What models of change can be used to implement change in postgraduate medical education?

Dear Editor

I greatly enjoyed reading the article “Are they ready? Organizational readiness for change among clinical teaching teams” by Bank et al.1 This explored whether organizational readiness for change (ORC) could facilitate curriculum change in postgraduate medical education (PGME). The study reported that clinical staff felt responsible for change, viewing “program directors” as their leaders, and as being part of a learning culture. However, the study reported difficulties in implementation due to insufficient managerial support and the absence of an implementation plan. This included the “absence of timelines”, as well as “insufficient re-evaluation cycles, training facilities and financial resources”.1

As a keen observer, I would like to bring to the attention of the readers the opportunity to use previously described models of change in healthcare settings. If these models were applied, they could enhance and guide the implementation process in PGME. The models of change that have been used in healthcare settings include Kotter’s Model,2 Lewin’s Model,3 balanced scorecard,4 and Gantt Charts.5

Kotter emphasizes the importance of a conducive environment for change which he calls the “climate for change”. He focuses on the need to engage and enable those around you.2 This seems to have occurred in Bank et al’s study as they report that clinical staff are “committed to change” and “working together as a team”.1 However, Kotter insists on achieving short-term wins for successful implementation. Therefore, I feel the addition of some key performance indicators or metrics in the implementation plan may help to demonstrate the benefits of change and be parameters of success.2

Lewin on the other hand is more concerned with readiness for change as a precursor to its implementation and change becoming permanent.3 In Bank’s study, despite clinical staff not showing any resistance, their readiness for change is questionable as staff need to be trained to deliver the new curriculum. When confident, staff are more likely to participate and take ownership of the change. Therefore, I suggest that the implementation plan should consider how staff can be facilitated and supported to develop new skills.

The “absence of tasks and timelines” can be overcome by using a balanced scorecard.1 This provides a framework for implementation as for each objective there are measures, targets, and initiatives. A balanced scorecard builds consensus providing visual representation and allows for the early detection of negative outcomes. I believe that the lack of an implementation plan described by Bank et al could be helped by using a balanced scorecard as it allows for a culture of measurement, greater dialogue between program directors and clinical staff, as well as an improved understanding of why competency-based medical education is superior.4

Furthermore, a visual aid such as a Gantt Chart can be used for helping implementation of change. This timetables the expected time to complete certain tasks and allocation of resources.5 I feel that given the shortcomings in “tasks and timelines, evaluation cycles, and financial resources,” this may be effective in monitoring implementation.1

To conclude, the above-listed formal planning tools could help to implement change in PGME. Underpinning these tools are principles that assess the impact on the organization, the management of uncertainty and resistance, as well as the sources of responsibility. I suggest that Bank et al may consider this approach and hope that this letter reaches them and other readers who might be looking for a successful implementation of change in PGME.

Dear Editor

Thank you for the opportunity to respond to Mr Mahmood’s letter. We appreciate the insightful comments made by Mr Mahmood in regard to our article “Are they ready? Organizational readiness for change among clinical teaching teams.”1 He describes several change models that can be used to implement change in postgraduate medical education (PGME) based on strategies previously used in healthcare settings. Additionally, he suggests the combined use of parts of these models for change in PGME.

As noted in our manuscript, change is known to be challenging and requires a proper change management strategy to improve the chances for success.1 Indeed, on a limited scale, change management strategies are used in healthcare settings. Unfortunately, these strategies rarely make a transfer into change processes in PGME. Therefore, for this study, we chose organizational readiness for change (ORC) as our change model, or “lens,” to improve the chances for successful change in PGME. The rationale for choosing this model is that it was previously, and successfully, used in undergraduate medical education2 which made us believe it could be of value in PGME as well.

That said, we completely agree with Mr Mahmood that there is more than one way to skin a cat and that readiness for change is just one of many possible lenses to approach change processes. Undeniably, other change management strategies can bring valuable assets to the table as well. In our view, the use of ORC as a lens to look at a change process does not exclude the use of any other strategies or lenses. The assessment of ORC, in this case with using the questionnaire “Specialty Trainings Organizational Readiness for Change” (STORC),3 mainly serves as a diagnostic tool prior or during a change process. It leaves freedom for change leaders to use other change models as well. For instance, the assessment of ORC could help to determine in which of the eight stages of Kotter’s change model problems may be expected.4,5

To conclude, we can only agree that other change models besides or combined with the assessment of ORC could be useful in PGME. Therefore, we strongly encourage change leaders to demonstrate which change models are used in their educational settings and share their best practices in order for others to learn from.