How to Change an Organization Without Blowing It Up - GreenProf

WINTER 2013
VOL.54 NO.2
Karen Golden-Biddle
How to Change an
Organization Without
Blowing It Up
REPRINT NUMBER 54213

CHANGE MANAGEMENT
How to Change an
Organization Without
Blowing It Up
There is a middle ground between wholesale change and
tentative pilot projects — and it could allow your organization
to operate far more effectively.
BY KAREN GOLDEN-BIDDLE
TOO OFTEN, conventional approaches to organizational transformation resemble the Big Bang
theory. Change occurs all at once, on a large scale and often in response to crisis. These approaches
assume that people need to be jolted out of complacency to embrace new ideas and practices. To
make that happen, senior management creates a sense of urgency or takes dramatic action to trigger
change. Frequently, the jolt comes from a new CEO eager to put his or her stamp on the organization.
Yet we know from a great deal of experience that Big Bang transformation attempts often fail,
fostering employee discontent and producing mediocre solutions with little lasting impact. 1
But meaningful change need not happen this way. Instead of undertaking a risky, large-scale
makeover, organizations can seed transformation
by collectively uncovering
“everyday disconnects” — the disparities
between our expectations about how work is
carried out and how it actually is. The discovery
of such disconnects encourages
people to think about how the work might
be done differently. Continuously pursuing
these smaller-scale changes — and then
weaving them together — offers a practical
middle path between large-scale transformation
and small-scale pilot projects that
run the risk of producing too little too late.
Researchers tend to overlook this option
because few managers have employed
it until recently, assuming they needed to
take an all (Big Bang) or small (pilot projects
sequestered away from the dominant
organizational culture) approach to organization
change. That may have been more
true in the past when organization boundaries
were less malleable, communication
Health-care employees
can identify new ways to
improve patient care.
THE LEADING
QUESTION
What increases
the
odds of
successful
organizational
change
FINDINGS
There is a middle
path between a
risky, large-scale
makeover and limited
pilot projects.
Look for disconnects
between how you
expect work to be
done and how it
actually is done.
Determine how to
turn the inevitable
surprises you and
your organization
discover into opportunities
for change.
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CHANGE MANAGEMENT
ABOUT THE
RESEARCH
This article is based on
ideas developed from
more than 25 years of
research, i teaching and
conducting executive education
and consulting in
the theory and practice of
large-scale change.
The research I have conducted
comprises three
large, multiyear and multisite
ethnographies — a
Fortune 200 manufacturing
organization, a large nonprofit
service organization
and a provincial health-care
system in Canada — as
well as interview-based
investigations of organizations
undergoing large-scale
change, including Theda-
Care. The ideas have been
refined and tested in executive
education sessions
with, for example, the
company Ericsson and
the American Society of
Health System Pharmacists,
as well as in MBA
and EMBA courses.
more difficult and people less mobile. However,
today’s complex and connected global environment
makes step-by-step transformation by
managers inside most organizations a real possibility,
if senior leaders recognize and help cultivate
their employees’ collective capability to discover
everyday disconnects. Organizations can practice
uncovering these disconnects on a scale extensive
enough to make a real difference, yet at a rate that
keeps the effort focused and manageable within
budgetary and time constraints.
My research has found that organizations take
three approaches to discovery that are particularly
effective both for uncovering everyday disconnects
in their work and for seeding transformation from
the bottom up. (See “About the Research.”) These
techniques can be used together, in any combination,
or individually. All three techniques share a
common trait: They take rigid, prescriptive activities
like work design, best practices or training;
strip them of their chief assumptions; and turn
them into powerful instruments for finding new
and better ways of getting things done.
The three techniques are:
1. Work discovery: Instead of assuming that you
know how work is designed, examine it firsthand as
it is actually conducted. Determine how to turn the
(inevitable) surprises you uncover into assets.
2. Better practices: Instead of simply adopting
other organizations’ best practices, screen the way
work gets done in your organization through those
best practices in order to generate new ideas. In
other words, use best practices to generate even
better practices.
3. Test training: Instead of locking down standard
operating procedures during training,
experiment with other, potentially better possibilities
for changing the way the work will get done.
Use training for testing these possibilities.
Each technique strips away assumptions and
gains additional power by pairing something unfamiliar
with something familiar. Work discovery
pairs the familiar territory of managers’ offices with
the less familiar territory of frontline operations. A
focus on better practices imports the unfamiliar
into the organization via others’ practices and pairs
them with the (familiar) way work is currently
being done. Test training pairs new standard operating
procedures with possible new procedures that
emerge during training. Such pairings prompt people
to look beyond familiar expectations and see
the actual work in light of the possible instead of
just the prescribed or presumed. By using these
techniques, people throughout an organization can
collectively surface everyday disconnects, see new
possibilities in deeply familiar contexts and generate
new ways of working. As a result, improvement
multiplies methodically, reliably and continuously,
and you can achieve continuous, sustainable
change in the organization without having to blow
it up and then reassemble the pieces.
The Three Discovery Techniques
Generating new possibilities for organizational
change requires a collective capacity to see beyond
what is currently done. Yet moving past what we expect
to see and identifying new possibilities is not a
capability that has been cultivated widely, either by
individuals or by organizations. Absorbed in our
everyday work, we overlook possibilities right in
front of us. That’s a problem. After all, renowned
management thinker Peter Drucker once explained
his ability to generate insights by saying simply, “I
just look out the window and see what’s visible —
but not yet seen.” 2 As Drucker suggested, the ability
to see past what is currently seen — and, in the
workplace, currently done — is essential for transformation.
Fostering this capability begins with
implementing discovery techniques.
Work Discovery: Examine Firsthand the Work
Where It Is Actually Conducted Seeing the organization’s
work as it is conducted by people on the
front lines takes senior managers and others out of
their familiar habitats and enables them to compare
close-up observations of the work with their expectations,
uncovering disconnects in the process.
Consider, for example, how people in ThedaCare
Inc., a medium-sized community health system in
Wisconsin, created a new model of inpatient care.
Known as collaborative care, the model has garnered
national visibility for its exceptional quality and
safety, as well as patient and clinician satisfaction.
This model is designed around the patient, pulling
care to the bedside whenever needed and enabling
staff to focus on getting patients well.
36 MIT SLOAN MANAGEMENT REVIEW WINTER 2013 SLOANREVIEW.MIT.EDU

For Kathryn Correia, senior vice president of
ThedaCare at the time, the origins of the innovative
collaborative care model began in 2003. Seeing her job
as bringing out the best of the organization, she
looked around the hospital, searching for possible
answers to questions such as: “What is it that has to be
right What is the most important thing a hospital
actually contributes to the delivery of high-quality
patient care, versus the many things that we do in little
clusters such as radiology, lab, outpatient surgery,
respiratory therapy” Early conversations ensued with
managers and clinicians (including nurses, physicians
and pharmacists) around these questions. To look
more closely at the hospital’s emergency, inpatient
and outpatient flows of care delivery, Correia brought
together a broad group of clinicians and managers
from across the system. Because each clinician knew
only part of the flow of patient care and the managers
weren’t in constant contact with direct patient care,
the group decided to map the current care delivery
flows from the viewpoint of patients.
They could have taken a different approach, of
course. For example, they could have sat down with
a flow chart and figured out inefficiencies; they
could have identified how medical/surgical units
are organized in other systems; or they could have
searched the literature for ideas that had worked at
other organizations. Instead, acting as if they were
patients, the group members followed the paths
typical patients take in receiving care. Those following
an inpatient’s path experienced the flow
from admission to discharge. Those following an
outpatient’s path experienced the flow from visiting
specialty physicians’ offices to getting tests done
and returning to the physicians’ offices.
The managers and clinicians soon noticed that
once patients made contact with ThedaCare’s system
and were admitted, the care flow was anything
but clear. Patients went off in different directions
depending on what tests were ordered or why the
patients had been admitted.
When the clinicians and managers came back together,
they realized there was no way to map the
care flow. While they could see how patients got into
the hospital through the admission process, they
had no clear idea of how patients got out. There was
no obvious pattern for how patients moved through
the system to get well and be discharged.
Having uncovered the disconnect between their
expectation (that there was a clear patient flow) and
the reality (that there wasn’t), the team wondered if
they might benefit from walking alongside real
patients in order to get a deeper understanding of
patients’ actual experiences of the care flow. Members
of the team were assigned to individual patients
and asked them to describe what was going on for
them during each step of their experience. Convening
afterward, the group agreed that the results were
eye-opening. They had seen for the first time how
much the outpatient and inpatient flows were interfering
with each other and with getting patients
well. For example, if it was midafternoon and inpatients
needed tests in radiology to determine if they
could go home, they had to wait until they could be
squeezed in between previously scheduled appointments
— often causing hours of delay.
Above all, the team members noticed how much
of what went on actually got in the way of care and
created negative experiences for patients. A particularly
revealing example was the long distances
outpatients had to walk to get to labs so they could
undergo tests that doctors had prescribed for them.
Walking with the patients, the team members
observed that some — for example, the elderly, pulmonary
patients (who have trouble breathing) and
others who were seriously ill or severely out
of shape — were out of breath by the time they
reached the blood-work lab. They saw patients
struggling and worrying about being late as they
tried to find their way through the seemingly endless
corridors. No one had noticed this before. The
system was placing undue burdens on these
patients. The clinicians and managers had not
expected that, and they knew it was definitely not
how they wanted to treat patients. As one manager
later said, “It was a big ‘aha.’ And it helped make visible
that we were doing neither inpatient nor
outpatient care as well as we would like.”
This “aha” moment brought quick agreement to
focus first on redesigning inpatient care. And it
helped the team members realize that while they
wanted to deliver the best care, their hospital’s current
efforts were vague at best and chaotic at worst.
Extraordinary efforts were often required to advance
patients through the system. For example, nurses
would need to make repeated “hurry-up” calls to
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CHANGE MANAGEMENT
obtain overdue lab results needed to determine what
antibiotics the patient should receive. The prevalence
of these efforts pointed to the critical role of
nurses in providing ongoing, high-quality care. By
the end of the initial stage, the team members all had
vivid, firsthand experience of critical disconnects,
and they were beginning to generate alternative possibilities
for how work could be done differently.
Embracing the need to change inpatient care
delivery, hospital clinical staff and managers, in conversation
with ThedaCare leadership, undertook the
building of a new model. A new, smaller design
group again followed the flow with patients, this
time creating a highly detailed chart of the current
inpatient care process and paying close attention to
how this process kept patients in the hospital, with
little work consistently directed toward helping
them get out. This approach contrasted with a common
hospital practice of hiring utilization review
nurses (“care managers”), who assemble documentation
focused on justifying to insurance companies
why patients are admitted and need to stay longer.
The vice president of nursing described how the
team “realized at a different and deeper level that the
old process was oriented to justifying patient stays.
We needed a different process — one that focused on
optimal recovery and on pulling the patient through
the hospital system.” In the ensuing months, the organization’s
leadership supported the team’s efforts
to build a new model. For example, the team noticed
that nurses lacked important information about
why physicians pursued specific treatment plans.
Having that understanding of care was not only useful
in answering patient questions but also critical in
identifying potential errors, such as improper treatment
sequencing. To address this and other
concerns, all clinicians were given access to the context
and rationale of a specific treatment plan as part
of the care process redesign, and a clinical trio, comprised
of a nurse, physician and pharmacist, was
created. The trio met together with the patient and
family to determine a single plan of care.
The new model of general acute care the organization
created, which ThedaCare calls collaborative
care, enables staff to think about patient stays with
an emphasis on getting patients well. In contrast
to models organized around medical condition,
the collaborative care model is designed to help
advance all patients similarly through the system,
regardless of medical diagnosis, while also accommodating
each patient’s unique needs.
The scope of change in process was extensive. The
doctor, nurse and pharmacist trio would collectively
meet with the patient and family within 90 minutes
of admission. The electronic medical records were
redesigned to reflect a single plan of care. The typical
centralized nursing unit was replaced with multiple
nursing alcoves located just outside patient rooms.
And patient rooms were designed for safety, privacy
and easy interaction with the care team. Designed
during 2005 and 2006 and first implemented in February
2007 in one medical-surgical unit, this care
model has subsequently spread to all medical-surgical
and many specialty units with dramatic results.
When patients in the initial collaborative care units
were compared with like patients on non-collaborative
care units, the team found that average length of
stay decreased by at least 10% with the new model,
and direct costs decreased on average 20% to 25%.
Nurse productivity increased by 11%, and the percentage
of patients who were satisfied with their care
increased to 95%, up from 68% prior to implementation
of the new model. 3
Although the implementation of collaborative
care at first glance looks similar to a traditional pilot
project in that it involved the use of a design team
and was first rolled out in one unit, it was conceived
as part of a larger exploration of what care delivery in
the broader system at its best might become. The initial
unit design and rollout was always connected to
this larger possibility, even though the possibility
itself was in the process of becoming defined.
The care process redesign did not start by trying
to improve unit functioning and then scaling up.
Rather, the team began by exploring care delivery
through mapping inpatient, outpatient and emergency
care flows. Only after examining actual
patient experiences and learning how their system
burdened patients were the team members able to
settle on inpatient care as a starting point and to
imagine real possibilities for designing a fully
patient-centric care model.
Finally, while implementing the new model in the
first unit, staff and leadership examined and identified
the specific units next in line for the new model.
This examination prompted consideration about
38 MIT SLOAN MANAGEMENT REVIEW WINTER 2013 SLOANREVIEW.MIT.EDU

what parts of the collaborative care model were
essential to retain and what could be altered in
spreading the model to subsequent units. Those involved
in the first unit rollout had come to understand
that the relational aspect of the model was most important
to retain. It mattered that the nurse, physician
and pharmacist trusted each other and interacted
well with each other and with the patient and family.
While other parts of the model might be altered, the
collaborative clinical trio would remain.
Better Practices: Instead of Adopting the Best
Practices of Others, Screen Your Work Through
Those Best Practices in Order to Generate New
Ideas Organizations often devise new ways of working
by simply adopting best practices used elsewhere.
But such best practices can be more effectively used
as a discovery technique, enabling people to go
beyond replication and discover new possibilities for
meaningful change.
Using others’ best practices as a discovery technique
asks people to compare their expectations of
how work is currently done with what might be offered
by the best practice. This discovery tool
imports the unfamiliar in the form of others’ best
practices and pairs them with the familiar. Exploring
this pairing enables people to move beyond their expectations
and tease out new possibilities that are
suggested by best practices elsewhere. Overlaying
your current practices with someone else’s best practices
in this way generates better practices — better
than best because they are relevant in highly specific
ways to your organization’s work.
Consider the checklist, a well-publicized best practice.
It was originally created to reduce errors and
standardize the behavior of airline pilots, and it has
since been widely adopted in other contexts. To reduce
errors in surgical settings, for example, the use of
a checklist prompts members of the surgical team to
identify aloud their names and the name of the
patient, the procedure type to be undertaken and an
itemized list of the instruments and equipment at
hand. In exploring the use of the checklist, surgical
unit staff members of an academic medical center
were asked to use role-play as a way of experiencing
what this best practice might offer for their own work.
In the role-play debriefing, staff members were
asked two questions. The first question was, What
would you do differently in your work as a result of
practicing with the checklist, and what things do
you want to incorporate as unit practice The
responses identified items that had been on the
standard checklist as well as some additional ones,
such as: Be sure the patient’s ID tag is visible; mark
with a red pen or bright highlighter any patient
requests or conditions requiring extra attention
during or after surgery.
The second question was: What didn’t the
checklist cover that you wished it had, and/or what
didn’t you know how to address in its use Instead
of merely generating a list of items, this question
prompted an exploration of different possible clinical
relationships. The group considered not only
who was responsible for a given activity, which was
a question they had identified before starting the
role-play, but why that particular person was responsible
and whether only one person actually
was or should be responsible. And they went further
and asked: What would it take for doctors and
nurses to work in full partnership How might all
clinical members work to their fullest scope By
considering what they didn’t know in addition to
what they had learned in exploring what the checklist
might offer, the staff could step back from their
usual absorption in their day-to-day work and generate
new possibilities for enhancing how they
related with each other in delivering patient care.
Benchmarking, itself a best practice that identifies
others’ best practices, can also be used to spur
people to think about how the conduct of their
work could be organized differently. In attempting
to improve performance, organizations often compare
their work processes, strategy and performance
metrics to those of competitors. Such benchmarking
tells you how your organization stacks up
against best-in-class organizations and enables you
to take action to close the gaps with them.
But benchmarking deployed in this way results in
imitation. Granted, it is imitation of an organization
believed to be the “best,” but using benchmarking to
follow the leaders limits the usefulness of this technique
for discovery by overlooking its potential as
something unfamiliar that can be paired with the
familiar to generate new ideas.
A university task force on curriculum redesign
used benchmarking for discovery when it expanded
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CHANGE MANAGEMENT
the typical comparison group from competitor universities
and their curricula to include the teaching
conducted in corporate, military and nonprofit organizations.
Widening the focus enabled unfamiliar
organizations to be paired with the familiar content
and sequence of the university’s teaching in its current
curriculum. In exploring what the best practices in the
more unfamiliar organizations might offer, task force
members uncovered a disconnect — not in content,
but in pedagogy. A prime example was the difference
between the current university curriculum’s heavy use
of teacher-focused lecture and in-class sessions versus
the other organizations’ emphasis on learner-focused
experiences. Incorporating ideas such as technologyenabled
classrooms or student-generated content
altered how traditional teaching occurred and broadened
the notion of a course. As a result, task force
members were able to step back from the usual gap
analyses that benchmarking produces and not just
consider the curriculum but also develop a more
engaging model for teaching students that included
learning beyond the classroom.
Test Training: Use Training to Experiment With
Emergent Possibilities for the Way Work Will Be
Done Organizations typically test inventive solutions
that are in final development in order to identify adjustments
or refinements prior to full implementation.
The benefits of this approach are well documented.
Mistakes are identified and more readily corrected,
opportunities for improvement are found and can be
incorporated and the product or model is optimized
and verified before full deployment.
In contrast to refining and establishing proof of
concept, test training focuses on uncovering disconnects
between people’s expectations for how
proposed solutions might operate and the actual
experience of the solution in experimental settings
such as training or trials. This enables people to see
and come to understand what they don’t know
about the solution as well as to continue to shape it
for implementation, often in significant ways.
Consider an example from ThedaCare’s design
of its collaborative care model. To prepare for implementation
of the new model, nurses from the
unit were taken away from their normal duties for
six weeks, and physicians and pharmacists joined
them for intensive periods. Using volunteers as
“patients,” clinicians trained together in a mockedup
collaborative care unit that matched the newly
designed ones, with private rooms for all patients;
newly designed supply servers outside the patient
room yet accessible to clinicians inside the room;
and, in place of the nursing station, a central area
visible from all rooms. Part of the training was
designed to inculcate new practices like getting
accustomed to what would be stored in the new
private rooms, using the new drug dispenser and
using revised electronic medical records to assure
reconciliation of medication.
A central feature of the new model was the creation
of a trio of physician, nurse and pharmacist
who would deliver care at the patient bedside. To be
effective, the trio required its members to work as a
clinical team, asking questions of each other in front
of the patient and addressing patient questions as a
team. So a second part of the training was designed
to help clinicians see beyond their current expectations
of how they should relate to one another and
entertain possibilities for greater collaboration.
Organization development specialists on staff
worked with nurses to help them see beyond their
existing role, which involved nurses taking direction
from doctors with little opportunity to give input, and
instead become partners with physicians and pharmacists.
As one specialist observed, “This is a different
challenge for nursing staff — to be able to give to and
receive feedback from other members of that professional
team, especially if something is not going well.”
Conversely, organization development staff
worked with pharmacists and physicians to help them
let go of the expectation that they would perform all
the important tasks. As one pharmacist said, “We were
holding onto a lot of things that nurses were already
double-checking and that the doctors were doublechecking,
so we needed to build more trust that it was
being covered.” The line manager responsible for physician
engagement noted that trial made “the biggest
difference” in helping physicians accept being in a
team with nurses and pharmacists in the patient’s
room. They realized, she said, that they truly were in a
team and that the pharmacist and nurse had something
to add and contribute and challenge them on, in
a more collaborative way. “The physicians now speak
about the learning that they’ve received because a
pharmacist or nurse is there,” the line manager said.
40 MIT SLOAN MANAGEMENT REVIEW WINTER 2013 SLOANREVIEW.MIT.EDU

Takeaways About Designing
Discovery Techniques
All three types of discovery techniques share characteristics
that differentiate them from more
conventional change practices. Building on organizations’
experiences implementing them, I have
derived a set of key principles leaders can keep in
mind when encouraging the design and use of discovery
techniques within their own companies:
• Everyday disconnects should prompt collective reconsideration
(discovery) of expectations or
understanding of how work is conducted and the
entertaining of new possibilities.
• Discovery techniques generate insights and possibilities
for change because they help people come
to see what they don’t know rather than confirming
what they do know and maintaining the status quo.
• Discovery techniques operate by pairing something
familiar with something unfamiliar to uncover
everyday disconnects that illuminate people’s
expectations for work, and prompt consideration of
how it might be done otherwise.
• Discovery techniques are deployed in the midst of,
or close to, the doing of the organization’s regular
work. When disconnects are uncovered, it is this
close proximity that brings home the significance
and impact of what is not being done, as well as the
opportunity to generate new solutions.
• Instead of simply dismissing the current way of
doing things as out-of-date, discovery techniques
relate and draw upon the present, as seen in light
of comparing expectations and actual conduct of
work, in order to see future possibilities.
• Although individuals in some of the examples did
separately notice everyday disconnects, discovery
techniques work for seeding transformation because
they connect such efforts and/or foster the
collective uncovering and engaging of disconnects.
By designing and adopting discovery tools that
uncover everyday disconnects, organizations can:
1. Achieve the benefits of transformation without
risking wholesale disruption of operations.
2. Build a culture of continuous improvement that
is embraced by leadership and employees
throughout the organization.
3. Avoid the often exorbitant costs of Big Bang
transformation associated with wholesale replacement
of employees.
4. Leverage existing employee knowledge and experience
for transformation.
5. Cultivate collective, not just individual, capacity
in surfacing disconnects and generating new
insights and ideas that seed transformation.
Most importantly, organizations that cultivate
the uncovering of everyday disconnects and explore
possibilities for meaningful change will find
themselves no longer caught between the equally
unattractive possibilities of Big Bang transformation
or remaining in a steady state.
Karen Golden-Biddle is a senior associate dean, professor
of organizational behavior and Everett W. Lord
Distinguished Faculty Scholar at Boston University
School of Management in Boston, Massachusetts.
Comment on this article at http://sloanreview.mit.edu/x/
54213, or contact the author at smrfeedback@mit.edu.
REFERENCES
1. See, for example, B. Burnes and P. Jackson, “Success
and Failure in Organizational Change: An Exploration of the
Role of Values,” Journal of Change Management 11, no. 2
(June 2011): 133-162; K. Golden-Biddle and J. Mao, “What
Makes an Organizational Change Process Positive” in
“The Oxford Handbook of Positive Organizational Scholarship,”
ed. K.S. Cameron and G. Spreitzer (New York:
Oxford University Press, 2011); McKinsey & Company,
“Creating Organizational Transformations: McKinsey
Global Survey Results,” August 2008, www.mckinseyquarterly.com;
and M. Beer and N. Nohria, eds., “Breaking
the Code of Change” (Boston, MA: Harvard Business
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2. R. Lenzner and S.S. Johnson, “Seeing Things as They
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3. C. Bielaszka-DuVernay, “Redesigning Acute Care Processes
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2011): 422-425.
i. See, for example, K. Golden-Biddle and J.E. Dutton,
eds., “Using a Positive Lens to Explore Social Change and
Organizations: Building a Theoretical and Research Foundation”
(New York and Hove, U.K.: Taylor and Francis
Group, Routledge, 2012); A. Langley, K. Golden-Biddle, T.
Reay, J-L Denis, Y. Hébert, L. Lamothe and J. Gervais,
“Identity Struggles in Merging Organizations: Renegotiating
the Sameness-Difference Dialectic,” Journal of
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167; J. Howard-Grenville, K. Golden-Biddle, J. Irwin and J.
Mao, “Liminality as Cultural Process for Cultural Change,”
Organization Science 22, no. 2 (March/April 2011): 522-
539; and T. Reay, K. Golden-Biddle and K. Germann,
“Legitimizing a New Role: Small Wins and Micro-Processes
of Change,” Academy of Management Journal
49, no. 5 (October 2006): 977-998.
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