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MODULE 20: LEADERSHIP & STRATEGIC MANAGEMENT
Section 20.2: Change Management Models (ADKAR, Kotter)
Technology doesn’t change organizations; people do. This section provides a deep dive into formal change management frameworks, giving you a structured playbook to guide individuals and teams through the human side of technological disruption.
SECTION 20.2
Change Management Models
The Pharmacist’s Playbook for the Human Side of Health IT.
20.2.1 The “Why”: Technology is the Tool, People are the Process
In the world of health informatics, we are surrounded by dazzling technology. We speak of cloud-based EHRs, artificial intelligence for clinical decision support, and interoperable data fabrics. It is easy to become mesmerized by the technical complexity and sheer power of these systems. It is also easy to fall into the most dangerous trap in our profession: the belief that the technology itself creates change. It does not. A billion-dollar EHR system is nothing more than an expensive paperweight if the clinicians it is meant to serve refuse to use it, find dangerous workarounds, or fundamentally misunderstand its purpose.
Technology doesn’t change organizations; people do. This is the central, unshakeable truth of health IT. The real work of an informatics pharmacist is not just building order sets or configuring alerts; it is guiding people through the difficult, often emotional, and always disruptive process of changing the way they work. Every major informatics project is, at its heart, a massive change management initiative. You are not just installing software; you are performing a delicate and complex upgrade on the “human operating system” of the hospital.
Resistance to change is not a character flaw. It is a normal, predictable human reaction to disruption. As a pharmacist, you would never dismiss a patient’s side effect as them being “difficult.” You would investigate the cause, understand the mechanism, and find a solution. Similarly, you must learn to view resistance not as an obstacle to be crushed, but as a symptom to be diagnosed. Is the resistance caused by a lack of awareness of why the change is needed? A lack of desire because the new workflow seems harder? A lack of knowledge on how to use the new system? Or a lack of ability to perform the new skills under pressure? Without a structured way to diagnose and treat these “symptoms,” your project is destined for failure, regardless of how brilliant the technology is.
This is why mastering formal change management models is not a “soft skill” for an informatics leader; it is a core competency. Frameworks like Prosci’s ADKAR model and Kotter’s 8-Step Process are your evidence-based guidelines for the human side of implementation. They provide a playbook, a common language, and a set of diagnostic tools to move your stakeholders from a state of resistance and anxiety to one of adoption and proficiency. They transform you from a technical builder into a clinical change agent, capable of ensuring that the technology you implement actually delivers on its promise to improve patient care.
Retail Pharmacist Analogy: The Traumatic Switch to a New Pharmacy Management System
Every experienced retail pharmacist has lived through this nightmare. For years, your pharmacy has used a familiar, if imperfect, software system (let’s call it “OldPharm”). Your fingers have a muscle memory for every keystroke. You can process a refill, adjudicate a claim, and print a label in seconds, almost without thinking. You know its quirks, its workarounds, and its limitations. It’s an extension of your brain.
Then, Corporate announces that everyone is switching to “NewPharm” in two weeks. The “training” consists of a few generic webinars. On Monday morning, OldPharm is gone, and NewPharm is on every screen. The result is pure chaos.
- The Technical Success, The Human Failure: The software is technically “live.” It can process prescriptions. But the pharmacy’s efficiency plummets by 70%. Wait times balloon from 15 minutes to over an hour. Your most experienced technicians, who could once multitask with ease, are now struggling to perform the simplest functions.
- The Resistance: The team’s language is full of anger and frustration. “Why did they do this?” (Lack of Awareness). “This is so much slower! The old way was better.” (Lack of Desire). “I don’t know where to find the patient’s insurance info!” (Lack of Knowledge). A technician fumbles with the scanner for five minutes trying to input a new script, a task that used to take 30 seconds. (Lack of Ability).
- The Aftermath: After a few brutal weeks, the team develops clunky new workflows. Patient satisfaction has cratered. Team morale is destroyed. Crucially, no one from Corporate follows up to see how it’s going, gather feedback, or celebrate the fact that the team survived. (Lack of Reinforcement). The change was forced, not managed.
Now, imagine a different scenario. A skilled PIC, acting as a change leader, would have managed this transition entirely differently, intuitively using the principles you are about to learn. They would have insisted on getting early access to a test version, identified workflow gaps, created their own custom “cheat sheets” (Knowledge), designated and trained their lead tech as a super-user (Ability), and explained to the team exactly how the new system would eventually reduce data entry errors (Awareness & Desire). This is change management. It is the science of preventing the “NewPharm” disaster from ever happening.
20.2.2 A Tale of Two Frameworks: Individual vs. Organizational Change
In this deep dive, we will focus on two of the most respected and practical change management frameworks. It is crucial to understand that they are not competing models; they are complementary tools that look at the challenge of change from two different altitudes.
The ADKAR® Model
The Individual’s Journey
Developed by Jeff Hiatt of Prosci, ADKAR is a bottom-up model. Its focus is on the individual. It posits that for an organizational change to be successful, every single individual affected by that change must successfully transition through five distinct stages. It is a powerful diagnostic tool that helps you pinpoint exactly why a change is failing for a specific person or group.
The core question of ADKAR is: “What does this individual need right now to move to the next step of the change process?”
Kotter’s 8-Step Process
The Organization’s Roadmap
Developed by Harvard Business School professor John Kotter, this is a top-down model. Its focus is on the organization. It provides an 8-step strategic roadmap for leaders to create an environment where change can happen successfully on a large scale. It’s less about individual psychology and more about creating momentum, aligning leadership, and embedding the change into the culture.
The core question of Kotter is: “Have we created the necessary strategic conditions for this large-scale change to succeed?”
The Analogy: The Telescope and the Microscope
Think of Kotter’s model as your telescope. You use it at the beginning of a project to look out at the entire organizational landscape. It helps you see the big picture, identify the major strategic steps you need to take, and chart the overall course for your journey.
Think of ADKAR as your microscope. Once your journey is underway, you use it to zoom in on specific areas. When you encounter resistance or a lack of adoption, you use ADKAR to diagnose the problem at the individual or team level. The telescope (Kotter) sets the direction, but the microscope (ADKAR) is what allows you to solve the real-world problems you encounter along the way. A master change leader is fluent in using both tools in concert.
20.2.3 Masterclass 1: The ADKAR Model – Engineering Individual Change
ADKAR is the informatics pharmacist’s single most valuable diagnostic tool. The model’s power lies in its simplicity and its sequential nature. An individual must progress through the five stages in order. For example, trying to build Knowledge in someone who has no Desire to learn is a waste of time and resources. Your first job is to identify a person’s “barrier point”—the first element they have not yet achieved—and focus all your energy there.
Awareness of the need for change.
This is the foundational block. It addresses the “why.” Team members must understand the business, clinical, or strategic reasons for the change. This is not the “how” of the change, but the fundamental rationale. Without awareness, you will be met with confusion and questions like, “Why are we doing this? The old way worked fine.”
The Pharmacist’s Role: Chief Translator of “Why”
As the clinical expert on the project team, you are uniquely positioned to build awareness. You can translate high-level corporate goals (e.g., “reduce length of stay”) into tangible clinical meaning for the frontline staff. Your credibility as a pharmacist is your superpower here.
| Audience | Ineffective Awareness Message (Generic) | Effective Awareness Message (Pharmacist-Translated) |
|---|---|---|
| Staff Nurses | “We are implementing a new IV pump interoperability system to improve data capture for billing.” | “I know this is a big change, but here’s why it matters. Last year, there were 12 documented cases where a patient’s IV rate was programmed incorrectly. This new system will make that type of error virtually impossible by pulling the ordered rate directly from the EHR into the pump. This is about protecting you and your patients from a very real risk.” |
| Hospitalist Physicians | “Management wants us to use the new sepsis order set to meet our quality metrics.” | “I’ve analyzed our data from the last quarter. For septic patients where this new order set wasn’t used, the average time from arrival to antibiotics was 110 minutes. For every hour we delay, mortality increases. This order set is designed to get that time under 60 minutes. This isn’t about metrics; it’s about saving lives by acting faster.” |
| IT Network Engineers | “We need you to prioritize the network upgrade for the pharmacy.” | “The pharmacy’s current network latency is causing a 10-second delay every time a pharmacist verifies an order. Multiplied by thousands of orders a day, this adds hours of wasted time and directly impacts how quickly a stat antibiotic gets from the pharmacy to a patient in the ED. Upgrading this segment is a critical patient safety initiative.” |
Desire to support and participate in the change.
Once people understand the “why,” the next question they ask is personal: “What’s in it for me?” (WIIFM). Desire is about individual motivation. It’s the personal choice to engage with the change. This is often the most challenging element, as it’s tied to personal incentives, fears, and the perceived impact of the change on an individual’s daily work.
The Pharmacist’s Role: Empathy, Influence, and Pain Point Relief
Your job here is to be a detective and a diplomat. You must uncover the sources of resistance and find ways to build desire. This means spending time with end-users, listening to their concerns with genuine empathy, and framing the change as a solution to their existing problems.
Masterclass on Resistance: It’s Not What You Think
Resistance is not a sign of insubordination; it’s a sign of a threat perception. People resist change because they fear losing something valuable:
- Loss of Competence: “I’m the expert in the old system. In the new one, I’ll be a novice again.”
- Loss of Control: “The new system forces me to do things in a certain order. I lose my autonomy.”
- Loss of Time: “This is going to slow me down and I’m already overwhelmed.”
- Loss of Relationships: “The new workflow means I won’t interact with the unit secretary anymore, and she’s a key part of my informal communication network.”
Your job is not to argue with these fears, but to acknowledge them and show how the change can mitigate them or provide a greater benefit. For example, to the expert fearing loss of competence, you can offer them a role as a super-user, repositioning them as an expert in the new world.
Knowledge of how to change.
Once a person has the awareness and desire, they need the “how.” Knowledge encompasses the training, education, and information required to perform the new skills and implement the new workflows. This seems straightforward, but it’s where many projects fail by providing ineffective, generic training.
The Pharmacist’s Role: The Architect of Clinical Training
This is your domain. As the clinical informatics expert, you are responsible for ensuring the training is not just “clickology” (which buttons to click) but is rooted in clinical workflow. Clinicians learn by doing, and the training must reflect their daily reality.
Playbook for Effective Clinical IT Training
- Scenario-Based, Not Feature-Based: Don’t teach the features of the software. Teach the workflow. Instead of a lesson on “The Medication Order Entry Screen,” create a lesson called “Admitting a Patient with Community-Acquired Pneumonia” that takes them through the entire process from start to finish.
- Use Realistic Patient Cases: Build your training scenarios around the most common patient types for that unit. For an oncology training session, use a complex chemotherapy patient. For the ED, use a trauma patient.
- Led by Peers: The most effective trainers for nurses are other nurses. The best trainers for physicians are other physicians. Your role is to develop a “train-the-trainer” program, equipping clinical super-users with the materials and confidence to teach their peers. Your presence lends technical support, but the message is delivered by a trusted colleague.
- Create a “Sandbox” Environment: Give users a safe, realistic training environment where they can play, practice, and make mistakes without fear of harming a real patient. This is critical for building confidence before go-live.
Ability to implement the change.
Ability is the bridge between knowing and doing. A person can have perfect knowledge from a classroom session but still lack the ability to perform the new skills in a high-pressure, real-world clinical environment. Ability is about demonstrated competence. This is the stage that occurs during and immediately after go-live.
The Pharmacist’s Role: The At-The-Elbow Coach
During go-live, your place is not in a command center; it’s on the units. You must be visible, available, and proactive. Your role is to provide immediate, at-the-elbow support to translate classroom knowledge into real-world ability.
| The Problem: Knowledge vs. Ability Barrier | Your Diagnostic Question | Your Intervention |
|---|---|---|
| A nurse knows they are supposed to scan the patient’s wristband, but in a code situation, they forget this new step and go straight to the medication drawer. | “Did you know you were supposed to scan the wristband?” (If yes, it’s an Ability barrier, not Knowledge). | This is about muscle memory and practice. You can implement non-punitive reminders, have super-users gently coach in real-time, and ensure the scanner is placed in an ergonomic, easy-to-reach location. |
| A physician is trying to order a TPN and cannot find the right order set. They get frustrated and place a series of disconnected, dangerous individual orders instead. | “Were you shown how to use the ‘TPN’ keyword in the search during training?” (If no, it’s a Knowledge barrier). | This indicates a gap in training. You need to provide a quick, 1-minute re-education on the spot and then take that feedback back to the training team to improve the curriculum for the next wave of users. |
Reinforcement to make the change stick.
Without reinforcement, people will naturally revert to their old ways of working. Reinforcement includes any action or event that strengthens the new behavior. This can be positive (recognition, celebrating success) or negative (accountability for not following the new process). This is the element that ensures the change is sustained long after the project team has disbanded.
The Pharmacist’s Role: The Sustainer and Optimizer
Your work is not done at go-live. You must partner with operational leaders to ensure the new workflows are hardwired into the organization’s culture. You are also the primary person to gather data that proves the change was successful, which is the most powerful form of reinforcement.
Playbook for Reinforcement
- Measure and Publicize Success: Before the project, establish a baseline metric (e.g., medication error rate, time to antibiotics). After go-live, run the same report and share the positive results widely. “Thanks to your adoption of the new BCMA workflow, we have reduced wrong-dose errors on the medical-surgical unit by 90% in the last month. This is a huge win for patient safety.”
- Celebrate Champions: Publicly recognize the super-users and early adopters who helped their peers. Work with nurse managers to have this contribution noted on their annual performance reviews.
- Create Feedback Loops for Optimization: The go-live product is never perfect. Create a simple, clear process for end-users to submit suggestions for improvement. When you implement a requested change, communicate it back to the person who suggested it. This shows that their voice matters and reinforces their engagement.
- Incorporate into Policy: Work with the Pharmacy & Therapeutics (P&T) Committee and nursing leadership to update official hospital policies and procedures to reflect the new standard workflows. This makes the change official and permanent.
20.2.4 Masterclass 2: Kotter’s 8-Step Process – Orchestrating Organizational Change
If ADKAR provides the microscope to manage individual transitions, Kotter’s 8-Step Process provides the telescope for orchestrating the entire organizational campaign. As an informatics pharmacist, you may not be the ultimate leader of this process, but you will be a key player in the “guiding coalition.” Understanding this framework allows you to see the big picture, understand the strategic decisions being made by executive leadership, and contribute to them effectively. Kotter’s model is a sequential, top-down approach that creates the conditions necessary for change to thrive on a large scale.
Visualizing the Kotter Model: A Three-Phase Campaign
Phase 1: Create a Climate for Change
Thawing the frozen organization.
1
Create a Sense of Urgency
2
Form a Powerful Guiding Coalition
3
Create a Strategic Vision
Phase 2: Engage & Enable the Organization
Introducing the new ways of working.
4
Communicate the Vision
5
Empower Broad-Based Action
6
Generate Short-Term Wins
Phase 3: Implement & Sustain the Change
Refreezing the organization in the new state.
7
Consolidate Gains and Produce More Change
8
Anchor New Approaches in the Culture
The Pharmacist’s Role in Each of Kotter’s 8 Steps
| Kotter’s Step | Strategic Goal | The Informatics Pharmacist’s Contribution |
|---|---|---|
| Phase 1: Create a Climate for Change | ||
| 1. Create Urgency | Make the status quo seem more dangerous than the uncertainty of change. | This is your data-storytelling moment. You pull and present data that highlights the problem: medication error rates, adverse drug events, workflow inefficiencies, delays in therapy. You make the current state tangible and unacceptable. |
| 2. Form a Guiding Coalition | Assemble a group with enough power, credibility, and expertise to lead the change. | You advocate for the right people to be at the table. You ensure influential but skeptical physician leaders and respected frontline nurses are on the steering committee. You serve as the clinical SME within this coalition. |
| 3. Create a Strategic Vision | Craft a simple, clear, and compelling picture of the future state. | You help ground the vision in clinical reality. You ensure the vision statement is not just IT jargon but speaks to improved patient outcomes and better clinician experiences. “A future where all chemotherapy orders are guided by evidence-based protocols, eliminating calculation errors.” |
| Phase 2: Engage & Enable the Organization | ||
| 4. Communicate the Vision | Use every possible channel to communicate the new vision and strategies, over and over again. | You become a primary communicator, presenting at departmental meetings, grand rounds, and nursing huddles. You translate the vision for each audience (as discussed in the ADKAR section on Awareness). You “walk the walk” by using the new system and demonstrating your belief in it. |
| 5. Empower Action | Remove barriers that are blocking the path to the vision. | You are a chief obstacle remover. This can be technical (fixing bugs), process-related (redesigning a bad workflow), or political (using your influence to get a department to cooperate). You identify and dismantle roadblocks for the frontline staff. |
| 6. Generate Short-Term Wins | Create visible, unambiguous successes as soon as possible to build momentum. | You plan for a phased rollout, starting with a pilot unit that is likely to be successful. You then measure and heavily publicize the success of that pilot (e.g., “The 4th-floor med-surg unit reduced their missing medication requests by 80% in the first week!”). This builds credibility and quiets naysayers. |
| Phase 3: Implement & Sustain the Change | ||
| 7. Consolidate Gains | Use the credibility from short-term wins to tackle bigger changes and keep up the momentum. | After a successful CPOE rollout for basic med/surg orders, you leverage that success to get buy-in for the next, more complex phase: implementing CPOE for ICU drips or pediatric weight-based dosing. You prevent the organization from declaring victory too early. |
| 8. Anchor in Culture | Make the change stick by embedding it into the organization’s norms, policies, and promotion criteria. | You work with HR and clinical leadership to make proficiency with the new systems a part of annual competencies. You ensure new employee orientation includes thorough training. You help write the new P&T and nursing policies that make the new workflow the official standard of care. |
20.2.5 Integrating the Models: Your Unified Change Leadership Playbook
The true mastery of change management comes from understanding how these two models—the organizational telescope and the individual microscope—fit together. Kotter’s model sets the stage and creates the organizational momentum, while ADKAR provides the tools to ensure the individuals on that stage can perform their new roles. A successful change initiative requires both.
Masterclass Table: Mapping ADKAR to Kotter’s Framework
This table illustrates how the strategic activities in Kotter’s process directly enable the individual transitions described in the ADKAR model. As a change leader, you will be working on both fronts simultaneously.
| Kotter’s Strategic Action (Top-Down) | Directly Enables this ADKAR Outcome (Bottom-Up) | Informatics Example |
|---|---|---|
| 1. Create Urgency 3. Create a Vision 4. Communicate the Vision |
AWARENESS | Presenting medication error data (Urgency) and showing how a new CPOE system will prevent them (Vision) builds Awareness among physicians about why the change is necessary. |
| 2. Form a Guiding Coalition 5. Empower Action 6. Generate Short-Term Wins |
DESIRE | When a respected physician champion from the Guiding Coalition advocates for the change and you remove a key workflow obstacle for them (Empowerment), you build Desire in their peers to participate. |
| 4. Communicate the Vision 5. Empower Action (via training) |
KNOWLEDGE | Part of Communicating the Vision and Empowering Action is providing comprehensive, workflow-based training, which directly builds Knowledge of how to use the new system. |
| 5. Empower Action (via support) 6. Generate Short-Term Wins |
ABILITY | Providing at-the-elbow support during a pilot rollout (Empowerment) and helping a unit achieve an early success (Short-Term Win) turns their Knowledge into demonstrated Ability. |
| 6. Generate Short-Term Wins 7. Consolidate Gains 8. Anchor in Culture |
REINFORCEMENT | Celebrating the Short-Term Win, using that momentum to tackle the next phase (Consolidate Gains), and updating hospital policy (Anchor in Culture) all provide powerful Reinforcement that makes the change permanent. |
Your Final Playbook: From Theory to Practice
As a Certified Pharmacy Informatics Analyst, you are now equipped with a powerful, evidence-based approach to managing the human side of change. Your final, unified playbook should look like this:
- Before the Project Begins (The Strategic View): Mentally walk through Kotter’s 8 steps. Ask the critical questions: Is there a compelling sense of urgency? Is the right leadership coalition in place? Is there a clear and simple vision? If the answer to any of these is “no,” your first job is to raise these strategic risks with project leadership. Use your influence to help build this foundation.
- During Project Implementation (The Tactical View): Shift your focus to ADKAR. As you interact with stakeholders—nurses, doctors, technicians, fellow pharmacists—constantly run the ADKAR diagnostic in your head. Is this person’s resistance coming from a lack of Awareness? Desire? Knowledge? Pinpoint their specific barrier and apply the targeted interventions you’ve learned.
- After Go-Live (The Sustainability View): Re-engage with the later steps of Kotter’s model. Focus on Reinforcement. Measure your outcomes. Publicize the wins. Work to anchor the new processes into the organization’s culture. This ensures your hard work delivers lasting value and is not just a temporary “project.”
By mastering these frameworks, you elevate yourself from a system builder to a true clinical leader. You possess the tools not just to implement technology, but to lead people through transformation, ensuring that the systems you build achieve their ultimate purpose: safer, more effective care for every patient.
