TeamSTEPPS 2.0: Module 8. Change Management

Instructor's Guide

TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.

Instructor Outline: Change Management

Icon: An eye Instructor Note: In this module, you will present information about change management and how to achieve a culture of safety. Cultivating a culture of safety requires an organizational change strategy to be in place. This module will highlight Kotter's eight steps of change and introduce change management strategies that can be adopted by any organization.

The Change Management module includes the content provided in the outline below. There are two options for facilitating the instruction of this module. One option is to facilitate the Change Management Activity described on pages 6-7, which will highlight the important aspects of culture change. Following this activity, the information on pages 17-21 should be used to provide further instruction. Alternatively, a lecture-based approach can be used to review the 8 Steps of Change in detail (pages 9-16), followed by the additional information included on pages 17-21.


# Content Page # Approx. Time
1. Introduction 5 2 mins
2. Change Management Activity 6-7 40 mins*
3. Eight Steps of Change 8—16 40 mins
(Pages 9-16*)
4. Errors Common to Organizational Change 17 2 mins
5. Culture Change Comes Last, Not First 18 2 mins
6. Change Strategies 19-20 8 mins
7. Roadmap to a Culture of Safety 21 2 mins

* In this module, there are two options for presenting information. Please see the Instructor Note above for additional information.

Additional Resources: Below are sources of additional resources you may wish to use to customize this module or to obtain additional information.

  • Kotter, J. (1996). Leading change. Boston, MA: Harvard Business School Press.
  • Kotter, J. & Rathgeber, H. (2005). Our iceberg is melting: Changing and succeeding under adverse conditions. New York, NY: St. Martin's Press.
Icon: Document


  • Eight Steps of Change
  • Errors Common in Organizational Change
  • Culture Change Comes Last, Not First
  • Change Strategies
  • Roadmap to a Culture of Safety
Icon: A clock Module Time: 60 Minutes
Icon: Materials Materials:

  • Flipchart or Whiteboard (Optional)
  • Markers (Optional)





TeamSTEPPS provides a set of strategies and tools for improving performance and patient safety. A key element in implementing TeamSTEPPS is changing the organization's culture. This module will help guide you through the phases and steps necessary to successfully change your organization's culture.

Following this module, you will be able to:

  • List the Eight Steps of Change.
  • Identify errors common to organizational change.
  • Discuss what is involved in creating a new culture.
  • Begin planning your organizational change strategy.

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 (Optional) Exercise: Change Management Activity

Icon: An eye Instructor Note: Almost every participant in TeamSTEPPS has been part of an organizational change initiative. Therefore, we recommend you lead the participants through a discussion, rather than lecturing on the topic of change management. The following exercise will facilitate that discussion and ensure that all important aspects of culture change are discussed. This exercise has been used in numerous TeamSTEPPS Master Training courses. Below are the steps.

Step 1. Story Telling (10 Minutes).

  1. Instruct the participants to form groups of two or three.
  2. Instruct the participants to individually "Think of a story (e.g., a critical incident) that you experienced related to organizational change. The story can be an example of either a successful or unsuccessful change effort. It can be something that is work or non-work related. Think about: How and why was the change introduced and by whom? How was it received? Were there any barriers? How were these barriers overcome? What happened? Was it successful? Why?"
  3. Instruct the participants to take turns sharing their stories with their partners. While listening, they should take notes about things that were critical to either the success or failure of the change that is being described. Allow participants 5 minutes to share their stories.
  4. Ask three or more participants to share their stories with the entire group. Be sure to allow participants to ask the person sharing the story any questions. You should also ask questions or highlight key points, if appropriate.

Step 2. Identify Best Practices (10 Minutes)

  1. Allow participants 2-3 minutes to reconvene into their groups and identify best practices (i.e., do's and don'ts) related to implementing new programs in an organization.
  2. Lead a facilitated discussion in which participants present their best practices for organizational change. As the facilitator, you should record these best practices on a whiteboard or flipchart. (Note: It is possible to create a list of up to 50 best practices from this activity!)

Step 3. Prioritize Best Practices (10 Minutes)

  1. Instruct participants to reconvene into their groups and identify the one or two most important best practices (i.e., do's and don'ts) related to implementing new programs in an organization. Participants should identify their one or two practices from those listed in Step 2; however, participants may add new practices if they choose to do so.
  2. Ask each group to report which best practices they identified as most important. Record the responses by placing check marks next to the best practices you listed on the whiteboard or flipchart. Be sure that all groups are given an opportunity to share their responses.
  3. Ask the participants to review the final list of "important" best practices. Do they agree with the final list? Would they recommend any changes?

Step 4. Review Kotter's Eights Steps of Change (5 Minutes)

  1. Present the slide listing Kotter's eight steps of change (refer to the next page) and review the steps with the participants.
  2. Compare Kotter's eight steps to the list the participants identified.
  3. Ask the class to discuss any similarities and differences.

Step 5. Common Errors to Change (5 Minutes)

  1. Ask participants what some of the common errors are when trying to make an organizational change.
  2. Compare the errors to those found presented on the slide that accompanies page 17.
Icon: A clock Time: 40 Minutes
Icon: Materials Materials:

  • Flipchart or Whiteboard
  • Markers

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 Eight Steps of Change

Eight Steps of Change. Image: Penguins climb an iceburg with eight labeled steps. The steps are discussed below.


Harvard Business School Professor Dr. John Kotter has outlined an eight-step model for successful change efforts. Steps 1-4 help unfreeze the status quo; Steps 5-7 introduce new practices; and Step 8 grounds the changes in a new culture to ensure sustainability. Because we know that implementing and sustaining change is difficult, it requires a comprehensive strategy. Briefly, the steps are:

  • Step 1: Create a Sense of Urgency. Help others see the need for change and the importance of acting immediately.
  • Step 2: Pull Together the Guiding Team. Make sure there is a powerful group guiding the change—one with leadership skills, credibility, communications ability, authority, analytical skills, and a sense of urgency.
  • Step 3: Develop the Change Vision and Strategy. Clarify how the future will be different from the past and how you can make that future a reality.
  • Step 4: Communicate for Understanding and Buy-in. Make sure as many others as possible understand and accept the vision and the strategy.
  • Step 5: Empower Others to Act. Remove as many barriers as possible so that those who want to make the vision a reality can do so.
  • Step 6: Produce Short-Term Wins. Create some visible, unambiguous successes as soon as possible.
  • Step 7: Don't Let Up. Press harder and faster after the first successes. Be relentless with instituting change after change until the vision becomes a reality.
  • Step 8: Create a New Culture. Hold onto the new ways of behaving and make sure they succeed until they become a part of the very culture of the group.

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 (Optional) Set the Stage and Create a Sense of Urgency

Set the Stage and Create a Sense of Urgency

Icon: An eye Instructor Note: Pages 9-16 (Slides 4-14) are optional content. They review each step in the Kotter Model in more detail. If you choose to conduct the Change Management Activity described on pages 6-7, you will cover the key aspects of change management. If you choose to skip the slides that review each step in the Kotter Model, you may proceed to Errors Common to Organizational Change (page 17).


The first phase in implementing change is setting the stage. As we noted previously, the first step is to create a sense of urgency. Ensuring a sense of urgency among people is crucial to getting cooperation for change. Unless individuals understand the urgency of a situation, complacency sets in and change becomes very difficult, if not impossible. Think about the forces of complacency—what are some of them?

Begin thinking about who are the key stakeholders, groups, and individuals in the organization who must feel the need for change for team training to happen. Are they on-board yet?

Talking about the need for change, the consequences of not changing, and ways to solve the problems is essential to making the case for change.

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 (Optional) Pull Together the Guiding Team

Pull Together the Guiding Team


For the change effort to be successful, a powerful group must lead the change, and members of that group must work together as a team. Key characteristics that must be represented on the team include leadership, credibility, communication, expertise, authority, and a sense of urgency.

Remember that no one person can implement wide-scale change; a coalition is essential. Most organizations have a guiding coalition, or team of individuals who lead the change efforts, already in place. Think about your organization. Is there a guiding coalition already established? Do they have the right mix of skills, knowledge, and capabilities?

One recommendation is to consider existing committees within the organization and designate the one most appropriate as the Guiding Coalition. Especially in larger organizations, a Change Team should be in place in each unit. These teams could all report updates to the Guiding Coalition.

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 (Optional) Develop the Change Vision and Strategy

Develop the Change Vision and Strategy


An organization fosters a "culture of safety" with its practices, processes, and procedures. Patterns of behavior determine the commitment, style, and proficiency of an organization in relation to safety. A positive culture of safety has:

  • Foundation built on mutual trust.
  • Shared perceptions on the importance of safety.
  • Confidence in the efficacy of preventive measures.

The second phase in implementing change is deciding what to do. Leaders must create a compelling vision—one that answers the questions "What do we want to achieve?" and "Where do we want to be in the future?" It is important that the vision engage both head and heart. Leadership must also develop the strategy to make that vision a reality. It is also important that the Guiding Coalition be instrumental in the creation of the vision and strategy.


  • Does your organization have a vision and strategy in place?

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 (Optional) Communicate for Understanding and Buy-In

Communicate for Understanding and Buy-In


The third phase in implementing change is making it happen. When the vision and strategies have been determined, they must be effectively communicated. Failure to implement change is often the result of undercommunicating or communicating poorly. In addition, everyone involved must both understand and accept the vision and strategy.

Creating a vision and implementing change are time consuming and a great deal of hard work. It's essential that trust be built in the early stages within and among the Guiding Coalition/Change Team, staff, and leadership. It's also important that an environment be established where concerns can be brought forward and discussed without fear of retribution. Every communication channel available should be used to put forth the vision and the strategies in a planned way. It's also essential that the Guiding Coalition and Change Team model the expected behavior of staff.

Accept and plan for resistance. Resisters help to clarify the problem. By addressing their concerns, you can actually improve the change.

Use the following actions to overcome resistance to change:

  • Acknowledge change as a process.
  • Empower stakeholders.
  • Encourage all stakeholders.
  • Set concrete goals.
  • Show sensitivity.
  • Model process skills.
  • Develop strategies for dealing with emotions.
  • Manage conflict.
  • Communicate.
  • Monitor process dynamics.

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 (Optional) Empower Others to Act

Empower Others to Act



Leaders must change the systems or structures that undermine the change vision and remove other obstacles to change. They should also encourage risk taking and nontraditional ideas, activities, and actions. It is essential that leaders remove as many barriers as possible so that those who want to make the vision a reality can do so.

Empowering others to act involves:

  • Giving people freedom and direction.
  • Giving people permission to find their own team-driven solutions.
  • Encouraging people to speak up, even to differing views.
  • Encouraging people to take risks.
  • Affirming and refining the vision—make room for others' ideas.
  • Telling people as much as you know.
  • Encouraging teamwork and collaboration.
  • Encouraging personal reflection and learning.
  • Providing people with training and support.
  • Using existing quality improvement methods in your organization to track activities on a daily basis.
  • Setting short-term goals.

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 (Optional) Produce Short-Term Wins

Produce Short-Term Wins


Creating visible, unambiguous successes connected to the change effort as early as possible demonstrates success of the initiative. Plan and create the wins and be sure to visibly recognize and reward people who made the wins possible.

Some additional issues to think through:

  • Think through the power of short-term wins in the first unit to be trained or early adopters of the change.
  • Think of the method you use to integrate lessons learned into your own process modification. Will that method apply here?
  • How do you plan to leverage lessons learned to drive change in the second unit to be trained? To design and drive change as you train up multiple departments across the organization?
  • What measures provide evidence of success?
  • It takes a lot of courage to openly communicate when resisters are present (e.g., at a staff meeting). What method do you find successful for communicating to staff when numerous resisters are present? How can you leverage your Change Team to strategize, plan, and control the impact of resistance?
  • What means or methods tend to build momentum? Is your facility a "story-telling" place? Are stories an effective manner to help staff hear and internalize the short-term "win"?

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 (Optional) Don't Let Up

Don't Let Up


Press harder and faster after the first successes. Be relentless in instituting all the necessary changes until the vision is a reality. To realize the vision, you may have to change systems, structures, and policies that don't fit together and don't fit the transformation vision. You may need to reinvigorate the process with new projects, themes, and change agents.

Kotter recommends that to solidify the changes you should:

  • Hire, promote, and develop people who can implement the change vision.
  • Reinvigorate the process with new projects, themes, and change agents.

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 (Optional) Create a New Culture

Create a New Culture


The final phase in implementing change is making it stick. Hold onto the new ways of behaving and make sure they succeed, until they become a part of the culture of the group. Also develop a means to ensure leadership development and succession. Remember that changing culture comes last, not first. It is only after people change their actions that there can be a change in culture.

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 Errors Common to Organizational Change

Errors Common to Organizational Change


Training is not a standalone function. Pitfalls commonly arise and derail organizations that are overly eager in their rush to change. Listed on this slide are some things to avoid.

New approaches and methods become part of a culture when they are effective. Kotter identifies ways to institutionalize change and counter these errors. These include:

  • Build new habits and skills.
    • Providing opportunities for discussions and tools to reinforce skill, such as the TeamSTEPPS Pocket Guide, may assist staff in institutionalizing processes.
  • Reward incremental change.
  • Make all staff accountable.
  • Assign responsibilities for change actions.
  • Encourage mutual leadership.

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 Culture Change Comes Last, Not First

Culture Change Comes Last, Not First


According to Kotter, the process of anchoring change in the culture has the following characteristics:

  • It comes last, not first. Most alterations in norms and shared values come at the end of the transformation process.
  • It depends on results. New approaches usually sink into the culture only after it's very clear that they work and are superior to old methods.
  • It requires a lot of talk. Without verbal instruction and support, people are often reluctant to acknowledge the validity of new practices.
  • It may involve turnover. Sometimes the only way to change a culture is to change the key people.

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 TeamSTEPPS Change Model

TeamSTEPPS Change Model. Image: The shift process shown in this slide has three phases, which are discuseed below.


While TeamSTEPPS teaches teamwork skills and strategies and tools to enhance teamwork, TeamSTEPPS is at its roots an organizational change initiative. This slide depicts the TeamSTEPPS Model of Change, which can be organized into three phases:

Phase 1: Setting the stage and deciding what to do—Assessment.
Phase 2: Making it happen—Training and implementation.
Phase 3: Making it stick—Monitoring, integrating, and providing coaching for the initiatives to sustain over time.

As you can see, each of these major action organizers correlates with Kotter's steps. We will apply the TeamSTEPPS Change Model during the Implementation Planning module.

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 Change Management Models

Change Management Models


The TeamSTEPPS Change Model is one of a number of change management strategies. These include PDSA, Six Sigma—DMAIC, IHI's Model for Improvement, and CUSP. Each strategy includes similar components.

Your organization may already use or be familiar with one of these approaches. If so, TeamSTEPPS recommends that you use the approach your organization already knows instead of the TeamSTEPPS Change Model. As shown in the slide, the implementation of TeamSTEPPS tools and strategies fits within the components of other models for change. As such, TeamSTEPPS can complement and be coordinated with your existing change strategy.

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 Roadmap to a Culture of Safety

Roadmap to a Culture of Safety. Image: Penguins try various strategies to find their way to safety.


These steps and activities form a high-level roadmap to create a culture of safety. They provide an outline for a vision and strategy. In the next activity, we'll begin to think through these issues in our organization. Once the vision and strategy are determined, you must take these high-level ideas and develop a TeamSTEPPS Action Plan for your organization.

Icon: An eye Instructor Note: You should update the group on where your initiatives currently stand and the work that is left to accomplish.

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Page last reviewed March 2019
Page originally created September 2012
Internet Citation: TeamSTEPPS 2.0: Module 8. Change Management. Content last reviewed March 2019. Agency for Healthcare Research and Quality, Rockville, MD.
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