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CHAPTER 5  Leading and Managing Change in the Pediatric Intensive Care Unit

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TABLE
Change Leadership/Management Models
5.1

Author

Name

Principles

Kurt Lewin

Theory of Planned
Change

1. Unfreeze.
• Determine what needs to change.
• Ensure strong support from senior management.
• Create the need for change.
• Manage and understand doubts and concerns.
2. Change.
• Communicate often.
• Dispel rumors.
• Empower action.
• Involve people in the process.
3. Refreeze.
• Anchor changes into culture.

• Develop ways to sustain change.
• Celebrate success.

Ronald Lippitt

Phases of Change
Theory

1 .
2.
3.
4.
5.
6.
7.

Identify the problem.
Assess motivation, capacity, and readiness for change.
Identify available resources.
Define desired change.
Define change agent’s role (e.g., advocate, facilitator, consultant, expert).
Maintain the change.
Terminate change agent’s role.

Everett Rogers

Five-Stage
Change Theory
(Diffusion of
Innovation

Theory)

1 .
2.
3.
4.
5.

Knowledge: Expose individual to the new idea.
Persuasion: Convince individual to adopt the new idea.
Decision: Individual decides to adopt or reject the new idea.
Implementation: Individual adopts the change.
Confirmation: Individual accepts the change as advantageous.

John Kotter

Leading Change
Model

1 .
2.
3.
4.
5.
6.
7.
8.

Establish a sense of urgency.
Create the guiding coalition.

Develop a vision and strategy.
Communicate the change vision.
Empower employees for broad-based action.
Generate short-term wins.
Consolidate gains and produce more change.
Anchor new approaches in culture.

within the NHS but also the public at large. The report criticized
and described the systemic failures of the NHS, misguided focus
on healthcare costs rather than healthcare value, and provided a
multitude of examples in which the inability of the NHS to address its known flaws led to unnecessary patient suffering. This
unmitigated language created an overwhelming and uniformly
shared sense of urgency and concern that led to a unifying commitment for change from political leaders and the British public
at large, allowing development of a guiding coalition.2,3 The inclusion of social media and communication experts among the
core leadership team ensured that the vision for change was communicated broadly and consistently. Local groups were empowered to seek out input from community members and leaders
about how the NHS could better serve patients’ needs and improve their healthcare value. Individuals were encouraged to each
participate in their own way. As a result, a broad-based network
of leaders, unified under the umbrella of the Change Day initiative, pursued and led team-specific actions and change initiatives.
While this all-accepting approach allowed participants to make
individual pledges as simple as “to meet and greet patients
with a smile,” it also created space for city and regional health

commissions to fold their local efforts into a national movement.
Subsequent analysis of the psychological factors that led to
Change Day success highlighted the impact of allowing daily
participation and commitment to self-initiated, small tests of
change. These small successes, in turn, affirmed both personal
agency and group efficacy, promoting and restoring a sense of
“vocational and organizational identity.”12

Models and Tools to Facilitate Change
Leadership and Management
Theories of Change
Others have described change theories with many similarities to
Kotter’s eight-step model. Examples include Lewin’s Theory of
Planned Change,13–15 Lippitt’s Phases of Change Theory,16 and
Rogers’s Diffusion of Innovation Theory17 (see Table 5.1). The
advantages of Kotter’s model over these four include the treatment
of change as a continuous rather than a discrete event (Lewin),
establishing distributed leadership and empowering frontline


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S E C T I O N I   Pediatric Critical Care: The Discipline

initiative and action rather than focusing on the change agent and
a top-down approach (Lippitt), and description of active leadership rather than passive management and subsequent undirected
diffusion of ideas and change (Rogers).
Despite these advantages, Kotter’s Leading Change model
lacks specific details on how to best accomplish each of the eight
steps. Additionally, Kotter’s model does not include a step that
assesses current attitudes and receptivity for change or a step that
focuses on identifying facilitators and barriers to change. Understanding current organizational culture, behavior, biases, attitudes, and knowledge provides extremely useful guidance. Change
leaders and managers increase the likelihood of success if they
analyze how various aspects of the existing organization must interact with internal and external variables when implementing a
specific intervention. Without this tactical step that defines how
to accomplish the strategic goal, the inspirational vision remains
nebulous and can be dismissed as a grand idea but too hard or
even impossible to enact.

Bringing Theory to Practice
The Consolidated Framework for Implementation Research
(CFIR)18 provides a bridge between the inspirational vision
and practical question of “How do we get there?” Proposed by
Damschroder et al. in 2009 as a framework to understand adoption of new initiatives in health services, the CFIR gives a roadmap not only for accomplishing implementation research but
also for achieving successful implementation of a proposed
change.18 Five domains comprise the CFIR: intervention characteristics, outer setting, inner setting, individuals involved, and
the implementation process (eFig. 5.1). In turn, key constructs
define each of these domains and are explicitly defined to facilitate use. Within 5 years of introduction, the CFIR model was
described in 26 separate publications, a testament to the framework’s success and utility when introducing change in the form
of new healthcare initiatives.19 One of these studies used the
CFIR model to evaluate the implementation of the ICU Liberation improvement initiative across five adult ICUs and two additional specialty care units in a single tertiary care academic
medical center. The authors outlined in great detail how their
adoption of the ICU Liberation initiative fit within the CFIR
model and provided a “lessons learned” summary of points to
consider during ICU Liberation implementation.20 By applying
the CFIR to their work, this multiprofessional group of ICU
specialists outlined a roadmap to guide other centers seeking to
replicate the work.

Tools for Assessing Readiness for Change
Kotter’s change model and the inner setting domain of the CFIR
require change leaders to understand their team’s culture, readiness to accept change, capacity to absorb new information, and
willingness to adopt new practice. Interprofessional team collaboration encompasses these aspects and can be assessed using several
different surveys. One example, the Assessment of Interprofessional Team Collaboration Scale (AITCS), prompts participants
to answer 37 questions in the three domains of partnership/shared
decision-making, cooperation, and coordination in order to understand how people perceive the quality of interactions among
team members during their daily work.21 During the ICU Liberation collaborative, adult and pediatric participating centers used
the AITCS to assess their degree of interprofessional collaboration

before and after ICU Liberation participation.22,23 Staff responses
allowed each site’s change leaders to identify specific domains in
which implementation work should focus. Among the pediatric
centers, the before and after responses suggested that participation
in the ICU Liberation quality initiative coincided with higher
AITCS domain scores.23
While the AITCS discerns team culture, it does not specifically address an organization’s openness to adopting a specific
clinical care initiative. For this, the Organization Readiness for
Change Assessment (ORCA) provides insight.24 Developed by
the Veterans Health Administration, the ORCA asks respondents
to answer questions directed to a specific change initiative. Designed to be administered as part of the preparation for introducing a new clinical practice initiative, the ORCA asks 20 questions
within the three domains of evidence, context, and facilitation.
The evidence domain assesses baseline understanding and perception of the strength and quality of medical evidence upon
which the planned clinical practice change is based. The context
domain overlaps with the AITCS questions about teamwork but
attempts to draw a distinction between whether resistance to
change is based on the specific proposed intervention or is a more
global resistance to change of any sort. Last, the facilitation domain of the ORCA focuses on understanding how respondents
perceive their leadership and management team’s ability to develop consensus, define clear roles and responsibilities, ensure
adequate resources, and regularly and transparently report the
impact of the change initiative on meaningful patient outcomes.
When used together with the AITCS, the ORCA can further
focus implementation activities and resources on expressed needs
and concerns, help identify facilitating and resisting forces
impacting change, and predict the likelihood of success at change
implementation given the current inner setting as described by
the CFIR model.
Additional tools to identify individual tasks needed to enact
change must also be applied within the CFIR model. Lewin’s

Force Field Analysis presents one mechanism to identify the driving forces that facilitate change, the restraining forces that resist
it, and the relative impact each force has in promoting or preventing movement to the new desired state (Fig. 5.2). Once
identified and assigned a relative level of importance, each of
these identified forces can then be analyzed further using process
improvement tools. The Institute for Healthcare Improvement
(IHI) has assembled an open-access 10-item quality improvement (QI) toolkit to guide healthcare teams in this work
(Table 5.2).25 With this toolkit, the guiding coalition and
bedside PICU team members can work with implementation
facilitators to develop not just a step-by-step plan to achieve individual aims but also to determine appropriate performance
measures that demonstrate the impact, success, or failure of the
work in meeting the stated goals.
Conducting focus groups can also be extremely useful in prioritizing issues and needs, eliciting common opinions that might
facilitate or resist the change initiative, and generating new ideas
on how to approach change planning. The Agency for Healthcare
Research and Quality describes focus groups as “a collection of
several individuals who all discuss a particular subject, voicing and
discussing their opinions and ideas on that subject.” Focus groups
should be led by a facilitator with specific training and experience
in leading these discussions to maximize open and honest exchanges among participants while preventing off-topic conversations that derail the discussion. Exact composition, size, and
number of sessions held can vary greatly depending on the


32.e1

Inner setting
Individuals
involved

Intervention
(adapted)

Adaptable periphery

Core components

Outer setting

Core components

Adaptable periphery

Intervention
(unadapted)

Process

•  eFig. 5.1  Consolidated Framework for Implementation Research (CFIR) domains.18 Intervention: This do-

main refers to the characteristics of the planned intervention. A key element of this domain relates to how
well the intervention fits within the current team dynamics and function. In most instances, any externally
designed intervention must be adapted in some way to meet the specific characteristics and needs of the
team. As the puzzle piece cutout of the figure displays, without adaptation, a poor fit occurs. Team member
perception of the intervention’s legitimacy will also impact implementation success. Aspects impacting perception include whether the intervention was developed externally or internally, the expertise and reputation
of the developers, the quality of supporting evidence, the applicability and advantages over other options,
and the quality and comprehensiveness of the presentation. Tactical considerations will also impact acceptance of the intervention. These include whether the intervention can be adapted to meet local requirements
and needs, if it can be first tested on a small scale and easily reversed if proven ineffective, and how disruptive the change would be to existing workflow. Last, the cost of intervention implementation will be important. Costs include needed time and effort, money, equipment, and opportunity costs of implementing the
change. Outer setting: This domain reflects how factors external to the people carrying out the intervention
will impact implementation. Factors include patient needs, perceived value to the patient, peer pressure from
external competitors doing the same work, and existing organizational policies and incentives that impact
the ease with which the change can be completed. Inner setting: This domain addresses the team’s structure, existing behaviors and culture, communication quality both among team members and to external

groups, the ability to and readiness for change, and capacity and resource availability to implement the intervention. Individuals involved: This domain addresses characteristics of the individual members of the
team. Aspects include skill and educational level, self-belief that one’s skills and knowledge are sufficient to
perform the intervention, sense of personal agency and identity as a valued part of the team, and other
personal character traits that impact individual response to change. Process: This domain addresses the
way in which the clinical practice change and intervention are planned and executed. Factors include the
engagement of formal and informal team leaders and influencers, recruitment of change champions, input
from external consultants, and the transparency and quality of quantitative and qualitative reporting of the
intervention’s impact on meaningful outcomes.


CHAPTER 5  Leading and Managing Change in the Pediatric Intensive Care Unit

Beginning
State

Current
State

33

Desired
State

Driving Forces

Restraining Forces

CHANGE CONTINUUM
force field analysis. In any change process, a continuum exists defined along time
or specific milestones. From a beginning to a current to a desired end state, various forces can facilitate

or hinder movement along the continuum. These forces can be strong or weak (line width), continuous or
intermittent (solid or dashed line), or begin or end at different points along the change continuum.18

•  Fig. 5.2  ​Lewin’s

TABLE
Institute for Healthcare Improvement Quality Improvement Essentials Toolkit
5.2

Tool

Purpose

Cause and effect diagram

Identifies individual causes and their relationships that contribute to a specific outcome. Typically, five categories of causes
are considered: people, environment, materials, methods, and equipment. This is also known as a fishbone diagram.

Driver diagram

Identifies the primary and secondary forces or drivers that contribute to the overall aim of the change initiative. In contrast
to the Cause and Effect Diagram, the Driver Diagram develops specific interventions designed to impact behaviors or
processes and permits small tests of change.

Failure modes and effects
analysis

Specifically evaluates steps in the process in which adverse or undesired actions (i.e., failure modes) could occur, what
causes contribute to those failures, and the potential consequences (i.e., failure effects) of those failures on the overall
system.

Flowchart

Develops a visual graphic of each step in the current process to create a shared understanding among all team members.
As part of the brainstorming process for designing the change initiative, this provides a valuable tool for identifying steps
that create bottlenecks or that do not add value, steps in which communication breakdowns can occur, and points in
which interventions identified in the Driver Diagram can be tested.

Histogram

Presents summary data and metrics in graphic form.

Pareto chart

Evaluates the frequency of individual factors that impact an overall effect in order to identify the smaller subset of factors
that have the largest contribution to the end result.

Plan-do-study-act worksheet

Allows repeated evaluation of the impact of small tests of change.

Project planning form

Provides a timeline representation of each of the action steps identified in the other tools in this list.

Run chart and control chart

These two graphs provide visual presentation of metrics such as guideline compliance and discrete outcomes. After
compiling at least 15 points for the Run Chart, a Control Chart allows a higher-level summary and takes into account
common and uncommon variation to create an expected vs. unexpected range of variation (i.e., upper and lower control

limits) in the specific metric.

Scatter diagram

Provides a graphical representation of the relationship between two variables to determine cause-and-effect relationships.
The specific variables to be graphed can be selected by those identified in the Cause-and-Effect Diagram or the Failure
Modes and Effects Analysis.

These tools are available at />
complexity of the questions being asked and the presence of
preexisting tensions or biases among team members. Recent
methodologic studies suggest that having eight participants per
group is the most frequently recommended size and that 90% of
identified themes and ideas occur by the sixth session.26

Tools to Implement Change
While these tools play key roles in planning change and outlining
specific steps, implementing change requires keen focus on communication, education, and transparency about the impact on
meaningful outcomes. These aspects are crucial when considering


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S E C T I O N I   Pediatric Critical Care: The Discipline

the second half of Kotter’s eight-step model and the process and
inner setting domains of the CFIR model. The NHS Change Day
offers an example. By including three social media and communication experts in the core team, the leaders ensured frequent and
consistent communication to its large workforce during the initiative. Social media platforms, community outreach initiatives, and
public release of a Change Day video and website met the NHS’s

goals of educating the public and garnering support at the
national, local, and individual levels.1
However, communication cannot be limited to advertising
that a change initiative is about to occur. In leading and managing
change, communication becomes an educational initiative that
provides the rationale for why change is needed and offers the
evidence supporting the effectiveness of the proposed clinical
practice change. Summaries of the work accomplished using the
CFIR model and IHI QI tools can be used to communicate the
rationale behind, urgency for, and process of change. Communicating the impact of change on meaningful outcomes allows discussion of short-term successes and becomes part of the education
process. By committing to transparent discussion of the performance measures and outcomes following the change in clinical
practice, frontline staff gain trust in the process and can see for
themselves how the work is improving patient care.
Debriefing events and open results review can be quite impactful on communication and education during a change initiative.
These sessions provide an opportunity to discuss outcomes in a
transparent fashion that acknowledges successes, highlights lessons learned, and outlines opportunities for improvement. The
ICU-Resuscitation (ICU-RESUSC) study provides an example in
the PICU setting. This 10-site US collaborative introduces postarrest interprofessional debriefing as part of an ongoing, unitwide initiative to improve cardiopulmonary resuscitation (CPR)
quality. In a single center, these debriefing events have both sustained the CPR training efforts and correlated with improved
post-arrest neurologic outcomes.27 By debriefing all personnel
from in-unit cardiac arrests within 3 weeks of the CPR event, the
authors created a forum open to all PICU staff that allowed honest dialogue about a stressful event, displayed CPR quality metrics, and reviewed relevant literature.27,28 The inclusion of open
discussions of ongoing CPR training interventions and patient
outcomes following CPR made the CPR QI efforts transparent.
This provided a way to discuss short-term results openly and identify opportunities for improvement. Since then, this comprehensive CPR training and debriefing program is being implemented
in 10 US PICUs as part of the ICU-RESUSC study evaluating
post-arrest neurologic outcomes.29 As described in Kotter’s eightstep model, not only have these investigators anchored the change
in their own unit, they are also introducing similar change in
other tertiary care PICUs across the country.
Successful change leadership and management requires a blend

of educational approaches in addition to debriefing events or reporting results. Computer-based learning (CBL) has become a
common component of many healthcare initiatives. Advantages
of this educational platform include cost-effectiveness by decreasing the number of instructors needed to reach the target audience,
increased accessibility by eliminating the time and location restrictions of traditional classroom teaching, flexibility in allowing
learners to complete or review the material at their own pace or as
just-in-time training, and automated tracking of completion rates
among required staff. Disadvantages include inability to answer
questions not covered in the material, inability to interact in real
time with other students, and lack of spontaneous discussions that

promote deeper understanding. Unfortunately, the superiority of
CBL compared with in-person education in achieving sustained
knowledge retention has not been demonstrated in a rigorous
fashion, and the best method and format of CBL modules has not
been proven.30 Nevertheless, CBL has demonstrated effectiveness
in discrete tasks such as arterial blood gas interpretation among
ICU nurses31 and for more broad-based education in postgraduate nursing critical care courses.32 Pediatric residents working
on an in-patient oncology rotation also had favorable reaction to
use of CBL modules as a supplement to traditional didactic
education when used in a just-in-time format during their 4-week
rotation.33
Peer coaching has also been an effective component of education initiatives that helps bridge the gap between didactic or
independent learning and bedside practice. As a nonevaluative
partnership between colleagues, peer coaching has also been described as having identified “super-users” available during patient
care to serve as a real-time resource. These super-users often undergo additional interactive education regarding the new change
in practice and typically are recognized as informal leaders or
individuals with particular expertise. Waddell and Dunn named
the essential components of peer coaching in nursing staff development to be (1) recognizing the time-sensitive need for education or information transfer, (2) hands-on training of the
new practice, (3) demonstration of competency in the new skill,
(4) nonevaluative feedback, (5) opportunity for questioning and

clarification, and (6) self-assessment.34 Examples of peer coaching success in inpatient and ICU settings include increased use
of ceiling lifts for patient transfers35 and improved recognition of
delirium in ICU patients.36

Sustaining Change
The ability to sustain gains following change implementation also
requires specific attention. Without intentional planning on how
to anchor the new clinical practice as part of standard behavior,
old habits and practices are likely to creep back. For example, a
multiprofessional team of physicians, nurses, and pharmacists
from one tertiary care PICU spent 6 months developing a nursedriven sedation protocol. Upon completion of the protocol, an
extensive education program reached all PICU staff. These 1-hour,
small-group training sessions included a review of PICU sedation
literature, pharmacology review, and specific direction on use of
the sedation protocol and its interface with computerized order
entry and electronic medical record documentation. Peer coaching by a nurse educator with bedside nursing occurred as part of
just-in-time training in order to answer questions and evaluate for
appropriate protocol application. Pharmacy staff took responsibility for reviewing accuracy of medication ordering and titration
and performed daily audits of protocol compliance. In a subsequent analysis of consecutive PICU admissions requiring invasive
mechanical ventilation 1 year before and 1 year after sedation
protocol implementation, the group observed a significant decrease in duration of lorazepam and morphine exposure with a
trend toward decreased duration of mechanical ventilation and
length of PICU stay.37 However, within 3 years of this observed
success, resources dedicated to protocol education, monitoring,
and communication were redistributed to other initiatives. Consequently, all of the observed improvements in the year following
protocol implementation had completely reverted back to preimplementation ranges for duration of sedation exposure, duration of mechanical ventilation, and length of PICU stay.38 The