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Change Management in Al Noor Hospital

The Journey of Noor Hospital During Change Submitted by: Rami Nour Al-Smadi On: Monday April 11th 2011 Table of Contents 1Abstract3 2Introduction3 3Case Summary4 4Discussion7 4. 1The Nature of Change7 4. 2Typology of Change8 4. 3Process of Change9 4. 4Factors Effecting Change:11 4. 4. 1Deep structure11 4. 4. 2Single-loop learning12 4. 4. 3Leadership styles and behaviors12 4. 4. 4Power, Politics and Stakeholder Management15 4. 4. 5Organization Transitions17 4. 5Alignment18 5Recommendation20 6Conclusion21 7References22 8Appendix 1 – Quality Policy23 23 Appendix 2 – Organization Chart24 10Appendix 3 – Interview with Executive Director25 11Appendix 4 – Interview with Director of Nurse Supervisor27 12Appendix 5 – Interview with Line Manager29 13Appendix 6 – Minutes of meetings31 1Abstract Which comes first, change or quality? Noor Hospital mission is to achieve continual improvement in hospital care and services. It aims is to seek recognition and strive for excellence. Therefore it began this process by creating a quality department which would take the lead to introduce quality initiatives in order to achieve ISO accreditation.

Now these initiatives for quality require change in processes and procedures. With change comes resistance which is a major obstacle that Noor Hospital is currently facing. This report begins with a summary of the organization then it cover change issues such as: Nature, typology, and process of change. Then it lists factors that effect change while relating it with Noor Hospital. It then diagnose Noor Hospital using the 8s Model and finally concludes with making recommendations such as alignment. To answer the question above of which comes first, change or quality?

In Noor Hospital it is both, you need to make change in order to achieve quality and because of wanting to achieve quality, change is needed. 2Introduction Good is no longer good enough. To survive in today’s competitive environment an organization needs to excel in their policies and procedures in order to achieve high quality standards. This is the main goal and mission of Noor Hospital to work towards successful implementation of quality programs to ensure effectiveness, efficiency, and equity of health services (Appendix 1).

Such mission will ultimately achieve user satisfaction and award the hospital ISO certification. However, the challenge will be, how long will it take to achieve such goal? How to manage change? What might be some of the obstacles, and how to overcome them? Why do staffs resist change, and what can be done to overcome such obstacle? Some of these questions will be answered through this report as we diagnose and analyze the case while relating it to various change management theories. 3Case Summary Noor Hospital is a 160 bed capacity governmental hospital in Sultanate of Oman.

It is a secondary hospital serving all governorate community and any emergency case coming from outside the governorate (like RTA and deliveries). It consists of different departments such as (medical, surgical, gynecology, obstetrics, orthopedic, etc….. ). In June 2008, instructions came from Ministry of Health to create a quality department for the Hospital, as a response to the fact that quality in healthcare organizations is quickly becoming a worldwide issue to both suppliers and consumers of those services. All countries worldwide are actively introducing quality in their health care system.

This is mainly due to the fact that providing care alone, any care, is no longer an acceptable option. However; patients and caregiver are insisting on enjoying this provided care with extreme quality. (WHO, 1995) As more and more hospitals in the country has adopted to implement quality procedures, and due to the fact that customers complaints have been obviously increased which reflect badly to the hospital’s reputation and threaten the executive director position to take immediate action to resolve this problem.

Accordingly, in his last regular meeting with other executive directors in the country at the quarter office of the Ministry of Health where all the executive directors agree on at least one point: Achieving quality improvement calls for significant changes in the hospital Executive director role, the executive Director has appointed his first employee in Quality Assurance Department to take the responsibility in implementing Total quality management procedures.

Few weeks after, the executive director, who become to realize that that TQM would give method and structure to his personal desire to improve the performance of hospital services and it is the right way to do and improve the business, has nominated this employee (under certain criteria) to be sent for two weeks training in certified (ISO certificate) hospital. After the training was completed, awareness lectures were given to the other hospital staff members. Almost all departments got an awareness lecture in quality for four hours per week.

The awareness lectures ensured that staff understands the reasons why change and quality is needed in healthcare. Change is needed for the standardization and variance control. Unless hospital has standards in procedure manuals, it would not be possible to get accredited and licensure certifications. Two months following the awareness session, an expert from ISO certified hospital conducted a workshop for two days, and feedbacks on the awareness lectures were given. The quality department has taken the responsibility of improving quality in the hospital through establishing a professional quality management system.

There are some changes that took by having the quality system. The first change was putting a proper process for handling the incident report, before the change, incident report coming from all departments was used to go straight to the executive director, then she was referring it back to the relevant department for their comment and after she reviews the comment, then the action is made. Now the incident report goes to the quality department first, where it gets reviewed.

The quality personnel discuss the incident with the concerned department and get their feedback within time limit and add their recommendation based on procedure manual. Then the incident is passed on to the executive director for review and action. On a yearly basis, Ministry of Health compiles the number of incident reports from all the hospitals. During the regularly data collection of incident reports in Noor Hospital which has to be sent to Ministry of Health, it was realized that the departments under administration and finance were not following the new procedures and therefore, the incident report was not recorded.

These departments refuse to follow the new process, they still insist on practicing the old system by sending the report to their director and therefore passing the quality department. This practice has given the quality an inaccurate number of incidents to be reported to Ministry of Health. The executive director talked to the director of administration and financial affairs (see appendix II organization chart), still some incidents and complaints are not referred to quality department

The next new initiative for the quality personnel will be reviewing, creating or updating procedures and manuals to come up with a standardized manual for all hospitals. There is already a huge resistance from senior consultants who says: “why should we do new things if we are not making mistakes” and “if the old manuals are there why to write new ones”. Initially, an announcement circulated for all departments explaining this new initiative with a time limit. Due to the large resistance, this matter has been delayed for a month yet nothing is done.

To further understand the case, interviews were conducted with the Executive Director, nurse, and line manager (see appendix 3, 4, & 5). In the next sections, we will further discuss the case and relate it to the nature, typology and process of change and discuss key factors that effect change. We will then summarize and make recommendations for future. 4Discussion 4. 1The Nature of Change Lewis (1951) as cited in Hayes (2007) explained the insight of the nature of change. He symbolized nature of change to a river.

The state of ‘no change’ does not mean that everything is stationary, it means that the river is flowing at a given velocity and direction, this is known as ‘stable quasi-stationary equilibrium’. In this condition there is a balance between forces pushing for and resisting change. In Noor Hospital before the quality initiative, the work was flowing with a balance between the two forces. However, when there is a change in individual, group or organization behavior this will cause a change in river’s velocity or direction.

In this case there is imbalance between forces pushing for and resisting change. When the quality department was introduced and new procedures were implemented, an imbalance happened between forces pushing for change to new procedures and individuals resisting the change. Lewis (1951) as cited in Hayes (2007) goes on to explain that there are two approaches that can result in change. First approach is to increase the forces pushing for change; this will result in increased tension and may accompany high aggressiveness and high emotional and low level of constructive behavior.

This is the case in Noor Hospital, where the department of finance and administration resisted the change and refused to follow the new procedure. The second approach is by diminishing the forces that oppose or resist change, the result will be low tension and low aggressive behaviors as a result high constructive behavior and ultimately creating a permanent change. Noor Hospital should work on this approach; however, as we diagnose this organization, we will find out what are the reasons for resisting change and therefore be able to give recommendation or improvement. 4. 2Typology of Change Weick & Quinn (1999) as cited in Hayes (2007) suggests that change can be divided into two main types: continuous and discontinuous or incremental and transformational change. Continuous or incremental change occurs when there is a small continuous adjustment across organization that can cumulate and create substantial change. The organization is in equilibrium and focusing on ‘doing things better’ through continuous adaptation and modification of processes.

Whereas in discontinuous, episodic or transformational change occurs when the organization is moving away from their equilibrium and breaking away from the past. The organization will begin to ‘do things differently or doing different things’. In Noor Hospital when Ministry of Health realized that quality in healthcare has become a necessity for an organization to remain competitive and become accredited, it began introducing changes through the quality department. These changes are continuous and incremental change in order to do things better.

Nadler et al. (1995) as cited in Hayes (2007) combined the two types of change (incremental and transformational) with the extent to which the organization’s response to change (proactive or reactive). They then concluded that there are four types of change: Tuning (incremental and proactive), Adaptation (incremental and reactive), Re-orientation (transformational and proactive), and Re-creation (transformational and reactive). In Noor Hospital the change was incremental and reactive which makes it adaptation type of change.

Adaptation is a response to a pressing external demand for change such as introducing quality initiatives in order to become ISO certified hospital. Such type of changes occurs within the same existing paradigm and over a period of time the incremental change can lead to an organization to transform its deep structure and reinvent itself. This paradigm is known as gradualist paradigm which suggests that fundamental change can occur through process of continuous adjustment and does not need a discontinuous process in order to bring about transformational change (Hayes, 2007). In contrary, the punctuated quilibrium paradigm believes that in order to bring about transformational change, a break away from the past needs to occur and organizational need to do things differently this can only occur during periods of disequilibrium (Hayes, 2007). Noor Hospital case fits more with the gradualist paradigm and through their continuous adjustment by introducing new initiatives and over a period of time; they will bring about transformational change and become ISO certified hospital. 4. 3Process of Change Kotter (1995) cited in Hayes (2007) identifies the following tasks which lead the change process. . Create a sense of urgency: which is done by unfreezing and moving people from their comfort zone. Alerting them for need of change and motivating them for new ways. Information was based to the staff through awareness sessions; however, the staff did not feel the urgency of it and what is in it for them. Therefore, it created resistance with some of the staff. 2. Form a powerful team: which is needed to direct the process of change and it might not include all the senior managers but employees with experience, information and contacts are of much value.

The quality personnel faced some problems at this step as some of the management staff was not willing to accept change so they refused to be a part of team. 3. Create a vision: it is necessary to develop a vision which is easily communicated, realistic, appeals to employees and customers, conveys a picture of organization’s present and future and provide guidance in decision making. In our case the vision was to have total patient satisfaction by responding to their complaints on time and in effective manner. Then ultimately receiving ISO accreditation. 4.

Communicate the vision: which is necessary to do as all those people effected by change need to hear the message repeatedly. And it involves more than spoken and written words. The quality personnel worked on “walk the talk”. And on time to time various meetings were arranged to repeat the message. But as the culture of the organization is very tight so there was always a communication gap. 5. Empower people to act on vision: which is done by creating an environment in which people are confident and they believe that they can work with no pressure and can have others support to make things happen.

Any of those barriers which can stop people in implementing the change should be removed. But unfortunately this step was lacking in the hospital. As some of the management staff (seniors and finance department) were not happy with the idea that quality personnel is in charge of the incident reports and is making decisions. So they were not sending all the reports to the quality department and didn’t agree and approve any of the decisions made by quality personnel. 6. Create short term wins: which is necessary because the whole process of change takes long and it can make the people lose the sense of urgency and they may be distracted.

That’s why it is important to plan for short term, visible and achievable goals which can be celebrated and awarded along the way to the major goal. In spite the resistance this step could be very helpful to award those who work hard which will automatically effect those who resist the change in a positive way seeing the benefits the change has. 7. Consolidate the improvements and produce more change: early wins should be celebrated but victory shouldn’t be declared too soon as it may kill the momentum. With early wins the leaders should keep on introducing more changes to the system and structure.

In hospital, the departments which showed improvements with time were appreciated and were set as example for other departments to follow. 8. Institutionalize the new approaches: leaders should show others the benefits, new approaches, attitudes and results that change has produced and reinforce the new changes till everyone in organization accepts them and they become a part of culture. This needs to be done in the hospital. For people who are resistant to change should be shown the positive outcome in terms of patient satisfaction. . 4Factors Effecting Change: There are several factors that hinder or slow down the change process. These factors are as follow: 4. 4. 1Deep structure Deep structure is the routines, processes, assumptions of an organization which influence the action of people working there. Deep structures are mainly hidden from view and what others can see is only the “tip of the iceberg”. Hayes (2007) writes that deep structures are mainly the choices an organization makes which show its basic activity in maintaining the existence.

Organizational culture, structure, strategy, control and power distribution represent organizations deep structures and it takes a lot to alter these systems of interrelated organizational parts. Greenwood and Hinings (1996) as cited in Hayes (2007) argues that there is a resistance which limits the change and it is strongest when the mutual dependency network is tightly coupled. In loosely coupled fields the change is easy, common and is evolutionary and lasts for long.

In our case we consider the hospital as a tightly coupled organization as some of the members of the senior management are not willing to let go old ways of working may be due to fear of losing their position and power. They don’t want to change the structure of work methods and accept new change. 4. 4. 2Single-loop learning According to Hayes (2007) organizational learning takes place when a group recognizes and adopts a more effective way of functioning. It involves achieving and maintaining balance between structure, systems, technology and people of organization.

Organizational learning is divided into single loop and double loop learning. Single loop learning is to detect and correct errors which lead to modification of rules within current thinking boundaries. While double loop learning do things differently or do different things. It challenges the usual and accepted ways of thinking. In our case study single loop learning took place as it is basically following the rules and as there was not a fundamental challenge so single loop learning was used to promote change management and for strategy formulation.

This started with almost all the hospital members refining their mental models in order to do things better. The overall structure of incident report was not changed but it was improved and was designed to go through proper channels to be more effective. 4. 4. 3Leadership styles and behaviors Leaders play the most important role in the process of change by deciding what needs to be done, how it can be done, and making sure that it is done. Burpitt (2009) writes that there are two types of leader behaviors known as initiating structure and consideration.

And leaders, who are operating in the transactional mode work on clarifying the tasks, providing a structure, encourage the employees to show their best capabilities, offering rewards for good performance and perhaps threatening when the goals are not being met. While operating in a transformational mode leaders create a vision for change, minimize the resistance, increase employees’ awareness for valued outcomes by expanding and elevating their needs and encouraging them to adopt new working ways. In short any alteration in a firm’s established ractices is transformational leadership, while in times of stability organizational needs are referred to as transactional leadership. In Noor Hospital, there seems to be two kinds of leadership behavior. The executive director is showing transformational leadership behaviors whereas the director of finance and administration is showing transactional leadership behavior. Therefore due to their behaviors, it explains why the executive director is coping and leading the change well, while director of finance and administration is resisting the change.

When is come to leadership styles, there are four common types of leadership styles known as: 1. Authoritarian: also known as autocratic or directive style in which the leader tells employees what needs to be done and how it will be done. This style fits more with the director of finance and administration. He wants things done his way and doesn’t want to change it. 2. Consultative: in this style the leader takes input from people who are resistant and ask them what exactly they don’t like about change, provide answers to’ what is in for me’.

We believe the executive director demonstrate this style but not to its full description. She has combination of authoritarian and consultative styles. When she was asked in the interview about communication, she believed that the current methods used are not very effective. Therefore, as a consultative leader, she need to work on this limitation and provide answers for staff on what is in it for them. 3. Participative: this style is used when employees are empowered and are comfortable on way of change and leaders work on sustaining the commitment employees are showing.

In our hospital to some extent this leadership style is being used. 4. Delegative: this style is used when leaders trust their employees and have full confident in them and allow them to make decisions In our hospital traditional command and control needs to be eroded and for that collective leadership is recommended because when a single individual is not able to create and implement change then collective leadership formulates a vision by bringing together all the skills and experience.

At the same time formulates the ability to influence others. The members need to play complementary roles and work together so further improvements can be achieved by (Hayes, 2007): 1. Maintaining the internal harmony between all the members of leadership team, including executive director, finance director, nursing in charge and other head of departments ( known as strategic coupling) 2. Maintain the relationship between of the leadership group and their organizational constituencies. known as Organizational coupling) this step in important in the hospital as if any of the member of leadership team either head of finance department or executive director lose touch with their constituencies than this will reduce the leaders influence on others as they might feel that the leader is not doing the job properly. 3. Coherence between the leadership’s team vision and the demands of external stakeholders. (Known as Environmental coupling) is necessary to be maintained because if the leadership group gets detached from their environment than performance also declines.

It is difficult to maintain balance at all the three levels. But with knowledge and interpersonal skills of the members of team this can be achieved. 4. 4. 4Power, Politics and Stakeholder Management Power is always discussed along politics. The two are closely linked to each other. The small difference between both of them are in discussion of power focus on underlying forces while politics is more focused on the behavior of employees, especially those with senior levels. Research suggests that managing politics agenda was essential to the success of the change management process.

Considerations of power issues are critical to developing a clear understanding of change management (Buchanan & Badham 1999a, Boje & Rosile 2001, Clegg & Ross-Smith 2003) as cited in Stanley (2007). What is the role of power and politics in change management process? This phase of change management is often overlooked, yet it is the phase that often stops successful change from occurring. Politics in organizations is about power. Power is important among members of the organization when striving for the resources and influence necessary to successfully carry out their jobs.

Power is also important when striving to maintain jobs and job security. Power usually comes from credibility, whether from strong expertise or integrity. Power also comes from the authority of one’s position in the organization. Some people have a strong negative reaction when talking about power because power often is associated with negative applications, for example, manipulation, abuse or harassment. However, power, like conflict, exists in all human interactions and is not always bad. It is how power and conflict are used and managed that determine how power and conflict should be perceived.

Matters of power and politics are critically important to recognize and manage during organizational change activities. When we starts change management, we often mean shifts in power across management levels, functions and groups. To be successful, the change effort must recruit the support of all key power players, for example, senior management, middle managers who having strong expertise and those very junior employees who having the integrity. In our case the change has been driven by the executive director the most powerful mainstream of change management, his support should be the main key in our process of change.

It is wised to mention here the negative role of the director of the administration and financial affairs who was agreeing against any development showing no interest and cooperation with the committee members of change management. And the problem also was in his vital role in the organization, the was managing all day to- day operations in the hospital, and involving in everything related to internal and external inquirers, including administrative, financial, maintenance, general and patients services sections.

So the only way to manage his negative approach was in implementing Top-down leadership strategy. It is time to change, Nadler (1978) as cited in Patten (1992) argues that political behavior tends to be more intense in times of change as change upsetting the balance of power. Conger (2000) as cited in Eubanks (1992) argues the case of top down leadership by suggesting three advantages. The first advantage is where Top Management (like our executive director) acts like generals all employees including the like troops have a very limited perspective of the situation.

The second advantage is the legitimate power and formal authority that is attached to his position. The third advantage is the attribution of power and responsibility that is often bestowed on executive director. The best strategy was after that to ensure alignment of power with the change effort is to develop a network of power-players who interact and count on each other to support and guide the change effort. We have conducted deep analysis to identify the characteristics of our employees who have the high power and support us strongly and meanwhile who work as blockers against our process.

On the other hand we should be aware of those who does not have power but they do not support or support with minimal efforts. The reason behind this analysis is to identifying power and commitment to influence or increase support of our champions and on the side winning or reducing support of those who oppose the change as per figure (1) cited in Hayes (2010) on the next page. 4. 4. 5Organization Transitions This phase occurs when the organization works to make the actual transition from the current state to the future state. In consultations, this phase usually is called implementation of the action plans.

The plans can include a wide variety of “interventions,” or activities designed to make a change in the organization, for example, creating and/or modifying major structures and processes in the organization. These changes might require ongoing coaching, training and enforcement of new policies and procedures. In addition, means of effective change management must continue, including strong, clear, ongoing communication about the need for the change, status of the change, and solicitation of organization members’ continuing input to the change effort.

Ideally, the various actions are integrated into one overall Change Management Plan that includes specific objectives, or milestones, that must be accomplished by various deadlines, along with responsibilities for achieving each objective. Rarely are these plans implemented exactly as planned. Thus, as important as developing the plan, is making the many ongoing adjustments to the plan with key members of the organization, while keeping other members up-to-date about the changes and the reasons for them. 4. 5Alignment Assessment of effectiveness needs to be aligned up, down, and across the organization.

Indicators of individual and group effectiveness need to be aligned with indicators of departmental effectiveness which in turn need to be aligned with indicators of organizational effectiveness. On a cross functional basis, almost everything the organization does is covered within the 8s model of alignment. By using this model the organization leaders can anticipate what needs to be changed in order for the strategy to work. The underlying principals of 8s model is that different organization required different kinds of strategies, structure, system, style, resources, staffing, shared values and strategic performance (Higgins, 2005).

Below are the components of the 8s model and how it relates to our case: 1. Strategies and purposes: the new strategy is to become a competitive and accredited hospital. In order to achieve accreditation, a quality department was created to implement the changes. 2. Structure: In order to achieve the new strategy, a quality department was created to implement the change initiatives. 3. System and process: Review of the current process and making modification in order to achieve quality. For example, changing the process of handling incident report.

Reward system is not clearly defining to the hospital staffs; it should be modified to encourage innovation. As well as the communication could be improved by promoting an open system. 4. Leader ship style: As discussed above the impact leadership styles has on change and alignment. Leadership styles can be more performance oriented, by empowerment of the staff to get their focus on quality. The positive attitude of the executive director about the hospital success seen in the commitment to quality and prompting change. 5.

Staff: the biggest alignment challenge is to change staff attitude about quality and efficiency. The training program was a good introduction of the change initiative and gave staff an idea on way forward; however, there needs to be an ongoing communication in order to give a chance for everybody to get aligned with quality journey. In the interview with nurse supervisor and line manager they stated that the main challenge for implementing change was staff are not aware of the reasons for change, and the reasons were unclear.

If the urgency for change is not created and if the staff does not realize what is in it for them, then this can definitely cause obstacles in implementation and create resistance. 6. Resources: The two main challenges that Noor Hospital is facing is staff and time. Only one person heading and handling the quality initiatives may not be enough. There should be more than one staff to handle various initiatives and stages of awareness and implementation. The second challenge is time. Expecting result in a very short time, maybe stressful on staff.

In times of change, enough time needs to be given to individuals to adapt and follow the change process. 7. Shared Values: the core values and believes and how it influence the patient satisfactions, the culture of the hospital staff should be aligned with hospital strategy and to foster the quality culture, staff should be encouraged and empowered 8. Strategic performance: The overall organization as a whole strategic performance is quality and excellence. The initiatives are aimed to achieve such goals; however, there is no evidence yet to show the successful implementation of the initiatives.

As seen from the diagnosis about, Noor Hospital has misalignment in elements such as leadership style, staff, resources, shared values, which in turn effect the overall strategic performance. Mis-alignment can lead to failure especially misalignment of leadership style and culture. The failure to communicate is really the failure of leadership as one of the leaders key skill is communication. Thus the realignment action with appropriate style and cultural realignment is leading to success. (Higgins, 2005) 5Recommendation As we have reviewed Noor Hospital and related the theories of change to our case study.

We would like to make the following recommendation for future improvement of change management: 1. In order for Noor Hospital to break its deep structure we are recommending implementing radical change. 2. This change should be led by a strong leader who exhibits collective, consulting and participating leadership styles and begins by educating people, making them aware of the need for change and its positive outcomes and empowering individual in this process. This leader needs to work on putting its staff or departments to work together as a team. 3. One last recommendation which is the most important one is “alignment”.

In the 8s model we concluded that there is misalignment in Noor Hospital. Therefore, we recommend leaders to review the misalignment between leadership style, staff, resources, shared values, and ultimately the overall effect on strategic performance. 6Conclusion The key to any system’s prosperity and the long term survival is the quality of the fit (alignment) between all elements of system, because alignment promotes organizational effectiveness, whereas alignment of various systems reinforces rather than disrupt each other. The change can be enhanced by having all elements aligned together.

Noor Hospital’s mission to remain competitive and achieve accreditation can only happen when there is alignment between strategy and purpose, structure, systems and processes, leadership style, staff, resources, shared values and ultimately the strategic performance. Unfortunately, through our diagnosis, Noor Hospital has shown unsuccessful alignment which could be some of the reason for failure to implement and sustain the change. The report makes recommendations for Noor Hospital to consider in order achieve satisfaction of both internal customers (hospital staff) and external customers (patients). 7References

Burpitt, W. 2009. Exploration versus Exploitation: Leadership and the paradox of administration. Institute of Behavioural & Applied Management. Research Paper. Retrieved from www. ProQuest. com on April 8th 2011. Eubanks, P. 1992, “The CEO Experience: TQM/CQI”, Hospitals & Health Networks, vol. 66, no. 11, pp. 24 Hayes J. , 2007. The theory and practice of change management. 2nd ed. N. Y. : Palgrave Macmillan. Hayes J. , 2010. The theory and practice of change management. 3rd ed. N. Y. : Palgrave Macmillan. Higgins, J. 2005.. “The Eight ‘S’s of successful strategy execution’ Journal of Change Management, Vol. No. 1,3-13. Ministry of Health, Sultanate of Oman, 2005, First Version. The comprehensive manual of quality assurance standards in primary health care. Patten, T. H. , Jr. 1992, “Beyond Systems – The Politics of Managing in a TQM Environment”, Global Business and Organizational Excellence, vol. 11, no. 1, pp. 9 SHANLEY, C. 2007. Management of change for nurses: lessons from the discipline of organizational studies. Journal of Nursing Management, 15: 538–546. doi: 10. 1111/j. 1365-2834. 2007. 00722. x World Health organization (WHO) 1995: Used of standards and indicators in health care quality assurance.

WHO-EM/PHC/114/E/L, annex6. 8Appendix 1 – Quality Policy 9Appendix 2 – Organization Chart 10Appendix 3 – Interview with Executive Director Interview with the Executive Director 1. Regarding the pace of change, how do you see the hospital as a whole is experiencing the rapid change? Change is wanted given that all aspects are considered and the change is well planned. 2. What was the main reason or trigger for the change? New administrational changes at different levels 3. What were some of the challenges organization faced in implementing such change? mployee resistance plus some community pressure 4. What were some of the strength hospital has that aided in implementing change? Staff enthusiasm and well to change for the better 5. If you were to start over, would you have done anything differently? Why and why not? yes ,good planning 6. How widely accepted are the hospital goals among the all staff? Goals are well accepted but methods are the area of dispute 7. To what extent do senior managers make an effort to keep in touch with staff at all level in the hospital? There are semi regular meeting at different levels 8.

To what extent are the standard ways of operating in the hospital difficult to change? Very difficult to change what people are comfortable with and to introduce new plans need a lots of effort 9. To what extant is the hospital structure clear to everyone? Very clear 10. To what extant does your manager communicate in an open and direct manner? To reasonable extent 11. To what extent is communication mechanism in the hospital effective? Very limited 12. Where you work in the hospital, to what extant is there trust and mutual respect among the staff? Acceptable to a certain degree 13.

How challenged do you feel in your present job? very much 14. To what extent do you feel encouraged and reach higher levels and standards of performance in your work? Highly 15. I have a job that matters, (from disagree strongly to agree strongly)? strongly agree 16. To what extent is the hospital currently achieving the highest level of staff performance of which they are capable? very limited 11Appendix 4 – Interview with Director of Nurse Supervisor Interview with Nurse Supervisor 1. Regarding the pace of change, how do you see the hospital as a whole is experiencing the rapid change?

There is a resistance to change among staff and the top management. The staff that had gone for study and came back had faced a serious challenge from the direct supervisor or staff. 2. What was the main reason or trigger for the change? Increase number of incident, patient dissatisfaction, low staff performance, health services demands, 3. What were some of the challenges organization faced in implementing such change? People resistance to change, reason for change not clear, job demands, Staff shortage 4. What were some of the strength hospital has that aided in implementing change?

Reasoned for change clear to every body, increase in number of staff and clear job description and responsibility 5. If you were to start over, would you have done anything differently? Why and why not? Yes, because each person has their own idea and different thinking and the way you do things is differ from others. 6. How widely accepted are the hospital goals among the all staff? It is accepted among all staff from different department. 7. To what extent do senior managers make an effort to keep in touch with staff at all level in the hospital?

Few of them only keep in touch with staff in regular basis and take their opinion in different aspects 8. To what extent are the standard ways of operating in the hospital difficult to change? First of all let the people understand what is standard, then to follow the standard, and then think about changing it (top manager’s needs to change their thinking way towards the benefit of organization instead of their benefit) 9. To what extant is the hospital structure clear to everyone? Hospital structure is clear only for few people, for example to those who works in administration and hold a position. 10.

To what extant does your manager communicate in an open and direct manner? Manager communicate openly to most of staff but some of the concepts not clearly explained for staff to understand 11. To what extent is communication mechanism in the hospital effective? To some extent only, communication mechanism at all levels of hospital needs to be improved and we are working on it 12. Where you work in the hospital, to what extant is there trust and mutual respect among the staff? Between staff and staff there is a good trust and respect but between staff and top managers there is a gap needs to be improved 3. How challenged do you feel in your present job? It is challenged because holding a post in a place you didn’t have experience on it challenge you and your performance toward achieving goals and satisfaction of staff and patient. 14. To what extent do you feel encouraged and reach higher levels and standards of performance in your work? I try to reach high level in my performance, but of course there are so many challenge and obstacles to reach it. For example, no support from top managers, overload of works and limited time. 15.

I have a job that matters, (from disagree strongly to agree strongly)? Strongly agree to this statement and this makes me to work hard to achieve my goal and to give a good quality of performance 16. To what extent is the hospital currently achieving the highest level of staff performance of which they are capable? The staff performance level still not reached high level, and it is differ from one department to another. To reach highest level we need to have a clear standard and guidelines + clear hospital structure and support from top managers 12Appendix 5 – Interview with Line Manager

Interview with Line Manager 1. Regarding the pace of change, how do you see the hospital as a whole is experiencing the rapid change? Change is not much accepted, there is a resistance to among staff and the top management. Chance is not given to staff for creativity 2. What was the main reason or trigger for the change? The need for change came from increased health services demands, the number of incident, patient compliance because patient now knew how the care should be provided. 3. What were some of the challenges organization faced in implementing such change?

Reason for change maybe not clear to people so they resistance the change, 4. What were some of the strength hospital has that aided in implementing change? The hospital has talented staff, where they can be used for innovation creativity, and they knew their responsibilities. 5. If you were to start over, would you have done anything differently? Why and why not? Yes, the new way of handling the incident report gave a since of better way of doing things. . 6. How widely accepted are the hospital goals among the all staff? It is accepted among all staff from different department. . To what extent do senior managers make an effort to keep in touch with staff at all level in the hospital? Not all of managers are closed to their staffs, but there are regular departmental meetings where they can discuss their concern, and may take the staff concerns to higher level. 8. To what extent are the standard ways of operating in the hospital difficult to change? Staffs are not much oriented to the standards, but some supervisors are trying to keep their staffs updated by giving and asking their staffs to update themselves .

Top managers need to be committed to change because as a health care provider we should knew that frequently things changing and we need to work parallel to this chang, 9. To what extant is the hospital structure clear to everyone? Hospital structure is clear, only with some few people need to be enforced. 10. To what extant does your manager communicate in an open and direct manner? Most managers communicate openly and effectively to the staff but some of the change concepts not clearly explained to the staff. 11. To what extent is communication mechanism in the hospital effective?

To some extent only, communication mechanism at all levels of hospital needs to be improved and we are working on it 12. Where you work in the hospital, to what extant is there trust and mutual respect among the staff? To some extant only, we can say the trust is not at the level it should be especially with top managers trust is not as should be. 13. How challenged do you feel in your present job? Working in health field is challenging because of the environment of competition and new things which needs knowledge and experience and the performance toward achieving goals and satisfaction of staff and patient. 4. To what extent do you feel encouraged and reach higher levels and standards of performance in your work? To some extant but I try my best to reach high level in performance, but of course there are some obstacles to reach it. For example, no support from top managers, overload of works and. 15. I have a job that matters, (from disagree strongly to agree strongly)? Strongly I do agree to this statement it makes me to work hard to achieve my goal and to give high performance 16. To what extent is the hospital currently achieving the highest level of staff performance of which they are capable?

The staff performance is not in high level, there should be guidance to the procedure. 13Appendix 6 – Minutes of meetings Our first group meeting was done in class where we drew a sketch of the organization to try to understand the structure and what were the main issue. See below. After that most of our communication continued via e-mail where an outline was made and team members assigned to specific sections to research and write on. Then all the parts were put together to ensure flow.