HLTH 4100 Week 9 Stalled Change Analysis Paper Example

Announced in March, Half-Done by June: A Change Analysis of the Stalled Thirty-Minute Admission Acceptance Rule and Where Kotter's Steps Were Skipped

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Walden University

HLTH 4100: Healthcare Organization Theory and Behavior

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Month Day, Year

Announced in March, Half-Done by June: A Change Analysis of the Stalled Thirty-Minute Admission Acceptance Rule and Where Kotter's Steps Were Skipped

The Change That Stalled

In March, the hospital's chief nursing officer announced a new rule: inpatient units must accept an admitted emergency department patient within 30 minutes of a bed being assigned, unless the charge nurse documents a safety reason. The announcement came by email, followed by a slide at the nursing leadership meeting. By June, the quality department's data showed that 31% of admissions met the 30-minute standard, up from 22% before the rule but far from the goal. Median acceptance time had fallen from 95 minutes to 78. Charge nurses documented a safety reason for most delays, often the same reason: shift change in progress. The change had been announced successfully and implemented halfway. This paper explains the stall using Kotter's model of leading change and Lewin's earlier model, and proposes how to restart it.

The Models

Lewin (1947) pictured change in three phases, in which an old habit is first loosened, then replaced, then made to stick. Kotter (1996) later laid out an eight-step sequence, from building urgency and assembling a guiding group through vision, communication, clearing obstacles and early wins to consolidating and embedding the change in the culture, and he argued that skipped steps explain many failures. The value of a model here is that it gives a checklist for asking which steps were done and which were skipped.

Where the Steps Were Skipped

Urgency. The announcement cited boarding data from the monthly quality report. But unit staff did not see that report, and nothing in their daily work showed them the patients waiting downstairs. Urgency existed at the leadership level, not on the units. In Lewin's terms, the old pattern was never unfrozen where it mattered.

Guiding coalition. The rule was designed by the chief nursing officer and the emergency department director. No unit charge nurses, the people who would carry it out, were involved, and neither was the veteran day charge nurse whose informal influence the power analysis identified. Without a coalition that included the people with influence on the units, the rule had authority but not support.

Removing obstacles. The most obvious obstacle, the unwritten norm against accepting patients during shift change, was not addressed. The rule allowed a documented safety reason for delay, and charge nurses used shift change as that reason. The rule thus accommodated the very practice it was meant to change.

Short-term wins. The improvement from 22% to 31% was real but was not shared with the units. Staff did not know their efforts were having any effect.

Steps three and four, vision and communication, were partly done: the vision was clear but was communicated once, by email.

What the Units Said About the Rule

When I asked six charge nurses about the 30-minute rule in June, their responses fell into three groups. Two said they supported the goal but had never been asked how it could work on their unit. Three said the rule did not account for shift change, staffing shortages or patients who arrived unstable, and that documenting a safety reason was the only way to protect themselves. One said she had not known the rule was still in effect, because no one had mentioned it since the email in March. None described the rule as a priority of their own. Those answers match the steps the change skipped: no coalition that included them, no attention to their obstacles and no ongoing communication.

What the Stall Reveals About the Organization

The stall is consistent with everything this course has found about the hospital. The structure gives no one below the vice presidents authority across units, so the rule was issued from the top and left to charge nurses to interpret. The culture treats a patient as the unit's concern only on arrival and treats cross-unit authority as suspect, so a rule from above was met with quiet accommodation rather than open resistance. The informal power map shows that influence on the units sits with a few experienced nurses, none of whom were asked to help. A change that ignores structure, culture and power is likely to stall at exactly the point where it meets them, which is what happened.

How to Restart the Change

Create urgency on the units. Post each unit's own daily boarding hours, the time its admitted patients waited downstairs, on the unit huddle board, alongside its falls and pressure injuries.

Build a coalition that includes the units. Ask the veteran day charge nurse, a night charge nurse from the most cohesive night team and the hospitalist lead to join a small working group that redesigns the rule with the emergency department director.

Remove the shift-change obstacle directly. Ask the working group to solve the shift-change problem rather than allow it as an exception, for example by holding report for an arriving patient until the admitting nurse is settled, or by having the outgoing nurse receive the patient.

Generate and share short-term wins. Report weekly to each unit how many of its admissions met the standard and recognize the units that improve most.

Anchor it. Once performance holds above 70% for two months, add the measure permanently to unit dashboards and to nurse managers' annual goals, which Kotter's final step requires and which the structure analysis also recommended.

What the Models Do Not Explain

Change models describe steps but say little about whether a change is right. The working group may find that a 30-minute standard is unsafe at some hours and propose a different one. A good change process should allow for that, which means the coalition needs real authority to adjust the rule, not just to promote it. Organization theorists caution that stage models can make change look more orderly than it is (Scott & Davis, 2007). The hospital should expect the restarted change to move unevenly and should measure it monthly rather than declaring success at the next leadership meeting.

References

Kotter, J. P. (1996). Leading change. Harvard Business School Press.

Lewin, K. (1947). Frontiers in group dynamics: Concept, method and reality in social science; social equilibria and social change. Human Relations, 1(1), 5-41. https://doi.org/10.1177/001872674700100103

Scott, W. R., & Davis, G. F. (2007). Organizations and organizing: Rational, natural, and open system perspectives. Pearson Prentice Hall.