives. An employee might tell me they can see the benefits, but they are not sure they are ready.

Next is preparation. At this point, people are warming up to the change. They might ask questions, start gathering information, or start picturing how it will affect their work. Action is where behavior actually changes, such as trying a new workflow, logging into a new system, or learning a new process. Lastly, maintenance is one of the really important stages. This is the toughest part, and we are going to talk about why later on in this presentation. This is about sustaining the change, preventing the slide back to the old way, and building confidence through repetition.

What is powerful about this model is that it reminds us that people do not jump from zero to action. If we expect them to, we will lose them. Effective change management means meeting people where they are and helping them to move one step at a time.

Kotter's 8 Steps

John Kotter provided a definitive roadmap for large-scale organizational change through a structured eight-step process. These steps begin by creating a sense of urgency and building a guiding coalition, and culminate in the vital task of anchoring new practices within the organizational culture. In my experience, hospitals have successfully utilized this model for major transformations, such as the massive undertaking of rolling out electronic medical records or the complexities of restructuring an entire hospital system. It works well because it provides a predictable sequence for what is otherwise a chaotic human experience.

The process moves through establishing urgency, creating the guiding coalition, developing a vision and strategy, communicating the change vision, empowering broad-based action, generating short-term wins, consolidating gains to produce more change, and finally anchoring new approaches in the culture. This model emphasizes that skipping even a single step or moving too quickly through the initial phases can create a fragile foundation for the initiative as a whole.

RE-AIM Framework

I find that the RE-AIM framework asks us to think beyond adoption alone, emphasizing a more comprehensive view of how change operates in a clinical setting. This model focuses on reach within the target population, the effectiveness of the intervention, provider adoption, the quality of implementation, and long-term maintenance. I find this particularly relevant when we are scaling evidence-based interventions in healthcare, as it ensures we are not just launching a program but sustaining its impact. Something we must keep in mind when navigating change management, especially changes involving new procedures, is how these frameworks apply to our current technological shift. This is particularly true right now as we are integrating more artificial intelligence into healthcare. When we apply a framework like RE-AIM to AI, we are forced to ask whether the tool is reaching the intended patient population and whether our providers are truly adopting it into their daily workflows rather than letting it exist as a background process. We have to ensure that the implementation remains consistent and that we maintain the integrity of our care as these tools evolve.

Psychological Safety

In my years of practice, I have observed that one factor consistently predicts whether a team adapts well or struggles: psychological safety. Amy Edmondson defines psychological safety as a shared belief that the team is safe for interpersonal risk-taking. In other words, people feel they can speak up, ask questions, admit they do not know something, and push back on decisions. This is how they truly become part of the change management process.

If a team does not feel psychologically safe, they will not tell you they are confused, they will not admit they need help, and they will not share early warning signs that a change is breaking down. Instead, they will quietly struggle, which is an outcome none of us want for ourselves or our teams. Leaders play a major role in creating this environment by inviting input and asking what specific concerns their staff may have. They respond appreciatively, even if the answer is inconvenient or critical, by saying thank you for bringing that forward. This reinforces safety. They also normalize learning from mistakes because change is inherently messy. People will make errors as they learn, and leaders who frame this as part of the learning curve reduce fear and increase engagement. When a team feels safe, they move through the phases of change quickly with fewer errors and take true ownership of the process. It is one of the most powerful and underrated tools in our profession.

I often think of Maria, a seventeen-year veteran healthcare worker I encountered who felt panicked when her hospital announced a new AI-driven procedure. She was deeply upset, but fortunately, her supervisor asked what was on her mind. Instead of shutting down or pretending to feel better, Maria was able to be honest. When her supervisor responded appreciatively, thanking her for letting her know and noting that many others felt the same way, Maria felt less isolated. By normalizing the learning curve and acknowledging the difficulty, the supervisor helped Maria gain confidence. Because she felt psychologically safe, Maria was able to move from fear to curiosity, from silence to dialogue, and from avoidance to engagement. Leaders who foster this environment ensure that even the most daunting transitions go more smoothly.

PDSA / Model for Improvement

I have often relied on a model you likely recognize, as it serves as the workhorse of quality improvement in healthcare. The Plan-Do-Study-Act cycle is an iterative process that enables rapid learning and significant risk reduction. Within this framework, teams design small tests of change by first planning the intervention and then testing it. After they do the work, they analyze what happened to study the results. Finally, they act by deciding whether to adapt the current approach, adopt it fully, or abandon it entirely.

I have found that this iterative nature is what makes the model so effective in clinical environments where conditions change rapidly. It allows us to fail small and learn fast, rather than committing to a large-scale implementation before we understand the nuances of how it affects our workflow. When we use this cycle, we are essentially building a bridge of evidence, one small plank at a time.

PDSA Planning Worksheet.

I can offer a practical example of how this functions in a clinical setting. Suppose a team plans to revise a discharge checklist for ten patients. They start by doing a trial on a single unit. They then study the results, focusing on the risk of readmission at thirty days. Based on what they learn, they act by adapting the checklist to address any flaws they discover before scaling the change across the entire hospital. Starting with a small sample like this lowers the stakes and increases buy-in because the team can see the evidence of success before a full rollout.

I have observed that this approach is particularly effective because it transforms a potentially overwhelming mandate into a manageable series of experiments. It allows staff to refine their own workflows, fostering a sense of agency and reducing the friction often associated with top-down directives. By the time the final procedure is implemented, it has already been vetted by those who will use it most.

Consolidate Framework for Implementation Research (CIFR)

I want to introduce the Consolidated Framework for Implementation Research, which is one of the most widely used and modern frameworks available to us today. It provides a comprehensive lens by examining five specific domains that influence the success of any initiative. If a hospital is rolling out a new falls prevention protocol, for example, we can use these domains to map the entire landscape of that change.

The first domain is the intervention itself, which in this case is the falls prevention protocol. The inner setting involves the staff and the unit's existing culture. The outer setting includes external factors such as regulatory pressures or national safety standards. We then consider the individuals involved, specifically their personal beliefs and confidence levels regarding the new protocol. Finally, we look at the implementation process, which encompasses the actual work of piloting, training, and adjusting the strategy as we go.

The CFIR model helps leaders understand precisely why change succeeds or fails by analyzing all five of these domains. It allows us to anticipate specific barriers and identify facilitators before we are midstream in a project.

Normalization Process Theory

Normalization process theory explains how new practices become routine within organizations by emphasizing four specific constructs. This model is particularly effective at helping sustain change in complex systems through coherence, cognitive participation, collective action, and reflexive monitoring. When we look at coherence, we are asking if the change makes sense to those involved. Cognitive participation involves people becoming truly involved, while collective action is the phase in which we execute the plan. Finally, reflexive monitoring allows us to evaluate the plan and see how it is functioning in the real world.

If a large hospital system introduces a new digital sepsis early warning tool, this theory explains how that tool moves from a new requirement to a standard routine. Under coherence, the staff must understand the purpose and value of the tool. For example, nurses and physicians learn to use the tool to detect subtle changes in vitals and begin to see clearly why the tool exists and how it differs from their previous methods. In the participation phase, individuals must buy in and commit. We see this when unit champions or super users volunteer to promote the tool, physicians agree to respond to the alerts, and nurses commit to documenting assessments in a way that supports accurate alerting.

The next phase is collective action, where the team coordinates new behaviors and workflows. In our sepsis example, nurses integrate the tool into their routine vital checks and review alerts during huddles. Physicians simultaneously adjust their rounding workflows so that sepsis alerts are discussed in real time. Finally, through reflexive monitoring, the teams evaluate and refine the practice. If data after three months shows a 25 percent reduction in time to antibiotics, it reinforces the effort. Staff provide feedback that some alerts feel redundant, which allows us to refine thresholds and improve accuracy. As staff see these positive outcomes, their confidence and adoption grow, solidifying the tool as a routine process.

ADKAR

ADKAR focuses specifically on the individual’s journey through change. I find this model helpful because it reminds us that organizational change only happens when each person moves through their own psychological transition. ADKAR is an acronym for five distinct stages: awareness, desire, knowledge, ability, and reinforcement.

The process begins with awareness, where we clearly communicate why the change is necessary in the first place. This is followed by desire, which addresses the staff member's personal motivation and answers their internal question about how this shift affects them. Once that motivation is established, we move to knowledge, which involves providing the specific skills and training required to function in the new environment. However, knowing how to do something is different from ability, as demonstrated when the individual actually implements new behaviors in a real-world clinical setting. Finally, we focus on reinforcement to ensure the change is sustained over time and that people do not revert to old habits. By following this sequence, we support the person behind the professional.

Psychological Safety Updates

I cannot emphasize enough how psychological safety serves as the bedrock for every model we have discussed. This is precisely where the micro behaviors of leaders come into play. By inviting dissenting views and showing genuine appreciation for every contribution, you create an environment where staff feel secure enough to engage with new processes. When leaders frame failure as a learning opportunity rather than a personal or professional shortcoming, they remove the paralysis of fear that often stalls progress.

As we look at the landscape of organizational development today, you will notice that these models have begun to converge. Whether we are discussing the individual steps of ADKAR or the structural domains of CFIR, the core themes remain consistent. They all prioritize clear communication, the necessity of personal buy-in, and the vital importance of a supportive culture. By 2022, the field had reached a point where these frameworks looked effectively alike because they all centered on the same fundamental human needs. We have moved toward a unified understanding that successful change is less about the technical transition and more about how we support the people navigating it.

CFIR Refresh

I find that the CFIR framework was updated to integrate equity and sustainability more deeply into broader healthcare contexts. This evolution reflects our modern understanding of how interventions succeed or fail in diverse, often resource-constrained environments. We all recognize that, in healthcare, we frequently operate within those constraints, and this model accounts for those systemic pressures.

By centering equity, the framework prompts us to consider whether a change serves all patient populations or if it inadvertently widens existing disparities. It also forces us to look at sustainability from the outset, ensuring that a new protocol can be maintained long after the initial excitement and funding have faded. It remains the gold standard in implementation research for healthcare because it is robust enough to handle the messy, real-world variables we face every day in our clinics and hospitals.

Framework Evolution Timeline

I have provided a timeline (in the handout) spanning from 1947 to 2022 that illustrates the evolution of these models. Each one serves as a specific tool you can select depending on the unique requirements of your change management initiative.

I believe that having this historical context allows us to see how our field has shifted from rigid, top-down structures toward the more nuanced, human-centered approaches we use today.

Change in Yourself

Now I want to shift our focus to the personal level. We have discussed the frameworks and the organizational models, but let us look at how change functions within you. What do you feel when you hear the word change? Why is it so difficult? As a psychologist, I am fascinated by the brain and how it interacts with our daily experiences. When most people hear the word change, they instinctively pull back. Brains are emotional organs that crave stability. They want us to be calm, cool, and collected, and staying with what we have already been doing feels much safer than adjusting to the unknown. Even positive changes are difficult. Think about the stress of having children, buying a house, or starting a new job. These are choices we make voluntarily, yet they still trigger a physiological reaction because they require significant adjustment.

I find it helpful to recognize that this resistance is not a personal failing or a sign of a difficult staff member; it is a biological reality. When we ask our teams to adopt a new protocol, we are essentially asking their brains to exit a state of comfort and enter a state of high alert. If we do not acknowledge this internal friction, we risk overlooking the primary reason why even the best-designed systems can falter at the point of human implementation.

Underlying Drivers

This occurs because of what we call underlying psychological drivers. When change feels hard, it is not just the task itself that is the problem; it is the psychology beneath it. Consider a scenario in which your hospital announces new AI procedures, and staff begin to push back. They are reacting to what that change means to them personally. The first driver is an identity threat. In healthcare, our professional identity runs deep. If someone sees themselves as the expert, the helper, or the calm presence in a storm, new technology can feel like it is challenging the very core of who they are.

The second driver is the choice between curiosity and threat. Your brain asks in a split second if you should lean in or pull back. Is this tool going to help me or replace me? That immediate reaction is often a survival instinct. Then we encounter loss aversion. Humans naturally hate losing what they already have. Even if AI will eventually save time and make your job easier, the immediate fear focuses on what is being taken away. I often illustrate this by telling people I can make their lives perfectly calm for the next week, but to do so, I must take their cell phone away for those seven days. Most people immediately feel a sense of resistance. That represents loss aversion winning over a potential gain.

We also experience cognitive dissonance, which appears as a conflict between two ideas. You might think that you are very good at your job, yet you feel completely confused by a new system. That mismatch between your usual competence and your current uncertainty is uncomfortable but entirely normal. Finally, there is social comparison. None of us wants to feel like we are the last ones to adopt something new. We look around and see others who seem to be getting it faster or appearing happier, which creates internal stress and self-doubt.

It is vital to keep in mind that these five drivers are not flaws. They are fundamentally human. The more leaders understand these underlying psychological forces, the better we can guide our teams through transitions with clarity, compassion, and confidence.

Replaced Versus Irrelevant

To truly understand the impact of the psychological drivers I have described, we should return to Maria's experience. Having been in the hospital for seventeen years, she knows every workflow and prides herself on being the steady hand during chaos. When leadership announces a move toward AI-driven procedures, Maria does not immediately see it as a fascinating opportunity. Instead, she internally questions if it will make her job harder or eventually replace her. She worries about losing the efficiency she worked so hard to master. As someone who identifies as a problem solver, she fears that technology might strip her of her status as the expert in the room. This creates intense cognitive dissonance; she wonders why a seasoned veteran like herself feels so confused, while her younger colleagues seem so much more at ease.

When leaders recognize these reactions as normal, they can intervene effectively. It is important to distinguish between the fear of being replaced and the fear of being irrelevant. While AI can handle specific tasks, it cannot replicate human insight, empathy, or contextual connection.

I find that by acknowledging veterans' expertise, such as Maria's, while introducing new tools, we bridge the gap between tradition and innovation. The goal is to position the technology as a partner that enhances their professional identity rather than a competitor that erases it. When we speak to these deeper concerns directly, we move the conversation from technical resistance to emotional resilience.

How to Manage Through the Fears

In reality, the fear of irrelevance is often much deeper than the fear of job loss. When we normalize these feelings during change management, we can teach our teams a four-step process to regain their footing. First, name it; naming your anxiety tames the physiological response. Second, reframe the story; instead of asking if AI will replace you, ask how it can enhance your human capabilities. Third, stay in a learning mode, accepting that you do not need to know everything on the first day. Finally, find your irreplaceable value in your wisdom and the trust you build with others.

We see this process in action when Maria meets with her supervisor. Her leader starts by acknowledging that the change feels significant and that most people are feeling a mix of stress and curiosity. This simple naming of the emotion allows Maria to physically relax. The supervisor then reframes the situation by explaining that the technology is meant to amplify, not replace, her expertise, and emphasizes that Maria provides the meaning behind the data. By encouraging a curious mindset and highlighting Maria’s unique ability to calm a panicked family or navigate a crisis, the supervisor reinforces her relevance. Maria moves from avoidance to engagement because she knows she is still essential.

Stress Management

Beyond leadership interventions, we must also prioritize individual stress management during these transitions. If we can maintain our own equilibrium, we are much better equipped to lead others. I recommend focusing on five fundamental pillars. Proper sleep and nutrition are paramount; a rested brain handles change far better than one fueled solely by caffeine and stress. I also encourage the use of breathing techniques, such as box breathing, to calm the nervous system in real time.

Increasing physical exercise to 30 to 40 minutes, 4 times a week, can dramatically lower cortisol levels. Socialization is equally vital; when you are stressed, you should check in with your peers rather than checking out. Lastly, I often recommend simple meditative activities like coloring, which is evidence-based to activate the parts of the brain associated with calm and playfulness.

I find that when we treat these pillars as clinical necessities rather than luxuries, we build the cognitive reserve needed to navigate complex organizational shifts. These practices are not just about personal wellness; they are about maintaining the professional capacity to provide high-quality care when the environment around us is in flux. By modeling these behaviors, we give our teams permission to do the same, creating a more resilient workforce overall.

Case Vignette: Reducing Readmissions

Now, let us shift our perspective back to the organization. An organization is ultimately a collection of individuals, and you cannot change the system without changing the people within it. Consider the case of Mr. Jackson, a patient admitted for heart failure. In a system without coordinated change management, his discharge is chaotic. A short-staffed nurse skims through a thick packet of papers, a hospitalist misses a medication conflict, and the scheduling team is too backed up to book a timely follow-up. Mr. Jackson goes home overwhelmed and eventually ends up back in the emergency department on day ten. This is not a failure of individual effort but a failure of system alignment and communication.

If we apply a structured change management approach with an AI tool, Mr. Jackson’s story changes. The AI flags his high-risk status and provides the nurse with a simplified, patient-friendly script. It highlights medication discrepancies for the hospitalist and automatically finds an available cardiology slot within five days. The system even sends Mr. Jackson daily texts to monitor his weight and symptoms.

This successful outcome is not due to the technology acting as a magic fix; it happened because the team understood the tool, believed in its value, and integrated it into a psychologically safe workflow. When we combine sound technology with structured change management and safe teams, we improve patient outcomes and significantly reduce staff burnout.

Stakeholder Mapping

So when we do change management, one of the first things we have to do is identify the stakeholders. We have to ask who is interested in this. In this particular situation, we are in the medical system. Usually, the chief medical officer has high power and high interest, and the strategy is for him or her to deeply engage in the change. The nurses have high power and medium interest, and they must be empowered to take part in the change.

The patients have lower organizational power but a very high interest in their well-being. So they need clear communication and support. This is a simple model for identifying your stakeholders. So when any kind of change is being implemented, we have to know who the stakeholders are first.

I find that mapping stakeholders in this way prevents us from overlooking the very people who can either champion or unintentionally stall an initiative. By understanding the intersection of power and interest, we can tailor our engagement strategies to meet people where they are. This ensures that the chief medical officer remains a visible sponsor while the nurses receive the autonomy they need to integrate the change into their practice.

Change Versus Transition

In my years of practice, I have observed a critical distinction between change and transition. Change itself is situational. It might be a new policy we are introducing, a restructuring of a system or a unit that we work in, or the adoption of an entirely new system. It can happen quickly and externally, and leadership often assumes that it is completed once we announce it.

Transition, however, is that whole psychological piece we have been talking about. It is the inner process people move through to let go of an old way and embrace a new way. Transition takes time, and it involves emotions, uncertainty, grief, and even excitement. In healthcare, we have to recognize that successful change depends not only on somebody telling us what to do, but also on how well we are supported through it. Without transition, change does not stick.

Three Stages of Transition

I have found that William Bridges provides a powerful depiction of this process. Change is the external event that starts where it says 'ending' in the red box. Every change starts with something ending: the old process, the old identity, and the old comfort zone. When that happens, people experience denial, shock, anger, frustration, stress, and ambivalence. This occurs not because they are resistant, but because they are grieving the loss of familiarity and the uncertainty it brings. Then there is the neutral zone, which we often call the messy middle. This is a foggy zone where the old way no longer counts, and the new way has not yet become automatic. It is uncomfortable, but it is also where creativity and innovation can live if we support people well. The last stage is the new beginning, where people feel acceptance and hope. They might feel skepticism as they learn the importance, but they eventually feel enthusiastic. We must remember that change is fast, but transition is slow.

If we go back to Maria, our seventeen-year veteran who initially felt threatened by the arrival of AI, we can see how she moves through these three stages. At first, she thinks about how this will complicate her workflow and wonders whether she can learn it or if she will lose her job. She moves through denial, thinking it won't affect her, followed by shock that everything is changing. She feels anger and asks why we cannot stick to what works. She experiences stress and ambivalence, knowing improvements are needed but feeling overwhelmed. Maria is not resisting change; she is letting go of the familiar.

Now she enters the messy middle, the neutral zone. She tries the AI tool, clicks the wrong thing, and gets an error message. She worries she is slower than her coworkers and feels her confidence draining. This is the hardest stage because it feels like she is doing everything wrong, yet this is also where learning and new habits develop. This is where her supervisor normalized the experience by saying that everyone is learning and that it is just part of the process. This support helped Maria reach a new beginning. She sees that the AI identifies patient risks she would have had to manually scan for, saving her time and enhancing her clinical judgment. She realizes her role still matters, and the tool makes things better. The software did not change; what changed was that Maria had support through her emotional journey.

Organizational Change Can Be Represented As Three States of Change 

Here is another way to look at it. If we look at this process, we move from our current state to our transition state and finally to our future state. The organization follows this path, and the individual follows it as well. We go from our current state, which is how I do my job now, through the transition state, and into the future state, which represents how I will do my job, hopefully even better.

I find it helpful to visualize these parallel paths because they remind us that the organizational shift and the individual psychological journey must happen simultaneously. If the organization moves to the future state while individuals remain stuck in the transition state, the new system will likely fail or require significant workarounds. Our goal as leaders is to synchronize these movements so that the people and the processes arrive at that improved future state together.

Integration of Project Management and Change Management

I find it helpful to look at implementation from two distinct perspectives that must work in tandem. On one hand, we have project management. This is the solution designed and developed to be delivered effectively. It represents the technical side of the equation, focusing on the tasks and the specific systems we are changing.

On the other hand, we have change management. This is the solution embraced, adopted, and utilized effectively. This represents the people side of the shift. While project management ensures the tool is functional and available, change management ensures that individuals within the organization actually use it and integrate it into their daily practice.

In my experience, many healthcare initiatives fail not because the technical side was flawed, but because the people side was neglected. You can have the most sophisticated software in the world, but if the staff does not embrace or utilize it, the project remains a technical success but a functional failure. To achieve the best outcomes for our patients and our teams, we must balance the rigor of project management with the empathy of change management.

An Organizational Move From The Current to The Future

In my experience, without solid change leadership, we lose people along the way. If you look at the progression of any initiative, it ultimately requires individuals to move from their own current state to their own future state. They start here at the beginning of the change and then move into the transition. As that process unfolds, you see we have lost a couple of people, and by the time we get to the final stage, we have lost many more.

This is what happens if we do not do change management well. Now, sometimes we lose people because we just needed to lose them, or they decided to opt out of the change and went somewhere else. You should keep that in mind. However, as leaders in organizations, we really need to ensure we implement this change effectively so we do not lose people. Sometimes we lose our best people, and we certainly do not want to. When we fail to provide the necessary psychological and structural supports, the most talented individuals are often the first to seek out environments that make them feel more secure and valued. Our goal is to ensure the bridge between the old and new ways is sturdy enough for everyone to cross.

You Are the Agents of Change

I always tell people when I am doing change management in organizations that you, every one of you, are the agents of change. It is not just your leader or the people on the front lines; it is everybody. In a clinical environment, change is a collective effort that requires alignment from every role. When we view ourselves as active participants rather than passive recipients of a new policy or technology, we reclaim our agency.

I have found that when physicians, nurses, administrators, and support staff all see themselves as stakeholders in the transition, the process moves from a top-down mandate to a shared mission. Each of you has the power to influence your unit's culture by modeling curiosity, offering constructive feedback, and supporting your colleagues through the messy middle of transition. We are all responsible for the success of our systems and, ultimately, the quality of care we provide to our patients.

The ABCs of Change

I find your breakdown of the ABCs of change—Awareness, Buy-in, Competence, and Support—to be a fantastic way to simplify the complexities of the ADKAR methodology for a busy healthcare team. By framing these as four essential pillars, you create a structural roadmap that makes the daunting task of organizational shift feel manageable.

In my experience, when a clinical team understands that Awareness is about the "why," Buy-in is about the "will," Competence is about the "skill," and Support is about the "sustainability," they can pinpoint exactly where a project might be wobbling. For instance, if you have awareness and competence but no buy-in, you end up with a team that knows how to use a new tool but simply chooses not to. Conversely, if you have buy-in but no support, the initial enthusiasm will quickly turn to frustration when the first technical hurdle appears.

When we look at these pillars through the lens of healthcare, we see that they are interdependent. Awareness of a new patient safety protocol leads to buy-in when staff see it saves lives. Competence through hands-on training ensures they can execute the protocol under pressure, and ongoing support prevents them from drifting back to old habits during a busy shift. This holistic approach is what allows a transition to become part of the culture rather than just another "flavor of the month" initiative.

Building Awareness

I find that your approach to awareness serves as the bedrock for the entire transition. When we are explicit about the "what," "why," and especially the "what is not changing," we provide the psychological safety clinicians need to engage. In the context of your outpatient clinic example, this clarity prevents the physical, occupational, and speech therapists from feeling that their professional autonomy is under threat. By explaining that the goal is alignment rather than replacement, we honor their individual expertise while solving the systemic issue of inconsistent care.

The distinction you make about who delivers the message is backed by significant organizational research. While the executive sponsor provides the high-level vision and the "why now," the immediate supervisor must translate that vision into the "how" of daily operations. This is because trust is built in the day-to-day workflow. If a supervisor cannot explain the details, the vision from the top feels like an empty mandate.

To avoid the "rumor mill" in our post-concussion pathway rollout, we need to ensure that information is accessible and facts are prioritized. When staff have ready access to the data—such as the drop in neurology referrals—they can see the business case for the change. This transforms the initiative from an arbitrary administrative task into a necessary step for the clinic's health and patients' safety.

SBAR Messaging Tool.

I find your application of the SBAR tool to leadership communication to be a masterstroke in change management. In healthcare, we are practically hard-wired to respond to this format; it cuts through the noise and speaks the language clinicians already use to ensure patient safety. By repurposing a clinical handoff tool for an organizational handoff, you are meeting your team exactly where they are, using a familiar structure to introduce unfamiliar changes.

In your example of the post-concussion pathway, the SBAR provides a logical "hook" for each discipline. When the Situation and Background are laid out so clearly, the Assessment—that we are losing trust and confusing patients—becomes undeniable. This makes the Recommendation feel like a collaborative solution rather than a top-down order. It transforms the "unified model" from a bureaucratic hurdle into a clinical necessity.

Using SBAR in this way also builds that critical trust we’ve been talking about. It shows that leadership has done the work to assess the actual environment and isn't just changing things for the sake of change. When a PT or an SLP hears a recommendation backed by this kind of logic, their "messy middle" becomes a little less foggy because the "why" and the "what" are anchored in clinical reasoning.

Creating Buy-in

This is probably the most difficult phase to manage because it depends heavily on an individual's comfort with change. You can ensure people are aware, but it is much harder to influence their internal commitment.

When we go back to our clinic example, buy-in among occupational therapy practitioners, physical therapists, and speech-language pathologists increases when they understand the specific benefits. These include reduced test duplication, easier collaboration, clearer roles, better patient outcomes, and stronger relationships with referrers. When these benefits are clear, they can form a personal commitment. Each clinician identifies what matters most to them. The occupational therapy practitioner (OTP) might focus on patient safety, the physical therapist on measurable progress, and the speech-language pathologist on consistent communication. This is how they truly begin to get buy-in.

We also want to ensure we connect these benefits to staff's daily frustrations. When people see that a change addresses a specific pain point they experience every day, their resistance often transforms into advocacy. Buy-in is not about convincing people to follow a mandate; it is about helping them discover their own reasons for wanting the new system to succeed.

Readiness Pulse Tool.

I find that assessing the readiness for change is a critical step that we often skip in our rush to implement a solution. To do this effectively, we can use a simple Readiness Pulse Tool. This is a short survey designed to help predict resistance and tailor our interventions before we even begin the rollout.

In this tool, we ask staff to rate their level of agreement on a scale of 1 to 5 across four key dimensions. The first dimension is importance, which measures whether staff believe the change is truly necessary. The second is support, which evaluates if leaders are perceived as genuinely supportive and engaged. Third, we assess resources to determine whether the necessary time, training, and tools are available. Finally, we assess self-efficacy to determine if individuals feel they have the personal ability to adapt and succeed.

By gathering this data, we move from guessing how our team feels to having actionable insights. If the scores for resources are low, we know we need to pause and provide more tools before moving to the next phase. If the importance score is low, we must go back and strengthen our awareness messaging. This data-driven approach allows us to meet our team exactly where they are.

Trust + Speed in Change.

I find that your focus on Frances Frei and Anne Morriss provides a vital perspective on the relationship between trust and organizational momentum. They highlight that rapid change is only effective when it is built on a foundation of trust. Without it, moving quickly is often perceived as reckless or dismissive of the staff's well-being.

When we are in the buy-in phase, building that trust is paramount. Speed often breaks trust, so leaders must prioritize clarity and vulnerability. In my experience, this means communicating clearly, admitting their own missteps when they occur, and demonstrating consistent reliability.

By focusing on these elements, leaders can actually increase the "speed of trust" within their teams. When staff believe their leaders are authentic and that the logic behind the change is sound, they are more willing to commit to the transition, even when it feels difficult. It is the steady presence and honesty of the leader that allows the team to eventually move faster without leaving anyone behind.

Competence: Equipping People to Succeed

I find that your focus on competence is the bridge between intention and results. In my experience, buy-in means nothing without competence; people must feel truly capable to move forward. When we look at competence, we want to ensure our teams have access to effective training that includes hands-on exercises. This ensures that staff actually practice the change rather than just hearing about it.

We also need to provide job aids, such as reminders and checklists, to help staff apply new processes in real time. This should be supported by one-on-one coaching from supervisors to reinforce new behaviors and by direct access to subject-matter experts, which allows staff to ask questions and avoid costly missteps. Competence bridges the gap between understanding and action. Without it, change creates anxiety instead of progress. We must always ask what our people specifically need to feel competent in the face of this change.

When staff feel equipped with the right skills and tools, their confidence grows, and the transition moves from a theoretical concept to a practical reality. This mastery is what ultimately stabilizes the new way of working and prevents a return to old, less efficient habits. By investing in this "skill" portion of the equation, we move the team from the anxiety of the unknown into the confidence of professional mastery.

Providing Support

Even the most well-designed transitions can wither without long-term reinforcement. Employee feedback is the lifeblood of this phase, as it surfaces real-world challenges and offers ideas for improvement that leadership might have overlooked. We must always seek this feedback to refine the process and show the team that their operational reality matters.

Celebrations and recognition are equally critical because they motivate staff and provide visible evidence of progress. By acknowledging both small wins—like a single week of perfect documentation—and major milestones, we maintain momentum. We also need to ensure that our incentive programs are aligned; if we ask for quality but only reward speed, we create a conflict that undermines the change.

Finally, accountability systems ensure that the change is consistently monitored and not forgotten as soon as the next priority arises. When leaders provide this kind of consistent support, staff feel validated, and the new adoption becomes truly embedded in the organizational culture. This is the ultimate goal of the entire process—moving from a "new" way of working to simply "the way we work." It is that sense of "scaffolding" we discussed, where mentoring and safety nets allow even those without innate talent for a specific change to step up and succeed.

Unlocking Potential Through Support.

When you provide the support people need through mentoring, coaching, and safety nets, hidden potential emerges. It is a powerful reminder that support systems often drive growth more effectively than innate talent alone. Even if a team member lacks a natural inclination for a specific new skill, this scaffolding approach allows them to step up and succeed.

Leaders who invest in scaffolding do more than just manage a transition; they multiply their team's capability for change. By providing these structured supports, you are not just maintaining the status quo—you are unleashing untapped potential within your people.

The synergy of these four elements is what makes a transformation permanent. Awareness creates clarity, while buy-in creates motivation. Competence then creates confidence, and support creates the necessary momentum. When these forces align, change does not just happen; it sticks. You move from a state of temporary adjustment to a culture of continuous growth and resilience.

Positive Attitude Manages Changes

In my years of practice, I have observed that a positive psychology perspective is a game-changer for organizational culture. I believe in moving teams away from toxic positivity and toward intentionally activating supportive mindsets. For me, the PERMA model serves as a brilliant framework for this, providing a structured way to ensure the human spirit remains nourished even during high-stress transitions. By focusing on these specific elements, I aim to help leaders shift the emotional frequency of an entire clinical unit.

When I discuss positive emotions and humor, I emphasize that we are essentially hacking our biology to counterbalance the brain's natural negativity bias. I advocate for the 70% rule, setting a tangible standard for communication where leaders find real, authentic things to praise to physically calm their teams' nervous systems. In my view, laughter is not just a social nicety; it is a physiological intervention that releases hormones to sustain staff for hours after the initial joy.

I find that engagement and flow occur when people are so fully absorbed in their work that they lose track of time. This state of flow is a natural stress reducer that grows when staff feel included and connected to the mission. This ties directly into meaning and purpose. I've seen that when a healthcare provider reconnects with their "why," their brain begins to interpret challenges as hurdles rather than walls. I argue that people will inherently learn and adapt more quickly when a change is explicitly linked to the reason they chose their profession in the first place.

Finally, I see accomplishment and gratitude as the areas where support truly comes to life. I believe in celebrating small wins—such as reducing conflicting instructions for a single week—to create the momentum needed to keep going. When I see a leader recognize effort and voice genuine gratitude, it reinforces a sense of belonging and creates emotional resilience. This ensures that staff feel supported both structurally and psychologically.

For the physical, occupational, and speech practitioners, I use the PERMA model to turn a standardized pathway into a shared success story. Because the leader invited input, the team found meaning in the new process's role in helping them deliver consistent care. Through hands-on training and the celebration of small wins during huddles, they did not just gain competence; they gained a sense of shared accomplishment. This holistic approach is how I ensure morale remains high even as the workload shifts.

Leadership

I have found that leadership is the cornerstone of any transformation, yet it is often the most misunderstood. Successful transitions require a delicate balance between three distinct components: leadership, project management, and change management. It is all too common for leaders to delegate the entire process to a project management team—experts in technical systems who may lack the tools to navigate the human psychological transition.

I frequently observe leaders taking a hands-off approach after the initial kickoff, assuming their job is done once a committee is in place. This is a critical error. As change management experts emphasize, a leader's involvement is required throughout the entire project lifecycle. When companies lean too heavily on the technical aspects, they often neglect the "people side" of change, leading to friction and stalled progress.

When leadership remains active and visible, it provides the authority and credibility that project managers simply cannot offer. Even a perfectly designed technical solution will fail if there is no leader to champion the vision or model the new behavior. To achieve a successful balance, the leader must stay engaged with both the logistical milestones and the team's emotional well-being.

A Leader's Role in Managing Change and Transitions

I find it essential for leaders to realize just how pivotal their role is in the change management process. Before I can guide anyone else, I must first work through my own reaction to the change. Whether I'm unhappy with a mandate from the Joint Commission or overly enthusiastic about a new system, I have to exercise deep self-awareness. This core component of emotional intelligence ensures my personal state doesn't blind me to the team's concerns or hinder our collective progress.

Once I am grounded, I make it a point to recognize that change is inherently difficult and that reactions will vary across every level of the organization. When I acknowledge this difficulty—rather than dismissing it as "resistance" or weakness—I can adopt the mindset that my primary job is to help my people through the transition in a healthy way. This is the stage where I actively lean on the ABCs of change (Awareness, Buy-in, Competence, and Support) to guide the staff.

Furthermore, I believe a leader must model a change-ready attitude at all times. There are certainly times when I have to "fake it till I make it" to provide the team with a sense of stability. I know that if I appear hesitant or cynical, that energy will permeate the entire department. My goal is to be the steady hand on the wheel.

Lastly, my golden rule of change leadership is to communicate, communicate, and then communicate some more. In my experience, over-communication is always better than under-communication. In the absence of information, I've seen people fill the void with fear and rumors. By being visible and repetitive with both the vision and the facts, I build the trust necessary to keep the momentum moving forward.

The Role of Communication During Change

I find that communication is the heartbeat of any successful transformation, and I believe its role in supporting each of the ABCs of change cannot be overstated. When I communicate effectively, I am not just moving information; I am building the infrastructure of trust and clarity that allows people to move from their current state to the future state.

In my experience, everyone has a critical role in communicating the change. It starts with me providing the vision at the top, but it is just as much about the supervisors and managers who translate that vision into daily tasks. Furthermore, I believe each of us plays a role in how we communicate with our peers. Change management is not a top-down mandate; it is a movement that involves the entire organization. We are all agents of change. I have found that peer-to-peer communication is often the most influential, as it is where the "messy middle" is navigated in real time.

I want to reiterate my belief that it is always better to over-communicate than to under-communicate. When information is scarce, I have seen anxiety grow, and rumors fill the vacuum. By providing consistent, transparent updates through multiple channels, I ensure that everyone stays aligned and feels seen throughout the transition. Whether it is a formal town hall, a unit huddle, or a quick check-in between colleagues, I view every interaction as an opportunity to reinforce the "why" and the "how" of the change.

Building a Communication Plan

I have found that a model of transformative communication is exactly what separates a successful transition from a chaotic one. While large organizations often have dedicated specialists, I believe it is vital to assign a small group to oversee the plan if that function doesn't exist. In my clinic example, I know we cannot rely on a single announcement; we need a structured, repeated strategy that aligns with the entire process.

The first step I take is identifying the specific audiences. For our clinic, this includes the clinicians, the front desk and scheduling staff, referring physicians, and the patients and families. I've learned that because each group has different needs, I must never send the same message to everyone. I then identify key messages and timing: clinicians need to know the "what" and the support available, while the front desk needs to understand the scheduling shifts. For referring physicians, I focus on the new standardized report, and for patients, I emphasize how this benefits their care.

I also make it a point to carefully sequence the timing. In my experience, clinicians should always hear the news first, followed by support staff, then referrers, and finally the patients. I do this to prevent staff from being blindsided by questions they aren't prepared to answer. Furthermore, I determine the content and frequency. My plan might include an initial kickoff meeting, a one-page summary, weekly updates, and short training videos. I find that this frequency is what prevents people from filling in the blanks with assumptions.

I believe that who delivers the message is just as important as the message itself. I have the clinic director announce the vision at an all-staff meeting, but I rely on discipline leads to reinforce it in team-specific huddles. I've found that the front desk supervisor is the right person to communicate workflow changes to their staff, while clinicians are the best messengers to patients. People need to hear from the person they trust the most in their daily workflow. Without this level of planning, I’ve seen change feel chaotic; with it, every stakeholder knows what is coming, why it matters, and how they fit into the system.

CONNECT Model in Action

I find that the CONNECT model provides a vital tactical framework for the high-stakes conversations that inevitably occur during any transition. It is one of the core models in transformative communication, designed to ensure that even the most difficult interactions remain productive rather than defensive. By following this sequence, I can address resistance directly while maintaining the team's psychological safety.

In this model, I start by controlling my own emotions, ensuring my nervous system is calm before I engage. I then offer respect to acknowledge the other person's value, followed by naming the facts of the situation without adding judgment. Once the facts are on the table, I name the response or reaction I am observing in others, demonstrating empathy and active listening.

From there, I explain my position clearly and transparently, leading into the identification of common goals—the shared "why" that connects us. Finally, I test assumptions by asking open-ended questions to ensure I haven't misunderstood the staff's concerns.

I believe this structured approach prevents the "messy middle" from devolving into conflict and instead turns resistance into an opportunity for deeper alignment. It moves the conversation from a confrontational "me vs. you" dynamic to a collaborative "us vs. the problem" mindset.

Common Communication Mistakes

I find that understanding common communication mistakes is just as vital as having a plan. The most pervasive myth in leadership is that telling someone something is the same as having them listen to and understand it. In reality, communication requires deep empathy and precise timing. Organizational psychology teaches us that when our brains are under stress—which is exactly what happens during a change announcement—our cognitive capacity shrinks.

When people are thinking about how a new policy affects their job security or their daily workflow, they simply cannot process the technical details I am providing. This is why a single town hall or one email summary is never enough. Consider a hospital rolling out a new electronic medical record; if leadership stops at a one-time announcement, I am often shocked weeks later when the nurses aren't using the system. The failure wasn't a lack of information; it was the mistake of treating communication as a volume-based task rather than an emotional one.

I have learned that we don't move simply because we've been informed. We move because we understand the "why" and feel safe enough to take that first step. Even if I do everything right, I will still encounter resistance. In my experience, resistance isn't a sign of failure; it’s a natural part of the human transition process.

The key is to shift from "telling" to "ensuring comprehension," which requires repeated messaging across different states of mind. By acknowledging that resistance is a psychological process rather than a performance issue, I can lead the team through the valley of frustration and into the new way of working.

Resistance

I find that framing resistance as a lack of motivation to change is a powerful way to shift the perspective on organizational friction. In my years of practice, I have observed that resistance is rarely about someone being intentionally difficult; instead, it is often a signal that the underlying drivers of motivation haven't been addressed.

Why Resistance Happens

I have learned that resistance always occurs for valid reasons, and we must categorize it to address it effectively. It generally stems from three distinct areas: emotional (fear, fatigue, or burnout), cognitive (lack of understanding or misinformation), or structural (limited resources or increased workload). When I see leaders trying to solve these issues, I remind them that blanket solutions never work; we have to diagnose and treat the specific root cause.

I also have to be mindful that resistance is often subtle. It isn't always a loud protest; it can manifest as negativity, such as gossip or even celebrating when a new initiative fails. It can look like avoidance, with staff simply ignoring the new systems and reverting to old habits. In more extreme cases, I've seen people build barriers by recruiting peers to join their opposition or using their professional status to be controlling, defending the status quo simply to slow down the pace of change.

When I recognize these signals, I can begin active resistance management. I often encounter organizations that suggest we should "just ignore it" and assume everyone will eventually get on board. I highly recommend that you never, ever ignore resistance. If we leave it unaddressed, it sends the signal that the team's concerns are invalid, eroding trust and allowing misinformation to become the dominant narrative. By facing resistance head-on, I can transform that friction into an opportunity for better alignment and a more resilient transition.

The Cost of Ignoring Resistance

I find that when resistance is ignored, adoption rates plummet, staff disengage, and turnover begins to rise. Especially in healthcare, ignoring resistance isn't just a costly mistake—it’s dangerous because it directly increases patient safety risks. I’ve learned that resistance is not an obstacle to be avoided, but a signal that shows exactly where my attention is needed most.

In my practice, I treat resistance as a valuable diagnostic tool. If I ignore it, I’m essentially ignoring the "check engine light" of the transition. When I lean in and address the root causes, I’m not just fixing a problem; I’m safeguarding the clinical environment and ensuring that the new system actually improves care rather than complicating it.

THREE Avenues of Resistance Management

I find that framing resistance as a lack of motivation to change is a powerful way to shift the perspective on organizational friction. In my years of practice, I have observed that resistance is rarely about someone being intentionally difficult; instead, it is often a signal that the underlying drivers of motivation haven't been addressed. When I look at why resistance happens, I focus on several key psychological barriers.

First, there is the fear of loss. People often resist because they fear losing something they value—whether it’s their professional autonomy, their status as an expert, or simply the comfort of a known routine. This is closely tied to a lack of trust. If there isn't a foundation of trust in the leadership or the logic behind the change, staff will naturally pull back. Without that security, any new initiative feels like a threat rather than an opportunity.

I also see resistance stemming from low self-efficacy. If clinicians don't feel they have the skills or competence to succeed in the new system, their anxiety manifests as resistance. They aren't saying "I won't do it"; they are often saying "I'm afraid I can't do it." Finally, we have to consider poor timing and exhaustion. When teams are already at their limit, even a positive change can meet resistance simply because cognitive load is too high.

By viewing resistance as a symptom of these unmet needs, I can stop trying to "convince" people and start solving the actual problem. If I can increase the dissatisfaction with the status quo, clarify the vision, and provide simple first steps, the resistance naturally begins to melt away.

CONNECT Model Applied to Resistance

Applying the CONNECT model to resistance turns a potentially confrontational moment into a collaborative dialogue. When a nurse tells a leader that a new checklist is simply "extra work," the leader has a structured way to navigate that friction rather than reacting defensively.

In this scenario, I start by controlling my emotions. Before I say a word, I ensure my own nervous system is calm so I don’t mirror the nurse's frustration. I then offer respect by acknowledging her reality, saying something like, "I hear your concerns about how this impacts your workflow." This immediately lowers the stakes.

Next, I name the facts without judgment: "I know this adds two minutes to the process, but the data shows it reduces clinical errors by 20%." At this point, I pause to note the response, observing her body language and listening to her feedback. If necessary, I can explain my position further, but I quickly move to emphasize our common goal: patient safety.

Finally, I test assumptions by asking open-ended questions like, "What part of this feels the most burdensome?" or "How can we make this fit better into your shift?" By following this sequence, I shift the dynamic from me versus the nurse to both of us versus the problem. It transforms resistance into a shared problem-solving session where staff feel heard, and the goal remains clear.

Psychological Safety in Change

Psychological safety is the bedrock upon which all other change efforts are built. In my practice, I have seen that teams with high psychological safety are the ones who speak up, share new ideas, and admit mistakes without fear of retribution. This openness enables a clinical unit to sustain improvements more effectively over the long term.

As I’ve noted before, psychological safety directly reduces the fear that fuels resistance. When staff feel safe, they don't have to waste emotional energy protecting themselves from perceived judgment; instead, they can channel that energy into navigating the transition.

In a psychologically safe environment, the "messy middle" of a rollout becomes a space for learning rather than a source of anxiety. If a physical therapist feels safe enough to say, "I’m struggling with this new documentation requirement," we can solve that problem in real time. Without that safety, that same therapist might simply ignore the change or build silent barriers against it. By prioritizing this sense of security, I ensure the team remains agile and connected to the mission, even when the workload feels heavy.

Micro-Behaviors of Leaders

Psychological safety is built through small, consistent signals—what I call micro-behaviors. These are the daily actions that signal to staff that it is safe to speak up, challenge the status quo, or admit they are struggling. When I work with leaders, I emphasize that these habits are what keep feedback from disappearing into a void.

One of the most powerful things I do is ask, "What might I be missing?" This simple phrase shows a genuine openness to the team's expertise. In the hospital, rolling out the AI system, for example, the director used this in an emergency department huddle. When a nurse explained that the alert timing interrupted medication administration, the director validated that input and adjusted the schedule. Because the nurse felt heard, she saw the leader as curious rather than defensive.

I also believe in thanking staff for raising concerns, even when those concerns feel challenging. When a physician questioned the accuracy of the AI's risk scores, the director didn't shut him down. Instead, she said, "Thank you. That's exactly the kind of critical thinking we need." By treating dissent as a contribution, she made it safe for the team to engage in critical problem-solving.

Modeling humility is another essential micro-behavior. I find that when a leader shares their own learning experiences, it reduces shame for everyone else. When the director admitted she initially misunderstood how the risk buckets were calculated and had to ask for help, she modeled that it is okay not to have all the answers immediately.

Finally, I always emphasize the need for follow-up. One of the most common complaints I hear in hospitals is that leadership doesn't really listen. To counter this, the director sent an email after the rollout: "You raised concerns about duplicate documentation, so we removed three unnecessary fields." Seeing that feedback leads to tangible change proves to the staff that their voices matter. These micro-behaviors are the small signals that ensure a transition isn't just a temporary mandate, but a sustained improvement.

Data on Leadership & Resistance 

Data on leadership and resistance provides a compelling case for moving away from top-down mandates and toward a more human-centered approach. Evidence consistently shows that when leaders are active and visible and address their teams' psychological needs, the success rates of organizational transitions increase dramatically.

Tool: Resistance Journal

I find that a resistance journal is one of the most practical tools for moving from a reactive to a proactive leadership stance. When I see a leader struggling with friction, I recommend they pause and log four specific elements: the resistance encountered, the type (emotional, cognitive, or structural), the response they attempted, and the actual outcome.

By documenting these interactions over time, I can look back and analyze patterns that would otherwise be lost in the daily rush. This is where technology like AI becomes incredibly useful; it can help me synthesize that data to determine whether a particular department is stuck in a structural bottleneck or whether the messaging consistently fails to address a specific emotional fear.

I believe that using a journal before acting prevents me from making impulsive decisions based on a single loud voice. Instead, it provides a clear, evidence-based map of the unit's climate. When I analyze these logs, I am often able to see that what I thought was "difficult behavior" is actually a recurring lack of resources or a specific gap in my communication plan. This shifts my role from being a "firefighter" to being a strategic leader who solves problems at their root.

Key Takeaways for Resistance

I find that the most important shift a leader can make is viewing resistance as data rather than defiance. We should never treat our employees as if they are being difficult; instead, we should see their pushback as a signal that something in the transition requires our attention.

The first step for any leader is to diagnose the root cause of the friction. I determine if the resistance is emotional, such as fear or burnout; cognitive, stemming from a misunderstanding or a lack of information; or structural, caused by workload issues or resource gaps. Once the cause is identified, I use intentional communication tools, such as the CONNECT model, to ensure the conversation remains productive and grounded in facts and common goals.

This approach must be supported by psychological safety strategies that enable staff to speak up. I have observed that when people feel their voices are valued, it leads to genuine engagement rather than forced compliance. Finally, leaders must model the exact behaviors they want to see. Culture always follows leadership, and if I want a team that is curious, respectful, and open to change, I must demonstrate those qualities myself. Many leaders miss this by retreating to their offices, but staying visible and responsive proves to the team that their feedback is the fuel for a better, more sustainable way of working.

Change Fatigue & Workplace Well-being

Change fatigue is a critical factor that many leaders overlook, yet research from major governing bodies consistently links it to high levels of burnout and stress. In nursing specifically, we see that the combination of heavy workloads, excessive overtime, and a constant influx of new technology compounds fatigue. I have learned that we cannot simply expect staff to absorb every new initiative without providing them with the necessary buffers to stay resilient.

The primary leadership implication here is the need for careful sequencing. I believe we must stop throwing changes at people all at once and instead prioritize what comes first and what comes second. By pacing our transitions, we prevent the "tsunami effect" that often leads to disengagement. It is also vital to normalize the reality of the trade-off in workload. When I acknowledge that a new process will feel heavy and take time away from other tasks, I show the team that I care about their daily experience. If I ignore that burden, the staff feels their reality is invisible to leadership.

To manage this over the long term, I recommend embedding 30-, 60-, and 90-day review cycles into the implementation process. This allows me to pause and assess the impact of the change at regular intervals. During these reviews, I continue to treat resistance as valuable data rather than defiance, using it to refine the workflow. Finally, by aligning our recognition programs with psychological safety practices, we reinforce the behaviors that lead to a healthy culture. When staff feel seen and safe, they are much better equipped to handle the inevitable fatigue that comes with a transforming healthcare environment.

Not All Change Is Good

I find that Ashley Goodall’s 2024 work on the problem with change serves as a vital reminder that more change is not always better. He effectively highlights how excessive and poorly justified shifts create deep fatigue, lower morale, and ultimately erode performance. The research confirms that when we pile on initiatives without wisdom, we are not innovating; we are simply destabilizing the team.

In a high-stakes environment like a hospital, this becomes a matter of safety. Piling on changes without proper sequencing leads to burnout and clinical errors, and it causes us to lose our best people along the way. I have learned that protecting stability is just as important as driving innovation. As leaders, we must have the discernment to distinguish between essential progress and disruption that lacks a clear benefit.

But let’s assume you have done everything right—you followed the ABCs of change, you were transparent, and you sequenced your goals—yet suddenly it seems things aren't sticking. When a transition begins to stall or revert to old habits, we have to look at how we sustain the momentum through the "messy middle."

This is where the 30, 60, and 90-day review cycles become essential. Instead of assuming the work is done once the "go-live" date passes, I use these milestones to check the department's pulse. If the change isn't sticking, I revisit the structural supports. I ask whether the new workflow actually fits the reality of a busy shift, or whether we've inadvertently created a bottleneck that makes the old way of working more attractive.

I also look back at the resistance data I’ve collected. If adoption is dropping, is it because of a new emotional hurdle, like a loss of confidence, or is it a cognitive issue where the initial training has been forgotten? By treating this "stuck" period as another data point, I can adjust the plan, provide additional coaching, or even simplify the process to ensure it becomes a permanent part of the culture rather than a passing phase.

Habit Formation

We often underestimate the sheer power of habit formation in healthcare. It is never enough to simply announce a new way of working; we have to lean into the science of repetition. Charles Duhigg’s work on the Habit Loop is a perfect framework for this, as it highlights that for a behavior to stick, it must move from a conscious effort to an automatic response.

To make a change stick, I focus on three essential elements. First, staff need clear cues. These are the visual reminders, checklists, or automated reinforcements in the electronic record that signal it is time to perform the new behavior. Without a strong cue, the brain defaults to the old routine. Second, we must provide reinforcement. This isn't just about a one-time "thank you"; it’s about consistent positive recognition and feedback that secures long-term commitment and motivation. Finally, I rely on leadership modeling. When the staff sees their leaders consistently using the new tool or following the new protocol, it validates the effort and makes the new habit the unit's social norm.

The message here is clear: Change doesn't end at implementation. It only becomes real when we repeat it and reinforce it until it is woven into the fabric of the daily shift. If we don't design for habit, we are just hoping for luck.

Why Does Sustainment Fail?

Even the most well-designed initiatives often collapse because we treat the "go-live" date as the finish line. In reality, sustainment is where the real work begins, and it typically fails for very specific reasons.

One major reason is that the initial energy and focus simply fade after the pilot phase. When the implementation team leaves the floor and the excitement of the "new" wears off, staff naturally drift back to the path of least resistance. This is often compounded by competing priorities. In a hospital, there is always another crisis, another mandate, or another policy coming down the line. If the new change isn't anchored, it gets buried under the weight of the next priority.

However, the two biggest culprits are a lack of reinforcement and a complete absence of accountability. Without consistent feedback and a system that ensures everyone is following the new standard, the message to the team is that the change was optional. I believe that for a change to stick, we must have an accountability system that keeps sustainment visible. This doesn't mean being punitive; it means having the discipline to check the data, follow up on lapses, and ensure that the "new way" remains the only way we do things.

To prevent this failure, I focus on building review cycles into the schedule from day one. By treating sustainment as a formal phase of the project rather than an afterthought, I can address competing priorities and provide the reinforcement necessary to turn a temporary pilot into a permanent habit.

Scale-Up Checklist

I find that moving from a pilot to a system-wide rollout is one of the most high-stakes phases of any transition. Many organizations make the mistake of trying to scale initiatives immediately, but expansion without readiness is a primary reason system-wide efforts fail. I recommend using a scale-up checklist to ensure you are moving deliberately rather than reactively. This process protects the organization from premature scaling and increases the likelihood that a strong pilot project can successfully evolve into a sustainable, system-wide improvement.

The first step in this narrative is ensuring the pilot results are clear. I look for a consistent signal—not just a single week of good numbers, but ongoing data that demonstrates improvement, stability, and alignment with the targeted outcomes. Once the data is solid, I have to ask if we have the resources to scale. Scaling always adds a significant load to the system, so I must confirm that we have the staff time, technology support, funding, and general capacity to carry that load across multiple sites.

I also focus heavily on whether the staff is trained and comfortable. Scaling fails if a new clinic interprets the change differently from the pilot site did, so standardized training, clear workflows, and job aids must be finalized before the rollout moves forward. This requires leadership commitment at every level. Local buy-in is essential; without it, the initiative will hit invisible roadblocks, such as competing priorities or passive resistance from managers who don't feel a sense of ownership.

Finally, I ensure that measurement systems are in place before we expand. Having run charts, dashboards, and basic metrics ready enables us to track fidelity and adoption across all sites in real time. This lets us identify early signals that something isn't working before the problem becomes systemic. By treating scaling as a strategic process rather than a foregone conclusion, I ensure the transition actually sticks and becomes part of the organizational culture.

30-60-90 Day Review

I find that implementing a 30, 60, 90-day review cycle is the difference between a change that evaporates and one that becomes permanent. Instead of assuming success after the initial launch, these milestones allow me to treat the implementation as a living process that requires refinement and honest assessment.

At the 30-day mark, the primary focus is on measuring adoption. For instance, a Chief Information Officer might report that while 78% of clinicians have tried a new AI tool, only 42% are using it consistently. This data is invaluable because it tells me that adoption is uneven and that confidence is likely an emerging barrier. Rather than being discouraged, I use this information to target where support is most needed before bad habits set in.

By the 60-day mark, I move from broad metrics to deep feedback through structured surveys and focus groups. This is where specific technical and psychological challenges come to light. Providers might report forgetting to activate the tool, not knowing how to customize templates, or being frustrated by lag times in voice-to-text conversion. Identifying these specific hurdles allows me to accelerate system optimization and schedule targeted 20-minute refresher sessions. This proactive approach proves to the staff that we are listening and that the system is being refined to work for them, not against them.

Finally, at the 90-day mark, I evaluate overall progress to decide how to strengthen or modify the rollout in the long term. At this stage, I look for indicators like consistent use increasing to 71% and a system-wide decrease in documentation time. I also look at the qualitative results; for example, seeing that providers who received coaching show significantly higher satisfaction.

The ultimate outcome of this 90-day review is that the change is reinforced and officially woven into the organizational fabric. When adoption is solid, temporary supports like coaching programs can become permanent resources, and the new workflow is finalized in the medical record system. This structured review cycle ensures that we don't just launch a project, but actually sustain an improvement.

Stop-Start-Continue Tool

I find that framing a transition around three simple questions—Stop, Start, and Continue—is one of the most effective ways to create a balanced and structured reflection. Often, in the rush of change, we focus so intently on what is broken that we forget to acknowledge what is already functioning well. This model changes that dynamic by encouraging a holistic view of the work.

When I ask, "What are we stopping?" I am helping the team identify outdated practices or habits that no longer serve our mission. This is a crucial step in reducing change fatigue, as it signals that we aren't just adding more work; we are actively clearing away the old to make room for the new.

Next, I ask, "What are we starting?" This clarifies the new strategies and behaviors that align with our current goals. It gives the team a clear target for their energy and ensures the purpose of the change is well understood.

Finally, and perhaps most importantly, I ask, "What are we going to continue?" This focuses on what is already working well. By explicitly naming the successes we intend to maintain, I reduce the anxiety that everything is being upended. It recognizes the expertise and hard work of the staff, showing them that we value the foundations they've already built.

This approach transforms a potentially skeptical environment into one of shared problem-solving. It isn't just about innovation; it's about wisdom and respect for the existing culture. It provides a roadmap that feels manageable and grounded in reality, which is essential for any sustainable healthcare improvement.

Key Takeaways on Sustainment & Scale

I find that the transition from a successful pilot to a lasting, system-wide culture is where most leadership legacies are defined. It is a phase that requires moving beyond the initial excitement and into the disciplined work of reinforcement and structural anchoring.

My key takeaways for ensuring that your efforts don't just spark, but actually catch fire, center on these principles:

Sustainment is a deliberate choice, not a natural outcome. I have seen time and again that change fades quickly without consistent reinforcement. By instituting 30, 60, and 90-day reviews, you anchor new practices by identifying early drift and correcting it before it becomes a permanent regression. These reviews turn the "messy middle" into a structured period of optimization rather than a slow slide back to old ways.

True sustainment relies on the science of habit formation. We must design feedback loops that provide staff with clear cues and immediate, positive recognition. When the new way of working becomes the path of least resistance, the habit loop is closed. Furthermore, scalability requires caution. I believe in scaling only after the pilot has demonstrated clear success and the system has shown its readiness. Expansion without readiness is simply scaling failure.

Finally, the ultimate goal is to move beyond mere resilience toward anti-fragility. In a healthcare system, we don't just want to survive the stress of change; we want to build a system that gets stronger because of it. By treating every piece of resistance as data and every review as a learning opportunity, we create a continuous improvement culture in which the organization constantly evolves to be better, faster, and safer for both staff and patients.

AI Transformation: Human First, Tech Second

I find that Brian Evergreen’s 2023 perspective on AI transformation perfectly mirrors the change management principles we’ve already discussed. It is far too easy to get caught up in the technical specifications of a new tool and forget that the human element is what ultimately determines its success. I truly believe that for AI to work in a clinical setting, we must adopt a human-first, tech-second approach.

Successful implementation is not just about installing a new software package; it requires a complete redesign of our structures, workflows, and organizational culture. If we simply layer complex AI on top of a broken manual process, we don't fix the problem—we just automate the chaos. The goal of this transformation should be to ensure that automation actually enhances human flourishing. In healthcare, this means freeing up clinicians to do the high-value, empathetic work that only they can do, rather than drowning them in more digital tasks.

Without this careful balance, AI adoption risks alienating the workforce. If staff feel that the technology is being used to replace their judgment or micromanage their time, resistance will be immediate and justified. Worse, it can undermine patient care if the human-to-human connection is lost in the process. By focusing on redesigning the workflow around the person first, we ensure that the technology serves the caregiver, which, in turn, enables the caregiver to better serve the patient.

AI Governance & Safety: What Leaders Must Address

When we integrate AI into healthcare, we must treat governance and safety not as optional hurdles, but as the foundational architecture of the entire system. Global bodies like the World Health Organization have already set the stage with over 40 recommendations specifically addressing the ethics and governance of large language models. Their message is clear: transparency, human oversight, and rigorous risk management are non-negotiable.

This is echoed by professional organizations across the spectrum—from the American Medical Association to those representing nursing, OTP, PT, and SLP. They are all demanding clarity on liability, consistent oversight, and explicit attention to bias mitigation. We have to acknowledge that AI can be biased and, without active management, inadvertently widen disparities in care rather than close them.

We are also seeing this operationalized through regulatory and accrediting bodies. The FDA now provides lifecycle guidance for AI-enabled medical devices, while the Joint Commission has introduced a certification for responsible use of health data. This shift moves AI from being a "tech project" to being a core component of clinical quality and safety.

For leaders, these cannot remain as static policy documents sitting on a shelf. They must be baked into your AI strategy and operationalized through practical methods, such as the Plan-Do-Study-Act (PDSA) cycle. This is how you move beyond mere compliance to build real-world trust with your staff and patients. When a clinician knows that there is a structured system for oversight and bias checking, their fear of the "black box" begins to dissolve, and they can focus on how the tool actually helps them provide better care.

AI Deskilling Risk

I find that deskilling is one of the most significant, yet under-discussed, risks in the AI transformation of healthcare. It is the gradual erosion of clinical judgment, diagnostic reasoning, and procedural competence that occurs when we over-rely on automated systems. To manage this change effectively, we must recognize that if tasks once performed with great skill become passively delegated to machines, the human "clinical muscle" begins to atrophy.

One of the most effective strategies to combat this is implementing AI-off intervals. These are intentional, scheduled periods during which clinicians practice without AI assistance. For example, a radiologist might read every fifth scan "blind" to the AI's suggestions, or a nurse anesthetist might run simulations in which automated controllers are temporarily disabled. These intervals ensure that independent judgment remains sharp and that the clinician can override the system when it inevitably encounters an outlier or a technical failure.

I also believe in using what some researchers call a "Dashboard of Disagreement." This tool flags cases where a human clinician’s judgment contradicts the AI’s recommendation. Instead of seeing these as errors, we treat them as high-value learning moments. Analyzing these cases in monthly conferences helps us determine whether the human saw a nuance the AI missed, or if the clinician was falling prey to their own biases.

The goal is never to reject the technology, but to move toward Centaur Mode—a strategy in which tasks are divided so that the AI handles low-risk, repeatable work while the clinician retains full cognitive control over high-stakes reasoning. By designing our workflows with these "off-ramps" and checkpoints, we protect the heart of clinical expertise while still capturing the efficiency gains of the digital age.

Pulling It All Together

Effective change management is about integrating specific, human-centered practices before, during, and after any transition. Before the change ever begins, the work is about strengthening trust and building teams. This is where I advocate for a deep understanding of both yourself and others to reduce resistance before it takes root. During the change, I lean on emotional intelligence to anticipate friction, communicate with clarity, and consistently reinforce our shared purpose. Once implementation is underway, the focus shifts to sustaining momentum by gathering honest feedback, recognizing every contribution, and celebrating our successes. When I view change as a continuous process, I am creating a culture where evolution is simply part of how the organization thrives.

I want to emphasize that the work you do is incredibly complex. It requires more than clinical excellence; it demands adaptability and a willingness to guide others through the fog of uncertainty. I see change management not as a single skill, but as a disciplined mindset and a practice. Every time you engage in this kind of training, you are strengthening your ability to influence culture and ultimately improve the patient experience.

Healthcare will continue to evolve rapidly through new technology, shifting workflows, and changing patient needs. Your ability to lead through those changes remains the greatest predictor of success and staff well-being. I invite you to choose one practice to implement in the next 30 days. Perhaps you will adopt a new communication habit, focus on building psychological safety, or start using the ABCs of change management. I truly believe that small, intentional changes are what create meaningful momentum.

Thank you for your time, your attention, and your unwavering dedication to the healthcare system and the patients you serve.

References

See additional handout.