Section 9.1: Principles of Organizational Change

9.1.1 The “Why”: Moving Beyond “Because I Said So”

As a pharmacy leader, you will be the source of countless directives, from simple workflow adjustments to sweeping technological overhauls. The most common—and least effective—method for implementing these is through positional authority: “This is the new way we’re doing it. Make sure it happens.” This top-down, command-and-control approach is the managerial equivalent of prescribing a potent medication without explaining the diagnosis, the mechanism of action, or the potential side effects. While you may achieve temporary compliance, you will have sown the seeds of resentment, confusion, and resistance, virtually guaranteeing the change will fail in the long run.

Studies consistently show that up to 70% of organizational change initiatives fail to meet their stated objectives. They fail not because the new idea was flawed, but because the human element—the complex web of fears, habits, loyalties, and motivations of the people involved—was ignored. They fail because leaders mistake issuing a memo for leading a transformation. The “Why” of this entire section is to equip you with the strategic frameworks that serve as your antidote to this staggering failure rate. These models are not academic theories; they are battle-tested blueprints for navigating the treacherous terrain of human psychology during times of transition.

To be a successful change agent, you must trade the mindset of a manager for that of a clinician. Your organization is the patient, and the proposed change is the therapeutic intervention. A clinician would never initiate treatment without first understanding the patient’s history, diagnosing the underlying condition, anticipating adverse reactions, and creating a comprehensive treatment plan with built-in follow-up. The models we will explore—Lewin’s, Kotter’s, and ADKAR—provide the diagnostic and therapeutic framework for your “patient.” They force you to move beyond the “what” of the change to the “why” (creating urgency and awareness), the “who” (building a coalition and engaging stakeholders), and the “how” (providing knowledge, removing barriers, and reinforcing new behaviors). In the high-stakes, high-stress environment of pharmacy operations, where a botched change can have direct consequences on patient safety and team morale, approaching change with anything less than this clinical rigor is professional negligence.

9.1.2 The Foundational Model: Lewin’s Change Management Model

Developed in the 1940s by psychologist Kurt Lewin, this model is the bedrock of change management theory. Its power lies in its simplicity. Lewin viewed the change process not as a simple A-to-B transition, but as a three-stage journey that acknowledges the powerful forces maintaining the status quo. He used the analogy of changing the shape of a block of ice: you must first melt it (Unfreeze), then pour it into a new mold (Change), and finally solidify it in its new form (Refreeze).

Stage 1: Unfreeze

This is the most critical and often most difficult stage. It’s about preparing the organization for change. The goal is to overcome the inertia and dismantling of the existing mindset. You must create a palpable sense that the current way of doing things is no longer viable or acceptable. This involves two parallel efforts: increasing the driving forces that push for change and decreasing the restraining forces that hold the status quo in place.

Masterclass Table: “Unfreezing” Your Pharmacy Team

Technique	Description	Pharmacy Leadership in Action
Presenting a “Burning Platform”	This involves showing incontrovertible evidence that the status quo is unsustainable. The “platform” is on fire, and staying put is not an option.	You need to implement a new, more rigorous inventory management system. Action: At a staff meeting, you present a detailed report showing a 15% increase in drug expiration waste over the last year, costing the pharmacy $50,000. You show that these losses directly impact the budget for technician salary increases. You have just created a burning platform.
Challenging Current Beliefs & Norms	Gently but firmly questioning the “we’ve always done it this way” mentality.	Your pharmacy’s workflow for handling prior authorizations is slow and inefficient. Action: You facilitate a brainstorming session. You ask: “If we were building our PA process from scratch today, knowing what we know about electronic PAs and new software, what would it look like? Let’s ignore our current process for a moment.” This gives them permission to see beyond the status quo.
Creating Psychological Safety for Dissent	To unfreeze, you need people to admit the current state is flawed. They will only do this if they feel safe to voice concerns without fear of retribution.	You suspect the current method for IV compounding has hidden risks. Action: You start by admitting a mistake you made in the past. You then ask, “What are the parts of our current IV process that make you the most nervous? What’s the one thing you wish we could fix to prevent a potential error?” You are actively soliciting criticism of the current state.

Stage 2: Change (or Transition)

Once the organization is “unfrozen” and ready to move, you enter the transition stage. This is the messy middle. It’s the period of learning, confusion, and discovery as the old ways are left behind and the new ways are not yet fully mastered. People are often resistant, uncertain, and less productive during this phase. As a leader, your role here is to be a source of clarity, support, and direction. This is where leadership is most visible and most needed.

Stage 3: Refreeze

Change is fragile. Once the new processes are in place, there is a powerful gravitational pull back to the old, familiar ways of working. The Refreeze stage is about stabilizing the organization and anchoring the change into the culture, ensuring it becomes the new status quo. Without a deliberate refreezing process, you risk the “snap-back,” where all the hard work of the transition is lost as people revert to their old habits.

Masterclass Table: “Refreezing” the New Normal

Technique	Description	Pharmacy Leadership in Action
Integrate into Formal Structures	The change must be woven into the fabric of the organization’s official systems.	You have implemented a new technician-led medication history program. Action: You update the lead technician’s job description to include “Medication History Program Oversight.” You create a formal SOP for the process. You build a new report in the pharmacy system to track the percentage of patients with a technician-verified history.
Adjust Reward & Recognition Systems	What gets rewarded gets done. The incentive structure must align with the new behaviors.	You are trying to foster a culture of proactive error reporting. Action: You create a “Good Catch of the Month” award. During performance reviews, you specifically praise employees who have reported near-misses, framing it as a vital contribution to patient safety, rather than a mistake.
Provide Continuous Support & Training	Refreezing doesn’t mean the learning stops. It means providing ongoing resources to solidify and improve upon the new skills.	The pharmacy has adopted a new, complex sterile compounding software. Action: Six months after go-live, you hold “advanced user” workshops to teach shortcuts and new features. You ensure all new hires are trained on the system as part of their standard onboarding.
Communicate Success & Tell the Story	Continuously share data and stories that prove the change was successful. This reinforces the “why” and cements the new reality.	A year after implementing a new inventory system to reduce waste. Action: You post a graph in the breakroom showing that expired drug waste has decreased by 75%, saving the hospital $200,000. You write in the department newsletter: “Because of your hard work adopting the new inventory system, we were able to purchase a new clean hood for the IV room.”

9.1.3 The Strategic Roadmap: Kotter’s 8-Step Process for Leading Change

If Lewin’s model provides the foundational three phases of change, Harvard Business School Professor John Kotter’s 8-Step Process provides a detailed, granular, and actionable roadmap for navigating those phases. Developed from studying hundreds of organizations, Kotter’s model is a pragmatic guide for leaders. It emphasizes the importance of a thoughtful, strategic sequence of actions. Skipping steps is a primary reason why change initiatives fail. We will explore each step in detail, translating it into the context of pharmacy leadership.

Phase 1: Creating a Climate for Change (Lewin’s “Unfreeze”)

1. Create a Sense of Urgency

This is the catalyst for the entire process. You must make the team feel that change is not just a good idea, but an absolute necessity. Complacency is the enemy of progress. Your task is to break through the “everything is fine” mentality by presenting compelling evidence that the status quo is more dangerous than the uncertainty of change. This is not about fear-mongering; it’s about creating a rational, data-driven case for action.

Pharmacy Application: The hospital’s readmission rates for heart failure patients are too high, and post-discharge medication confusion is a major contributing factor.

• Don’t say: “We need to get better at discharge counseling.”
• Do say: “Last quarter, 22% of our CHF patients were readmitted within 30 days, which is above the national average and resulted in significant financial penalties for the hospital. Our interviews with these patients revealed that over half of them were confused about their diuretic regimen. We are failing these patients at a critical transition, and we must design a better process.” You could even bring in a patient (with their consent) to share their story of a confusing discharge.

2. Build a Guiding Coalition

No leader, no matter how brilliant, can implement significant change alone. You need to assemble a group of influential and respected individuals from across the department to champion the change. This coalition must have a mix of skills, credibility, and authority. It should include not just managers, but also informal leaders—the senior technician everyone listens to, the optimistic pharmacist who is always trying new things. This group will be your strategic brain trust and your evangelists.

Pharmacy Application: For the CHF discharge project, your coalition should not just be you and the pharmacy director. It should include:

• The cardiology-focused clinical pharmacist.
• A highly respected lead technician who can speak to workflow realities.
• A staff pharmacist from the central pharmacy who understands distribution challenges.
• Crucially, a nurse manager or champion from the cardiology floor. Change in the pharmacy often requires change outside the pharmacy.

3. Form a Strategic Vision and Initiatives

The sense of urgency creates the motivation to move, but the vision tells people where to go. A clear, compelling vision paints a picture of the future state that is attractive and understandable. It should be easy to communicate in five minutes or less and should be able to guide decision-making. The vision is the “true north” of your change effort.

Pharmacy Application: For the CHF project:

• Bad Vision: “Our goal is to implement a new discharge counseling workflow.” (This is a task, not a vision).
• Good Vision: “We will create the safest and most effective medication discharge process in the hospital, where every heart failure patient leaves with a clear understanding of their medications and a pharmacist they can call, empowering them to manage their health at home and dramatically reducing their chances of returning to the hospital.”

Phase 2: Engaging and Enabling the Organization (Lewin’s “Change”)

4. Enlist a Volunteer Army

With your vision in place, you need to communicate it broadly and passionately to get buy-in from the rest of the team. This is about moving from a small guiding coalition to a large group of people who believe in the vision and want to help make it a reality. You need to speak to their hearts as well as their minds. Use every communication channel available: staff meetings, team huddles, emails, newsletters, and one-on-one conversations.

5. Enable Action by Removing Barriers

As your volunteer army begins to work, they will inevitably run into obstacles. These barriers can be structural (outdated SOPs, rigid job descriptions), technological (software that doesn’t support the new process), or human (a middle manager who actively undermines the change). Your job, and that of your guiding coalition, is to be a “barrier-buster.” You must actively seek out and remove these impediments to empower your team to succeed.

Pharmacy Application: In your CHF project, a barrier might be the hospital’s policy that “only nurses can provide discharge paperwork.” Your coalition must work with nursing leadership to redefine this process, creating a new collaborative workflow where the pharmacist provides the medication-specific part of the discharge education. Another barrier might be that pharmacists don’t have enough time; you may need to re-engineer other tasks to free up 15 minutes for each CHF discharge.

6. Generate Short-Term Wins

Major change can be a long slog, and teams can lose motivation. To keep the momentum going, you must plan for and celebrate short-term wins. These are unambiguous, visible successes that prove the change is working. A good short-term win is relevant to the overall vision, achievable without waiting for the entire project to finish, and can be publicly recognized. These wins provide a powerful psychological boost, silence the cynics, and build credibility for the guiding coalition.

Pharmacy Application: Instead of waiting a year to see if readmission rates fall, you could launch the new discharge process as a pilot on just one cardiology unit. After the first month, you can calculate the medication reconciliation error rate for that unit and show that it dropped by 50%. You then celebrate this win with the pilot team, building enthusiasm for the hospital-wide rollout.

Phase 3: Implementing and Sustaining Change (Lewin’s “Refreeze”)

7. Sustain Acceleration (Don’t Let Up)

After a few short-term wins, it’s tempting to declare victory and move on. Kotter warns that this is a critical error. Complacency can creep back in. Instead, you must use the credibility and momentum from your early wins to tackle even bigger, more complex parts of the change. Keep the urgency high. Continue to set new goals and analyze what’s working and what isn’t. This is about building on the foundation you’ve laid.

8. Institute Change (Anchor It in the Culture)

Finally, to make the change stick, it must become “the way we do things around here.” This is the Refreeze stage. You must anchor the new behaviors in the organization’s culture. This involves connecting the change to performance, succession, and the core values of the department. New employees should be onboarded into the new way of working as the standard, not the exception.

Pharmacy Application: For the CHF project:

• Performance Management: The annual performance review for clinical pharmacists now includes a metric for “completion of CHF discharge counseling protocols.”
• Promotion: When hiring a new clinical coordinator, you specifically look for candidates who have experience with transitions of care programs.
• Storytelling: At department meetings, you regularly share positive stories and thank-you notes from patients who benefited from the new discharge process. This makes the new behavior part of the department’s identity.

9.1.4 The Individual’s Journey: The Prosci ADKAR® Model

While Lewin’s and Kotter’s models provide an organizational-level, top-down view of change, the ADKAR model, developed by Prosci founder Jeff Hiatt, provides the essential bottom-up perspective. It recognizes a fundamental truth: Organizational change only happens when the individuals within the organization change their behaviors. You can have the best process in the world, but if your people don’t adopt it, it will fail. ADKAR provides a framework for understanding and managing the journey that each individual must go through to make a change successful.

ADKAR is an acronym for the five sequential building blocks that an individual must achieve for a change to be realized. If any block is weak or missing, the change will stumble. As a leader, your role is to diagnose where your team members are in the ADKAR process and provide targeted support to help them get to the next stage.

Awareness

The Goal: The individual understands the nature of the change, why the change is being made, and the risk of not changing. This is the logical, rational starting point. It’s not about agreeing with the change yet, but simply understanding the case for it.

Pharmacist Leader’s Role: You are the primary communicator of the “why.” You must connect the change to a clear business, clinical, or patient safety need.

• Change: Implementing a new two-technician check system for filling automated dispensing cabinet cassettes.
• Action: You don’t just announce the new SOP. You present a summary of two recent medication errors that were traced back to ADC stocking errors. You explain that this new process is a direct response to prevent those specific errors from recurring. You have built Awareness of the problem.

Desire

The Goal: The individual makes a personal decision to support and participate in the change. This is the emotional component. It moves beyond understanding to wanting. Desire is often driven by answering the unspoken question: “What’s in it for me?” (WIIFM).

Pharmacist Leader’s Role: You are the coach and motivator. You must connect the change to the individual’s personal motivators. This requires understanding your team. Some are motivated by patient safety, others by efficiency, others by professional development, and some by reducing personal frustration.

• Change: Same ADC-filling change.
• Action: In a team huddle, you explain how this new process will reduce the number of frustrating calls from nurses about missing meds, making the technicians’ day smoother. You also frame it as a professional development opportunity, giving technicians more ownership over medication safety. You are building Desire by appealing to their personal WIIFM.

Knowledge

The Goal: The individual knows how to change. This encompasses the knowledge, skills, and training required to implement the change. This stage is about learning the new processes and tools.

Pharmacist Leader’s Role: You are the trainer and educator. You are responsible for ensuring your team receives clear, effective, and hands-on training.

• Change: Same ADC-filling change.
• Action: You don’t just email the new SOP. You conduct a mandatory in-service where technicians practice the new workflow with dummy cassettes. You provide job aids and checklists to be used at the workstation. You have built Knowledge.

Ability

The Goal: The individual can demonstrate the required skills and behaviors. This is the crucial step where knowledge is translated into action. It’s one thing to know how to do something; it’s another to be able to do it proficiently and consistently in a real-world environment.

Pharmacist Leader’s Role: You are the coach and facilitator. You must create opportunities for practice and provide constructive feedback.

• Change: Same ADC-filling change.
• Action: For the first week, you or your lead technician personally observe and coach each team as they perform the new check. You provide immediate, supportive feedback (“That was great. Next time, let’s make sure we’re both initialing the log at the same time.”). You are building Ability through practice and feedback.

Reinforcement

The Goal: The individual continues to demonstrate the new behavior because there are mechanisms in place to make the change stick. This includes recognition, rewards, and celebrating success. Without reinforcement, people will revert to old habits.

Pharmacist Leader’s Role: You are the champion and sustainer of the change. You must ensure that the new behavior is seen as valuable and is positively acknowledged.

• Change: Same ADC-filling change.
• Action: A month after implementation, you pull a report that shows ADC stocking errors have dropped to zero. You post this result and publicly thank the technician team for their diligence. You mention their success to the hospital’s Director of Nursing, who sends a thank-you email to the team. You have provided powerful Reinforcement.

9.1.5 Synthesizing the Models: The CPOM Unified Change Framework

These three models—Lewin, Kotter, and ADKAR—are not competing theories. They are different lenses for viewing the same complex process, and their true power is unlocked when they are integrated. Lewin provides the high-level phases. Kotter provides the organizational-level, leader-driven roadmap. And ADKAR provides the individual-level, people-centric journey. A masterful change leader operates on all three levels simultaneously.

The CPOM Unified Change Framework integrates these models into a single, comprehensive playbook. It structures Kotter’s 8 steps within Lewin’s 3 phases, while showing how each group of actions is designed to move your individual team members through their own ADKAR journey.

Masterclass Table: The Unified Change Playbook

Phase (Lewin)	Leader’s Objective	Key Steps (Kotter)	Target Outcome (ADKAR)	CPOM Actionable Playbook for Pharmacy
UNFREEZE	Prepare for Change: Create the motivation and build the case for leaving the status quo.	1. Create Urgency	Awareness	Gather and present compelling data (e.g., error rates, financial waste, patient satisfaction scores, staff turnover). Share patient stories that highlight the deficiencies of the current process. Analyze and discuss external threats (e.g., new regulations, competitor actions, changing reimbursement models). Facilitate team discussions about current frustrations and challenges.
		2. Build Coalition	Desire	Identify and recruit formal and informal leaders who have credibility and expertise. Ensure the coalition represents different roles (pharmacists, technicians, administrative staff). Clearly define the coalition’s role, responsibilities, and authority. Foster a sense of shared purpose and teamwork within the coalition.
		3. Form Vision		Collaborate with the coalition to draft a clear, inspiring, and concise vision of the future state. Ensure the vision is easily understandable and speaks to the values of the team. Develop concrete strategic initiatives that will bring the vision to life.
		4. Enlist Army		Communicate the “why,” “what,” and “how” of the vision through multiple channels (meetings, huddles, emails). Translate the vision into tangible benefits for each role (the WIIFM). Empower people to ask questions and provide input. Model the desired behaviors and enthusiasm yourself.
CHANGE	Implement the Change: Provide the tools, support, and momentum to navigate the transition.	5. Remove Barriers	Knowledge	Conduct formal training sessions, workshops, and create user-friendly job aids. Provide access to sandbox/test environments for new technologies. Actively solicit feedback on what is preventing progress (systems, processes, people). Work with the coalition to systematically dismantle identified barriers.
		6. Generate Wins	Ability	Identify and implement pilot programs or phased rollouts. Provide at-the-elbow coaching and real-time feedback. Track and measure the performance of these early initiatives. Publicly celebrate and reward the teams and individuals involved in these short-term successes.
		7. Sustain Acceleration	Ability	Analyze the short-term wins to identify lessons learned. Use the momentum to tackle more significant or complex barriers. Continue to communicate the vision and report on progress. Bring new people and projects into the change effort to keep it fresh.
REFREEZE	Sustain the Change: Anchor the new behaviors into the culture to ensure they last.	8. Institute Change	Reinforcement	Update official SOPs, job descriptions, and performance review criteria to reflect the new way of working. Implement recognition and reward systems that are explicitly tied to the new behaviors. Share success stories and data that quantify the positive impact of the change. Ensure the new hire onboarding and training process incorporates the change as the standard procedure. Continuously monitor for “snap-back” and address it immediately.