The handwriting on the wall: program transformations utilizing effective change management strategies.
Abstract: Historically, there have been indications that we need to change the way we work and think about our health care processes. Yet, with the urgency to keep abreast of the changing needs of our patients, have we seen these signs? Moreover, how do we respond to the inevitable change processes that must occur?

In 2010, St. Michael's entered into a five-year partnership with Baxter Canada. The overall goal is to improve the quality of care and life for people living with chronic kidney disease. This initiative was undertaken in response to concerns identified internally related to existing health care delivery processes within the renal program. As in any work environment, the depth and breadth of inevitable changes evoke a variety of responses that are based on the individual's attitudes regarding change. As we embarked on this journey, the nursing leadership team and staff within the program were encouraged to review their usual responses toward change utilizing the book, Who Moved My Cheese? (Johnson, 1998).

It is imperative to identify the attitudes of those people involved in change processes. This awareness facilitates the use of specific strategies to enhance the effectiveness of their engagement in the process and the outcome of the initiative. Reading the writing on the wall prepares people to participate in and embrace changes that promise to benefit those for whom we provide professional care.

Key words: chronic disease management, change management
Subject: Diabetes therapy (Quality management)
Authors: Amos, Anita
Johns, Colleen
Hines, Nordia
Skov, Tracey
Kloosterman, Linda
Pub Date: 04/01/2012
Publication: Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136
Issue: Date: April-June, 2012 Source Volume: 22 Source Issue: 2
Topic: Event Code: 360 Services information; 353 Product quality
Product: Product Code: 8089030 Diabetes Therapy Clinics; 8000431 Diabetes Therapy NAICS Code: 621498 All Other Outpatient Care Centers; 621 Ambulatory Health Care Services SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: Canada Geographic Code: 1CANA Canada
Accession Number: 295433798
Full Text: Introduction

This article describes the approach taken by the Diabetes Comprehensive Care Program (DCCP) at St. Michael's to improve the quality of care processes and life for the patients within the program. It focuses on the use of the principles of change discussed in the book Who Moved My Cheese? (Johnson, 1998).

St. Michael's, an urban teaching hospital, offers a multifaceted chronic renal insufficiency program including an in-centre hemodialysis unit that provides conventional intermittent, short daily and nocturnal intermittent hemodialysis therapies. The renal transplantation aspect of the DCCP is a referral centre for multiple regional dialysis centres that includes assessment coordination for cadaveric and a variety of live donor alternatives, peri-operative in-patient, and outpatient follow-up care. The home dialysis unit provides patient education and follow-up care for both peritoneal dialysis and all hemodialysis modalities. The DCCP also includes an interdisciplinary Kidney Care Centre, Multidisciplinary Diabetes Care Clinic, urology and ophthalmology services.


Over the last few years, we have been scrutinizing our processes and systems, efficiencies, outcomes, patient and staff satisfaction, and many other facets of the program. We gained invaluable information in terms of gaps in care processes, strengths and areas for improvement. However, it is often more productive to have people external to the program review processes to gain an objective insight. St. Michael's invited Baxter Canada to help us gain a better understanding of the strengths and opportunities for improvement within the DCCP.

Baxter took a two-tiered approach to glean the information that the program was seeking. The first was to conduct interviews with clinicians, allied health and leadership from home dialysis, pre-dialysis and in-centre hemodialysis area staff. They gathered information pertaining to organization of the health care delivery system, community linkages, self-management support, decision support, clinical information systems and barriers within the program.

The second initiative was to assess St. Michael's readiness to change from both an organizational leadership and clinical readiness perspective. This was accomplished through the use of a "Change Readiness Survey" that was developed collaboratively by Baxter Canada and the University of Guelph. All staff, physicians and management within the renal program were invited to participate. In February 2010, the survey results were presented to the St. Michael's senior leadership team. They indicated that, overall, the program staff were ready for change--and indeed, needed it to deal with high workload demands, communication issues, and work stress identified by all disciplines and roles.

Based on these self-perceptions, survey results and interview findings, St. Michael's entered into a five-year partnership with Baxter Canada to implement a Renal Disease Management Initiative (RDMI). The RDMI initiative supports the DCCP to "establish, monitor and optimize patient outcomes and operational performance indicators" (Baxter Canada and St. Michael's, 2010). It is aligned with St. Michael's organizational strategic plan to implement a quality improvement initiative known as SOAPEE: Safety, Outcomes, Access, Patient Experience, Equity and Efficiency. Other strategic alignments include provincial Ministry of Health initiatives and organizations: the Ontario Chronic Disease Prevention and Management (CDPM) framework, Ontario Renal Network (ORN) and the Toronto Central LHIN 2010-2013 Integrated Health Service Plan (November 2009).

The RDMI is composed of the following components: leadership and governance, education and accreditation, patient self-management, risk stratification, longitudinal care (transitions) and population health outcomes. It is designed to improve the clinical and economic outcomes for the chronic kidney disease population through the redesign of care delivery processes and rigorous monitoring of specific indicators.

Within the project charter of our RDMI, St. Michael's has agreed on eight (8) specific areas for improvement within our program in response to the survey and interview results. They are to: increase and promote the use of home therapies through clinician referral, patient education and treatment choice; prevent or delay initiation of dialysis through improved patient care co-morbidity management; improve seamless coordinated care throughout the renal continuum; demonstrate a decrease in hospital utilization for patients treated with home-based modalities; demonstrate cost avoidance through increase in home-based therapy utilization; embed a culture of quality improvement through rigorous data capture, analysis, reporting and action planning; embed the principles and practices of self-management for patients and providers; and improve targeted resource allocation and care planning (Baxter Canada and St. Michael's, 2010).

To address the first of six components of the RDMI (leadership and governance), we have formed the Executive Steering Committee that is responsible for creating and maintaining an environment for the execution of the plan. The Operations/ Quality Committee is accountable for the day-to-day operation of the project using evidence-based medicine and clinical practice guidelines. This includes meeting the goals, timelines and measurement criteria identified within the project charter. Routine and rigorous data analysis and review of key performance indicators (KPIs) by health care teams drive quality improvement initiatives in the areas of: clinical, humanistic, financial, and program outcomes (Baxter Canada and St. Michael's, 2010).

Education and accreditation, the second component, is addressed through Baxter's provision of on-site consulting support to St. Michael's staff. Baxter brings to the table knowledge and skills regarding the concepts and processes associated with change management, strategic planning, quality improvement, and project management (Baxter Canada and St. Michael's, 20 1 0) .

The third component of the RDIV I, patient self-management, involves the delivery of Baxter's Pathways to Empowerment education program. The program provides staff with tools and coaching for them to utilize in their patient interactions that facilitate the promotion of patient self-confidence and self-efficacy through principles of self-management (Baxter Canada and St. Michael's, 2010).

Risk stratification, the fourth component of RDMI, is aimed at the provision of proactive patient care with a focus on co-morbidity management while increasing the utilization of home-based dialysis therapies where medically appropriate. Patients are classified using a methodology that scores the individual health status of our specific population as high-, medium-or low risk. The purpose is to develop guidelines (care maps) that are designed to provide proactive care based on the patient risk level with a focus on co-morbidity management. Risk stratification tools for ESRD support the program as it seeks new ways to ensure targeted and focused health care planning and resource allocation (Baxter Canada and St. Michael's, 2010).

As in any multifaceted nephrology program, the patients at St. Michael's often move from one patient care area to another and back again with regularity. The fifth component of RDMI is the implementation of effective strategies that maintain seamless patient care coordination, communication and integration of health care service delivery throughout the trajectory of care. Traditional healthcare models--where episodic (acute) care dictates where integration of health care services emerges across the continuum of care--tend to be ineffective in the management of chronic longitudinal care. We are utilizing value stream mapping to identify opportunities to improve care coordination and integration of health care services, resulting in lower costs of care (Baxter Canada and St. Michael's, 2010).

A disciplined and organized approach toward data capture and analysis of the KPIs associated with the quality improvement initiatives designed to support clinical practice changes address the sixth component--population health outcomes (Baxter Canada and St. Michael's, 2010).

Overview of change

Change is inevitable. Change does, however, create instability in our lives, as few issues are ever permanently resolved and conflict may arise between those supporting the status quo and those advocating for change. This instability can be very stressful, and the change demanding. At the same time, change can be exciting and challenging. There are a number of change theories discussed in the literature, examples of which are: Thorndike's Connectionism, which looks at the associations between stimuli and response (Heimann, 2010); the Trans-theoretical Model, which involves emotions, cognition and behaviour, with the dynamic interaction of the pre-contemplation, contemplation, preparation, action and maintenance stages (Heimann, 2006); the Theory of Reasoned Action, which addresses behaviour, intention, attitudes and norms (Heimann, 2003, Nov.), and the popular Health Belief Model (Heimann, 2003, July), which is based on perceived susceptibility, severity, benefits, barriers, and cues to action and self-efficacy.

While the theories differ in their approach, the types of change are consistent. The first three types of change--straight-forward change, learning to do something a different way, and responding to something that obviously needs to be changed are relatively easy changes to accomplish. However, the fourth type--changing something that you absolutely know you cannot change--involves a challenge or a threat to our beliefs that underpin our lives. It involves adopting a new way of seeing the world, and many of us are uncomfortable about moving outside of our comfort zone. When we do so, our sense of security is threatened. Moving into uncharted waters means that we can't necessarily rely on our tried and proven approaches to accomplishing our goals (Kohn, 2007).

Lastly, change that is imposed upon us and over which we believe we have no control is the most complex type of change and often the barriers may seem insurmountable. When we believe that change is being imposed upon us, our natural response is to feel cheated, under-valued and disempowered. Often we create barriers to making this type of change succeed and feel vindicated if it doesn't (Kohn, 2007).

Our comfort zone involves routines and patterns, easily set and potentially very difficult to step away from. The beliefs we hold are complex and once entrenched, are often stronger than any evidence provided to the contrary. Change involves negotiation, but before that can begin, it is imperative that individuals understand their typical responses to change and identify different ways of adapting (Albrecht, 2010).

To transition from a person who is terrified by change to one who embraces it, we need to learn to see change differently. Change was never meant to challenge our core beliefs but rather, in the health care setting, to improve the care that we provide based on what is valued by our patients and ourselves. Utilizing the simple approach discussed in Who Moved My Cheese? (Johnson, 1998), St. Michael's is attempting to minimize inherent stress while leading staff through change processes. This approach was chosen because it takes a very complex issue and breaks it down into simple workable solutions. It also provides for a bit of fun while at the same time is quite revealing.

Given the scope of this project, it is fairly safe to say that significant changes within our program affecting all members of the health care team are inevitable. Despite the fact that many recognize the problems, change may still be problematic for some in that they "have always done it that way" or they have created the system/process and have a sense of ownership. People respond to change differently and, therefore, often their responses will vary depending upon what aspect of their life will be affected by the change--personal versus work life. They may believe that it is often safer not to change. But is it?

Key to the success of any initiative is to understand potential responses to change and the underlying reasons for this response. St. Michael's believes that, as an organization, they have the responsibility to foster the development of the skills required by their staff in order to better position themselves to adapt to the challenging times in which we find ourselves. Part of the RDMI involves the use of the messages learned from the book Who Moved My Cheese? (Johnson, 1998).

The book is a parable that talks about four characters; two mice and two little people, who live in a maze and how they look for cheese to feed them and make them happy. The maze depicts where we look for what we want in life and the cheese represents what we want to have in life. During the story, the characters find cheese that they feed on until it disappears. When it is gone, each of the characters responds in a different manner.

Sniff, one of the mice, is always on the lookout for impending change and is usually aware of its coming before others. Scurry, the other mouse, sees what is needed and takes action immediately. Both of the mice respond rapidly when the cheese is gone and are off to find new cheese within the maze.

Hem, one of the little people, feels uncomfortable in new situations and wishes that change wasn't happening. He denies and resists change fearing that it will lead to something worse. When the cheese disappears, he blames everyone else for the situation and refuses to move beyond--out into the maze for new cheese. Haw, the last of the characters, is able to laugh at himself for not wanting to change, and is then able to move on and explore the maze to enjoy the taste of new cheese. He learns to adapt when he sees that the change leads to something better. When they found the first cache of cheese and when the supply disappeared, Haw shared with the reader what he had learned through his experience with change by leaving messages on the walls of the maze. He hoped that his friend Hem would move out into the maze and embrace the inevitable changes that are a fact of life (Champ, 2010).

Application of the handwriting on the wall to RDMI

One aspect of the work being done in the DCCP is that the team charged with the RDMI is to assist staff to build change competencies. If they learn and practise these skills, the staff will become champions and transform the organization. The messages written on the walls by Haw in Who Moved My Cheese? are excellent cornerstones for discussions, as the staff move through the change process. Initially, the change process includes a recognition that change happens and that it is better to watch for the signs of impending change that are generally apparent in our environment. Being aware of the changes that are happening and adapting to them rapidly allows staff to prepare for the next round of inevitable change, to enjoy it, and to be ready for more.

To date, we have begun work in the Kidney Care Centre and will gradually extend to other key areas within the DCCP. As we begin work in each of the areas, the RDMI team presents background information about the initiative, as previously discussed. It is important for the staff to know that the journey we are about to embark upon is in response to the interviews with representatives across the program, as well as the "readiness" survey in which they participated. The reason for this is to demonstrate that the concerns/issues identified by their team members are the impetus for the changes that are to occur, and are not imposed upon them by management.

With this in mind, it is important that staff recognizes that change happens and an awareness of their response to change is essential. To address this, we introduce Who Moved My Cheese? The self-assessment carried out during these sessions helps staff to identify what is important to them. For example, we all know that having cheese makes us happy, but sometimes changes are made, either by our own determination or imposed upon us. This can affect our cheese supply and we respond in different ways. What is their cheese and, how important is it to them? What, if anything, are they are willing to let go? How does each individual respond when someone takes away or threatens their cheese supply? In short, the question is: are you Sniff, Scurry, Hem or Haw?

In terms of the inevitability of change, many of us have heard the adage stating that insanity is doing the same thing over and over again and expecting different results, and we chuckle and agree. Why is it that in healthcare, we often hear "We've always done it that way"? Just because something may have worked before, doesn't mean it still does. We are usually motivated by the basic desire to make things better. This means change! The status quo is constantly being challenged, as new research and literature are published. It is this that forms the basis for the changes in care and its related processes. Yes, they keep moving the cheese!

When change processes occur, it is generally over a very short period of time (Langley, Nolan, Nolan, Norman, & Provost, 2009). All of a sudden we are saying that the change was too fast and without a lot of forethought. The thinking behind most change begins long before the actual change is to take place so, in reality, if staff is aware of what is happening in their environment, they would easily be able to anticipate change. Unfortunately some of that thinking is not transparent or obvious, unless they are sensitive to the cues. Like many other organizations, St. Michael's has many forums for sharing information regarding what is going on strategically within the hospital, e.g., Ministry of Health announcements and their potential impact, clinical research announcements, education opportunities, and so on.

So what do we do with this information? Through the transition work within the RDMI we are utilizing clinical practice guidelines and published research findings to create or revise policies, procedures, and education programs that are evidencebased. These types of activities provide for short-term wins and, when broken up into manageable portions, are not so ovewhelming. Not only do staff members learn more about the care they provide, but they also become engaged and enthusiastic about the work they are doing through a sense of accomplishment and pride.

When trying to improve efficiencies and the quality of care, the staff is provided with survey results (patient and staff), comments from stakeholder interviews, and the results of value stream mapping. Employees are usually motivated to change by the stories this information provides. Awareness of the current state allows them to envision a future state. They can identify the problem and are able to develop potential solutions. Generally speaking, the initial negative responses to change evolve into those that promote change. The fear that may have originally existed takes a back stage and allows them to think outside the box, developing creative visions for the future state. Basically it asks the question, "What would you do if you weren't afraid?" (Johnson, 1998).

One aspect of building change competencies with the staff is to assist them to recognize sources of information that will create an awareness of potential future changes. This also entails an examination of the effects of these changes and their potential impact on themselves, the patients, and the organization. This is further broken down to determine the likelihood of these possible outcomes. As they learn these skills, staff will become more adept at anticipating change, recognizing its significance to their environment, and preparing them for the cheese to move, thus avoiding extinction.

As employees learn to anticipate change, they also develop an ability to recognize when changes are happening. Identifying when the status quo will no longer be effective requires all health care personnel to stay abreast of what is happening around them. Ministry of Health and Long-Term Care (MoHLTC) initiatives such as the Chronic Disease and Prevention Management (CDPM) framework, and the establishment of the Ontario Renal Network (ORN), the Toronto Central LHIN 2010-2013 Integrated Health Services Plan, and Bill 46-"Excellent care for All" creates quality expectations and have set the stage for many of the current change initiatives.

On an organizational level, the adoption of SOAPEE (the Quality Improvement initiative), the bid to be a Registered Nurses' Association of Ontario (RNAO) Best Practice Spotlight Organization, and the signing of a Memorandum of Agreement with Baxter to embark on the RDMI have been clear messages that quality at St. Michael's is valued. Ingrained in health care personnel is an understanding of the need to evaluate which activities may no longer be achieving desired results. Education regarding the RDMI has set the stage for staff to be made aware of the scope of issues and concerns that were identified by those working within the program.

During the RDMI transition work, staff is encouraged to look at what is currently happening and to express a vision of the future. When these views differ, they are invited to identify what beliefs, activities and processes are currently in place that interfere with them achieving their goals. As they cite the barriers, it becomes obvious that they must make changes. Any movement in a new direction will help them on their way to "find new cheese" (Johnson, 1998). Indeed, they might not be successful in reaching their goals immediately, but if they don't do anything, they will never succeed. As we move through the change continuum, taking the pulse of the staff and their response to the initiatives is integral to addressing the roadblocks based on beliefs.

Creating an environment where staff can adapt to change quickly requires emotional intelligence and, often, some unlearning. Discussion regarding the culture of the organization and emotions that manifest themselves, as barriers to change, mitigates the associated stress. Self-awareness of personal responses to change and the barriers that they may impose can help staff put the concerns into perspective and begin the process of unlearning. Education regarding self-management principles facilitates the unlearning process where staff let go of their old beliefs, perceptions and interpretations, opening their minds to innovative approaches (Baxter, 2010). Previous ideas and perceptions may hold them back from moving out of their comfort zone to make the changes required and meet identified goals.

Generally speaking, people are not resistant to proposed changes but, rather, the perceived losses that may be experienced as a result of the transition processes. "It is not the changes that determine the success or failure of a project, it is the transitions. As suggested by Campbell (2008), changes are situational, and transitions are more psychological. Changeready environments foster creative and effective working relationships among colleagues, innovative thinking, and assist in advancing best practices. Adapting to change demands that staff move beyond their fears or "let go of old cheese so they can enjoy new cheese sooner" (Johnson, 1998).

It is only after their minds are open to new and innovative thinking that staff can objectively assess the issues, create a clear vision of the goal, identify strategies or steps that need to occur for the goal to be met, and determine how they will know the goal has been met.

The RDMI Project Charter specifies areas for improvement within the DCCP. The issues, goals and strategies are determined by a committee composed of members from each of the clinical areas within the scope of the RDMI. This is fuelled by information acquired through activities such as value stream mapping, stakeholder interviews, patient and staff surveys, risk stratification, and working group meetings. With these data in hand, the staff progress through the quality improvement process--articulation of issues, identification of goals, determination of metrics and strategies to achieve the vision. Communication regarding information relative to the proposed changes is communicated throughout the committee structure with all levels having the opportunity to participate in the development of the plan. This way, staff develops a sense of ownership and that buy-in propels them out into the maze where they develop and implement strategies, and assess their effectiveness in achieving their goals or targets. Concurrent to this, required education and supports to facilitate the identified changes are identified and implemented.

The RDMI committee structure ensures a "disciplined and organized approach towards data capture, analysis and quality improvement initiatives designed to support clinical practice changes" (Baxter Canada and St. Michael's, 2010). Each committee has a role in moving the change processes forward and each is held accountable by another. It is important to note that there is no end point to this initiative and the goal is to embed this approach to quality improvement into the daily lives and practices of the staff of St. Michael's DCCP.

Change is meant to be enjoyed. The energy and enthusiasm in a room of committed care providers is palpable. As cited by Campbell, "One of the unique characteristics of human beings is how a good deal of their motivation comes from the pictures they carry in their minds" (2008). This vision drives them forward. That isn't to say that resistance will not be encountered but, as outcomes such as standardized care processes, streamlined patient flow, improved staff and patient satisfaction emerge, the culture changes. The definition of the future state will be modified continuously and change will be a way of life. Just when you think you have the answer, you realize that you don't! The cheese is on the move!

The RDMI fosters growth and development in staff in a variety of arenas, including building change competencies. Helping staff to learn skills related to anticipating, monitoring and adapting to change will better position them to continually "move with the cheese and enjoy it!" (Johnson, 1998).


Constant change in the health care environment is extremely challenging but, nonetheless, our reality. Since few issues are ever permanently resolved, it is essential that care providers develop sustainable processes that allow them to keep pace with the demanded changes. Effective navigation through the instability created by change is essential. Spencer Johnson discusses principles of change in his book Who Moved My Cheese? These have been incorporated into the work of the St. Michael's/Baxter RDMI. While we work toward the successful implementation of such outcomes as standardized care processes, streamlined patient flow, and improved staff and patient satisfaction, the RDMI team is fostering the development of skills that will support staff to read the handwriting on the wall--while at the same time becoming the champions who will transform care in the St. Michael's DCCP.

Copyright [c] 2012 Canadian Association of Nephrology Nurses and Technologists


Albrecht, S. (2010). Understanding employee cynicism toward change in healthcare contexts. International Journal of Information Systems and Change Management, 4(3), 194-209.

Baxter Corporation. (2010). Pathways to empowerment: Self-management support strategies. Mississauga, ON: Baxter International Inc.

Baxter Corporation and St. Michael's. (2010). Renal disease management: Project charter. Mississauga, ON: Baxter Canada.

Campbell, R.J. (2008). Change management in health care: The Health Care Manager, 27(1) 23-39.

Champ, H. (2010). Who Moved My Cheese? [You Tube Video]. Retrieved from

Heimann, D. (2003, July 29). Change theory: Health belief model. Retrieved from

Heimann, D. (2003, November 11). Change theory: Reasoned action model. Retrieved from

Heimann, D. (2006, October 19). Change theory: Trans-theoretical model. Retrieved from

Heimann, D. (2010, September 10). Change theory: Thorndike's connectionism model. Retrieved from

Johnson, S. (1998). Who moved my cheese? New York: G.P. Putnam's Sons.

Kohn, M. (2007). Rapid change in healthcare organizations [PDF document]. Retrieved from Lecture Notes Online Website http://

Langley, G.L., Nolan, K.M., Nolan, T.W., Norman, C.L., & Provost, L.P. (2009) The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco, CA: Jossey-Bass Publishers.

Toronto Central LHIN. (2009, November). 2010-2013 Integrated Health Service Plan. Retrieved from

By Anita Amos, RN, BScN, CNeph(C), Colleen Johns, RN, Nordia Hines, BA, MA, Tracey Skov, RN, HBScN, MSN, and Linda Kloosterman, RN, BScN, CNeph(C) Anita Amos, RN, BScN, CNeph(C), Diabetes Comprehensive Care Program, St. Michael's Hospital, Toronto, ON

Colleen Johns, RN, Diabetes Comprehensive Care Program, St. Michael's Hospital, Toronto, ON

Nordia Hines, BA, MA, Diabetes Comprehensive Care Program, St. Michael's Hospital, Toronto, ON

Tracey Skov, RN, HBScN, MSN, Baxter Corporation, Mississuaga, ON

Linda Kloosterman, RN, BScN, CNeph(C), Baxter Corporation, Mississauga, ON

Address correspondence to: Anita Amos, RN, BScN, CNeph(C), Case Manager, Chronic Disease Management, St. Michael's Hospital, DCC]? 30 Bond Street, Toronto, ON M5B 1 W8. Tel: 416-864-6060 #3821; Fax: 416-864-3042; E-mail:

Submitted for publication: October 17, 2011.

Accepted for publication in revised form: January 3, 2012.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.