Good morning, everybody. Thank you so much for coming to our session bright and early. So we're really excited to be talking to you today about instituting change, change management in programs. And I have always loved this quote from the legendary UCLA basketball coach, John Wooden, that he said that good things take time to develop. And I think that's really true. And we here are going to be talking about how to develop change deliberately and successfully in the tripartite mission of education, clinical practice, and research. And really thinking about things from a systematic programmatic level, but also the individual, you know, human stakeholder level and connecting with individual people. And so that's what we're here to talk about. We're really excited. This session is going to have some content, some active learning components as well, sort of get the juices flowing at 7.15 in the morning, but we'll start with some introductions. So my name is Avi Cooper. I am a pulmonary and critical care physician at Ohio State, and I am the program director of our Pulmonary and Critical Care Medicine Fellowship. Let me echo my warm welcome to you all. Thank you for spending the 7 a.m. hour with us. We know there are 20 other places you'd rather be snorkeling, on a beach, on a boat, and you chose to spend your time here because I see in each and every one of you, you want to make change. You want to get things done. That's why you went into pulmonary and critical care and sleep medicine, to get things done. And we're going to actually talk about it in a less abstract way. I'm Lakshmi Santosh. I'm an associate professor at UCSF, University of California, San Francisco, and I'm the associate program director of the Fellowship and the Internal Medicine Residency, and it's my honor to chat with you all today. Thanks for being here. These two are a hard act to follow. So I'm Michelle Sharp. Thanks so much. If we can find my slide. There we go. Thanks so much for joining us. So I have a very unique road. I was certain I was going to be a clinician educator, maybe a program director, and then I fell in love with sarcoidosis, and I am lucky to work at one of the largest and oldest standing sarcoidosis programs in the country, but when I started, it was a program that had a part-time nurse and a couple of people who saw patients, and I had a vision. So I hope that my examples of how you can change not only who you are and your focus, but also once you reach a new situation, you can really be the change and see the vision in the future and create the thing that you believe in. I'm an assistant professor at Johns Hopkins University and the co-director of the sarcoidosis program. So thanks so much for coming. So we have a few objectives for today. Echoing what Dr. Sharp and Dr. Santos have talked about is we have all been agents of change in our programs in the different domains that we're going to talk about, education, research and clinical. We're going to share some lessons that we've learned along the way, things that have been facilitators of change, things that have been barriers and understanding those, pulling from the business literature and talking about some frameworks for change and how to approach that deliberately and successfully, and then how to build consensus and help others sort of understand your vision and, again, be successful in whatever programmatic change that you're trying to accomplish. So we'll start with some definitions of what change management is. So it's really approaching change within an organizational context in a deliberate and structured and thoughtful way. And it really has two sort of general aims. It's to maximize the success of whatever change and implementation that you're doing and to get stakeholder buy-in, because if the people that you work with, that you serve and that you collaborate with or manage are not sort of into what you're doing and buying into what you're selling, then whatever change that you're trying to implement ultimately won't stick, and it won't be sustained. And at the same time, the goal is to minimize disruption, because obviously with change, there can be challenges that come along the way, and often disruption is one of the main barriers because it can lead to dissatisfaction and unintended consequences. And so really you're trying to, again, maximize the success of the change and minimize the disruption and unintended consequences. And so we wanted to start with some personal experiences. And again, starting at this early hour, we wanted you all to take a moment, talk to the person next to you, take a couple minutes, and think about a time that you've implemented change programmatically in a clinical, educational, or research mission and struggled. So we've all had successes, we've all had struggles, I imagine. Think about the times in particular that were hard and discuss with your neighbor about what that was like, what struggles you encountered, and we'll ask a couple pairs to share. So just take a couple minutes to talk to your neighbor. And feel free to get up and move around and find a new neighbor. Two points, two nodes of active learning. Eschwinston. Richard. Oh, Jeremy, Jeremy, yeah. Two nodes of active learning in the second one in the second section. Yeah. Do you, you're going to ask them to report out, and then I'll take over the second one? Sure. Or do you want to, I think? It might make sense for you to. I think I was going to go over the... Exactly. Yeah. So you'll have it when that sign comes up. I was going to make this graphic and mail it to the two and I was like playing with it and I was like, whatever, it's fine. We found a third framework and it's getting too messy, but it's... I'm kind of... We told our husbands we were shooting for B pluses. Not for this, but in general. And they were like, your B plus is probably an A minus, guys. I hate to interrupt so many great conversations here. It seems like you were already solving each other's problems, brainstorming. I'd love to hear a couple of examples of changes that you all struggled with. Anyone want to share? Yes. So I'm Raji from New York. The first thing I did was to try to create what is called a geographic rounding. And instead of having patients scattered all over, to have them in one unit so that the whole team work in one area and they get to bond and know each other and work well. So what I had to do first is to define the problem and create the branding platform, basically. And the branding platform for me was that our PRESS Ganey scores are so low. And if we don't do anything about it, then that is going to impact our value-based purchasing. And soon we'll be out of job if we can't make revenue, can't make income. So that got everybody's attention. So I put together a coalition. I got people together in a room, a bunch of stakeholders from EVS to nursing, everybody that works on the unit. And then I tried to sell it. And then in selling the idea, I had to also be able to tell them what is in it for them. Because it's human nature, what is in it for me. If they can't see that there's something in it for them, then it's, because change is hard. People don't want to change, they love the status quo. Now while doing that, I identified a couple of loud individuals who everybody listens to. And they were the naysayers. And I can see how they can influence the rest of the team. So I pulled them aside after the meeting, tried to work with them. And my aim was to flip them. Yes. And in the process, because they're loud, I knew if I can flip them, then they will become my champions. And that's exactly what happened. This is perfect, Raji. You have hit on so many amazing themes that we're gonna emphasize throughout this. You know, you built a coalition, you created urgency. You flipped stakeholders. What we did was, we looked at our next press guinea score within a month. And we saw an upward trajectory. So we capitalized on that, just like the stock market before it comes down. And we celebrated that win. We put up a huge banner. Bless you. And people started to be more motivated as they saw that success. And success begets success. And that's how we did it. Wonderful. Thank you for sharing that example. Woohoo! Be proud of yourself. I'd love to hear one more example, if anyone wouldn't mind sharing. Anyone from the education realm or the research realm? Love it, because we're all learning from each other. How long do we have? Like a couple of minutes, right? Oh no, no, no. Give me like the 30 second version. Yeah. Wonderful. So I work in a center in Alberta, Canada, where three years ago, we had a case in ICU of an almost near brain death baby that was very conflicted, ended up with a tracheostomy, and lived for many, many months, causing a lot of mental stress and moral distress. And it was severe enough that the medical direction called for a steering committee to kind of come up with an algorithm of decision. And for some reason that I'm not entirely sure, I was okay to co-chair that committee. And just quoting you, I realized that things take a lot of time. So it was almost a three year experience of just engaging the stakeholders. Because there are so many people involved in the care of these patients, from decision making all the way until they go home and beyond, that doing that work of listening to everybody took three years. Yeah. At that point, we realized, we identify the big gaps in the care of those patients that needed to be changed. We also engage patients and families of these children to hear their stories as well. We review the evidence to see what was there in that. We thought we were gonna have like five to 10 papers. We ended up reviewing 100, was a little bit time consuming, but we put it all together in a scoping review. And with that, we thought, look, we can't change that unless we actually create a team that enforce this standardization of care in a research level. So rather than just get the stakeholders and say, okay, we're gonna make changes, I hope for the best, we actually need metrics to measure what we're doing, we're going in the right track, right? And the measures don't necessarily need to be quantitative. It could also be mixed methods and include qualitative research on that as well. And that's kind of the critical moment that we are. We are in a process where there's some people, what I was just gonna quote him, there's some people who wanna rush and wanna make the change right away and they're very loud in the room and there are other people that need time to reflections that we're kind of adopted on a strategy of embracing what people lack and have their research team back in the map and allow them to go at the rating that they have with the ideas that they have as opposed to try to have control of everything. This is great. Thank you, Maria. Clap for Maria. I think we should send Raji and Maria to Congress, eh? Because they know how to make change. So thank you for sharing. I hope that exercise really got the juices flowing of, you each, like I said, each and every one of you is passionate about something and you wanna get things done and brainstorming ideas of how to do that and now we're gonna give you a couple of different tools and frameworks to kind of just formalize that and systematize that and it's one of these things that once you miss a critical step, we've all learned the hard way that actually each of these steps doesn't matter and we'll talk about why. Before we go forward, has anyone maybe more educationally inclined in the room heard of the Currens Curricular Framework? Familiar to anyone? A couple of hands. So we'll talk about, Currens Framework is a framework from the medical education literature and how many of you work with residents, students, fellows? Yes, so a lot of people are working with learners. Even if you don't identify as an educator, many of us work with learners and I think it's so tempting to say, ah, the residents, they need more practice with their central lines. I'm gonna build a new simulation program to get them caught up to speed on the central lines, right? And it's so tempting for us to jump straight to the change or the intervention and these six steps of curriculum development are very well laid out and actually sequential in an order because if you miss a critical step, you'll actually lose some of the learners. So let's spend a moment to talk about it and it's familiar to some of you. The first step is actually as what Raji said, identifying the problem. Is the problem that the residents aren't getting enough central lines or is the problem that actually there's not rotations where they can practice or is it the problem that there's too many pick lines? What is actually the problem? So you have to kind of hone in on your problem. When your problem is too broad and abstract, it's hard to make change. So step one is really identifying the problem. Step two is actually a targeted needs assessment. I love how in Maria's example, they went to the literature, they looked at the data and I encourage you to do that. Look to the literature, look to the data. What's already been done with central line education for residents and also do a targeted needs assessment of your stakeholders, your learners, your med students and residents, whoever you're trying to make the change about. Because if you say the Ohio State University has done the central line program, it may not resonate as much at your university. So you wanna pair the literature, the evidence base that Maria found as well as your local experience and your local stakeholders. The third step is actually, goes back to identifying the problem, which is actually setting specific goals and objectives. That only works if you've refined that problem. The more narrow and targeted and smart goals, we've all learned about that, the better you can put in the learners specific goals and objectives. And then the next step is thinking about what educational strategy is best for your problem. Is simulation really the best strategy? Should there be a shadowing component? Should there be just-in-time training? What is actually the best educational strategy to match with your problem? And then, only then, step five is implementation, right? So if you had rushed to say, I'm just gonna go implement a sim program, you may have misidentified the problem. You may have not done a targeted needs assessment. You may not have chosen the correct educational strategy for that intervention. And then last but not least, remember, evaluation and feedback. That's how we all get better. And that's how the individuals, especially learners, know that you're authentic in creating this change for them. If you get evaluation and feedback and you take it seriously and you wanna improve. So this framework, CURN, is a little bit more familiar to educators, especially in medical education. And now we're gonna supercharge those powers that you have to layer on the COTR framework, which is from the business world of change management. Has anyone heard of the COTR framework? Again, a couple of hands, but not many. This is great. So once you kinda combine these two, you will have change-making superpowers and we'll demonstrate in our small groups. There's a couple of steps, and actually Raji and Maria mentioned a lot of them already and we'll go through each one. Creating urgency, building a coalition, creating a vision, communicating that vision, identifying roadblocks proactively, celebrating the small wins, as Raji did, consolidating the progress that you've made and institutionalizing it. What does that mean? Because when I first read this, I was like, okay, it's a bunch of MBA words. How does this relate to me as an educator and a clinician? So let's just spend a little bit more time explaining what this is. Urgency. So Raji talked in his example about why now, right? Why do I care? I have a busy APD in recruitment season. Oh, press Ganey scores are down. Uh-oh. That's why it is urgent. That's why this problem of geographic rounding matters to me now. So sometimes you'll find out that there's perennial problems, right? Smoking cessation, pulmonologist, it's a perennial problem. But how do you actually make that change resonate for people and create this urgency? So sometimes you kinda have to time your change cycles to a patient outcome, as tragic as it is, or as something in the news cycle, in the larger news cycle. So sometimes you have to actually look at how do I create that urgency? Is it something external, like a patient outcome or a press Ganey score? And sometimes you have to actually time that change cycle to hit with that urgency. Coalition. Both of you talked about assembling your team. Really being thoughtful about who are your stakeholders, assembling them, bringing in those naysayers early, right? Because those naysayers are gonna become your biggest allies. And if not, they'll give you helpful feedback along the way. So assemble your team early, including those naysayers early. Vision. And so the vision time is, I think, when we as clinicians often get a little bit tripped up, where we know what we want, but we don't necessarily communicate that vision to others. And so you kinda have to create this North Star. Why are we doing this? We never want a kid to die in this situation again. Why are we doing this? We don't wanna waste time waiting for those slow hospital elevators. So creating a simple vision to communicate and make that the North Star for your whole team. Communicate, communicate, and communicate. You cannot over-communicate with change management. How many of you receive 20 to 100 emails per day from your employer that you don't read? Everyone, right? So there's no such thing as over-communicating. You gotta send that email, hang that poster, put the QR code, social media, because people are just inundated with info. And so to make that message stick, to make your change stick, there's no such thing as over-communicating. Get it done again and again and again. We talked about roadblocks. Both of you shared roadblocks. Ugh, there's some stakeholders who don't want geographic rounding. It's hard. It's hard to make that change. So anticipate those roadblocks and identify with them. That is my pager. Someone is paging me. I will get back to them. And then celebrate those small wins, right? Because if you have this giant change ahead of you, like all three of us are gonna talk about, it's gonna be hard to make progress on that in a year. It takes time. So celebrate the small wins along the way. And consolidating the effort, what that means is once you've made progress, don't let it slip away, right? Make sure to kind of institutionalize that, consolidate it, put it all together, and eventually you lead to that final step, which is the culture change, the institutional change. It's finally happened. So I hope that explanation helped a little bit of cottage steps. And we're gonna actually dive even deeper into it. And we're gonna show you one more framework of types of change. So I'm turning it back to Avi while I look at this page. Okay, so thinking now that you've got some sort of frameworks to think about in terms of Kern and Cotter, ways to approach change, the next step is to understand what type of change that you're going to be doing. Almost like diagnosing the problem, understanding the context in which you're gonna be working, right? So as clinicians, when we're taking care of patients, the first thing you have to do to be able to fix a problem is to diagnose the problem and understand what you're dealing with, right? And it's the same thing in organizational change. You have to understand the type of change that you're trying to implement to be successful at it. And to know in which category to apply Kern or Cotter or whatever change framework you're using. This is also pulled from the business literature, but we've laid out here six types of organizational change that you're probably going to be dealing with in any given time. And so the first is strategic change. This is a change to policy or processes that have a specific goal in mind, generally tied to strategy and to vision. People-centric change, so this is something that directly affects people in their day-to-day lives and work inside an organization. Structural change, this is sort of on a larger scale, something that affects sort of the overall structure and setup of a larger organization. Technological change, introducing new tech interfaces, things that improve user experience that are, again, meant to improve people's experiences within the organization. Unplanned change, an unexpected event happens. And remedial change, responding to an identified problem. And, you know, Raja, you mentioned the need for geographic grounding and prescanean scores and things like that. I thought that was a great example. So what we want to do now is each of us is going to share different examples from medical education, clinical practice, and research of how sort of the different types of change that could be applied for each of these categories. So I'm going to be talking about the medical education examples. And some of these are honestly pulled from my recent direct experience as a APD and then a program director. The first would be strategic change, increasing fellowship complement, right? And doing that in a way to meet a specific goal and need for our fellowship. That's something that we have been doing as well, increasing the size of our program, given our overall vision and strategy. People subject change, updating a parental leave policy. So that's actually also something that happened at our home institution, that our GME office updated the parental leave policy to increase the amount of leave that new parents get. Structural change, changing responsibilities and evolving roles within an APD team. Lucky to be joined by one of the team members, Dr. Megan Conroy, an APD in our program. And, you know, that we've been honored. It's been fun to evolve the APD roles within our program. Technological change, new educational management platforms. This is actually something that, again, at our institution we went through where our educational management platform changed within the last five years. It was a major, major update at the institutional level that had a lot of impacts on everyone. Unplanned change, responding to a prolonged EHR downtime. Thankfully that hasn't happened to us locally, but it absolutely does happen to institutions across the world. And it's gonna affect learners. And then remedial change, addressing an ACGME citation. And not something that we've dealt with directly, but certainly accreditation bodies are always watching programs, responding to situations that arise, and issuing things like areas for improvement or citations that absolutely need to be addressed and need to spark change. So next, Dr. Santos is gonna talk about clinical. And we'll be brief on this because you all have examples to share. And each of these bullet points is a story, right? Is a journey that we've all been through that we could all talk more about in small groups. So one example of strategic change that I went through as a clinician was we used to have at one of our sites an open ICU where hospitalists would kind of co-manage and over literally a decade of advocacy changed it to a traditional closed ICU. Thank goodness, yay. People-centric change, getting funding for Moonlighters to help get extra days off for some of our residents and fellows to make sure that they were within the work hours was a great example of people-centric change. And for structural change, during the pandemic, my team and I actually tried to assemble resources to create a post-ICU clinic in the COVID era because the medical center had never wanted to fund an expensive post-ICU clinic. But when COVID came along, they suddenly became a little bit more interested so that we created that urgency, right? In terms of technological change, one of my research projects involves ICU transitions of care, one that I've also talked to Dr. Conroy about. She keeps coming up. And so we talked about how do you embed kind of a diagnostic pause within the EHR as a clinician when residents or clinicians are handing off to each other. An unplanned change, what do you do when I make the ICU schedule and everyone is out with COVID or their kid is sick? How do you staff up when the whole Jeopardy pool or the backup pool is depleted? And last, remedial change. We had one of our medical assistants in our clinic who was kind of underperforming, missing important critical tasks. How do you actually change the culture and change the educational environment to actually bring all team members up to speed? Turn it over to Dr. Sharpe for examples in the research world. Thank you. So strategic change. I shared with you that I have a sarcoidosis program and a big vision. And one of my visions when I took over or joined our leadership was to create a multidisciplinary team where patients don't have to do all the hard work. The team does the hard work. We work together, we meet, we talk about patient care and then we feed back to the patients. So from a strategic change, that was a big difference than how we were operating. And so again, in the things that we've talked about today, creating the urgency but also going to the stakeholders and figuring out what we needed to create a multidisciplinary collaboration. And starting small, it started with me buying everybody lunch every Friday and convincing them with food. And I was told it better be good food, not just pizza. To come to lunch and to just start talking and getting to know each other. So strategic change and three years later, we're now a multidisciplinary program. We actually even have a shared clinic from our cardiology and pulmonary world. But change takes time. People-centric change, so I stay up at night worrying about my team. Because at Hopkins, I am responsible for funding my entire team. Not just their salaries, but even their benefits. And so really thinking about how do I get funding to support research time for myself, my trainees, as they move to faculty. But also how do I make sure that my research coordinators who are near and dear to my heart always have a job and are always taken care of. Structural change, so as part of my big vision to create multidisciplinary care, I also have a big vision to solve sarcoidosis in my career. And I know the only way we're gonna do that is if we start working together. Teamwork makes the dream work. We actually also have to start using the same outcomes. Because if you guys know anything about sarcoidosis, we don't agree about anything. And what the right outcome is. So what I did is I said, hey, what do you want me to measure in cardiology? Neuro, what do you guys think is important? How about I do all the legwork with my research team and I write a big IRB for a registry and I just collect it all. I have no money to actually even pull it out of Epic right now, because I'm still building. But I'll collect it and put it there so that when we're ready, we can all pull it out and start working together and we all have the outcomes we want. And then we can figure out which one actually matters. So structural change. Technological change. So I also, if you know anything about me, you also know that patients are at the center of what I do in life. And so outcomes, I think, are really important. But I think knowing the patient outcome is the most important thing. So I worked with our team at Hopkins to build SmartForms in Epic and patient-reported outcomes. So now if you come to our clinic, you get a patient-reported outcome. You get a depression screener, an anxiety screener, a health-related quality of life screener. It automatically goes to you. So that we have instituted our technological change and one day I'll have the money to pull it out and measure it from a research standpoint. Unplanned change. So I did not realize how hard it is to do collaborative work with people outside of my institution. And the amount of paperwork that I have to put in when a collaborator moves. So I had one of our amazing Neurosarcoidosis fellows move to LA, who's been like a huge partner. And now I have to figure out how I can actually share data with her and we can work together. So that was a bit of an unplanned change. And there's a lot of paperwork associated. And then remedial change. So I created things in Epic. And as all of you know, from a research standpoint, clinical research that's not a structured research visit is hard and it has a lot of missing data. So one of the things that I have done is gone back on the back end and at least tried to see what's actually coming through to the system and how am I gonna address the missing data issue in the long run. So these are our research examples. We've gone through educational examples, clinical examples, and research examples. Now it's your turn. And so what I would like you to do is, or we would like you to divide yourselves into three groups. So we want a research group. We want an educational group and a clinical group. And if you are a research group, maybe come to this area. We'll put the educational group in the front on this side and the clinical group in the back. We want you to identify types of change required for each of the scenarios. We're gonna hand you a worksheet and map out the change management process using our amazing eight steps from Kotter. And then we would love to hear from you. So just, we're giving you a heads up. We're gonna ask one person to talk from your group. So everybody ready? And get up and move. I got the cheers over there. What is that? That's the research science. We heard cheers. There's cheers over there. No intervention. I heard it. Do you have questions? I thought we brought some extra. Oh, goodness. All right. Hi. Oh, all right. Yeah. Oh, hi. Oh, of course. Thank you very much. It's not about me. It's not about me. Yeah. I was like, um, excuse me, I'm not kidding. All right, everyone. Once again, hate to interrupt all these brilliant conversations that I see happening, but let's bring us all together so that we can all learn from each other. So we had some amazing group discussions in the clinician's group, in the educator group, in the research group. So which group wants to share their insights first? Which group wants to share their insights first? And again, the goal, as I was saying to all the groups, is not to fill out the handout prescriptively, but actually to spark this amazing dialogue and conversation of change management in your clinical educational research context. We have a representative from the research team who wants to start. All right. Good morning. My name's Kunj, Austin, Texas. We were, Maria and I, were the small coalition of research trying to make change in our program. We didn't really fill out the worksheet, but we did learn a lot about how to bring research into our divisions. And a lot of it is, well, at least what I learned, was starting out really, really small. And specifically, I was kind of coming in with this mindset that I have a faculty of 21 physicians that I work with, and I need to bring in research a little bit to everyone. And that's really probably not the right mindset. And realistically identifying one or two people that have the spark, that have the interest, and really aligning with them, and getting them interested, and supporting them, and hopefully getting other people to get interested in what they're doing. So this was an important session for me to kind of just have a frame shift in that thinking process. Earlier, there was a slide about having a North Star, and we kind of modified that concept just a little bit, and making sure that's a tangible North Star. So you can think about theoretical North Stars, but if you don't have a North Star that everyone can reach and understand, that's going to be problematic. So we kind of talked about that a little bit. And I guess the other part was always anticipating the next move. In this case, we're talking about grant writing, and it's not about, OK, I have money right now, and getting comfortable with that idea. Because at any moment, that money could dry up, and you have to be thinking about your faculty, your research coordinators, and their benefits. And so always just thinking about that next grant, and how to potentially get the next grant for more funding. And then the last one, I guess I would say, was just being ready for becoming an intern again. If you're starting a research program, we've been great clinicians. We've gone through medical school, and intern year, and residency, and become excellent clinicians. And starting a research program is almost like learning some complete new skill set. And that's sometimes hard for a seasoned clinician who's been very successful in taking care of patients, and now learning a new skill set, and being ready for a lot of rejection. So Maria, do you think I got everything? That was amazing. All right. Thank you so much for sharing those insights. We learned a lot, especially how you focused on, again, that creating that vision and dispitting roadblocks I think were two common themes that came up. How about someone from the education group? Thank you. And I, I, it's out of my hands. Thank you so much. Let's clap for that group. Solved it. A perennial problem for all of us, right? I love how you talked about that instead of the true North Star, it's kind of like the anti-hero, the common enemy. You celebrated the small wins. You anticipated those roadblocks, and then institutionalizing that change at the end of the day. That was awesome. Last but not least, how about our clinical group? All right. And in this day of tease meetings and a lot of things that feel not. and that we're participating in a really detailed debate about how to get something done, how to get access and so on, and clinical practice is really the thing that is really telling us how to make sure that this is done. Love it. Thank you so much, clinical group. Well, just to wrap up, I hope that this is a valuable session for whether you are a researcher, a clinician, or an educator. I hope that you walk out of here with some tools for how to approach change management a little bit more deliberately, with a couple of frameworks to play with as you institute your next change. Think back to Cotter or Kern for med ed, and take these steps home with you. And if you want, write down one change that you might take with you, or one thing that you learned on your handout to take with you as you go back with that passion to make the change at your institutions. Thank you all so much for participating and listening. This was a great session. Thank you.

change management

healthcare

education

clinical practice

research

Cotter framework

strategic change

people-centric change

structural change

technological change