1. The Problem With Satisfied Patients

    May 27, 2015 by BPIR.com Limited

    Originally posted on the Aatlantic by Alexandra Robbins

    When healthcare is at its best, hospitals are four-star hotels, and nurses, personal butlers at the ready—at least, that’s how many hospitals seem to interpret a government mandate.

    When Department of Health and Human Services administrators decided to base 30 percent of hospitals’ Medicare reimbursement on patient satisfaction survey scores, they likely figured that transparency and accountability would improve healthcare. The Centers for Medicare and Medicaid Services (CMS) officials wrote, rather reasonably, “Delivery of high-quality, patient-centered care requires us to carefully consider the patient’s experience in the hospital inpatient setting.” They probably had no idea that their methods could end up indirectly harming patients.

    Beginning in October 2012, the Affordable Care Act implemented a policy withholding 1 percent of total Medicare reimbursements—approximately $850 million—from hospitals (that percentage will double in 2017). Each year, only hospitals with high patient-satisfaction scores and a measure of certain basic care standards will earn that money back, and the top performers will receive bonus money from the pool.

    Patient-satisfaction surveys have their place. But the potential cost of the subjective scores are leading hospitals to steer focus away from patient health, messing with the highest stakes possible: people’s lives.

    The vast majority of the thirty-two-question survey, known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) addresses nursing care. For example, in a section about nurses, the survey asks, “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”

    This question is misleading because it doesn’t specify whether the help was medically necessary. Patients have complained on the survey, which in previous incarnations included comments sections, about everything from “My roommate was dying all night and his breathing was very noisy” to “The hospital doesn’t have Splenda.” A nurse at the New Jersey hospital lacking Splenda said, “This somehow became the fault of the nurse and ended up being placed in her personnel file.” An Oregon critical-care nurse had to argue with a patient who believed he was being mistreated because he didn’t get enough pastrami on his sandwich (he had recently had quadruple-bypass surgery). “Many patients have unrealistic expectations for their care and their outcomes,” the nurse said.

    In fact, a national study revealed that patients who reported being most satisfied with their doctors actually had higher healthcare and prescription costs and were more likely to be hospitalized than patients who were not as satisfied. Worse, the most satisfied patients were significantly more likely to die in the next four years.

    Joshua Fenton, a University of California, Davis, professor who conducted the study, said these results could reflect that doctors who are reimbursed according to patient satisfaction scores may be less inclined to talk patients out of treatments they request or to raise concerns about smoking, substance abuse, or mental-health issues. By attempting to satisfy patients, healthcare providers unintentionally might not be looking out for their best interests. New York Times columnist Theresa Brown observed, “Focusing on what patients want—a certain test, a specific drug—may mean they get less of what they actually need. In other words, evaluating hospital care in terms of its ability to offer positive experiences could easily put pressure on the system to do things it can’t, at the expense of what it should.”

    As a Missouri clinical instructor told me, “Patients can be very satisfied and dead an hour later. Sometimes hearing bad news is not going to result in a satisfied patient, yet the patient could be a well-informed, prepared patient.”

    * * *

    How far will a hospital go to satisfy a patient? Recently, some have rushed to purchase extra amenities such as valet parking, live music, custom-order room-service meals, and flat-screen televisions. Some are offering VIP lounges to patients in their “loyalty programs.”

    And because almost every question on the survey involves nurses, some hospitals are forcing them to undergo unnecessary nonmedical training and spend extra time on superfluous steps. Perhaps hospitals’ most egregious way of skewing care to the survey is the widespread practice of scripting nurses’ patient interactions. Some administrators are ordering nurses to use particular phrases and to gush effusively to patients about both their hospital and their fellow nurses, and then evaluating them on how well they comply. An entire industry has sprouted, encouraging hospitals to waste precious dollars on expensive consultants claiming to provide scripts or other resources that boost satisfaction scores. Some institutions have even hired actors to rehearse the scripts with nurses.

    In Massachusetts, a medical/surgical nurse told The Boston Globe that the scripting made her feel like a “Stepford nurse,” and wondered whether patients would notice that their nurses used identical phrasing. She’s right to be concerned. Great nurses are warm, funny, personal, or genuine—and requiring memorized scripts places a needless obstacle in their path.

    The concept of “patient experience” has mischaracterized patients as customers and nurses as automatons. Some hospital job postings advertise that they are looking for nurses with “good customer-service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.”

    By treating patients like customers, as the nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right. “Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.” Some hospitals have hired “customer-service representatives,” but empowering these nonmedical employees to pander to patients’ whims can backfire. Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milkshakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.

    More disturbing, several health systems are now using patient satisfaction scores (likely from hospitals’ individual surveys) as a factor in calculating nurses’ and doctors’ pay or annual bonuses. These health systems are ignoring the possibility that health providers, like hospitals, could have fantastic patient satisfaction scores yet higher numbers of dead patients, or the opposite.

    * * *

    On the nursing blog Emergiblog, one nurse reported that at a hospital that switched its meal service to microwaved meals, food-service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better.

    This applies to scripting, too: It does not improve healthcare, but makes it sound better. The University of Toledo Medical Center (UTMC) launched an entire program based on patient satisfaction, iCARE University, which mandated patient satisfaction course work and training for every university student and employee. “Service Excellence Officer” Ioan Duca told a publication sponsored by Press Ganey, a company that administers the surveys for hospitals, “I am really focused on creating a church-like environment here. We want a total cultural transformation. I want that Disney-like experience, the Ritz Carlton experience.”

    But hospitals, too, can offer poor care and still get high patient-satisfaction ratings, and an alarming number of them do. I examined Medicare’s provider data for thousands of hospitals—the data on every hospital in the country that the agency makes publicly available. I found the hospitals that perform worse than the national average in three or more categories measuring patient outcome. These are hospitals, in other words, where a higher number of patients than average will die, be unexpectedly readmitted to the hospital, or suffer serious complications. And yet two-thirds of those poorly performing hospitals scored higher than the national average on the key HCAHPS question; their patients reported that “YES, [they] would definitely recommend the hospital.”

    UTMC is a good example of how an emphasis on patient satisfaction does not make for better care. At the time of this writing, according to government data on hospitals’ rates of readmissions, complications, and deaths, UTMC appeared to be among the worst performers in the state, if not the country. UTMC has higher than average rates of serious blood clots after surgery, accidental cuts and tears from medical treatment, collapsed lungs due to medical treatment, complications for hip/knee replacement patients, and, more generally, “serious complications.” In addition, UTMC made headlines in 2013 when, during a transplant operation, hospital staff threw away a perfect-match kidney that a patient was donating to his sister.

    Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare.

    But research has shown that hiring more nurses, and treating them well, can accomplish just that. It turns out that nurses are the key to patient satisfaction after all—but not in the way that hospitals have interpreted.

    A Health Affairs study comparing patient-satisfaction scores with HCAHPS surveys of almost 100,000 nurses showed that a better nurse work environment was associated with higher scores on every patient-satisfaction survey question. And University of Pennsylvania professor Linda Aiken found that higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health. Failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, the quality of care really does get better.

    Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.

  2. South African Quality Institutes latest news

    April 26, 2015 by BPIR.com Limited

    South African Quality Institute (SAQI) http://www.saqi.co.za is the national body that co-ordinates the Quality effort in South Africa. Their monthly newsletter is an excellent source of information to keep up with the latest quality issues in South Africa.


    • The Customer Driven Organization: Employing the Kano Model, by Lance B. Coleman
    • Quality Qualification progress in South Africa, by Paul Harding
    • The Cost of not developing skills, by Jacques Snyders
    • Sustainability depends on a strong Governance Framework, by Terrance M. Booysen
    • Jumping kids is ability, by Jacques Snyders
    • Quinton has learnt Quality principles, by Richard Hayward

    Click here to download download this newsletter.








  3. Catch My Draft? Dissecting the ISO 9001:2015 draft international standard

    March 16, 2015 by BPIR.com Limited

    originally posted on Quality Progress by R. Dan Reid

    As you probably know, ISO 9001, the fundamental international quality management system (QMS) standard, is being revised. It is at the draft international standard (DIS) stage at the time of this column’s publication and due to be released in September 2015. Figure below shows the revision timeline.

    This article discusses some content in the current draft, but remember that changes still may be forthcoming, so you should not proceed too far with implementation of new content in the standard at this time.

    Vertical alignment
    It’s important to realize not everything in the new version of ISO 9001 is changing. The 2012 global user survey that was conducted to determine whether a revision to ISO 9001 was needed indicated a majority of users believed the standard was acceptable as-is or with slight modification.

    The support for change came largely from within the International Organization for Standardization (ISO) community, when a small task force recommendation to use a new and mandatory clause structure was supported by the ISO technical management board.

    The purpose of this support was to drive standardization among new or revised ISO management system standards, such as those related to quality, the environment, and occupational health and safety. The adopted proposal has been incorporated into the ISO directives, known as Annex SL, and also requires use of some common text under the required clause structure.1

    Some carryover content between the ISO 9001:2008 and ISO/DIS 9001:2015 has to do with the clauses involved in vertical alignment. Many organizations, including those that certify and implement QMSs, do not understand the critical role and linkage of the clauses as intended by the standard writers.

    The first process is to determine customer needs and expectations, which is located in two clauses of the new draft titled, Clause 4.2—Understanding the needs and expectations of interested parties, and Clause 5.1.2—Customer focus. There are three sources of specified requirements for organizations:

    1. Internal (for example, engineering).
    2. External (statutory and regulatory).
    3. External (customers).

    The DIS addresses the external requirements in these clauses, which are then input for the quality policy. There are requirements for top management related to the quality policy in ISO 9001—one of which necessitates a commitment to meet applicable specified requirements.

    W. Edwards Deming said management commitment to quality is insufficient without its also knowing what must be done to achieve quality. With ISO 9001 being the minimum set of requirements for a functional QMS, the QMS does not go that far. Without an effective process to determine customer requirements—the quality policy—effectiveness of the QMS is compromised. The quality policy is intended to drive conformance with specified requirements, as well as drive continual improvement of the QMS.

    Note that in ISO 9001, continual improvement of products and services is not required because it would be difficult—if not impossible—for regulated industries to meet that requirement under the current regulatory environment. Continuing suitability of the quality policy is to be reviewed in formal management review meetings.

    Quality objectives are to be established and to be consistent with the quality policy. The DIS defines an objective as a result to be achieved. Objectives start at the enterprise level to address the external specified requirements, such as regulatory and customer-related ones. There are generally five to 10 high-level objectives.

    More detailed objectives, however, are to be deployed to relevant levels and functions within the organization to support the enterprise-level objectives, which are meant to drive conformance with requirements. Objectives are required to be relevant to product and service conformity and to the enhancement of customer satisfaction, and they must be measurable.

    Objectives are part of planning the QMS, but after objectives are met, they should be revised to drive continual improvement. The need for adjustment of the objectives also should be evaluated in the management review process. The current standard lists the clauses in this order, but the revised draft lists objectives after planning, which arguably does not make as much sense. The process for setting objectives and flowing them to relevant levels and functions in the organization is a key driver of continual improvement in the standard. Organizations that do not use objectives in this manner are missing key value in the QMS implementation.

    Objectives are meaningless without plans to achieve them. Plans must list who is going to do what and at what time in the project or process, the required resources and how progress will be measured along the way. Resource determination should be made using data, taking into consideration workload on existing employees, budget and resource availability.

    Risks also must be considered in developing plans to ensure they are adequately prevented or mitigated by the QMS. Use of risk identification and quantification tools is recommended to appropriately prioritize efforts, based on data. Emphasis should be on error-proofing processes to prevent problems from occurring because detection is not as effective as it should be.

    Plans should be reviewed for adequacy prior to release. Plans are developed with some expected end in mind. Ask: Does that end go far enough to meet specified requirements and drive continual improvement? Sometimes, it is known up front that the plans are not adequate to achieve the objectives. When this is the case, management should approve and consider revising the objectives.

    Note that the clause on preventive action in the current ISO 9001 standard is not included in the draft revision. It was associated with the current corrective action clause, which is not truly an effective planning function. Current thinking is that planning the QMS up front is the best preventive action, making a clause linked to corrective action unnecessary.

    After sufficient plans are in place, metrics are needed to monitor progress in achieving the objectives and specified requirements. Just as objectives are set at the enterprise level and deployed to relevant levels and functions in the organization, so must the metrics be set. They must be in place at relevant functions and levels, and for products and processes that can affect quality or delivery. There should be leading, contemporaneous and lagging indicators to adequately monitor the progress of plans being carried out across the organization.

    Data for control charts in high-volume production processes are collected in real time, but a control chart can forecast future process performance if the process is statistically stable. If you have enough data and the process is stable, you can also accurately predict nonproduction process performance, such as achievement of annual cost savings. Lagging indicators, such as those about warranty issues and customer satisfaction, are also important to monitor and react to when necessary.

    With regard to customer satisfaction, many organizations track metrics that are actually indicators of customer dissatisfaction, such as complaints, returns and parts per million (ppm) defects. The assumption is that if these metrics show low occurrence, customer satisfaction is achieved, but this is not necessarily so.

    Your product or service performance may not be bad enough to cause a customer complaint, return or high ppm, but the danger is that a competitor may be satisfying and delighting customers, and your organization would not be able to detect this if it is tracking only customer dissatisfaction metrics.

    Looking at the ISO 9001 DIS, many of the core concepts remain unchanged from the current standard. The changes that are being proposed provide an opportunity to implement the existing requirements more effectively to add value to the organization and not just implement a QMS because customers require it.

  4. Integrated Management Systems: Unleashing the power of ‘ONE’

    March 13, 2015 by BPIR.com Limited


    Originally posted on LinkedIn by Sithandilizwe Sly Malunga

    PART I: What is the Integrated Management System (IMS)?


    In addition to delivering profits for their shareholders, companies around the world are increasingly being required to conform and comply with statutory, regulatory and other requirements in order to stay in business.

    Statutory requirements compel organisations to comply with local and national legislature e.g. Acts of Parliament, Local Authority By-Laws and related regulations in the regions or countries within which they operate.

    Other requirements include but not limited to industry codes and regulations such as UK Corporate Governance Code (United Kingdom), King Code of Corporate Governance (South Africa); national and international standards such as ISO 9001 Quality Management System, ISO 14001 Environmental Management System, OHSAS 18001 Occupational Health and Safety Assessment Series etc.; national and international accounting standards and international treaties and protocols such as those emanating from regional and international groupings such as the Common Market for Eastern and Southern Africa (COMESA), European Union (EU), United Nations (UN).

    In practise, an organisation will invest vast amounts of money, time and human capital in order to implement systems that will enable them to comply or conform with the diverse requirements stipulated upon them. Implementing a singular set of requirements can be simple and straightforward and with prudent project management costs are manageable. However, it can becomes complex when an organisation has to implement and comply with two or different more sets of requirements. It usually means two separate projects running concurrently which may result in exorbitant project costs as the projects are managed and funded separately; more time is needed for audits; awareness sessions and other processes related to implementation and maintenance as these should be done separately. As such some organisations particularly regional and global transnational conglomerates are increasingly exploring and leaning towards the implementation of integrated management systems in order to optimise on resource usage during the implementation and maintenance of statutory, regulatory and other requirements as discussed above.


    The scope of this article will be limited to the integration of ISO standards/management systems in particular:

    • ISO 9001- Quality Management System- Requirements;
    • ISO 14001- Environmental management systems – Requirements with guidance for use;
    • OHSAS 18001- Occupational health and safety management systems – Requirements;
    • ISO 31000- Risk Management -Principles and guidelines;
    • ISO22301-Societal security – Business continuity management systems – Requirements;
    • ISO 50001- Energy management systems – Requirements with guidance for use;
    • ISO 27000- Information technology – Security techniques – Information security management systems – Requirements ;
    • ISO 26000- Guidance on social responsibility; and
    • ISO 22000- Food safety management systems – Requirements for any organization in the food chain.
    • In addition, the article will attempt to show how other requirements, tools and techniques such as the Lean Six Sigma methodology, King Code of Corporate Governance, UK Corporate Governance Code, national and local legislation etc. can be blended into an IMS to drive continual improvement and enhance the effectiveness of compliance controls.


    An “Integrated Management System (IMS) is a management system that integrates all of an organisation’s systems and processes in to one complete framework, enabling an organisation to function as a single unit with integrated goals and objectives.”

    An integrated management system (IMS) integrates several related processes of an organisation into a single system for simpler implementation, management and maintenance. Most commonly incorporated into an IMS are ISO 9001 – Quality Management System), ISO 14001-Environmental Management System, and Occupational Health & Safety management systems. The approach is not just to link these management systems discretely, but to identify similar requirements and processes and establish how they interact so that they are seamlessly integrated, managed and executed without replication. The IMS model allows for resources common to all the systems to be pooled together and used optimally for the implementation and maintenance of management systems

    Drivers for implementation

    Organisations will have different reasons to implement management systems in their operations. Common drivers for implementation are wide-ranging and can be classified into four categories namely Enterprise, People, Market and Corporate citizenship. These drivers include but not limited to the following:

    In addition, the figure below depicts how different management systems can be applied to specific areas or objectives of an organisation with a view to positively impact stakeholder value.

    Benefits of implementing an IMS

    The implementation and maintenance of an IMS within an organisation has several benefits. Some of these are listed below:

    • Enhanced compliance and conformity to statutory, regulatory and other requirements;
    • Savings in cost and time as review meetings, audits, procedures for different management system are integrated.
    • Improved competitive advantage;
    • Increased customer satisfaction;
    • Improved profitability and shareholder value;
    • Fostering cross functional teamwork ( No more silos)
    • Business objectives and targets becomes more understandable across all levels of the organisation;
    • Effective cross-functional problem solving;
    • Communication, consultation and participation within the organisation is improved;
    • Duplication of processes, procedures and efforts is eliminated; and
    • Incorporation of additional compliance and conformity requirements is easier to implement and manage going forward.
    • This article will run over six parts with one part published on a weekly basis for the next six weeks.

    Part II will cover the implementation of IMS with a focus on process-based and risk –based implementation methodologies. This second part of the article will also explore the different approaches to implementation within an enterprise taking into consideration organisational culture, size of enterprise, nature of risks to which the organisation is exposed to and cost efficiency among other factors.

    For Part II of the article please click the link below:

    For Part III of the article please click the link below:

  5. Managing Resistance to Improvement

    February 26, 2015 by BPIR.com Limited

    Originally posted on LinkedIn by John Schultz

    Why Improvements Can Produce Anxiety

    Systems and processes exist in their current state because someone got them to that level of refinement. Flawed and inconsistent as these practices may now appear, at some point in the past, an effort—possibly heroic—was made to coordinate activities and relationships to create a sense of order.

    Then over time those involved learned to compensate for gaps and made the system operational. In turn, these employees built a mental model about who they were and what they could do based on this arrangement for getting work done. Proposed improvements often threaten these mental pictures and create self-doubt because the new way of operating will require skills and social structures that are not familiar. The thought of uncertainty then produce anxious feelings about loss of identity, loss of position, and loss of face that give rise to guarded behavior.

    These fears may take many forms from negative attitudes to active sabotage, and may become evident through reduced productivity, decreased quality, increased absenteeism, and produce increased grievances. The following are typical sources for anxiety:

    • Comfort with current operations: The old way for getting work done has been in place for some period of time, and seems to be working fine. Process operators and stakeholders don’t see a need to “reinvent the wheel.”
    • Doubt about the need and vision for improvement: There is uncertainty about the reason behind proposed improvements and how existing work structures and relationships will be impacted. The question—“what’s in it for me?”—has not been adequately answered.
    • Concern over loss: There is a perceived fear over how improvements will affect acquired skills, salary, status, quality of work, or other benefits attributed to the existing process.
    • Organization’s past history: Past proposals for improvement have been poorly handled—muddled implementation, lack of resources, inadequate training, or the eventual abandonment of activities—only to have remedies replaced by another “program of the month.”
    • The proposed improvement is flawed: There is a realization that the new way for operating has real problems that will ultimately create difficulty in the current or adjacent processes.

    Helping People Deal with Concerns over Improvement

    People confronted by altered circumstances frequently experience grief and will go through a distinct conversion process before taking on their new roles. The length of time at each stage varies depending on the situation, the type of support provided, and individual adaptability. Each step has its own set of recognizable characteristics. Accepting and understanding these stages will provide an opportunity for the project team—as agents of improvement—to reduce resistance and move system improvements forward.

    The following is an adaptation of Lynn Fossum’s thinking on behavior patterns people will go through upon encountering situation-altering events. This process is based on studies done by Elizabeth Kübler-Ross, who primarily worked with people confronted by mortality. However, she also observed that similar behaviors occurred for people wrestling with other types of loss.

    • Indifference: A belief that a proposed change will make little difference and nothing new is really going to take place. Or when it does, individual interests will be taken care of. As a result, work continues as usual.
    • Opposition: There is a realization that the old way of doing things will not work, and new rules apply. There is an active pushback to maintain old and familiar routines.
    • Consideration: A recognition that changes are starting to affect people’s work. Adaptations are required to reduce confusion. By modifying and tailoring work processes, some things begin to function better.
    • Cooperation: The new process begins to exhibit some successes. Workgroups can see results. The skeptics and cynics are proven wrong and leave or buy in.

    Although the urge to push new ideas upon a process without reflection can be tempting, doing so often works to undercut the improvement effort. Modifications that plan for and manage human relations concerns with the same attention as practical matters have a much better chance of being accepted. People experiencing change are less likely to feel intimidated when they can understand and anticipate how alterations may impact their work and ability to contribute. A pragmatic approach is generally viewed as less daunting and more acceptable. To be successful, improvement activities should include practices that reduce resistance and anchor the proposed improvement so others are not confronted with the same problem at some point later on.

    The resulting dilemma, therefore, when making improvements is not the technical aspects of change, but dealing with the human behavioral issues that are inevitably encountered. By not taking the time to consider stakeholder needs and circumstances, a well-crafted solution can fail to gain traction while process operators and supervisors come to grips with new and unfamiliar concepts. People who work in and manage the process then become grousing skeptics, procrastinators, and even active resistors. Due to frustration, improvements are half-heartedly accepted without creating a sense of ownership and a lasting impact.

    Groups affected by change need to be part of the decision-making and allowed to work their way through developments. The inclusion of workgroups can consume valuable time and create frustration for change agents; nevertheless, people will almost certainly not modify attitudes and behaviors because they were told, pushed or warned. Being an agent for change has contingencies, and one of them is followers. In most organizational and social-political settings people have options. They can quit, go on strike, reduce their output, protest and sabotage directives, or engage in a campaign to overthrow the status quo and gain control. Ultimately, change needs to be more than a spectator pursuit.

    Techniques for Dealing with Resistance to Improvements

    Fear and anxiety are a natural response to change, but they can be dealt with. However, this requires an atmosphere of openness where people can speak their mind and be listened to. The key to coping with resistance is to understand those affected by reforms and then actively take steps to address their issues.

    When there is abnormal resistance to a proposed improvement, it should be a signal that something may have been missed. Mistakes may have been made, concerns may not have been satisfactorily handled, or the proposal may not have been adequately presented and thus may have been misunderstood. The choice of responses and techniques that might be applied are multiple and somewhat dependent on the personal perspective of the individuals involved and the challenges encountered.

    The following strategies adapted from John Kotter and Leonard Schlesinger (1979) are methods for dealing with resistance to change. Any or all may be used depending on the situation. Each technique has situational uses and produces consequences that can have both favorable and unfavorable outcomes:

    • Two-way communication: Used when there is the assumption that information is lacking, inaccurate or being poorly analyzed. Involves listening to employee concerns and providing precise information.
    • Group participation and decision making: Ensures that those affected by the change have input into the design and realization activities. Employee groups take an active role in the implementation process.
    • Education and training: Special attention is paid to people’s needs and concerns through team building, confidence building and training to ensure skills are sufficient for alterations in responsibility.
    • Negotiation and bargaining: Through a process of open discussion, modifications are made to proposed changes. The rate of implementation and issues dealing with employee welfare are usually negotiated.
    • Economic incentives: Some form of compensation is provided to reduce losses that result from the change. Guarantees against the loss of wages and commissions also may be used in this case.

    Unfortunately, the pressure to get something done and move on often leads to transformational approaches that do not produce buy-in, but instead promote compliance in a situation in which continuing relations between levels of authority can become adversarial. Although expedient, such actions can destroy trust, undermine future relationships, create a strong feeling of loss and set the stage for whistle blowing and sabotage.